- The study examined adherence to ACC/AHA guidelines for preoperative cardiac evaluation in 711 patients undergoing peripheral vascular surgery in the Netherlands.
- The guidelines recommend preoperative noninvasive testing for 26% (185 patients) but testing was only performed in 21% (38 patients) of those cases.
- For the 89% (467 patients) whom guidelines did not recommend testing, clinical practice adhered in most cases. However, 11% (59 patients) received unnecessary testing.
Stich ii trial for supratentorial intra cerebral bleedgarry07
This document summarizes the STICH II trial which compared early surgery versus initial conservative treatment for spontaneous supratentorial lobar intracerebral haemorrhages between 10-100mL. The trial involved 601 patients randomized to either early surgery within 12 hours or initial conservative treatment with delayed surgery if needed. The primary outcome of death or severe disability at 6 months showed no significant difference between the groups. Secondary outcomes of mortality, functional scales also showed no significant differences, indicating that early surgery did not improve outcomes over initial conservative treatment for these types of hemorrhages.
Gerstein et al-2015-anesthesia_&_analgesiasamirsharshar
POISE-2 was a large randomized controlled trial that investigated the risks and benefits of continuing low-dose aspirin perioperatively in patients undergoing noncardiac surgery. The trial found no difference in the primary outcome of death or myocardial infarction within 30 days between those who received aspirin or placebo. However, major bleeding was more common in the aspirin group. While providing important new evidence, the document notes several limitations of POISE-2 including that over 60% of subjects may not have met guidelines for aspirin therapy and many received other antithrombotic drugs postoperatively. On balance, the optimal perioperative aspirin management strategy remains unclear based on POISE-2 alone.
This study reviewed the management of 1432 grown-up congenital heart disease patients over 10 years at a tertiary hospital in India. It found a early morbidity rate of 5.2% and identified previous sternotomy, emergency procedures, cross-clamp time over 45 minutes, and cyanotic disease as significant risk factors. Outcomes were generally good with a mortality rate of 1.4% and 86% follow-up completeness. However, the study was limited by its single center retrospective design and loss to follow-up of simpler cases.
The PRAMI Trial was a randomized controlled trial that studied 465 patients with acute ST elevation myocardial infarction (STEMI) treated with percutaneous coronary intervention (PCI) of the infarct artery. Patients were randomized to either preventive PCI of significant stenoses in non-infarct arteries immediately during the initial procedure or to undergo PCI of non-infarct arteries only if refractory angina and objective evidence of ischemia developed. The primary outcome of death from cardiac causes, nonfatal myocardial infarction, or refractory angina occurred in 9% of patients who received preventive PCI versus 23% of patients who did not, demonstrating that preventive PCI of non-infarct arteries reduced adverse cardiovascular events.
A randomized study assigned 465 patients undergoing emergency PCI for acute STEMI to either preventive PCI of stenoses in non-infarct arteries or PCI of the infarct artery only. At a mean follow up of 23 months, the preventive PCI group had lower rates of the primary composite outcome of death from cardiac causes, non-fatal heart attack, or refractory angina (9% vs 23%). Preventive PCI also reduced the risk of subsequent cardiovascular events within the first 6 months after the procedure. Procedure times and contrast usage were increased with preventive PCI, but complication rates were similar between the groups.
Primary PCI with stenting immediately after coronary reperfusion salvage procedures jeopardizes myocardium, improves prognosis, and is the current standard of care for acute STEMI .
No-reflow is defined as an acute reduction in myocardial blood flow despite a patent epicardial coronary artery .
The pathophysiology of no-reflow involves microvascular obstruction secondary to distal embolization of clot, microvascular spasm, and thrombosis .
No-reflow occurs in ~10% of cases of primary PCI and is associated with patient characteristics such as advanced age and delayed presentation and coronary characteristics such as a completely occluded culprit artery and heavy thrombus burden .
Surgery vs conservative strategy in aortic stenosisShivani Rao
1) This study compared outcomes of an initial aortic valve replacement (AVR) strategy versus a conservative watchful waiting strategy in asymptomatic patients with severe aortic stenosis using data from a large Japanese multicenter registry.
2) They found that the initial AVR strategy was associated with significantly lower risks of all-cause death, cardiovascular death, aortic valve-related death, and heart failure hospitalization at 5 years compared to the conservative strategy.
3) The benefits of initial AVR over conservative watchful waiting were seen both in propensity score-matched analyses and analyses of the full cohort adjusted for baseline differences, suggesting initial AVR may improve long-term outcomes in asymptomatic severe aortic stenosis.
Stich ii trial for supratentorial intra cerebral bleedgarry07
This document summarizes the STICH II trial which compared early surgery versus initial conservative treatment for spontaneous supratentorial lobar intracerebral haemorrhages between 10-100mL. The trial involved 601 patients randomized to either early surgery within 12 hours or initial conservative treatment with delayed surgery if needed. The primary outcome of death or severe disability at 6 months showed no significant difference between the groups. Secondary outcomes of mortality, functional scales also showed no significant differences, indicating that early surgery did not improve outcomes over initial conservative treatment for these types of hemorrhages.
Gerstein et al-2015-anesthesia_&_analgesiasamirsharshar
POISE-2 was a large randomized controlled trial that investigated the risks and benefits of continuing low-dose aspirin perioperatively in patients undergoing noncardiac surgery. The trial found no difference in the primary outcome of death or myocardial infarction within 30 days between those who received aspirin or placebo. However, major bleeding was more common in the aspirin group. While providing important new evidence, the document notes several limitations of POISE-2 including that over 60% of subjects may not have met guidelines for aspirin therapy and many received other antithrombotic drugs postoperatively. On balance, the optimal perioperative aspirin management strategy remains unclear based on POISE-2 alone.
This study reviewed the management of 1432 grown-up congenital heart disease patients over 10 years at a tertiary hospital in India. It found a early morbidity rate of 5.2% and identified previous sternotomy, emergency procedures, cross-clamp time over 45 minutes, and cyanotic disease as significant risk factors. Outcomes were generally good with a mortality rate of 1.4% and 86% follow-up completeness. However, the study was limited by its single center retrospective design and loss to follow-up of simpler cases.
The PRAMI Trial was a randomized controlled trial that studied 465 patients with acute ST elevation myocardial infarction (STEMI) treated with percutaneous coronary intervention (PCI) of the infarct artery. Patients were randomized to either preventive PCI of significant stenoses in non-infarct arteries immediately during the initial procedure or to undergo PCI of non-infarct arteries only if refractory angina and objective evidence of ischemia developed. The primary outcome of death from cardiac causes, nonfatal myocardial infarction, or refractory angina occurred in 9% of patients who received preventive PCI versus 23% of patients who did not, demonstrating that preventive PCI of non-infarct arteries reduced adverse cardiovascular events.
A randomized study assigned 465 patients undergoing emergency PCI for acute STEMI to either preventive PCI of stenoses in non-infarct arteries or PCI of the infarct artery only. At a mean follow up of 23 months, the preventive PCI group had lower rates of the primary composite outcome of death from cardiac causes, non-fatal heart attack, or refractory angina (9% vs 23%). Preventive PCI also reduced the risk of subsequent cardiovascular events within the first 6 months after the procedure. Procedure times and contrast usage were increased with preventive PCI, but complication rates were similar between the groups.
Primary PCI with stenting immediately after coronary reperfusion salvage procedures jeopardizes myocardium, improves prognosis, and is the current standard of care for acute STEMI .
No-reflow is defined as an acute reduction in myocardial blood flow despite a patent epicardial coronary artery .
The pathophysiology of no-reflow involves microvascular obstruction secondary to distal embolization of clot, microvascular spasm, and thrombosis .
No-reflow occurs in ~10% of cases of primary PCI and is associated with patient characteristics such as advanced age and delayed presentation and coronary characteristics such as a completely occluded culprit artery and heavy thrombus burden .
