2009 Focused Update:
ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults
J. Am. Coll. Cardiol. April 14, 2009; 53;1343-1382
Circulation. April 14, 2009;119;1977-2016
ACC/AHA 2007 Guidelines for UA & NSTEMISun Yai-Cheng
ACC/AHA 2007 Guidelines for the management of Patients with Unstable Angina/Non-ST-Elevation Myocardial Infarction
Circulation. 2007;116;e148-e304
J. Am. Coll. Cardiol. 2007;50;652-726
2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes: Executive Summary
Circulation. published online September 23, 2014
A novel approach to medical management of heart failure with reduced ejectionRamachandra Barik
The advent of newly available medical therapies for HFrEF has resulted in many potential therapeutic combinations, increasing treatment complexity. Publication of expert consensus guidelines and initiative aimed to improve treatment implementation have emphasized sequential, stepwise initiation and titration of medical therapy, which is labour intensive. Data taken from heart failure registries shows suboptimal use of medications, prolonged titration time and consequently little change in dose intensity, all of which, indicate therapeutic inertia. Recently published evidence indicates that four medication classes (1. renin-angiotensin-neprilysin inhibitors, 2. beta-blockers, 3. mineralocorticoid antagonists and 4. sodium-glucose cotransporter inhibitors), which we refer to as Foundational Therapy, confer rapid and robust reduction in both morbidity and mortality in most patients with HFrEF, and that they work in additive fashion. Additional morbidity and/or mortality may be observed following addition of several Personalized Therapies in specific subgroups of patients. In this review, we discuss mechanisms of action of these therapies and propose a framework for their implementation based on several principles. These include the critical importance of rapid initiation of all 4 Foundational Therapies followed by their titration to target doses, emphasis on multiple simultaneous drug changes with each patient encounter, attention to patient-specific factors in choice of medication class, leveraging inpatient care, use of the entire health care team and alternative (i.e. virtual visits) modes of care. We have incorporated these principles into a ‘Cluster Scheme’ designed to facilitate timely and optimal medical treatment for patients with HFrEF.
Introduction
ACC/AHA 2007 Guidelines for UA & NSTEMISun Yai-Cheng
ACC/AHA 2007 Guidelines for the management of Patients with Unstable Angina/Non-ST-Elevation Myocardial Infarction
Circulation. 2007;116;e148-e304
J. Am. Coll. Cardiol. 2007;50;652-726
2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes: Executive Summary
Circulation. published online September 23, 2014
A novel approach to medical management of heart failure with reduced ejectionRamachandra Barik
The advent of newly available medical therapies for HFrEF has resulted in many potential therapeutic combinations, increasing treatment complexity. Publication of expert consensus guidelines and initiative aimed to improve treatment implementation have emphasized sequential, stepwise initiation and titration of medical therapy, which is labour intensive. Data taken from heart failure registries shows suboptimal use of medications, prolonged titration time and consequently little change in dose intensity, all of which, indicate therapeutic inertia. Recently published evidence indicates that four medication classes (1. renin-angiotensin-neprilysin inhibitors, 2. beta-blockers, 3. mineralocorticoid antagonists and 4. sodium-glucose cotransporter inhibitors), which we refer to as Foundational Therapy, confer rapid and robust reduction in both morbidity and mortality in most patients with HFrEF, and that they work in additive fashion. Additional morbidity and/or mortality may be observed following addition of several Personalized Therapies in specific subgroups of patients. In this review, we discuss mechanisms of action of these therapies and propose a framework for their implementation based on several principles. These include the critical importance of rapid initiation of all 4 Foundational Therapies followed by their titration to target doses, emphasis on multiple simultaneous drug changes with each patient encounter, attention to patient-specific factors in choice of medication class, leveraging inpatient care, use of the entire health care team and alternative (i.e. virtual visits) modes of care. We have incorporated these principles into a ‘Cluster Scheme’ designed to facilitate timely and optimal medical treatment for patients with HFrEF.
Introduction
Acute Heart Failure: Current Standards and Evolution of Care.2015hivlifeinfo
Обсуждение последних данных, касающиеся диагностики и лечения острой сердечной недостаточности, в том числе использование биомаркеров для диагностики и оценке прогноза , преимущества и ограничения действующих стандартами медицинской помощи, и доказательств данных по современной терапии острой сердечной недостаточности.
