Top PDF 2013 ACC AHA Guideline Cardiovascular Risk Circ Journal.pdf

2013 ACC AHA Guideline Cardiovascular Risk Circ Journal.pdf

2013 ACC AHA Guideline Cardiovascular Risk Circ Journal.pdf

CQ2 was developed to assess the utility of long-term and lifetime risk assessment as an adjunct to short-term (10-year) risk assessment. It was recognized that there is little “discon- nect” with regard to approaches to prevention when the 10-year risk estimate is high (eg, >10% predicted 10-year risk); such patients merit intensive prevention efforts and should be con- sidered for drug therapy to reduce or modify adverse levels of causal risk factors. CQ2 was selected for evaluation to deter- mine whether quantitative or semiquantitative long-term risk assessment would provide differential information that could be useful in risk communication, specifically to patients esti- mated to be at lower short-term risk. However, it is unclear what the long-term predicted and observed risks for CHD and CVD are among individuals who are at low predicted 10-year risk. CQ2 was designed to identify studies that assessed both short- and long-term risk, focusing in particular on those stud- ies that provide long-term outcomes data for groups predicted to be at low 10-year risk. If a sufficiently large proportion of the population is at high long-term risk despite being at low short-term risk, then incorporating long-term risk assessment Table 6. Expert Opinion Thresholds for Use of Optional
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ACC AHA 2002 Guideline Update for Exercise Testing Circulation Journal version.pdf

ACC AHA 2002 Guideline Update for Exercise Testing Circulation Journal version.pdf

selecting the initial management strategy is seen in the revised Table 17. Patients are separated into low-, intermediate-, or high-risk groups based on history, physical examination, initial 12-lead ECG, and cardiac markers. (Note that this table is meant to be illustrative rather than compre- hensive or definitive.) Low-risk patients, who include pa- tients with new-onset or progressive angina with symptoms provoked by walking 1 block or 1 flight of stairs, in this scheme can typically be treated on an outpatient basis. Most intermediate-risk patients can be cared for in a monitored hospital bed, whereas high-risk patients are typically admitted to an intensive care unit.
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ACC AHA NHLBI clinical advisory statins Circ Journal.pdf

ACC AHA NHLBI clinical advisory statins Circ Journal.pdf

The voluntary withdrawal of cerivastatin (Baycol) from the U.S. market on August 8, 2001, by the manufacturer, in agreement with the Food and Drug Administration (FDA), has prompted concern on the part of physicians and patients regarding the safety of the cholesterol-lowering class of drugs called HMG CoA reductase inhibitors, more commonly known as “statins.” This American College of Cardiology/ American Heart Association/National Heart, Lung and Blood Institute (ACC/AHA/NHLBI) Clinical Advisory is intended to summarize for professionals the current understanding of statin use, focused on myopathy, and to provide updated recommendations for the appropriate use of statins, including cautions, contraindications, and safety monitoring for statin therapy. Its purpose is not to discourage the appropriate use of statins, which have life-saving potential in properly selected patients, particularly those with established coronary heart disease (CHD) and others at high risk for developing CHD. Included are recent myopathy information compiled by the FDA, information from clinical trials, and summaries from the recently released report of the Adult Treatment Panel III (ATP III) of the National Cholesterol Education Program (NCEP). 1
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2013 ACC AHA Guideline on the Treatment of Blood Cholesterol JACC version.pdf

2013 ACC AHA Guideline on the Treatment of Blood Cholesterol JACC version.pdf

This guideline does not require specific risk factor counting for risk assessment or the use of RCT risk factor inclusion criteria to determine statin eligibility. Rather, a global ASCVD risk assessment to guide initiation of statin therapy was chosen for several important reasons (see rationale in Table 7 and further discussion in Section 7.3 of the Full Panel Report Supplement): 1) The Cholesterol Treatment Trialists individual-level meta-analyses were used to evaluate the effect of statins in various important patient subgroups, including risk factor cutpoints used for RCT eligibility. The Expert Panel found that statin ther- apy reduces ASCVD events regardless of risk factor characteristics in both primary and secondary prevention. Therefore, the rationale for using fixed cutpoints to determine whether statin therapy should be used is refuted by a consideration of the total body of evidence. 2) Use of absolute ASCVD risk facilitates a quantitative assessment of the potential for an ASCVD risk-reduction benefit as compared with the potential for adverse effects. 3) Use of an RCT eligibility criteria–based approach results in failure to identify a substantial proportion of higher-risk in- dividuals who could benefit from statin therapy and over- identification of very-low-risk individuals who might not experience a net benefit from statin therapy over a 10-year period.
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ACC AHA ESC 2006 Guidelines Atrial fibrillation Circ Journal.pdf