Surgery vs conservative strategy in aortic stenosisShivani Rao
1) This study compared outcomes of an initial aortic valve replacement (AVR) strategy versus a conservative watchful waiting strategy in asymptomatic patients with severe aortic stenosis using data from a large Japanese multicenter registry.
2) They found that the initial AVR strategy was associated with significantly lower risks of all-cause death, cardiovascular death, aortic valve-related death, and heart failure hospitalization at 5 years compared to the conservative strategy.
3) The benefits of initial AVR over conservative watchful waiting were seen both in propensity score-matched analyses and analyses of the full cohort adjusted for baseline differences, suggesting initial AVR may improve long-term outcomes in asymptomatic severe aortic stenosis.
Same Wrist Intervention via the Cubital (Ulnar) Artery in Case of Radial Puncture Failure for Percutaneous Cardiac Catheterization or Intervention: The Multicenter Prospective SWITCH Registry
Appropriteness Criteria for Coronary RevascularizationLalit Kapoor
The document discusses guidelines for determining the appropriateness of revascularization procedures like angioplasty and coronary artery bypass grafting. It summarizes several major clinical trials that have compared medical therapy to revascularization and PCI to CABG. The guidelines developed by an expert panel rate 180 clinical scenarios on appropriateness based on factors like symptoms, risk level, coronary anatomy, and response to medical therapy. Revascularization is deemed appropriate for high-risk patients but uncertain or inappropriate for low-risk, asymptomatic patients or late interventions after heart attacks.
Fundación EPIC _ Left atrial appendage closure. Clinical evidence; where we a...Fundacion EPIC
Presentación de la ponencia "Cierre Percutáneo de Orejuela Izquierda. Evidencia clínica: dónde estamos?" realizada por Raul Moreno en los Diálogos EPIC_Cierre Percutáneo de la Orejuela Izquierda el 15 de Marzo de 2018 en Madrid (España)
Left atrial appendage closure. Clinical evidence; where we are? by Raul Moreno at Diálogos EPIC_Percutaneous left atrial appendage closure, March 15th 2018 in Madrid (Spain)
The document describes a classification system called TOAST (Trial of Org 10172 in Acute Stroke Treatment) for categorizing subtypes of acute ischemic stroke. The 5 subtypes are: 1) large artery atherosclerosis, 2) cardioembolism, 3) small vessel occlusion, 4) stroke of other determined etiology, and 5) stroke of undetermined etiology. The classification system was tested by two neurologists on 20 patients and found to have good interobserver agreement, with the physicians disagreeing on only one patient. The TOAST system categorizes stroke subtype based on clinical features and results of diagnostic tests, and can be applied both initially and after further evaluation, making it useful for clinical trials.
Manejo perioperatorio de la terapia antitrombótica, chest, 2012Felipe Posada
This guideline addresses the perioperative management of anticoagulant and antiplatelet therapy in patients requiring elective surgery or procedures. Key recommendations include:
1) Stopping vitamin K antagonists (VKAs) 5 days before surgery instead of shorter durations.
2) Bridging anticoagulation for patients at high risk of thrombosis during VKA interruption, such as those with mechanical heart valves or atrial fibrillation.
3) Continuing aspirin in moderate-to-high risk patients undergoing non-cardiac surgery instead of stopping 7-10 days before surgery.
The recommendations aim to simplify management and minimize risks of thrombosis and bleeding in the perioperative period.
This document discusses the role of hemodynamic monitoring via right heart catheterization for patients with acute heart failure. It summarizes that while past studies found no benefit of catheterization, their designs had limitations like including patients without severe acute heart failure. The document suggests catheterization may be useful for patients with impending respiratory or circulatory failure refractory to conventional therapy, especially in experienced centers focusing on variables beyond pulmonary artery occlusion pressure. Overall, it argues the potential value of catheterization in select acute heart failure cases was not fully assessed by prior investigations.
This document discusses strategies for diagnosing and treating stable coronary artery disease (CAD), including revascularization options of percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). It states that revascularization more effectively relieves angina, reduces medication usage, and improves quality of life compared to medical therapy alone. It also notes that guidelines recommend medical treatment prior to and along with revascularization. The document provides indications and considerations for revascularization and addresses strategies for non-ST elevation myocardial infarction (NSTEMI) and ST elevation myocardial infarction (STEMI) patients.
Practice guidelines for_central_venous_access__a.13Felipe Posada
This document provides guidelines for central venous access developed by the American Society of Anesthesiologists Task Force. It defines central venous access, outlines the purposes for developing the guidelines which are to provide guidance on placement and management of central lines and reduce adverse outcomes. It focuses on elective procedures performed by anesthesiologists and provides definitions but does not address clinical indications, emergency placement, peripherally inserted central catheters, pulmonary artery catheters, tunneled lines, or infectious complications treatment. The guidelines are intended for use by anesthesiologists and those under their supervision.
This document provides guidelines from the American Heart Association/American Stroke Association for the endovascular treatment of acute ischemic stroke. It analyzes results from 8 randomized clinical trials and other relevant data published since 2013. The guidelines provide recommendations for selecting patients for endovascular treatment, the endovascular procedure, and systems of care to facilitate endovascular treatment. Certain endovascular procedures using new devices like stent retrievers have been shown to provide clinical benefits in some patients with acute ischemic stroke when performed at high-volume centers with experienced staff.
Complete revascularization in patients with multivessel disease undergoing primary PCI was associated with a small increase in additional infarction in non-IRA territories compared to IRA-only revascularization. However, total infarct size and measures of cardiac function were similar between the two groups both before discharge and at 9 month follow up. While complete revascularization led to more type 4a MIs, the increased risk did not negatively impact clinical outcomes.
The PRAMI trial was a randomized controlled trial that compared preventive percutaneous coronary intervention (PCI) to PCI limited to the infarct artery in patients with ST-segment elevation myocardial infarction (STEMI) and multi-vessel coronary artery disease. The trial found that preventive PCI of non-infarct arteries with major stenoses significantly reduced the risk of adverse cardiovascular events compared to PCI limited to the infarct artery alone. However, the trial had a small sample size. Guidelines recommend PCI of a non-infarct artery be performed separately from primary PCI, but the optimal timing remains unclear due to varying results from observational studies.
The document discusses whether interventional closure of a patent foramen ovale (PFO) warrants treatment for cryptogenic stroke patients compared to medical therapy alone. Initial randomized controlled trials from 2012-2013 showed no clear benefit of PFO closure, but longer term follow-up studies published in 2017-2018 demonstrated PFO closure significantly reduced the risk of recurrent stroke compared to medical therapy. While PFO closure was found to increase the risk of atrial fibrillation, it had no effect on mortality or other serious adverse events. Thus, the recent evidence supports that PFO closure is superior to medical therapy alone and is a safe and effective treatment for preventing additional ischemic strokes in cryptogenic stroke patients with a PFO.
The document summarizes new guidelines from the American College of Chest Physicians (ACCP) on antithrombotic and thrombolytic therapy. Key points include:
1) The guidelines provide comprehensive recommendations for preventing and treating thrombosis in pregnant women, children, and perioperative/postoperative patients.
2) For pregnant women, the guidelines recommend stopping vitamin K antagonists before 6 weeks of gestation but continuing them for some with mechanical heart valves. Low molecular weight heparin or unfractionated heparin should be substituted for others.
3) Recommendations for preventing and treating thrombosis in children have been expanded significantly.
International Study Of Comparative Health Effectiveness With Medical And Inva...Chi Pham
The ISCHEMIA trial compared an invasive strategy (cardiac catheterization plus revascularization if needed) to a conservative strategy (medical therapy alone) in patients with stable ischemic heart disease and moderate or severe ischemia on stress testing. Over 5,000 patients were followed for a median of 3.3 years. The primary outcome of cardiovascular death, myocardial infarction, hospitalization for unstable angina or heart failure, or resuscitated cardiac arrest occurred in 13.3% of patients in the invasive group and 13.8% in the conservative group, with no significant difference between the groups. Medical therapy was optimized in both groups with high rates of statin, blood pressure, and aspirin use.
