READERS’
COMMENTS
Training for Intermediate Clinical Lipid Specialists Most efforts to educate physicians about lipid disorders, such as the National Cholesterol Education Program, target all physicians, with emphasis on those providing primary care. There remains, however, a gap in lipid practice between the community physician engaged in primary care and the lipid specialist practicing at a tertiary referral center. Although the majority of patients with high cholesterol or triglyceride levels can be managed readily by the primary care physician, the remaining cases still exceed the capacity of the 50 or so regional lipid clinics in the United States. To fill this gap, local community expertise in lipid disorders needs to be developed. The concept of the intermediate clinical lipid specialist has emerged-a physician who can serve as a resource for consultation and who can establish a standard of practice as an opinion leader in large and small communities. A new training nroaram in linid disorders initiated by the American’ Heart Association (AHA) is intended to help to meet this need. Six regional lipid clinics were chosen as AHA Training Centers for Clinical Management of Lipid Disorders on the basis of peer-reviewed competitive applications and are to be funded by an educational grant from Bristol Myers-Squibb. Each center will provide in-depth education in pathophysiology, diagnosis and manage ment of a wide spectrum of lipoprotein disorders to approximately 80 physicians per year. The trainee will be expected to undertake home study as well as a 3- to 5day intensive on-site course. The educational experience will involve didactic course material, laboratory experience, nutrition counseling, practical “handson” examination of patients, case study discussions and practice management seminars under the personal tutelage of a highly qualified faculty of lipid specialists. Each physician trainee will be encouraged to bring 1 or possibly more ancillary staff members, such as nurses and dietitians. The follow-up component is perhaps most important for successful implementation of a community-based lipid specialist program. The 6 Training Centers, in connection with other major referral lipid clinics, will continue to serve as tertiary referral centers for difficult cases. In addition, plans for telephone or facsimile consultation services are being developed. The centers will serve as, or be associated with, laboratory referral sites for compar-*
I
Letters (from the United States) concerning a particular article in the Journal must be received within 2 months of the article’s publication, and should be limited (with rare exceptions) to 2 double-spaced typewritten pages. Two copies must be submitted.
1400
THE AMERICAN
JOURNAL
ison with local laboratories and for provision of lipoprotein tests not commonly available in community laboratories. An annual l-day continuing education conference for course graduates and a newsletter are also planned. Practicing physicians who have the opportunity to serve as lipid consultants in their communities are encouraged to apply. Specialization will not be a selection criteria, although a significant amount of the physician’s time should be spent in direct patient care. Selection of trainees will be based in part on regional distribution. Training Centers are located at Baylor College of Medicine, Houston, Texas; Johns Hopkins University, Baltimore, Maryland; University of California, San Francisco and Berkeley, San Francisco and Berkeley, California; University of Iowa, Iowa City, Iowa; University of Washington, Seattle, Washington; and Washington University, St. Louis, Missouri. The first courses are scheduled to begin in January 1991. For information and applications forms, write: Eleanor Sanders, Coordinator, AHA/Squibb Lipid Disorders Training Centers, American Heart Association, 7320 Greenville Avenue, Dallas, Texas 75231. H. Robert
Berkeley,
Superko,
MD
California
Ventricular Arrhythmias During Spontaneous lschemic ST-Segment Depression In the February 15, 1990 issue of The American Journal of Cardiology, we reported our observations on the association of ventricular arrhythmias and increased ventricular ectopic activity during ischemit episodes.’ We believed it was important to emphasize even in the title of our report that we dealt with ambulatory patients. While our article was in press, the October 15, 1989 issue carried an article by Turitto et al2 on their experience with ventricular arrhythmia “during spontaneous ischemic ST-segment depression.” Onlv careful reading of the “Methods” section enabled us to realize that their investigation dealt exclusively with in-hospital-patients, and that the reason for hosaitalization in “all natients” (my emphasis) was “symptoms consistem with spontaneous angina , . . .” This raises the possibility that many of them could have been diagnosed as having unstable angina. This seems to have been the case for the 28 patients with “recent onset” angina and for the 15 others (although these 2 groups may have overlapped) with “worsening” angina; the latter-group may have included Patients with “crescendo” nain, also classified by many as unstable angi: na. Only for 17 patients do the authors clarify that “angina was stable.” If, as seems to be true, quite a few of the patients included in the Turitto et al study had unstable angina, this could explain
OF CARDIOLOGY
VOLUME
66
the somewhat higher incidence of ventricular arrhythmias, as well as the more malignant types (ventricular tachycardias during 6 ischemic attacks) in their study than in the study we reported. Shlomo
Stern,
MD
Jerusalem, Israel 3 1 January 1990 1. Stern S, Banai S, Keren A, Tzivoni D. Ventricular ectopic activity during myocardial ischemit episodes in ambulatory patients. Am J Cardiol 1990:65:412-416. 2. Turitto G,‘Zanchi E, Maddaluna A, Pellegrini A, Risa AL, Prati PL. Prevalence, time course and malignancy of ventricular arrhythmia during spontaneous ischemic ST-segment depression. Am J Cardiol 1989;64:900-904.