Формат: Microsoft PowerPoint (.ppt)
Размер файла: 1.68 Мб
Дата публикации: 7/24/2015
Patients with Chronic stable angina and unstable angina also present a dilemma for further management based on results of coronary angiography alone. Estimation of Fractional flow reserve (FFR) allows to identify ischemia producing lesions in coronary tree. It has been proved beyond doubt that interventions for the lesions causing ischemia improves morbidity and mortality.
Acute Heart Failure: Current Standards and Evolution of Care.2015hivlifeinfo
Обсуждение последних данных, касающиеся диагностики и лечения острой сердечной недостаточности, в том числе использование биомаркеров для диагностики и оценке прогноза , преимущества и ограничения действующих стандартами медицинской помощи, и доказательств данных по современной терапии острой сердечной недостаточности.
Формат: Microsoft PowerPoint (.ppt)
Размер файла: 1.68 Мб
Дата публикации: 7/24/2015
Patients with Chronic stable angina and unstable angina also present a dilemma for further management based on results of coronary angiography alone. Estimation of Fractional flow reserve (FFR) allows to identify ischemia producing lesions in coronary tree. It has been proved beyond doubt that interventions for the lesions causing ischemia improves morbidity and mortality.
Beta blockers have a variety of different uses in the management of ischemic heart disease. This presentation by Dr Vivek Baliga, Internal Medicine Physician talks about the role in ST elevation MI.
Beta blockers in SIHD: Yes, all patients should receive them !cardiositeindia
A presentation made by Dr. Akshay Mehta on the topic- Beta blockers in SIHD: yes, all patients should receive them !.
This was presented at the SIHD conference, Mumbai, 2015.
ACC/AHA 2009 Guidelines for STEMI & PCISun Yai-Cheng
ACC/AHA 2009 STEMI/PCI Guidelines
ACC/AHA Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction (STEMI) and the ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (PCI)
J. Am. Coll. Cardiol. 2009;54;2205-2241
Circulation. 2009;120;2271-2306
Heart Failure Care: How World-Class Performance is Within Your ReachHealth Catalyst
Less than 1% of heart failure (HF) patients with reduced ejection fraction are on target doses of all four drug classes within 12 months of an index hospitalization, yet these protocols have been proven to improve symptoms, slow disease progression, reduce costly admissions, and increase life expectancy. This data point must serve as a rallying cry in the nation’s quest to combat heart failure as a leading cause of death.
In this webinar, Dr. John Janas will:
Review the current HF treatment gaps
Discuss the latest evidence-based recommendations for changes to guideline-directed medical therapy (GDMT) and key changes to prior CHF guidelines
Explore the role that technology could play in improving HF care while reducing the burden on care teams
Management of Heart Failure in the ED Setting:
An Evidence-Based Review of the Literature
J Emerg Med, 2018 Sep 26.
doi: 10.1016/j.jemermed.2018.08.002
Diffusion-weighted imaging or computerized tomography perfusion assessment with clinical mismatch in the triage of wake up and late presenting strokes undergoing neurointervention with Trevo (DAWN) trial methods
Int J Stroke. 2017 Aug;12(6):641-652.
Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct
N Engl J Med. 2018 Jan 4;378(1):11-21.
A multicenter randomized controlled trial of endovascular therapy following imaging evaluation for ischemic stroke (DEFUSE 3)
Int J Stroke. 2017 Oct;12(8):896-905.
Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging
N Engl J Med. 2018 Feb 22;378(8):708-718.
The European Guideline on Management of Major Bleeding and Coagulopathy Follo...Sun Yai-Cheng
The European Guideline on Management of Major Bleeding and Coagulopathy Following Trauma: Fourth Edition
Rossaint et al. Critical Care (2016) 20:100
DOI 10.1186/s13054-016-1265-x
ACEP Policy for Fever Infants and Children Younger than 2 Years of Age in EDSun Yai-Cheng
Clinical Policy for Well-Appearing Infants and Children Younger Than 2 Years of Age Presenting to the Emergency Department With Fever
Ann Emerg Med. 2016;67:625-639
2015 AHA/ASA Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment
Stroke. 2015;46:3020-3035.
With the Proliferation of Mobile Medical Apps, Which Ones Work Best in the Emergency Department?