ACC AHA ESC 2006 Guidelines Atrial fibrillation Circ Journal.pdf

to continue antiarrhythmic treatment, perhaps because epi- sodes of AF became less frequent, briefer, or less symptom- atic. A reduction in arrhythmia burden may therefore consti- tute therapeutic success for some patients, while to others any recurrence of AF may seem intolerable. Assessment based upon time to recurrence in patients with paroxysmal AF or upon the number of patients with persistent AF who sustain sinus rhythm after cardioversion may overlook potentially valuable treatment strategies. Available studies are heteroge- neous in other respects as well. The efficacy of treatment for atrial flutter and AF is usually not reported separately. Underlying heart disease or extracardiac disease is present in 80% of patients with persistent AF, but this is not always described in detail. It is often not clear when patients first experienced AF or whether AF was persistent, and the frequencies of previous AF episodes and cardioversions are not uniformly described. Most controlled trials of antiarrhyth- mic drugs included few patients at risk of drug-induced HF, proarrhythmia, or conduction disturbances, and this should be kept in mind in applying the recommendations below.
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AHA ACC Guidelines for Secondary Prevention 2006 update Circ Journal.pdf

AHA ACC Guidelines for Secondary Prevention 2006 update Circ Journal.pdf

21. Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, Hochman JS, Krumholz HM, Kushner FG, Lamas GA, Mullany CJ, Ornato JP, Pearle DL, Sloan MA, Smith SC Jr, Alpert JS, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Gregoratos G, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK; American College of Cardiology; American Heart Association Task Force on Practice Guidelines; Canadian Cardio- vascular Society. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction). Circulation. 2004;110:e82–292. Erratum in: Circulation. 2005;111:2013–2014. 22. Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas
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ACC AHA Guideline Update Perioperative Cardiovascular Executive summary JACC.pdf

ACC AHA Guideline Update Perioperative Cardiovascular Executive summary JACC.pdf

A history of MI or abnormal Q waves by ECG is listed as an intermediate predictor, whereas an acute MI (defined as at least 1 documented MI less than or equal to 7 days before the examination) or recent MI (more than 7 days but less than or equal to 1 month before the examination) with evidence of important ischemic risk by clinical symptoms or noninvasive study is a major predictor. This definition reflects the consensus of the ACC Cardiovascular Database Committee. In this way, the separation of MI into the traditional 3- and 6-month intervals has been avoided (6,15). Current management of MI provides for risk strat- ification during convalescence (16). If a recent stress test does not indicate residual myocardium at risk, the likelihood of reinfarction after noncardiac surgery is low. Although there are no adequate clinical trials on which to base firm recommendations, it appears reasonable to wait 4 to 6 weeks after MI to perform elective surgery.
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ACC AHA SCAI 2005 guideline update percutaneous summary article Circ Journal.pdf

ACC AHA SCAI 2005 guideline update percutaneous summary article Circ Journal.pdf

or the new or revised recommendations are cited in parentheses at the end of each recommendation or comment. A list of abbreviations is included in the Appendix. The reader is referred to the full-text guideline posted on the World Wide Web sites of the ACC, the AHA, and the SCAI for a more detailed explana- tion of the changes discussed here. Please note that we have changed the table of contents headings in the 2001 ACC/AHA Guidelines for Percutaneous Coronary Intervention from roman numerals to unique identifying numbers.

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ACC AHA 2002 Guideline Update Stable Angina Summary article Circ Journal.pdf

ACC AHA 2002 Guideline Update Stable Angina Summary article Circ Journal.pdf

The noninvasive test findings that identify high-risk pa- tients are based on studies in symptomatic patients. These findings are probably also applicable to asymptomatic pa- tients but associated with a lower level of absolute risk in the absence of symptoms. The mere presence of left ventricular dysfunction in an asymptomatic patient probably does not justify coronary angiography. However, other high-risk non- invasive test findings that reflect myocardial ischemia, such as a high-risk Duke treadmill score, a large stress-induced perfusion defect, or an extensive echocardiographic wall- motion abnormality that develops at a low heart rate, are probably appropriate indications for coronary angiography, although there are only limited data to support this approach. The ability to improve outcome in such patients has not been demonstrated.
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ACC AHA Guidelines Myocardial Infarction Executive summary Circ Journal.pdf