This study analyzed angiographic data from 3,428 patients who underwent percutaneous coronary intervention (PCI) for non-ST-segment elevation acute coronary syndrome in the ACUITY trial to determine the incidence and impact of intraprocedural thrombotic events (IPTE). IPTE occurred in 121 patients (3.5%) and was associated with significantly higher rates of major adverse cardiac events, including death, myocardial infarction, and stent thrombosis at in-hospital, 30-day, and 1-year follow-up compared to patients without IPTE. IPTE was an independent predictor of adverse outcomes at 30 days and 1 year after adjusting for other factors. The results suggest that although infrequent, IPTE during PCI for acute
This study examined data from an implantable hemodynamic monitor in 32 heart failure patients over 9 months without using the data for management, and then over 17 months where the data was incorporated into management. The study found that right ventricular pressures increased before volume overload events requiring hospitalization. After using the hemodynamic data for management, hospitalizations decreased by 57% compared to the previous year. Long-term hemodynamic monitoring may help guide heart failure management and reduce hospitalizations.
Thrombectomy in Stroke: DAWN and DEFUSE3 trial dataSCGH ED CME
The document summarizes key findings from several recent clinical trials evaluating endovascular thrombectomy for acute ischemic stroke:
1. The HERMES meta-analysis of 5 randomized controlled trials from 2010-2015 found endovascular thrombectomy plus standard care significantly reduced disability at 90 days compared to standard care alone.
2. The DEFUSE3 trial of 182 patients found endovascular therapy plus medical therapy improved functional outcomes and reduced mortality compared to medical therapy alone for strokes 6-16 hours.
3. The DAWN trial of 206 patients found the same benefits for strokes 6-24 hours when a clinical-radiological mismatch was present. Both DEFUSE3 and DAWN saw no increase in serious adverse events.
COMPARES OPTIMAL MEDICAL THERAPY WITH INVASIVE THERAPY IN A PATIENT WITH STABLE ISCHEMIC HEART DISEASE WITH MODERATE TO SEVERE MYOCARDIAL ISCHEMIA ON NON INVASIVE STRESS TESTING
The document reports on a study from the ISCHEMIA trial investigating the impact of complete versus incomplete revascularization on clinical outcomes in patients with stable ischemic heart disease treated with an invasive versus conservative strategy. It finds that among patients treated with an invasive strategy, complete anatomic or functional revascularization was associated with improved outcomes compared to incomplete revascularization. However, after adjustment for covariates, the differences in outcomes between complete and incomplete revascularization were no longer statistically significant.
The focused update provides 3 new recommendations regarding perioperative beta-blocker therapy based on recent clinical trials:
1. It recommends beta-blocker therapy be continued in patients already taking beta-blockers for indications listed in the original guideline.
2. It provides a new weaker recommendation for clinicians to consider initiating and continuing beta-blocker therapy for intermediate-risk patients having surgery.
3. It acknowledges some studies suggested risks may outweigh benefits in some subgroups and clinical judgement is needed when initiating therapy.
Guías de manejo evaluación cardiovascular preoperatoria en cirugía no cardiac...sandoriver
This document provides updated guidelines for the perioperative cardiovascular evaluation and care of patients undergoing noncardiac surgery. It summarizes the key recommendations, which include:
1. Preoperative cardiac risk assessment with revised cardiac risk indexes is recommended for patients with poor functional capacity or other major cardiac risk factors undergoing vascular surgery.
2. A preoperative resting 12-lead ECG is recommended for patients with known coronary, peripheral, or cerebrovascular disease undergoing intermediate-risk surgery.
3. Preoperative coronary revascularization with bypass surgery or angioplasty is not recommended solely to reduce cardiac risk of noncardiac surgery. However, if revascularization is indicated for coronary disease, it is reasonable to perform it pre
The panel recommends the following for treatment of hypertension in adults:
- For those aged 60 years and older, treat to a blood pressure goal of less than 150/90 mm Hg.
- For those aged 30-59 years, treat to a blood pressure goal of less than 140/90 mm Hg.
- For those younger than 60 years with diabetes or chronic kidney disease, treat to a blood pressure goal of less than 140/90 mm Hg.
- Initiate treatment with one of four classes of antihypertensive drugs (angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, calcium channel blocker, or thiazide-type diuretic).
- For non
Same Wrist Intervention via the Cubital (Ulnar) Artery in Case of Radial Puncture Failure for Percutaneous Cardiac Catheterization or Intervention: The Multicenter Prospective SWITCH Registry
Appropriteness Criteria for Coronary RevascularizationLalit Kapoor
The document discusses guidelines for determining the appropriateness of revascularization procedures like angioplasty and coronary artery bypass grafting. It summarizes several major clinical trials that have compared medical therapy to revascularization and PCI to CABG. The guidelines developed by an expert panel rate 180 clinical scenarios on appropriateness based on factors like symptoms, risk level, coronary anatomy, and response to medical therapy. Revascularization is deemed appropriate for high-risk patients but uncertain or inappropriate for low-risk, asymptomatic patients or late interventions after heart attacks.
Fundación EPIC _ Left atrial appendage closure. Clinical evidence; where we a...Fundacion EPIC
Presentación de la ponencia "Cierre Percutáneo de Orejuela Izquierda. Evidencia clínica: dónde estamos?" realizada por Raul Moreno en los Diálogos EPIC_Cierre Percutáneo de la Orejuela Izquierda el 15 de Marzo de 2018 en Madrid (España)
Left atrial appendage closure. Clinical evidence; where we are? by Raul Moreno at Diálogos EPIC_Percutaneous left atrial appendage closure, March 15th 2018 in Madrid (Spain)
The document describes a classification system called TOAST (Trial of Org 10172 in Acute Stroke Treatment) for categorizing subtypes of acute ischemic stroke. The 5 subtypes are: 1) large artery atherosclerosis, 2) cardioembolism, 3) small vessel occlusion, 4) stroke of other determined etiology, and 5) stroke of undetermined etiology. The classification system was tested by two neurologists on 20 patients and found to have good interobserver agreement, with the physicians disagreeing on only one patient. The TOAST system categorizes stroke subtype based on clinical features and results of diagnostic tests, and can be applied both initially and after further evaluation, making it useful for clinical trials.
Manejo perioperatorio de la terapia antitrombótica, chest, 2012Felipe Posada
This guideline addresses the perioperative management of anticoagulant and antiplatelet therapy in patients requiring elective surgery or procedures. Key recommendations include:
1) Stopping vitamin K antagonists (VKAs) 5 days before surgery instead of shorter durations.
2) Bridging anticoagulation for patients at high risk of thrombosis during VKA interruption, such as those with mechanical heart valves or atrial fibrillation.
3) Continuing aspirin in moderate-to-high risk patients undergoing non-cardiac surgery instead of stopping 7-10 days before surgery.
The recommendations aim to simplify management and minimize risks of thrombosis and bleeding in the perioperative period.
This document discusses the role of hemodynamic monitoring via right heart catheterization for patients with acute heart failure. It summarizes that while past studies found no benefit of catheterization, their designs had limitations like including patients without severe acute heart failure. The document suggests catheterization may be useful for patients with impending respiratory or circulatory failure refractory to conventional therapy, especially in experienced centers focusing on variables beyond pulmonary artery occlusion pressure. Overall, it argues the potential value of catheterization in select acute heart failure cases was not fully assessed by prior investigations.
This document discusses strategies for diagnosing and treating stable coronary artery disease (CAD), including revascularization options of percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). It states that revascularization more effectively relieves angina, reduces medication usage, and improves quality of life compared to medical therapy alone. It also notes that guidelines recommend medical treatment prior to and along with revascularization. The document provides indications and considerations for revascularization and addresses strategies for non-ST elevation myocardial infarction (NSTEMI) and ST elevation myocardial infarction (STEMI) patients.