Annals of Emergency Medicine, August 2015 Vol. 66, Issue 2, A13–15
Use of tPA for the Management of Acute Ischemic Stroke in the ED: ACEP PolicySun Yai-Cheng
ACEP Clinical Policy
Use of Intravenous Tissue Plasminogen Activator for the Management of Acute Ischemic Stroke in the Emergency Department
Ann Emerg Med. 2015;66:322-333
Evaluation and Management of Acute Aortic Dissection: ACEP PolicySun Yai-Cheng
ACEP Clinical Policy
Evaluation and Management of Adult Patients With Suspected Acute Nontraumatic Thoracic Aortic Dissection
Ann Emerg Med. 2015;65:32-42
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.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
1. ACC Heart Failure Guidelines 2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults J. Am. Coll. Cardiol. April 14, 2009; 53;1343-1382 Circulation. April 14, 2009;119;1977-2016
2. Class I Benefit >>> Risk Procedure/ Treatment SHOULD be performed/ administered Class IIa Benefit >> Risk Additional studies with focused objectives needed IT IS REASONABLE to perform procedure/administer treatment Class IIb Benefit ≥ Risk Additional studies with broad objectives needed; Additional registry data would be helpful Procedure/Treatment MAY BE CONSIDERED Class III Risk ≥ Benefit No additional studies needed Procedure/Treatment should NOT be performed/administered SINCE IT IS NOT HELPFUL AND MAY BE HARMFUL Level A: Recommendation based on evidence from multiple randomized trials or meta-analyses Multiple (3-5) population risk strata evaluated; General consistency of direction and magnitude of effect Level B: Recommendation based on evidence from a single randomized trial or non-randomized studies Limited (2-3) population risk strata evaluated Level C: Recommendation based on expert opinion, case studies, or standard-of-care Very limited (1-2) population risk strata evaluated should is recommended is indicated is useful/effective/ beneficial is reasonable can be useful/effective/ beneficial is probably recommended or indicated may/might be considered may/might be reasonable usefulness/effectiveness is unknown /unclear/uncertain or not well established is not recommended is not indicated should not is not useful/effective/beneficial may be harmful
4. In pts presenting with HF, initial assessment should be made of the pt’s ability to perform routine and desired activities of daily living. Initial examination of pts presenting with HF should include assessment of volume status, orthostatic BP changes, measurement of weight and height, and BMI. Initial Assessment and Examination of Patients with HF Initial Clinical Assessment of Patients Presenting with Heart Failure NO CHANGE NO CHANGE
5. Initial lab evaluation of pts presenting with HF should include CBC, urinalysis, electrolytes (including Ca and Mg), BUN, creatinine, fasting blood glucose (glycohemoglobin), lipid profile, LFT, and TSH. 12-lead ECG and CXR should be performed initially in all pts presenting with HF. Initial Laboratory Evaluation Initial Clinical Assessment of Patients Presenting with Heart Failure NO CHANGE NO CHANGE
6. 2D echocardiography with Doppler should be performed during initial evaluation of pts presenting with HF to assess LVEF, LV size, wall thickness, and valve function. Coronary arteriography should be performed in pts presenting with HF who have angina or significant ischemia unless the pt is not eligible for revascularization of any kind. 2D Echocardiography Initial Clinical Assessment of Patients Presenting with Heart Failure Coronary Revascularization NO CHANGE NO CHANGE
7. Coronary arteriography is reasonable for pts presenting with HF who have known or suspected CAD but who do not have angina unless the pt is not eligible for revascularization of any kind. Coronary Revascularization Initial Clinical Assessment of Patients Presenting with Heart Failure Coronary arteriography is reasonable for pts presenting with HF who have chest pain that may or may not be of cardiac origin who have not had evaluation of their coronary anatomy and who have no contraindications to coronary revascularizations. NO CHANGE NO CHANGE I IIa IIb III I IIa IIb III
8. Initial Clinical Assessment of Patients Presenting with Heart Failure Measurement of BNP or N-terminal pro-BNP (NT-proNBP)) can be useful in the evaluation of pts presenting in the urgent care setting in whom the clinical diagnosis of HF is uncertain. Measurement of BNP can be helpful in risk stratification. Noninvasive imaging may be considered to define the likelihood of CAD in pts with HF and LV dysfunction. Measurement of BNP and Noninvasive Imaging Modified NO CHANGE I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III A
10. Patients with Reduced Left Ventricular Ejection Fraction Measures listed as Class I recommendations for pts in Stages A and B are also appropriate for pts in Stage C. Diuretics and salt restriction are indicated in pts with current or prior symptoms of HF and reduced LVEF who have evidence of fluid retention. Measuring LVEF NO CHANGE NO CHANGE