ACC AHA Guidelines Myocardial Infarction Executive summary Circ Journal.pdf

Figure 7. Long-term antithrombotic therapy at hospital discharge after STEMI. ASA indicates aspirin; LOE, level of evidence LV, left ventricular; and INR, international normalized ratio. *Clopidogrel is preferred over warfarin because of increased risk of bleeding and low patient compliance in warfarin trials. †For 12 months. ‡Discontinue clopidogrel 1 month after implantation of a bare metal stent or several months after implantation of a drug-eluting stent (3 months after sirolimus and 6 months after paclitaxel) because of the poten- tial increased risk of bleeding with warfarin and 2 antiplatelet agents. Continue aspirin and warfarin long term if warfarin is indicated for other reasons such as atrial fibrillation, LV thrombus, cerebral emboli, or extensive regional wall-motion abnormality. §An INR of 2.0 to 3.0 is acceptable with tight control, but the lower end of this range is preferable. The combination of antiplatelet therapy and warfarin may be considered in patients aged less than 75 years with low bleeding risk who can be monitored reliably.
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ACC AHA 2005 Practice Guidelines peripheral arterial disease Circ Journal.pdf

ACC AHA 2005 Practice Guidelines peripheral arterial disease Circ Journal.pdf

The results of these clinical investigations provided ade- quate scientific data to support the creation of the new cur- rent procedural terminology code (93668) in the United States for exercise rehabilitation for patients with claudica- tion (171). The key elements of such a therapeutic claudica- tion exercise program for patients with claudication are sum- marized in Table 18. Because patients with claudication often have concomitant clinical or occult coronary artery dis- ease, hypertension, and diabetes, adverse cardiovascular and physiological responses during exercise training are possi- ble, and this risk should be evaluated clinically before initia- tion of the therapeutic program. However, there is no evi- dence that patients with claudication need to undergo stress imaging or invasive angiographic studies before initiating an exercise program. Such safety has been maintained, with serious adverse events rarely documented in clinical practice or in research investigations, by prudent application of an initial standard treadmill exercise test. This test should be performed with 12-lead electrocardiographic monitoring before a therapeutic exercise program is initiated, so that ischemic symptoms, ST–T-wave changes, or arrhythmias may be identified (345). Although these patients will, by def- inition, have claudication-limited exercise (and therefore will not achieve a true maximal exercise performance), the findings from the exercise test can be used to determine that there are no untoward cardiovascular responses at the exer- cise level reached. The exercise test also provides informa- tion about claudication thresholds and heart rate and blood pressure responses for establishing an exercise prescription. Patient enrollment in a medically supervised exercise pro- gram with electrocardiographic, heart rate, blood pressure, and blood glucose monitoring is encouraged. It is also pru- dent to use monitoring routinely during the initial exercise sessions; individual clinical responses then would determine the need for monitoring in subsequent sessions. Many car- diac rehabilitation exercise programs can accommodate patients with claudication, providing an environment con- ducive for “lifestyle change” that underlies long-term com- pliance to exercise and risk factor modification.
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ACC AHA ESC Guidelines Supraventicular Arrhythmias Exec summary Circ Journal.pdf

ACC AHA ESC Guidelines Supraventicular Arrhythmias Exec summary Circ Journal.pdf

barrier to some extent. Although the first 8 weeks after conception is the period associated with the greatest terato- genic risk, other adverse effects may occur with drug expo- sure later in pregnancy. The major concern with antiarrhyth- mic drugs taken during the second and third trimesters is the adverse effect on fetal growth and development as well as the risk of proarrhythmia. Several of the physiological changes that occur during pregnancy, such as increased cardiac output and blood volume, decreased serum protein concentration, alterations in gastric secretion and motility, and hormonal stimulation of liver enzymes, can affect absorption, bioavail- ability, and elimination of many drugs. More careful moni- toring of the patient and dose adjustments are, therefore, necessary because the above-mentioned changes vary in magnitude during different stages of pregnancy. 202
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ACC AHA Guidelines Bypass Graft Executive summary Circ Journal.pdf

ACC AHA Guidelines Bypass Graft Executive summary Circ Journal.pdf

20% by 1 year. The initial cost and length of stay were lower for angioplasty than for CABG. Patients having angioplasty returned to work sooner and were able to exercise more at 1 month. The extent of revascularization achieved by bypass surgery was generally higher than with angioplasty. Long- term survival was difficult to evaluate owing to the short period of follow-up and the small sample size of the trials. However, for the Bypass Angioplasty Revascularization In- vestigation (BARI) trial, bypass patients had a 5-year survival of 89.3% compared with 86.3% for angioplasty. Secondary analysis revealed that in treated diabetic patients in the BARI trials, CABG led to significantly superior survival compared with percutaneous transluminal coronary angioplasty (PTCA). However, this finding was not evident in other trials. In long-term follow-up, the most striking difference was the 4- to 10-fold-higher likelihood of reintervention after initial PTCA. Quality of life, physical activity, employment, and cost were similar by 3 to 5 years after both procedures. The BARI trial suggested higher mortality associated with PTCA in several high-risk groups, including those with diabetes, unstable angina, and/or non–Q wave MI, and in patients with heart failure.
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ACC AHA Guidelines Percutaneous Coronary Executive summary Circ Journal.pdf