REPLY: We acknowledge differences in the incidence of ventricular arrhythmias during transient myocardial ischemia between our study’ and the one by Stern et al2 As was correctly pointed out, the discrepancy may be due to different selections of the patient population. Stern et al focused on patients with stable angina, while we devoted our attention to patients with spontaneous ischemic ST depression, as was clearly stated in the title of our article.’ We elected to use the definition “spontaneous angina” rather than “unstable angina” because we feel that the latter represents a mixed bag into which different categories of patients with exertional, spontaneous chest pain, or both, may fall3 Our study unequivocally showed that the frequency of ventricular arrhythmias depends on the severity of myocardial ischemia.’ In fact, the number of daily ischemic attacks and the total ischemic time doubled in the group with arrhythmias, as compared to the group without arrhythmias. Moreover, in patients with arrhythmias, ischemic attacks lasted twice as long in the presence of arrhythmias than they did in their absence. The characteristics of the overall population studied by Stern et al2 were remarkably similar to those without arrhythmias documented in our group, as far as the number of ischemic attacks, total ischemic time and duration of ischemic attacks were concerned. Their finding of a lower arrhythmogenicity may thus be expected based on these data. On the other hand, the frequency of arrhythmias related to ischemic attacks may have been overestimated in their analysis, because the occurrence of frequent ventricular premature complexes unrelated to ischemic attacks did not represent an exclusion criterion in their study (mean ventricular premature complexes/24 hrs 243 f 538). Their definition of “increased ventricular ectopic activity,” which formed the basis for their diagnosis of arrhythmogenic ischemic attacks in all their patients, may not be entirely accurate, based on the spontaneous variability of ventricular arrhythmias4 Gioia
Turitto,
MD
Wichita, Kansas 5 March 1990
COMMENTS
Training for Intermediate Clinical Lipid Specialists Most efforts to educate physicians about lipid disorders, such as the National Cholesterol Education Program, target all physicians, with emphasis on those providing primary care. There remains, however, a gap in lipid practice between the community physician engaged in primary care and the lipid specialist practicing at a tertiary referral center. Although the majority of patients with high cholesterol or triglyceride levels can be managed readily by the primary care physician, the remaining cases still exceed the capacity of the 50 or so regional lipid clinics in the United States. To fill this gap, local community expertise in lipid disorders needs to be developed. The concept of the intermediate clinical lipid specialist has emerged-a physician who can serve as a resource for consultation and who can establish a standard of practice as an opinion leader in large and small communities. A new training nroaram in linid disorders initiated by the American’ Heart Association (AHA) is intended to help to meet this need. Six regional lipid clinics were chosen as AHA Training Centers for Clinical Management of Lipid Disorders on the basis of peer-reviewed competitive applications and are to be funded by an educational grant from Bristol Myers-Squibb. Each center will provide in-depth education in pathophysiology, diagnosis and manage ment of a wide spectrum of lipoprotein disorders to approximately 80 physicians per year. The trainee will be expected to undertake home study as well as a 3- to 5day intensive on-site course. The educational experience will involve didactic course material, laboratory experience, nutrition counseling, practical “handson” examination of patients, case study discussions and practice management seminars under the personal tutelage of a highly qualified faculty of lipid specialists. Each physician trainee will be encouraged to bring 1 or possibly more ancillary staff members, such as nurses and dietitians. The follow-up component is perhaps most important for successful implementation of a community-based lipid specialist program. The 6 Training Centers, in connection with other major referral lipid clinics, will continue to serve as tertiary referral centers for difficult cases. In addition, plans for telephone or facsimile consultation services are being developed. The centers will serve as, or be associated with, laboratory referral sites for compar-*
I
Letters (from the United States) concerning a particular article in the Journal must be received within 2 months of the article’s publication, and should be limited (with rare exceptions) to 2 double-spaced typewritten pages. Two copies must be submitted.