Practice guidelines for_central_venous_access__a.13Felipe Posada
This document provides guidelines for central venous access developed by the American Society of Anesthesiologists Task Force. It defines central venous access, outlines the purposes for developing the guidelines which are to provide guidance on placement and management of central lines and reduce adverse outcomes. It focuses on elective procedures performed by anesthesiologists and provides definitions but does not address clinical indications, emergency placement, peripherally inserted central catheters, pulmonary artery catheters, tunneled lines, or infectious complications treatment. The guidelines are intended for use by anesthesiologists and those under their supervision.
This document provides guidelines from the American Heart Association/American Stroke Association for the endovascular treatment of acute ischemic stroke. It analyzes results from 8 randomized clinical trials and other relevant data published since 2013. The guidelines provide recommendations for selecting patients for endovascular treatment, the endovascular procedure, and systems of care to facilitate endovascular treatment. Certain endovascular procedures using new devices like stent retrievers have been shown to provide clinical benefits in some patients with acute ischemic stroke when performed at high-volume centers with experienced staff.
Complete revascularization in patients with multivessel disease undergoing primary PCI was associated with a small increase in additional infarction in non-IRA territories compared to IRA-only revascularization. However, total infarct size and measures of cardiac function were similar between the two groups both before discharge and at 9 month follow up. While complete revascularization led to more type 4a MIs, the increased risk did not negatively impact clinical outcomes.
The PRAMI trial was a randomized controlled trial that compared preventive percutaneous coronary intervention (PCI) to PCI limited to the infarct artery in patients with ST-segment elevation myocardial infarction (STEMI) and multi-vessel coronary artery disease. The trial found that preventive PCI of non-infarct arteries with major stenoses significantly reduced the risk of adverse cardiovascular events compared to PCI limited to the infarct artery alone. However, the trial had a small sample size. Guidelines recommend PCI of a non-infarct artery be performed separately from primary PCI, but the optimal timing remains unclear due to varying results from observational studies.
The document discusses whether interventional closure of a patent foramen ovale (PFO) warrants treatment for cryptogenic stroke patients compared to medical therapy alone. Initial randomized controlled trials from 2012-2013 showed no clear benefit of PFO closure, but longer term follow-up studies published in 2017-2018 demonstrated PFO closure significantly reduced the risk of recurrent stroke compared to medical therapy. While PFO closure was found to increase the risk of atrial fibrillation, it had no effect on mortality or other serious adverse events. Thus, the recent evidence supports that PFO closure is superior to medical therapy alone and is a safe and effective treatment for preventing additional ischemic strokes in cryptogenic stroke patients with a PFO.
The document summarizes new guidelines from the American College of Chest Physicians (ACCP) on antithrombotic and thrombolytic therapy. Key points include:
1) The guidelines provide comprehensive recommendations for preventing and treating thrombosis in pregnant women, children, and perioperative/postoperative patients.
2) For pregnant women, the guidelines recommend stopping vitamin K antagonists before 6 weeks of gestation but continuing them for some with mechanical heart valves. Low molecular weight heparin or unfractionated heparin should be substituted for others.
3) Recommendations for preventing and treating thrombosis in children have been expanded significantly.
International Study Of Comparative Health Effectiveness With Medical And Inva...Chi Pham
The ISCHEMIA trial compared an invasive strategy (cardiac catheterization plus revascularization if needed) to a conservative strategy (medical therapy alone) in patients with stable ischemic heart disease and moderate or severe ischemia on stress testing. Over 5,000 patients were followed for a median of 3.3 years. The primary outcome of cardiovascular death, myocardial infarction, hospitalization for unstable angina or heart failure, or resuscitated cardiac arrest occurred in 13.3% of patients in the invasive group and 13.8% in the conservative group, with no significant difference between the groups. Medical therapy was optimized in both groups with high rates of statin, blood pressure, and aspirin use.
This study analyzed angiographic data from 3,428 patients who underwent percutaneous coronary intervention (PCI) for non-ST-segment elevation acute coronary syndrome in the ACUITY trial to determine the incidence and impact of intraprocedural thrombotic events (IPTE). IPTE occurred in 121 patients (3.5%) and was associated with significantly higher rates of major adverse cardiac events, including death, myocardial infarction, and stent thrombosis at in-hospital, 30-day, and 1-year follow-up compared to patients without IPTE. IPTE was an independent predictor of adverse outcomes at 30 days and 1 year after adjusting for other factors. The results suggest that although infrequent, IPTE during PCI for acute
This study examined data from an implantable hemodynamic monitor in 32 heart failure patients over 9 months without using the data for management, and then over 17 months where the data was incorporated into management. The study found that right ventricular pressures increased before volume overload events requiring hospitalization. After using the hemodynamic data for management, hospitalizations decreased by 57% compared to the previous year. Long-term hemodynamic monitoring may help guide heart failure management and reduce hospitalizations.
Thrombectomy in Stroke: DAWN and DEFUSE3 trial dataSCGH ED CME
The document summarizes key findings from several recent clinical trials evaluating endovascular thrombectomy for acute ischemic stroke:
1. The HERMES meta-analysis of 5 randomized controlled trials from 2010-2015 found endovascular thrombectomy plus standard care significantly reduced disability at 90 days compared to standard care alone.
2. The DEFUSE3 trial of 182 patients found endovascular therapy plus medical therapy improved functional outcomes and reduced mortality compared to medical therapy alone for strokes 6-16 hours.
3. The DAWN trial of 206 patients found the same benefits for strokes 6-24 hours when a clinical-radiological mismatch was present. Both DEFUSE3 and DAWN saw no increase in serious adverse events.
COMPARES OPTIMAL MEDICAL THERAPY WITH INVASIVE THERAPY IN A PATIENT WITH STABLE ISCHEMIC HEART DISEASE WITH MODERATE TO SEVERE MYOCARDIAL ISCHEMIA ON NON INVASIVE STRESS TESTING
The document reports on a study from the ISCHEMIA trial investigating the impact of complete versus incomplete revascularization on clinical outcomes in patients with stable ischemic heart disease treated with an invasive versus conservative strategy. It finds that among patients treated with an invasive strategy, complete anatomic or functional revascularization was associated with improved outcomes compared to incomplete revascularization. However, after adjustment for covariates, the differences in outcomes between complete and incomplete revascularization were no longer statistically significant.
The focused update provides 3 new recommendations regarding perioperative beta-blocker therapy based on recent clinical trials:
1. It recommends beta-blocker therapy be continued in patients already taking beta-blockers for indications listed in the original guideline.
2. It provides a new weaker recommendation for clinicians to consider initiating and continuing beta-blocker therapy for intermediate-risk patients having surgery.
3. It acknowledges some studies suggested risks may outweigh benefits in some subgroups and clinical judgement is needed when initiating therapy.
Guías de manejo evaluación cardiovascular preoperatoria en cirugía no cardiac...sandoriver
This document provides updated guidelines for the perioperative cardiovascular evaluation and care of patients undergoing noncardiac surgery. It summarizes the key recommendations, which include:
1. Preoperative cardiac risk assessment with revised cardiac risk indexes is recommended for patients with poor functional capacity or other major cardiac risk factors undergoing vascular surgery.
2. A preoperative resting 12-lead ECG is recommended for patients with known coronary, peripheral, or cerebrovascular disease undergoing intermediate-risk surgery.
3. Preoperative coronary revascularization with bypass surgery or angioplasty is not recommended solely to reduce cardiac risk of noncardiac surgery. However, if revascularization is indicated for coronary disease, it is reasonable to perform it pre
The panel recommends the following for treatment of hypertension in adults:
- For those aged 60 years and older, treat to a blood pressure goal of less than 150/90 mm Hg.