ACC AHA Guidelines Percutaneous Coronary Executive summary Circ Journal.pdf

The American College of Cardiology/American Heart Asso- ciation (ACC/AHA) Task Force on Practice Guidelines was formed to gather information and make recommendations about appropriate use of technology for the diagnosis and treatment of patients with cardiovascular disease. Percutane- ous coronary interventions (PCI) are an important group of technologies in this regard. Although initially limited to PTCA, and termed percutaneous transluminal coronary an- gioplasty (PTCA), PCI now includes other new techniques capable of relieving coronary narrowing. Accordingly, in this document, rotational atherectomy, directional atherectomy, extraction atherectomy, laser angioplasty, implantation of intracoronary stents and other catheter devices for treating coronary atherosclerosis are considered components of PCI. In this context PTCA will be used to refer to those studies using primarily PTCA while PCI will refer to the broader group of percutaneous techniques. These new technologies have impacted the effectiveness and safety profile initially
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ACC AHA Guidelines Unstable Angina Executive summary Circ Journal.pdf

ACC AHA Guidelines Unstable Angina Executive summary Circ Journal.pdf

Coronary revascularization (PCI or CABG) is carried out to improve prognosis, relieve symptoms, prevent ischemic com- plications, and improve functional capacity. The decision to proceed from diagnostic angiography to revascularization is influenced not only by the coronary anatomy but also by a number of additional factors, including anticipated life ex- pectancy, ventricular function, comorbidity, functional capac- ity, severity of symptoms, and quantity of viable myocardium at risk. These are all important variables that must be considered before revascularization is recommended. For example, patients with distal obstructive coronary lesions or those who have large quantities of irreversibly damaged myocardium are unlikely to benefit from revascularization, particularly if they can be stabilized on medical therapy. Patients with high-risk coronary anatomy are likely to benefit from revascularization in terms of both symptom improve- ment and long-term survival. The indications for coronary revascularization in patients with UA/NSTEMI are similar to those for patients with chronic stable angina (see the ACC/ AHA/ACP-ASIM Guidelines for the Management of Patients With Chronic Stable Angina and the ACC/AHA Guidelines for Coronary Artery Bypass Graft Surgery).
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ACC AHA Guideline Update Perioperative Cardiovascular Executive summary Circ Journal.pdf

ACC AHA Guideline Update Perioperative Cardiovascular Executive summary Circ Journal.pdf

It is also appropriate to recommend secondary risk reduc- tion in the relatively large number of elective surgery patients in whom cardiovascular abnormalities are detected during preoperative evaluations. Although the occasion of surgery is often taken as a specific high-risk time, most of the patients who have known or newly detected CAD during their preoperative evaluations will not have any events during elective noncardiac surgery. After the preoperative cardiac risk has been determined by clinical or noninvasive testing, most patients will benefit from pharmacological agents to lower low-density lipoprotein cholesterol levels, increase high-density lipoprotein levels, or both. On the basis of expert opinion, the goal should be to lower the low-density lipopro- tein level to less than 100 mg per deciliter (2.6 mmol per deciliter). 93–95
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ACC AHA 2005 Guideline Update chronic heart failure Circ Journal.pdf

ACC AHA 2005 Guideline Update chronic heart failure Circ Journal.pdf

count, urinalysis, serum electrolytes (including calcium and magnesium), glycohemoglobin, and blood lipids, as well as tests of both renal and hepatic function, a chest radiograph, and a 12-lead electrocardiogram. Thyroid-function tests (especially thyroid-stimulating hormone) should be meas- ured, because both hyperthyroidism and hypothyroidism can be a primary or contributory cause of HF. A fasting transfer- rin saturation is useful to screen for hemochromatosis; sev- eral mutated alleles for this disorder are common in individ- uals of Northern European descent, and affected patients may show improvement in LV function after treatment with phlebotomy and chelating agents. Magnetic resonance imag- ing of the heart or liver may be needed to confirm the pres- ence of iron overload. Screening for human immunodefi- ciency virus (HIV) is recommended by some healthcare providers and should be considered in patients who are at high risk, although the majority of patients who have car- diomyopathy due to HIV do not present with symptoms of HF until other clinical signs of HIV infection are apparent. Serum titers of antibodies developed in response to infec- tious organisms are occasionally measured in patients with a recent onset of HF (especially in those with a recent viral syndrome), but the yield of such testing is low, and the ther- apeutic implications of a positive result are uncertain. Assays for connective tissue diseases and for pheochromocytoma should be performed if these diagnoses are suspected, and serum titers of Chagas disease antibodies should be checked in patients with nonischemic cardiomyopathy who have trav- eled in or immigrated from an endemic region.
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ACC AHA SCAI 2005 guideline update percutaneous Circ Journal.pdf

