AHA Statement on Community Cardiovascular Health

The American Heart Association (AHA) has issued a consensus guideline statement on improving cardiovascular health at the community level. The report appears in the Feb. 4, 2003, issue of Circulation. Circulation is available online atwww.circulationaha.org.

The AHA community guidelines use a public health approach to risk factor modification, in contrast with the high-risk approach that is used in clinical settings in which individual patients' risk levels are assessed and patients at high risk are treated intensively. The goal of the community-based guidelines is to prevent the onset of risk factors. This strategy has the potential to prevent first heart attacks or strokes in persons at average risk and to avoid the need for intensive pharmacotherapy to control risk factors such as hypertension, hyperlipidemia, and diabetes.

Behaviors targeted for change include diets high in cholesterol, saturated fat, salt, and calories, and low in plant-based foods; sedentary lifestyle characterized by less than 30 minutes of moderate-intensity activity per day; tobacco use or exposure to environmental tobacco smoke; lack of screening, counseling, and treatment for hyperlipidemia, hypertension, and other risk factors; and the lack of early recognition of symptoms of heart attack and stroke.

The community settings include entire communities, schools, work sites, religious organizations, or health care facilities.

Interventions include assessment of the community's cardiovascular disease rate to increase community awareness and to target further interventions, and education at the individual level or through the media to communicate the risk, causes, and corrective steps that can reduce cardiovascular risk. Legislative action may be needed to protect against exposure to environmental tobacco smoke or to provide resources for public health campaigns, clinical services, or rehabilitation.

CDC Report on Vaccine-Related Adverse Events

The Centers for Disease Control and Prevention (CDC) has issued a summary of vaccine-related adverse events reported in the United States from 1991 to 2001. The report is available online atwww.cdc.gov/mmwr/preview/mmwrhtml/ss5201a1.htm.

From 1991 to 2001, more than 1.9 billion doses of human vaccines were distributed, and nearly 129,000 vaccine-related adverse events were reported. Fever, rash, injection-site hypersensitivity and edema, and vasodilation were the most commonly reported reactions. Fourteen percent of reported reactions described serious adverse events, including death, life-threatening illness, hospitalization or prolongation of hospitalization, or permanent disability. Reports of deaths ranged from 1.4 to 2.3 percent, and reports of life-threatening illness ranged from 1.4 to 2.8 percent.

The CDC report notes that the data should be interpreted with caution because they describe events that occurred after vaccination, but they do not necessarily indicate that the events were caused by vaccination.

During the 11-year surveillance period, the influenza vaccine had the highest distribution (more than 500 million doses) and the lowest overall reporting rate (three reports per 100,000 doses distributed). Hepatitis B vaccine had the second highest distribution (more than 200 million doses) and an overall reporting rate of 11.8 reports per 100,000 doses distributed. Rhesus rotavirus vaccine-tetravalent had the highest overall reporting rate for a specific vaccine (156.3 reports per 100,000 doses distributed).

Nearly 45 percent of all reported adverse events occurred in children younger than seven years of age, and 18 percent occurred in infants younger than one year of age.

NAEPP Guidelines on Asthma Care

The National Asthma Education and Prevention Program (NAEPP) has issued guidelines for reducing asthma symptoms and preventing exacerbations. The recommendations are available online atwww.cdc.gov/mmwr/preview/mmwrhtml/rr5206a1.htm.

The NAEPP identified four components of asthma management—assessment and monitoring, controlling factors that contribute to asthma severity, pharmacotherapy, and education for partnership in care—and developed the following 10 key clinical activities:

1. Establish diagnosis using a history and physical examination documenting an episodic pattern of respiratory symptoms and from spirometry that indicates partially reversible airflow obstruction. Infants and children younger than five years should be treated as having suspected asthma once alternative diagnoses are ruled out.

2. Classify severity. After the patient's asthma is stable, severity is classified according to the level of medication required to maintain treatment goals.

3. Schedule routine follow-up care. The first follow-up visit should be scheduled within one month after initial diagnosis, with routine visits every one to six months and spirometry at least every one or two years after treatment is initiated and the symptoms and peak expiratory flow have stabilized.

4. Assess for referral to subspecialty care. Referral is recommended in the following circumstances:

   A single life-threatening asthma exacerbation occurs or the initial diagnosis is severe, persistent asthma.

   Treatment goals for the patient's asthma are not being met.

   The diagnosis is unclear or additional diagnostic testing is indicated.

   The patient has a history suggesting that asthma is being provoked by occupational factors, an environmental inhalant, or an ingested substance.

   The patient is younger than three years with moderate or severe persistent asthma.

   The patient is a candidate for immunotherapy.

   The patient or family requires additional education or guidance in managing asthma complications or therapy, following the treatment plan, or avoiding asthma triggers.

   The patient requires continuous oral corticosteroid therapy or high-dose inhaled corticosteroids, or has required more than two courses of oral corticosteroids in one year.

5. Recommend measures to control asthma triggers such as tobacco smoke, house dust mites, cockroaches, and cat and dog allergens.