- For those aged 30-59 years, treat to a blood pressure goal of less than 140/90 mm Hg.
- For those younger than 60 years with diabetes or chronic kidney disease, treat to a blood pressure goal of less than 140/90 mm Hg.
- Initiate treatment with one of four classes of antihypertensive drugs (angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, calcium channel blocker, or thiazide-type diuretic).
- For non
06 the anesthesia patient with acute coronary syndrome copiaUSACHCHSJ
This document discusses the management of patients with acute coronary syndrome (ACS) in the perioperative period. It begins with an overview of ACS, distinguishing between unstable angina, myocardial infarction without ST-segment elevation (NSTEMI), and myocardial infarction with ST-segment elevation (STEMI). It then reviews the diagnosis, pathophysiology, and standard treatment of ACS outside of surgery, including antiplatelet therapy, antithrombin therapy, and beta-blockade. The document indicates that the anesthesiologist must understand how ACS is typically treated to properly manage patients who present for surgery with ACS.
This patient has a history of myocardial infarction, triple vessel coronary artery disease, and is scheduled for elective non-cardiac surgery. Based on his positive stress test results and coronary angiogram showing severe blockages, the cardiologist recommends coronary artery bypass graft surgery prior to the planned surgery to improve his long-term prognosis and reduce perioperative cardiac risks.
12 – verónica aista – como se enseña la historia en educación básica (105 135)ANA HENRIQUEZ ORREGO
Este documento presenta una introducción a la enseñanza y el aprendizaje de la historia en la educación básica. Explica que la historia es importante porque es la memoria de la humanidad que nos introduce en la evolución de la civilización. A lo largo de la historia, los seres humanos han registrado el pasado de diversas formas para dejar constancia de sus logros. La enseñanza de la historia ha tenido diferentes objetivos como formar a los gobernantes, fortalecer la identidad nacional y legitimar las revoluciones. Actualmente
1) The study evaluated 5 types of contemporary drug-eluting stents used in 6,645 patients undergoing complex high-risk procedures. Target vessel failure was lowest with ultrathin sirolimus-eluting stents.
2) Echocardiographic markers of congestion including E/e', tricuspid regurgitation velocity, and inferior vena cava collapsibility predicted outcomes in 505 heart failure patients, both with and without atrial fibrillation. Higher congestion grade was associated with increased risk of cardiovascular death or hospitalization.
3) Right-sided congestion measures may provide prognostic value beyond clinical factors and natriuretic peptides in heart failure with preserved ejection fraction
This document summarizes the outcomes of an emerging pediatric cardiac surgery program's experience with surgical palliation of hypoplastic left heart syndrome (HLHS) and related anomalies between 2010-2014. The program achieved an overall hospital survival rate of 81% by utilizing different surgical strategies including the Norwood procedure, hybrid procedure, and salvage hybrid-bridge-to-Norwood procedure based on individual patient factors. Cardiac comorbidities such as obstructed pulmonary venous return influenced the choice to use a hybrid or salvage strategy. The program's flexible approach and matching of surgical strategy to patient characteristics helped achieve outcomes comparable to benchmark data, despite being a new program.
Invasive coronary physiology to select patients for coronary revascularisation has become established in contemporary guidelines for the management of stable coronary artery disease. Compared to revascularisation based on angiography alone, the use of coronary physiology has been shown to improve clinical outcomes and cost efficiency. However, recent data from randomised controlled trials have cast doubt upon
the value of ischaemia testing to select patients for revascularisation. Importantly, 20-40% of patients have
persistence or recurrence of angina after angiographically successful percutaneous coronary intervention
(PCI). This state-of-the-art review is focused on the transitioning role of invasive coronary physiology from
its use as a dichotomous test for ischaemia with fixed cut-points, towards its utility for real-time guidance of PCI to optimise physiological results. We summarise the contemporary evidence base for ischaemia testing
in stable coronary artery disease, examine emerging indices which allow advanced physiological guidance
of PCI, and discuss the rationale and evidence base for post-PCI physiological assessments to assess the success of revascularisation.
This study assessed the relationship between electrocardiographic (ECG) left ventricular hypertrophy (LVH) and blood pressure (BP) control in 17,312 hypertensive patients from China. 1) 8.1% of patients had ECG-LVH, which was more prevalent in males. 2) Patients with ECG-LVH had a significantly higher rate of unsatisfactory BP control, with an odds ratio of 1.42, compared to those without ECG-LVH. 3) Notable differences in BP control were also seen between males and females and in patients with diabetes, with ECG-LVH patients having poorer control.
preoperative evaluation for residents of anesthesia part 1mansoor masjedi
The document discusses the importance of preoperative evaluation in anesthesia. It notes that anesthesiologists now perform many roles beyond just anesthesia in the operating room, including focused clinical exams, medical optimization, reducing patient anxiety, and informed consent. A thorough preoperative evaluation can reduce surgical risks, delays and cancellations. Key aspects of the evaluation include assessing medical history and physical exam findings, laboratory tests, EKG, and risk classification using the ASA system. The goals are to identify health risks, heart conditions, optimize medical issues, and modify perioperative risk.
Does Preoperative Coronary Revascularization Improve Perioperative Cardiac Ou...Guilherme Barcellos
Draft que encontrei de apresentação em 201: Primeiro Encontro de Medicina Hospitalista da Argentina. Slides alguns já traduzidos, outros não - não encontrei versão final. De brasileiros no evento participaram eu, Lucas Zambon e Tiago Daltoé. Boas lembranças! Resgatei agora porque trata de evidência consolidada desde aquela época, e seguimos sobreutilizando o recurso. Ou algo novo que justifique?
1) Patients with advanced heart failure who were on optimal medical therapy faced poor survival and quality of life and high risk of death.
2) The study prospectively observed 166 ambulatory patients with advanced heart failure who were at high risk of death based on clinical features and hospitalization history.
3) At 1 year, only 47% of patients remained alive without mechanical circulatory support (MCS) or transplant, and risk of death or need for MCS varied significantly based on the patient's baseline INTERMACS profile.
Elevated Tissue Doppler E/E' on Index Admission Can Help Identify Patients at...crimsonpublishersOJCHD
Readmissions for congestive Heart Failure (CHF) are a major healthcare problem that contributes significantly to the overall healthcare expenditure. About 24% of patients are readmitted to the hospital within 30 days of discharge. We investigated whether a non-invasive estimate of left atrial filling pressure, an elevated ratio of early trans mitral flow velocity to early diastolic mitral annular velocity (E/E'), during the index admission for CHF could independently predict 30 day readmission.
This study compared the long-term (18-month) outcomes of supervised exercise (SE), stent revascularization (ST), and optimal medical therapy (OMT) for patients with claudication due to aortoiliac peripheral artery disease. 79 patients completed the 18-month follow-up assessment. The study found that both SE and ST resulted in significantly greater improvements in peak walking time and claudication onset time compared to OMT. SE and ST also provided durable improvements in quality of life measures up to 18 months. Both SE and ST had better long-term outcomes than OMT alone for treating claudication, demonstrating the durability of exercise interventions for peripheral artery disease.
Appropriteness Criteria for Coronary RevascularizationLalit Kapoor
The document discusses guidelines for determining the appropriateness of revascularization procedures like angioplasty and coronary artery bypass grafting. It summarizes several major clinical trials that have compared medical therapy to revascularization and PCI to CABG. The guidelines developed by an expert panel rate 180 clinical scenarios on appropriateness based on symptoms, risk level, coronary anatomy and medical therapy. Revascularization is deemed appropriate for high-risk patients but uncertain for intermediate-risk asymptomatic patients. CABG is preferred over PCI for left main stenosis and multi-vessel disease.
