Robert F. DeBusk’s research while affiliated with Stanford Medicine and other places

Wide variability presently exists in how patients are treated for suspected acute coronary syndromes (ACS) in the United States. Among the 6 million Americans presenting to the emergency department (ED) for evaluation of chest pain annually,1 of whom half are hospitalized,2 only 20% are found to have a heart attack.3 Moreover, 2% of ED patients actually having an acute myocardial infarction (MI) are mistakenly discharged home.4,5 Accordingly, 100 patients having chest pain must be evaluated in the ED, and 50 must be hospitalized, to diagnose the 10 who are having an acute MI, but this approach further fails to identify 1 additional patient discharged from the ED whose chest pain represented a heart attack. Thus, all patients reporting chest pain are treated as if they were at high risk, potentially resulting in overtreatment and higher costs. Guidelines developed by the American College of Cardiology (ACC) and the American Heart Association (AHA)6,7 permit many patients reporting symptoms of chest pain to be classified as having a low risk for death or nonfatal MI. However, decision support tools that might reliably establish this classification are not presently incorporated into the clinical workflow of EDs and other treatment settings, including urgent care clinics and other outpatient settings. To address the need for decisional support in the triage of patients reporting cardiovascular symptoms, we developed an online Decision Support System (DSS) that standardizes the initial evaluation of patients. The system incorporates 2 key functions: (1) It assists physicians and other health care professionals to comprehensively and accurately elicit patients' symptoms, irrespective of the patient's location; and (2) it transforms patients' symptoms of chest pain into a preliminary or “provisional” diagnosis linked to categories of high, moderate, and low risk for death or nonfatal MI based …

Erectile dysfunction (ED) and coronary artery disease (CAD) interact in complex ways: ED is increasingly recognized as a harbinger or risk factor for CAD; a small proportion of cases (about 1%) of acute coronary syndromes (ACS), including acute myocardial infarction and sudden cardiac death, occur during or after sexual activity; the absolute risk associated with coitus, including that associated with the use of phosphodiesterase 5 (PDE5) inhibitors to treat ED, is extremely low; virtually all patients experiencing ACS have previously existing (but usually undiagnosed) CAD; and patients often have ED after ACS as a result of psychological factors or drugs, such as beta-blockers, used to treat CAD. The Princeton Guidelines provide a pragmatic approach to stratifying the risk of ACS in patients with established CAD or at high risk for future ACS. Only a minority of patients destined to experience ACS, including those events related to coitus, have established CAD. Yet, most have > or =2 coronary risk factors. The most pragmatic approach to decreasing the risk of ACS in such individuals is to maximize risk factor control and institute combination pharmacotherapy, including statins. The PDE5 inhibitors ameliorate not only ED but also endothelial cell dysfunction. Research to establish the role for PDE5 inhibitors in the prevention and control of ACS is in its early stages. The recognition that ED is a potential harbinger of underlying CAD and future ACS is an important milestone in the management of ED. Progress in integrating PDE5 inhibitors into clinical practice will depend on the success with which patients with ED are evaluated and aggressively treated for endothelial cell dysfunction.

Erectile dysfunction (ED) is commonly associated with cardiovascular disease, which has potentially fatal consequences if not managed appropriately. Physicians and patients for a number of reasons commonly ignore ED. Increased awareness of the health consequences of ED would encourage men and health care professionals to address this condition more freely, permitting appropriate screening and treatment of cardiovascular disease. Concerns about the risks of treating ED in the cardiac patient should not prevent ED from being discussed and we suggest that early acknowledgment of ED might prevent cardiovascular morbidity and even mortality. Specific guidelines for the management of ED in cardiac patients, produced by 2 expert panels, can also be applied to men without known cardiovascular disease.

The National Heart, Lung, and Blood Institute convened a working group on outcomes research in cardiovascular disease (CVD). The working group sought to provide guidance on research priorities in outcomes research related to CVD. For the purposes of this document, "outcomes research" is defined as investigative endeavors that generate knowledge to improve clinical decision making and healthcare delivery to optimize patient outcomes. The working group identified the following priority areas: (1) national surveillance projects for high-prevalence CV conditions; (2) patient-centered care; (3) translation of the best science into clinical practice; and (4) studies that place the cost of interventions in the context of their real-world effectiveness. Within each of these topics, the working group described examples of initiatives that could serve the Institute and the public. In addition, the group identified the following areas that are important to the field: (1) promotion of the use of existing data; (2) facilitation of collaborations with other federal agencies; (3) investigations into the basic science of outcomes research, with an emphasis on methodological advances; (4) strengthening of appropriate study sections with individuals who have expertise in outcomes research; and (5) expansion of opportunities to train new outcomes research investigators. The working group concluded that a dedicated investment in CV outcomes research could directly improve the care delivered in the United States.

Nurse care management programs for patients with chronic illness have been shown to be safe and effective. To determine whether a telephone-mediated nurse care management program for heart failure reduced the rate of rehospitalization for heart failure and for all causes over a 1-year period. Randomized, controlled trial of usual care with nurse management versus usual care alone in patients hospitalized for heart failure from May 1998 through October 2001. 5 northern California hospitals in a large health maintenance organization. Of 2786 patients screened, 462 met clinical criteria for heart failure and were randomly assigned (228 to intervention and 234 to usual care). Nurse care management provided structured telephone surveillance and treatment for heart failure and coordination of patients' care with primary care physicians. Time to first rehospitalization for heart failure or for any cause and time to a combined end point of first rehospitalization, emergency department visit, or death. At 1 year, half of the patients had been rehospitalized at least once and 11% had died. Only one third of rehospitalizations were for heart failure. The rate of first rehospitalization for heart failure was similar in both groups (proportional hazard, 0.85 [95% CI, 0.46 to 1.57]). The rate of all-cause rehospitalization was similar (proportional hazard, 0.98 [CI, 0.76 to 1.27]). The findings of this study, conducted in a single health care system, may not be generalizable to other health care systems. The overall effect of the intervention was minor. Among patients with heart failure at low risk on the basis of sociodemographic and medical attributes, nurse care management did not statistically significantly reduce rehospitalizations for heart failure or for any cause. Such programs may be less effective for patients at low risk than those at high risk.

Standard office-based approaches to controlling hypertension show limited success. Such suboptimal hypertension control reflects in part the absence of both an infrastructure for patient education and frequent, regular blood pressure (BP) monitoring. We tested the efficacy of a physician-directed, nurse-managed, home-based system for hypertension management with standardized algorithms to modulate drug therapy, based on patients' reports of home BP. We randomized outpatients requiring drug therapy for hypertension according to the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) criteria to receive usual medical care only (UC, n = 76) or usual care plus nurse care management intervention (INT, n = 74) over a 6-month period. Patients receiving INT achieved greater reductions in office BP values at 6 months than those receiving UC: 14.2 +/- 18.1 versus 5.7 +/- 18.7 mm Hg systolic (P < .01) and 6.5 +/- 10.0 versus 3.4 +/- 7.9 mm Hg diastolic, respectively (P < .05). At 6 months, we observed one or more changes in drug therapy in 97% of INT patients versus 43% of UC patients, and 70% of INT patients received two or more drugs versus 46% of UC. Average daily adherence to medication, measured by electronic drug event monitors, was superior among INT subjects (mean +/- SD, 80.5% +/- 23.0%) than among UC subjects (69.2 +/- 31.1%; t(113) = 2.199, P = .03). There were no significant adverse drug reactions in either group. Telephone-mediated nurse management can successfully address many of the systems-related and patient-related issues that limit pharmacotherapeutic effectiveness for hypertension.