6. Treat or prevent all comorbid conditions, including allergic rhinitis, sinusitis, gastroesophageal reflux disease, and sensitivity to certain medicines such as aspirin, nonsteroidal anti-inflammatory drugs, and beta blockers can exacerbate asthma symptoms.

7. Prescribe medications according to severity. Evidence indicates that daily, long-term control medications are necessary to prevent exacerbations and chronic symptoms. Inhaled corticosteroids are preferred because they are the most effective anti-inflammatory medication available for treating the underlying inflammation of persistent asthma. All patients with asthma require a short-acting bronchodilator medication for managing acute symptoms or exacerbations when they occur; severe exacerbations require the addition of systemic (oral) corticosteroids to treat the increased inflammation.

Once therapy goals are achieved, a gradual reduction in treatment should be carefully undertaken to identify the minimum dose required to maintain control.

8. Monitor use of beta-agonist drugs. Patients whose need for a short-acting inhaled beta-agonist increases probably have inadequately controlled asthma. Such patients may need short-acting inhaled beta-agonist during upper respiratory viral infections and exercise-induced broncho-constriction. Using more than one canister of short-acting beta-agonist per month is considered above expected use.

9. Develop a written asthma management plan. Writing an asthma management plan helps clarify expectations for treatment and provides patients with an easy reference for remembering how to manage their asthma. The action plan should include written instructions on recognizing symptoms and signs of worsening asthma; taking appropriate medicines (i.e., type, dose, frequency); recognizing when to seek medical care; and monitoring responses to medications. Symptom-based plans may be equally effective as plans based on peak flow monitoring, although some patient preferences and circumstances (e.g., inability to recognize or report signs and symptoms of worsening asthma) may warrant a choice of peak flow monitoring.

10. Provide routine education on patient self-management. Effective asthma education is developed in a patient-provider partnership, tailored to the individual patient's needs relative to cultural or ethnic beliefs and practices. At a minimum, competent asthma education enlists and encourages family support, includes instructions on self-management skills, and is integrated with routine ongoing care.

AGA Report on Gastroesophageal Reflux Disease

A consensus development panel of the American Gastroenterological Association (AGA) has issued recommendations on the management of gastroesophageal reflux disease (GERD). The monograph “Improving the Management of GERD: Evidence-Based Therapeutic Strategies” is available online atwww.gastro.org/phys-sci/edu-cme/GERDmonograph.pdf.

The panel reviewed data on over-the-counter drugs used to treat symptoms of GERD and concluded that all products have been proved effective, to varying degrees, in relieving mild to moderate GERD when compared with placebo. A review of randomized controlled trials (RCTs) that compared two or more proton pump inhibitors found minimal clinical differences between the drugs. Omeprazole, lansoprazole, pantoprazole, and rabeprazole all produce comparable rates of healing and remission in patients with erosive esophagitis.

The panel found that the incidence of adenocarcinoma in patients with Barrett's esophagus is about 0.5 percent per year, rather than the previously thought rate of 1 to 2 percent per year. Although nearly all esophageal adenocarcinomas occur in patients with Barrett's esophagus, most patients with this condition will never develop this tumor, especially if the extent of metaplasia is less than 3 cm.

It was thought that surgical fun-doplication can prevent esophageal cancer by preventing acid reflux. However, data show that the rate of esophageal cancer is similar in patients who are treated surgically and those who are not.

Use of two new endoscopic procedures for treating GERD is increasing despite a lack of data about their efficacy. The panel found that there is currently no adequate data from RCTs to support endoscopic/intraluminal therapies. Physicians and the public should be educated about the risks and limitations of these therapies.

Epidemiologic studies consistently show modest but significant associations between pulmonary symptoms such as asthma and cough, but there is insufficient data to infer a causal relationship. There is evidence that GERD therapy can improve symptoms, however, lung function tests do not improve.

CDC Guidelines on Catheter-Related Infections

The Centers for Disease Control and Prevention (CDC) has issued evidence-based guidelines on preventing intravascular catheter-related infections. The recommendations are available online atwww.cdc.gov/mmwr/preview/mmwrhtml/rr5110a1.htm.

The incidence of catheter-related bloodstream infections varies considerably by type of catheter used, frequency of manipulation, and patient-related factors such as underlying disease and acuity of illness. Although the incidence of local or bloodstream infections associated with peripheral venous catheters usually is low, severe complications with considerable mortality have been associated with this type of catheter because of the frequency with which it is used. The majority of serious catheter-related infections are associated with central venous catheters, especially those that are placed in patients in intensive-care units.

The recommendations emphasize the following strategies:

• Educating and training health care professionals who insert and maintain catheters.

• Using sterile barrier precautions during catheter insertion.

• Using a 2 percent chlorhexidine preparation for skin antisepsis.

• Avoiding routine replacement of central venous catheters as a strategy to prevent infection.

• Using antiseptic- or antibiotic-impregnated short-term central venous catheters if the infection rate remains high despite adherence to other strategies.

The recommendations also identify performance indicators that health care institutions and organizations can use to monitor their success in implementing the recommendations.