This study reviewed 86 patients who underwent pericardiectomy for chronic constrictive pericarditis (CCP) at a single center from 2010-2014. Preoperatively, most patients were in NYHA class II or III. Tuberculosis was the cause of CCP in 32.6% of patients. The overall mortality rate was 2.3%. Postoperatively, 90.6% of surviving patients were in NYHA class I or II. The results showed pericardiectomy to be an effective treatment for CCP, with tuberculosis remaining a common cause in India.
This document provides an updated summary of guidelines for blood conservation in cardiac surgery from The Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists. Major revisions include new recommendations regarding dual anti-platelet therapy management before surgery, drugs that augment red blood cell volume or limit blood loss, blood derivatives, blood salvage management, minimally invasive procedures, extracorporeal membrane oxygenation, hemostatic agents, and insights into team-based interventions. The guidelines were updated based on a literature review using standardized search terms to ensure the recommendations reflect the most current evidence available.
This document discusses using intrathoracic impedance measures from implantable cardiac devices to monitor changes in intravascular fluid volume during volume reduction therapy for heart failure patients. It found that two impedance vectors, between the right atrial ring to left ventricular ring and the left ventricular ring to right ventricular ring, were most closely associated with changes in plasma volume as measured by hematocrit levels. Monitoring these specific impedance vectors may help more accurately guide volume reduction therapy by tracking changes in the intravascular fluid compartment.
The HOST-EXAM trial compared clopidogrel and aspirin monotherapy in patients who received percutaneous coronary intervention with drug-eluting stents. Over 5,400 patients were randomly assigned to receive either clopidogrel (75 mg daily) or aspirin (100 mg daily) for 24 months. The primary outcome, a composite of death, heart attack, stroke, hospital readmission for heart issues, and major bleeding, occurred in 5.7% of clopidogrel patients and 7.7% of aspirin patients. Clopidogrel monotherapy significantly reduced the risk of the primary outcome compared to aspirin monotherapy and was superior in preventing adverse clinical events.
1) Vasopressor support with agents like norepinephrine and vasopressin is recommended when fluid resuscitation fails to restore adequate blood pressure and organ perfusion in patients with septic shock.
2) The goals of vasopressor therapy are to restore tissue perfusion and normalize cellular metabolism by maintaining mean arterial pressure above 60-65 mmHg, though the optimal blood pressure target may vary between patients.
3) Monitoring a combination of clinical parameters and hemodynamic measurements like blood pressure can help evaluate the efficacy of vasopressor therapy and guide titration of medications to optimize both global and regional blood flow in septic shock patients.
Mangement of chronic heart failure 93432-rephrasedIrfan iftekhar
Cardiac resynchronization therapy significantly reduces morbidity and mortality in patients with heart failure. A randomized controlled trial found that cardiac resynchronization reduced the primary endpoint of death from any cause by 36% compared to medical therapy alone. Mortality was lower in the cardiac resynchronization group, demonstrating improved outcomes. While cardiac resynchronization is an effective treatment, its cost-effectiveness remains uncertain due to the therapy's expense. Further research is still needed to determine its overall value.
This expert consensus document from the World Heart Federation provides recommendations for antiplatelet therapy in East Asian patients with acute coronary syndrome or undergoing percutaneous coronary intervention. While current guidelines are based primarily on large Western clinical trials, few East Asian patients were included. Additionally, East Asians have differing risk profiles and responses to antiplatelet drugs compared to white patients. This consensus aims to determine the most appropriate antiplatelet strategies for East Asians based on available evidence.
The Emerging Role of BIomarkers and Bio-Impedancedrucsamal
This document discusses methods for assessing hydration status in patients with acute heart failure. It reviews classical assessment methods like history, physical exam, imaging techniques, and isotopic tracers, which is the gold standard but impractical. It then focuses on emerging roles of biomarkers and bioimpedance analysis which provide a less invasive way to estimate total body water content and fluid overload. These novel methods show promise for diagnosing, risk-stratifying, and guiding treatment decisions for acute heart failure patients.
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
TEST BANK For An Introduction to Brain and Behavior, 7th Edition by Bryan Kol...rightmanforbloodline
TEST BANK For An Introduction to Brain and Behavior, 7th Edition by Bryan Kolb, Ian Q. Whishaw, Verified Chapters 1 - 16, Complete Newest Versio
TEST BANK For An Introduction to Brain and Behavior, 7th Edition by Bryan Kolb, Ian Q. Whishaw, Verified Chapters 1 - 16, Complete Newest Version
TEST BANK For An Introduction to Brain and Behavior, 7th Edition by Bryan Kolb, Ian Q. Whishaw, Verified Chapters 1 - 16, Complete Newest Version
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Kat...rightmanforbloodline
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
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The UK is currently facing a Adhd Medication Shortage Uk, which has left many patients and their families grappling with uncertainty and frustration. ADHD, or Attention Deficit Hyperactivity Disorder, is a chronic condition that requires consistent medication to manage effectively. This shortage has highlighted the critical role these medications play in the daily lives of those affected by ADHD. Contact : +1 (747) 209 – 3649 E-mail : sales@trinexpharmacy.com
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPsychoTech Services
A proprietary approach developed by bringing together the best of learning theories from Psychology, design principles from the world of visualization, and pedagogical methods from over a decade of training experience, that enables you to: Learn better, faster!
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
2. 538 HOEKS ET AL.
Fig. 1. Application of the American College of Cardiology/American Heart Association algorithm for perioperative cardiovascular
evaluation for noncardiac surgery to the study population. Adapted from Eagle et al.7, with permission. CHF ؍congestive heart
failure; ECG ؍echocardiogram; MET ؍metabolic equivalent; MI ؍myocardial infarction.
Anesthesiology, V 107, No 4, Oct 2007
3. IMPLEMENTATION OF PERIOPERATIVE GUIDELINES 539
mentation of guidelines in daily clinical practice. Five have been used to reduce the incidence of perioperative
hospitals were located in the central part of the country, myocardial infarctions and other cardiac complications:
3 were located in the northern region, and 3 were preoperative coronary revascularization and pharmaco-
located in the southern region. Two centers were uni- logic treatment. The ACC/AHA guidelines recommend
versity hospitals, which act as tertiary referral centers. -blockers for patients at high cardiac risk. Evidence for
All consecutive patients who were admitted to the statins and -blockers in intermediate-risk patients is less
vascular surgery department of the participating hospital clearly described.
were screened. Patients older than 18 years who were We applied the ACC/AHA guideline definitions to the
undergoing peripheral vascular repair were eligible for study population. Because the guidelines were not explicit
participation in the survey, except those undergoing on the definition of advance age, we defined it as older than
thoracic or brain surgery. The total study population 70 yr. Poor functional capacity was defined as a patient
consisted of 711 patients. Patients had to provide in- being unable to walk four blocks on level ground or climb
formed consent. The medical ethics committees of the two flights of stairs without symptomatic limitation. Proce-
participating hospitals approved the study. dures were divided into high, intermediate, and low sur-
gery-specific risk. High-risk procedures included major vas-
Data Collection cular surgery, and intermediate-risk procedures included
Trained research assistants obtained data on patient carotid endarterectomy. Endovascular procedures were de-
characteristics, applied diagnostic procedures, cardio- fined as low-risk procedures.
protective treatment, and the surgical procedure from
the patients’ hospital charts. All data were entered into Endpoints
the electronic Case Record Form and transferred regu- This survey was designed to evaluate the application of
larly to the central database at the Erasmus Medical guidelines in patients undergoing peripheral vascular sur-
Center (Rotterdam, The Netherlands) via the Internet. gery. We specifically looked at noninvasive imaging, car-
Data entered into the electronic case record form were diovascular medication (-blockers, statins, and antiplatelet
automatically checked for completeness, internal consis- therapy), and preoperative revascularization. Antiplatelet
tency, and accuracy. The data management staff at the therapy included aspirin, dipyridamole, clopidogrel, or any
Erasmus Medical Center performed additional edit of combination of these agents. All-cause mortality and
checks. If necessary, queries were resolved with the adverse events were reported at 30 days and 1 yr after
local research assistants. surgery by the local research assistants. Cardiovascular
complications were defined as cardiac death, myocardial
ACC/AHA Guidelines infarction, cardiac arrhythmias, congestive heart failure,
The ACC/AHA Task Force published Practice Guide- cerebrovascular events, or revascularization.