1400
THE AMERICAN
JOURNAL
ison with local laboratories and for provision of lipoprotein tests not commonly available in community laboratories. An annual l-day continuing education conference for course graduates and a newsletter are also planned. Practicing physicians who have the opportunity to serve as lipid consultants in their communities are encouraged to apply. Specialization will not be a selection criteria, although a significant amount of the physician’s time should be spent in direct patient care. Selection of trainees will be based in part on regional distribution. Training Centers are located at Baylor College of Medicine, Houston, Texas; Johns Hopkins University, Baltimore, Maryland; University of California, San Francisco and Berkeley, San Francisco and Berkeley, California; University of Iowa, Iowa City, Iowa; University of Washington, Seattle, Washington; and Washington University, St. Louis, Missouri. The first courses are scheduled to begin in January 1991. For information and applications forms, write: Eleanor Sanders, Coordinator, AHA/Squibb Lipid Disorders Training Centers, American Heart Association, 7320 Greenville Avenue, Dallas, Texas 75231. H. Robert
Berkeley,
Superko,
MD
California
Ventricular Arrhythmias During Spontaneous lschemic ST-Segment Depression In the February 15, 1990 issue of The American Journal of Cardiology, we reported our observations on the association of ventricular arrhythmias and increased ventricular ectopic activity during ischemit episodes.’ We believed it was important to emphasize even in the title of our report that we dealt with ambulatory patients. While our article was in press, the October 15, 1989 issue carried an article by Turitto et al2 on their experience with ventricular arrhythmia “during spontaneous ischemic ST-segment depression.” Onlv careful reading of the “Methods” section enabled us to realize that their investigation dealt exclusively with in-hospital-patients, and that the reason for hosaitalization in “all natients” (my emphasis) was “symptoms consistem with spontaneous angina , . . .” This raises the possibility that many of them could have been diagnosed as having unstable angina. This seems to have been the case for the 28 patients with “recent onset” angina and for the 15 others (although these 2 groups may have overlapped) with “worsening” angina; the latter-group may have included Patients with “crescendo” nain, also classified by many as unstable angi: na. Only for 17 patients do the authors clarify that “angina was stable.” If, as seems to be true, quite a few of the patients included in the Turitto et al study had unstable angina, this could explain
OF CARDIOLOGY
VOLUME
66
the somewhat higher incidence of ventricular arrhythmias, as well as the more malignant types (ventricular tachycardias during 6 ischemic attacks) in their study than in the study we reported. Shlomo
Stern,
MD
Jerusalem, Israel 3 1 January 1990 1. Stern S, Banai S, Keren A, Tzivoni D. Ventricular ectopic activity during myocardial ischemit episodes in ambulatory patients. Am J Cardiol 1990:65:412-416. 2. Turitto G,‘Zanchi E, Maddaluna A, Pellegrini A, Risa AL, Prati PL. Prevalence, time course and malignancy of ventricular arrhythmia during spontaneous ischemic ST-segment depression. Am J Cardiol 1989;64:900-904.
REPLY: We acknowledge differences in the incidence of ventricular arrhythmias during transient myocardial ischemia between our study’ and the one by Stern et al2 As was correctly pointed out, the discrepancy may be due to different selections of the patient population. Stern et al focused on patients with stable angina, while we devoted our attention to patients with spontaneous ischemic ST depression, as was clearly stated in the title of our article.’ We elected to use the definition “spontaneous angina” rather than “unstable angina” because we feel that the latter represents a mixed bag into which different categories of patients with exertional, spontaneous chest pain, or both, may fall3 Our study unequivocally showed that the frequency of ventricular arrhythmias depends on the severity of myocardial ischemia.’ In fact, the number of daily ischemic attacks and the total ischemic time doubled in the group with arrhythmias, as compared to the group without arrhythmias. Moreover, in patients with arrhythmias, ischemic attacks lasted twice as long in the presence of arrhythmias than they did in their absence. The characteristics of the overall population studied by Stern et al2 were remarkably similar to those without arrhythmias documented in our group, as far as the number of ischemic attacks, total ischemic time and duration of ischemic attacks were concerned. Their finding of a lower arrhythmogenicity may thus be expected based on these data. On the other hand, the frequency of arrhythmias related to ischemic attacks may have been overestimated in their analysis, because the occurrence of frequent ventricular premature complexes unrelated to ischemic attacks did not represent an exclusion criterion in their study (mean ventricular premature complexes/24 hrs 243 f 538). Their definition of “increased ventricular ectopic activity,” which formed the basis for their diagnosis of arrhythmogenic ischemic attacks in all their patients, may not be entirely accurate, based on the spontaneous variability of ventricular arrhythmias4 Gioia
Turitto,
MD
Wichita, Kansas 5 March 1990