11. Patients with Reduced Left Ventricular Ejection Fraction ACE inhibitors are recommended for all pts with current or prior symptoms of HF and reduced LVEF, unless contraindicated . Use of beta blockers proven to reduce mortality (i.e., bisoprolol, carvedilol, and metoprolol) is recommended for all stable pts with symptoms of HF and reduced LVEF, unless contraindicated. Measuring LVEF Modified NO CHANGE
12. Patients with Reduced Left Ventricular Ejection Fraction Angiotensin II receptor blockers are recommended in pt with symptoms of HF and reduced LVEF who are ACE-inhibitor intolerant. Drugs known to adversely affect the clinical status of pts with symptoms of HF and reduced LVEF should be avoided or withdrawn whenever possible (e.g., NSAID, most antiarrhythmic drugs, and most CCB drugs). Angiotensin ll Receptor Blockers NO CHANGE NO CHANGE
13. Patients with Reduced Left Ventricular Ejection Fraction ICD is recommended as secondary prevention to prolong survival in pts with of HF and reduced LVEF who have a history of cardiac arrest, VF, or hemodynamically destabilizing VT. Secondary Prevention: Implantable Cardioverter-Defibrillator NO CHANGE
14. Patients with Reduced Left Ventricular Ejection Fraction ICD is recommended for primary prevention of SCD to reduce total mortality in pts with non-ischemic DCM or IHD at least 40 days post-MI, have LVEF ≤ 35%, with NYHA Fc II or III while receiving chronic optimal medical therapy, and who have expectation of survival with good functional status > 1 year. Primary Prevention: Implantable Cardioverter-Defibrillator Modified
15. Patients with Reduced Left Ventricular Ejection Fraction pts with LVEF ≤ 35%, sinus rhythm, and NYHA Fc III or IV despite recommended, optimal medical therapy and who have QRS duration ≥ 0.12 seconds, should receive cardiac resynchronization therapy, with or without an ICD, unless contraindicated. Resynchronization Therapy Modified
16. Patients with Reduced Left Ventricular Ejection Fraction Addition of an aldosterone antagonist is recommended in selected pts with moderately severe to severe symptoms of HF and reduced LVEF who can be carefully monitored for preserved renal function and normal K concentration. Creatinine ≤ 2.5 mg/dL in men or ≤ 2.0 mg/dL in women and K < 5.0 meq/L. The Risks of Aldosterone Antagonists NO CHANGE
17. Patients with Reduced Left Ventricular Ejection Fraction Recommendations for Atrial Fibrillation and Heart Failure It is reasonable to treat pts with atrial fibrillation and HF with a strategy to maintain sinus rhythm or with a strategy to control ventricular rate alone. New I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III A
18. Patients with Reduced Left Ventricular Ejection Fraction Digitalis can be beneficial in pts with symptoms of HF and reduced LVEF to decrease hospitalizations for HF. The Benefits of Digitalis NO CHANGE I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III B
19. Patients with Reduced Left Ventricular Ejection Fraction Hydralazine and Nitrate Combination A combination of hydralazine and a nitrate might be reasonable in pts with symptoms of HF and reduced LVEF who cannot be given an ACE inhibitor or ARB because of drug intolerance, hypotension, or renal insufficiency . NO CHANGE
20. Patients with Reduced Left Ventricular Ejection Fraction Long-term use of an infusion of a positive inotropic drug may be harmful and is not recommended for pts with current or prior symptoms of HF and reduced LVEF, except as palliation for pts with end-stage HF who cannot be stabilized with standard medical treatment. Infusion of Positive Inotropic Drugs NO CHANGE
22. Patients with Heart Failure and Normal Left Ventricular Ejection Fraction Physicians should control systolic and diastolic hypertension in pts with HF and normal LVEF, in accordance with published guidelines. Physicians should control ventricular rate in pts with HF and normal LVEF and atrial fibrillation. Physicians should use diuretics to control pulmonary congestion and peripheral edema in pts with HF and normal LVEF. Normal Left Ventricular Ejection Fraction NO CHANGE NO CHANGE NO CHANGE
23. Patients with Heart Failure and Normal Left Ventricular Ejection Fraction Coronary revascularization is reasonable in pts with HF and normal LVEF and CAD in whom symptomatic or demonstrable myocardial ischemia is judged to be having an adverse effect on cardiac function. Normal Left Ventricular Ejection Fraction NO CHANGE I IIa IIb III
24. Patients with Heart Failure and Normal Left Ventricular Ejection Fraction Restoration and maintenance of sinus rhythm in pts with atrial fibrillation and HF and normal LVEF might be useful to improve symptoms. The use of beta-blockers, ACEIs, ARBs, or CCB in pts with HF and normal LVEF and controlled hypertension might be effective to minimize symptoms of HF. The usefulness of digitalis to minimize symptoms of HF in pts with HF and normal LVEF is not well established. Normal Left Ventricular Ejection Fraction NO CHANGE NO CHANGE NO CHANGE