lines for Perioperative Cardiovascular Evaluation for
Noncardiac Surgery in 1996 and an update in 2002.7 The Data Analyses
core of the ACC/AHA guidelines is an algorithm that For each patient in our data set, we retrospectively
summarizes the stepwise process leading to practical determined whether ACC/AHA guidelines were fol-
recommendations as performing noninvasive testing lowed. We described the number of patients for
(fig. 1).7 According to this algorithm, after the urgency of whom guidelines were followed with percentages and
the surgery and the cardiac status of patients having corresponding confidence intervals (CIs). Differences
previous coronary revascularization within 5 yr or pre- in following guidelines were analyzed with chi-square
vious cardiac evaluation within 2 yr are assessed, the tests and Fisher exact test, when appropriate. Mortal-
patients are classified as major, intermediate, or minor ity rates were only described with percentages and CIs
perioperative cardiovascular risk. Major, intermediate, because small subgroup sample sizes limited statistical
and minor clinical predictors of risk, together with sur- power for statistical testing. All statistical analyses
gical risk and degree of functional capacity, can be de- were undertaken using version 13.0 of the SPSS pro-
termined as predictors of perioperative cardiac compli- gram for Windows (SPSS Co., Chicago, IL). In all anal-
cations. Patients with only minor or intermediate yses, a P value less than 0.05 was considered statisti-
clinical predictors and adequate functional capacity cally significant.
represent a low-risk population, irrespective of type of
surgery, and further evaluation is unnecessary. How-
ever, if any of the clinical markers of cardiac risk Results
present, additional noninvasive evaluation should be
considered. The mean age of the total 711 patients was 67 yr (SD ϭ
The main purpose of performing preoperative cardiac 10 yr), with many patients having a history of associated
risk assessment is to identify patients at high risk for risk factors (table 1). When stratified into surgery-spe-
perioperative cardiac events. In general, two strategies cific risk categories according to the ACC/AHA guide-
Anesthesiology, V 107, No 4, Oct 2007
4. 540 HOEKS ET AL.
Table 1. Baseline Characteristics (n )117 ؍ the 619 patients undergoing urgent or elective surgery,
25 patients (4%) underwent recent coronary revascular-
Demographics
Mean age Ϯ SD, yr 67 Ϯ 10 ization, of which 19 patients had no recurrent symptoms
Male sex, n (%) 496 (70) or signs. One other patient had a recent coronary eval-
Cardiovascular history, n (%) uation without recurrent symptoms or unfavorable re-
Angina pectoris 99 (14)
Myocardial infarction 106 (15)
sults. According to the ACC/AHA guidelines algorithm,
Heart failure 38 (5) those patients can undergo surgery directly without pre-
Stroke or TIA 123 (17) vious noninvasive testing. The remaining 599 patients
Arrhythmia 77 (11) were classified according to the guidelines as having
Valvular disease 50 (7)
Previous revascularization 116 (16) major (n ϭ 2), intermediate (n ϭ 295), and minor or no
Clinical risk factors, n (%) clinical risk predictors (n ϭ 302). Depending on this
Obesity 77 (11) clinical risk profile, functional capacity and surgical risk
Current smoker 256 (36) profile, noninvasive testing is recommended as shown in
Hypertension 273 (38)
Diabetes mellitus 149 (21) the algorithm and outlined in table 2. For example,
Renal insufficiency 51 (7) within the 295 patients with intermediate clinical risk
COPD 101 (14) factors, 48 patients had a poor functional capacity
Procedure, n (%)
and are recommended to undergo noninvasive testing,
Low risk 354 (50)
Intermediate risk 29 (4) whereas the 150 patients undergoing low-surgical-risk
High risk 328 (46) procedures can go directly to surgery. In total, 185
Functional capacity, n (%) patients (26%) fulfilled the criteria to recommend pre-
Poor 240 (34)
Moderate 471 (66)
operative noninvasive cardiac testing. However, clini-
cians had performed testing in only 38 of those cases
COPD ϭ chronic obstructive pulmonary disease; TIA ϭ transient ischemic (21%; 95% CI, 15–28%). Of those 38 patients, 17 (45%)
attack. had abnormal test results. Conversely, of the 526 pa-
tients for whom testing was not recommended, guide-
lines, 328 (46%) underwent high-risk procedures, 29 lines were followed in 467 patients (89%; 95% CI, 86 –
patients (4%) underwent intermediate-risk procedures, 91%) in clinical practice, as shown in the last columns of
and 354 (50%) underwent low-risk procedures. The 328 table 2. So 59 (11%; 95% CI, 9 –14%) patients were
open vascular procedures included infrainguinal arterial noninvasively tested while not recommended.
reconstruction (52%), abdominal aortic surgery (42%), As inherent to the algorithm, the 185 patients who
and 21 other procedures (6%). fulfilled the guideline criteria to undergo noninvasive
cardiac testing had a significantly higher cardiac risk
Risk Evaluation profile than the patients for whom testing was not rec-
As shown in the algorithm in figure 1, 92 of the total ommended (table 3). In clinical practice, a sex differ-
711 patients (13%) underwent emergency surgery. Of ence was observed because 84% of those patients who
Table 2. Agreement with the ACC/AHA Guidelines Regarding Noninvasive Testing
Noninvasive Testing Recommended
ACC/AHA Guideline Category Yes No
Clinical Functional Surgical Expected According Observed in Expected According Observed in
Category Capacity Risk to Guidelines Clinical Practice to Guidelines Clinical Practice
Emergency 92 89 (97%)
Revascularization 19 13 (68%)
within 5 yr
Recent coronary 1 1 (100%)
evaluation
Major 2 1 (50%)
Intermediate Low 150 128 (85%)
Intermediate Poor 48 9 (19%)
Intermediate Moderate/excellent Intermediate 8 6 (75%)
Intermediate Moderate/excellent High 89 20 (23%)
Minor or no Poor Intermediate/low 68 64 (94%)
Minor or no Poor High 46 8 (17%)
Minor or no Moderate/excellent 188 166 (88%)
Total 185 38 (21%) 526 467 (89%)
ACC ϭ American College of Cardiology; AHA ϭ American Heart Association.
Anesthesiology, V 107, No 4, Oct 2007
5. IMPLEMENTATION OF PERIOPERATIVE GUIDELINES 541
Table 3. Differences in Baseline Characteristics
Guideline Recommendation Observed in Clinical Practice
Testing Not Testing Testing Not Testing
Recommended Recommended Performed Performed
(n ϭ 526) (n ϭ 185) P Value (n ϭ 614) (n ϭ 97) P Value
Demographics
Mean age Ϯ SD, yr 67 Ϯ 11 68 Ϯ 9 0.084 67 Ϯ 11 67 Ϯ 9 0.716
Male sex, n (%) 360 (68) 136 (73) 0.196 415 (68) 81 (84) 0.002
Cardiovascular history, n (%)
Angina pectoris 59 (11) 40 (22) Ͻ0.001 72 (12) 27 (28) Ͻ0.001
Myocardial infarction 68 (13) 38 (21) 0.012 83 (14) 23 (24) 0.009
Heart failure 27 (5) 10 (5) 0.886 37 (6) 1 (1) 0.046
Stroke or TIA 99 (19) 24 (13) 0.070 109 (18) 14 (14) 0.422
Arrhythmia 44 (8) 33 (18) Ͻ0.001 69 (11) 8 (8) 0.378
Valvular disease 31 (6) 19 (10) 0.045 44 (7) 6 (6) 0.726
Previous revascularization 83 (16) 33 (18) 0.515 89 (15) 27 (28) 0.001
Clinical risk factors, n (%)
Obesity 53 (10) 24 (13) 0.275 63 (10) 14 (14) 0.219
Current smoker 188 (36) 68 (37) 0.805 229 (37) 27 (28) 0.071
Hypertension 181 (34) 92 (50) Ͻ0.001 232 (38) 41 (42) 0.399
Diabetes mellitus 90 (17) 59 (32) Ͻ0.001 131 (21) 18 (19) 0.532
Renal insufficiency 33 (6) 18 (10) 0.117 44 (7) 7 (7) 0.986
COPD 70 (13) 31 (17) 0.248 86 (14) 15 (16) 0.702
Procedure, n (%) Ͻ0.001 0.007
Low risk 353 (67) 1 (1) 320 (52) 34 (35)
Intermediate risk 29 (6) 0 23 (4) 6 (6)
High risk 144 (27) 184 (99) 271 (44) 57 (59)
Functional capacity, n (%) Ͻ0.001 0.795
Poor 146 (28) 94 (51) 208 (34) 32 (33)
Moderate 380 (72) 91 (49) 406 (66) 65 (67)
COPD ϭ chronic obstructive pulmonary disease; TIA ϭ transient ischemic attack.