ACC AHA SCAI 2005 guideline update percutaneous Circ Journal.pdf

The pathogenesis of the response to mechanical coronary injury is thought to relate to a combination of growth factor stimulation, smooth muscle cell migration and proliferation, organization of thrombus, platelet deposition, and elastic recoil (97,98). In addition, change in vessel size (or lack of compensatory enlargement) has been implicated (99). It has been suggested that attempts to reduce restenosis have failed in part because of lack of recognition of the importance of this factor (100). Although numerous definitions of resteno- sis have been proposed, greater than 50% diameter stenosis at follow-up angiography has been most frequently used because it was thought to correlate best with maximal flow and therefore ischemia. However, it is now recognized that the response to arterial injury is a continuous rather than a dichotomous process, occurring to some degree in all patients (101). Therefore, cumulative frequency distributions of the continuous variables of minimal lumen diameter or percent diameter stenosis are frequently used to evaluate restenosis in large patient populations (102) (Figure 2) (80). Although multiple clinical factors (diabetes, unstable angi- na [UA]/NSTEMI, STEMI, and prior restenosis) (103,104), angiographic factors (proximal left anterior descending artery [LAD], small vessel diameters, total occlusion, long lesion length, and saphenous vein grafts [SVGs]) (105), and procedural factors (higher postprocedure percent diameter stenosis, smaller minimal lumen diameter, and smaller acute gain) (102) have been associated with an increased incidence of restenosis, the ability to integrate these factors and predict the risk of restenosis in individual patients after the proce- dure remains difficult. The most promising potential ate/minor categories. A listing of other bleeding classifica-
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2013 ACC AHA Guideline on the Treatment of Blood Cholesterol Circulation Journal version.pdf

2013 ACC AHA Guideline on the Treatment of Blood Cholesterol Circulation Journal version.pdf

This guideline does not require specific risk factor counting for risk assessment or the use of RCT risk factor inclusion crite- ria to determine statin eligibility. Rather, a global ASCVD risk assessment to guide initiation of statin therapy was chosen for several important reasons (see rationale in Table 7 and further discussion in Section 7.3 of the Full Panel Report Supplement): 1) The Cholesterol Treatment Trialists individual-level meta- analyses were used to evaluate the effect of statins in various important patient subgroups, including risk factor cutpoints used for RCT eligibility. The Expert Panel found that statin therapy reduces ASCVD events regardless of risk factor characteristics in both primary and secondary prevention. Therefore, the ratio- nale for using fixed cutpoints to determine whether statin ther- apy should be used is refuted by a consideration of the total body of evidence. 2) Use of absolute ASCVD risk facilitates a quanti- tative assessment of the potential for an ASCVD risk-reduction benefit as compared with the potential for adverse effects. 3) Use of an RCT eligibility criteria–based approach results in failure to identify a substantial proportion of higher-risk individuals who could benefit from statin therapy and overidentification of very- low-risk individuals who might not experience a net benefit from statin therapy over a 10-year period.
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2013 AHA ACC Guideline Lifestyle Management report Circ Journal.pdf

2013 AHA ACC Guideline Lifestyle Management report Circ Journal.pdf

To formulate the nutrition recommendations, the Work Group used randomized controlled trials (RCTs), observational stud- ies, meta-analyses, and systematic reviews of studies carried out in adults (≥18 years of age) with or without established coronary heart disease/CVD and with or without risk factors for coronary heart disease/CVD, who were of normal weight, overweight, or obese. The evidence review date range was 1998 to 2009. To capture historical data or more recent evi- dence, date ranges were changed for subquestions in some instances. The evidence date ranges are described clearly in each CQ section. The Work Group assessed the impact of both dietary patterns and macronutrient composition on plasma low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and triglycerides and on systolic BP and diastolic BP over a minimum RCT interven- tion period of 1 month in studies performed in any geographic location and research setting.
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