underwent noninvasive testing were men, compared normal test result and patients with an abnormal test result.
with 68% males in the not-tested group (P ϭ 0.002). For example, in the 38 patients who were tested according
Furthermore, tested patients were more likely to have to the guidelines, the percentages of -blocker users were
evidence of an ischemic heart disease. Regarding the 71% and 77% for patients with normal and abnormal test
procedural risk, we observed a clear difference between results, respectively (P ϭ 0.73). These percentages are in
guideline recommendation and clinical practice because line with the group tested while not recommended, 78% in
one third of the tested patients underwent a low-risk patients with a normal test result, and 83% in patients with
procedure, whereas testing was hardly recommended in an abnormal result (P ϭ 0.60). Preoperative revasculariza-
this group. tion was observed in a small number of patients.
Thirty-six patients (5%) had cardiovascular complica-
tions within 30 days after surgery. In patients treated
Risk Modification
according to the guidelines with respect to noninvasive
Regarding the above guideline-based risk evaluation, dif-
testing, the percentage complications at 30 days was 7%
ferences were observed in cardiovascular medical therapy
(95% CI, 5–9%). In contrast, the complication rate was
among different subgroups of patients. Overall, patients
4% (95% CI, 1–7%) in patients tested in discordance with
who had not been tested, irrespective of guideline recom-
the guidelines. After 1 yr, total mortality was 11%. Mor-
mendation, received less cardioprotective medications,
tality was 11% (95% CI, 8 –14%) in patients tested according
whereas patients who underwent noninvasive testing were
to the guidelines and 12% (95% CI, 8 –16%) in patients who
significantly more often treated with cardiovascular drugs
were tested in discordance with the guidelines.
(-blockers 43% vs. 77%, statins 52% vs. 83%, platelet in-
hibitors 80% vs. 85%, respectively; all P Ͻ 0.05). No differ-
ences in medical treatment were observed between pa- Discussion
tients who had not been tested in accordance and
discordance with the guidelines (-blockers 42% vs. 48%, The value of using the ACC/AHA guidelines in patients
statins 52% vs. 52%, platelet inhibitors 80% vs. 78%, respec- undergoing vascular surgery is still under debate. Whereas
tively; all P Ͼ 0.20; fig. 2). some demonstrated improved risk stratification8 –9 and de-
Moreover, we did not observe significant differences in creased resource use,13 others showed that this did not
cardiovascular medical therapy between patients with a result in a beneficial outcome.10 –12,14 Our study demon-
Anesthesiology, V 107, No 4, Oct 2007
6. 542 HOEKS ET AL.
Fig. 2. Risk evaluation and modification. CI ؍confidence interval.
strated poor agreement between clinical practice and the deaths, or duration of stay in the hospital, or in long-term
ACC/AHA guideline recommendations for perioperative outcomes in patients who underwent preoperative coro-
cardiovascular evaluation for noncardiac surgery. Only one nary revascularization compared with patients who re-
of each five patients underwent noninvasive testing when ceived optimized medical therapy.15 These findings apply
recommended. Furthermore, high-risk patients defined by to patients with stable coronary artery disease, but the
ACC/AHA guidelines who did not undergo testing although optimal perioperative management for patients with left
recommended, received as little cardiac management as main disease, severe left ventricular dysfunction, unstable
the low-risk population. angina pectoris, and aortic stenosis must be investigated in
The core of the ACC/AHA guidelines is an algorithm that controlled clinical trials.
summarizes the stepwise process leading to practical rec- Besides coronary revascularization, an extensive pre-
ommendations as performing noninvasive cardiac testing. operative cardiac evaluation with noninvasive cardiac
In general, two strategies have been used to reduce the testing might improve outcome by inciting an improve-
incidence of perioperative myocardial infarctions and other ment in medical management in the perioperative pe-
cardiac complications: preoperative coronary revasculariza- riod. Perioperative -blockers and statins have in this
tion and pharmacologic treatment. In recent years, more way shown a significant benefit in decreasing perioper-
attention has focused on the role of pharmacologic treat- ative cardiac mortality and morbidity.16 –18 Because of
ment, whereas controversy remains to the appropriate increasing evidence of the beneficial effect of -blocker
management of patients identified preoperatively as having in the perioperative period, recently the guidelines sec-
significant but correctable coronary artery disease. In our tion on perioperative -blocker therapy is updated.19
study population, only a small number of patients under- Results on -blocker use from this survey, published
went preoperative coronary revascularization. Recently, before, showed an underuse of -blockers in vascular
the Coronary Artery Revascularization Prophylaxis trial surgery patients and also in high-risk patients.20 In the
demonstrated that in the short term, there is no reduction current study, we found that patients who had not been
in the number of postoperative myocardial infarctions, tested, irrespective of guideline recommendation, re-
Anesthesiology, V 107, No 4, Oct 2007
7. IMPLEMENTATION OF PERIOPERATIVE GUIDELINES 543
ceived less cardioprotective medications compared with care physician. In addition, the algorithm of the ACC/AHA
patients who underwent noninvasive testing. All of these guidelines could be too complicated for use in routine care,
patients were apparently regarded as a low-risk popula- as evident by several publications of the ACC/AHA algo-
tion and consequently received less medical treatment. rithm as a simplified formula.25 This reflects that guide-
Thus, high-risk patients in whom testing was recom- lines must be straightforward, simple to use, uniform,
mended but who did not undergo testing received low and based on recent scientific evidence.
medical therapy comparable to that of the real low-risk The limitations of this study are those inherent to
population. That is, underdiagnosis seems to lead to observational studies involving voluntarily participating
undertreatment. Conversely, patients who were tested hospitals. Although we included a wide spectrum of
while it was not recommended were medically treated hospitals, the results could be biased toward better-than-
as high-risk patients. This was irrespective of the test average practices. Nevertheless, because patient inclu-
result. sion was consecutive in all participating sites, we trust
A variety of barriers to guideline adherence have been that the survey depicts ongoing clinical practice. It
pointed out: out-of-date guidelines; lack of awareness, should be noted also that our study was limited by its
agreement, or self-efficacy; lack of outcome expectancy; sample size, reflected by the limited number of patients
the inertia of previous practice; and external barriers.21 in the subgroups. Larger studies are needed to confirm
It should also be noted that the treatment of individual observed findings.
patients is more complex than simply following guide- In conclusion, our study showed poor agreement be-
lines. In addition, the algorithm proposed in the guide- tween ACC/AHA guideline recommendations and daily
lines had to rely predominantly on observational data clinical practice for both noninvasive testing and cardiac
and expert opinion because there were no randomized management.
trials to help define the process. Several of those barriers
may be responsible for the poor adherence to guidelines
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