26. Patient with Refractory End-Stage Heart Failure (Stage D) Meticulous identification and control of fluid retention is recommended in pts with refractory end-stage HF. Referral for cardiac transplantation in potentially eligible pts is recommended for pts with refractory end-stage HF. Referral of pts with refractory end-stage HF to an HF program with expertise in the management of refractory HF is useful. Referral of Patients with Refractory End-Stage HF NO CHANGE NO CHANGE NO CHANGE
27. Patient with Refractory End-Stage Heart Failure (Stage D) Patients with refractory end-stage HF and ICD should receive information about the option to inactivate defibrillation. Options for end-of-life care should be discussed with the patient and family when severe symptoms in pts with refractory end-stage HF persist despite application of all recommended therapies. Severe Symptoms in Patients With Refractory End-Stage HF Consideration of an LVAD as permanent or “destination” therapy is reasonable in highly selected pts with refractory end-stage HF and an estimated 1-year mortality over 50% with medical therapy. NO CHANGE NO CHANGE NO CHANGE I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III B
28. Patient with Refractory End-Stage Heart Failure (Stage D) Continuous IV infusion of a inotropic agent may be considered for palliation of symptoms in pts with refractory end-stage HF. Continuous Intravenous Infusion of Positive Inotropic Agents Partial left ventriculectomy is not recommended in pts with non-ischemic cardiomyopathy and refractory end-stage HF. Routine intermittent infusions of vasoactive and inotropic agents are not recommended for pts with refractory end-stage HF. Modified NO CHANGE NO CHANGE I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III A
31. The Hospitalized Patient BNP or NT-proBNP should be measured in pts being evaluated for dyspnea in which the contribution of HF is not known. Final diagnosis requires interpreting these results in the context of all available clinical data and ought not to be considered a stand-alone test. ACS precipitating HF hospitalization should be promptly identified by ECG and troponin, and treated, as appropriate to the overall condition and prognosis of the patient. Patients Being Evaluated for Dyspnea New New
32.
33. The Hospitalized Patient Oxygen therapy should be administered to relieve symptoms related to hypoxemia. Whether the diagnosis of HF is new or chronic, pts who present with rapid decompensation and hypoperfusion associated with decreasing urine output and other manifestations of shock are critically ill and rapid intervention should be used to improve systemic perfusion. Oxygen Therapy and Rapid Intervention New New
34. The Hospitalized Patient Patients admitted with HF and with evidence of significant fluid overload should be treated with IV loop diuretics. Therapy should begin in ED or OPD without delay, as early intervention may be associated with better outcomes for pts hospitalized with decompensated HF. If pts are already receiving loop diuretic therapy, the initial IV dose should equal or exceed their chronic oral daily dose. Urine output and signs and symptoms of congestion should be serially assessed, and diuretic dose should be titrated accordingly to relieve symptoms and to reduce extracellular fluid volume excess. Treatment with Intravenous Loop Diuretics New
35. The Hospitalized Patient Effect of HF treatment should be monitored with careful measurement of fluid intake and output; vital signs; body weight, determined at the same time each day; clinical signs and symptoms of systemic perfusion and congestion. Daily serum electrolytes, BUN, and creatinine should be measured during the use of IV diuretics or active titration of HF medications. Monitoring and Measuring Fluid Intake and Output New
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37. The Hospitalized Patient Invasive hemodynamic monitoring should be performed to guide therapy in pts who are in respiratory distress or with clinical evidence of impaired perfusion in whom the adequacy or excess of intracardiac filling pressures cannot be determined from clinical assessment. In pts with clinical evidence of hypotension associated with hypoperfusion and obvious evidence of elevated cardiac filling pressures (e.g., elevated jugular venous pressure; elevated PAWP), IV inotropic or vasopressor drugs should be administered to maintain systemic perfusion and preserve end-organ performance while more definitive therapy is considered . Preserving End-Organ Performance New New
38. The Hospitalized Patient In pts hospitalized with HF with reduced EF not treated with oral therapies known to improve outcomes, particularly ACE inhibitors or ARBs and beta-blocker therapy, initiation of these therapies is recommended in stable pts prior to hospital discharge. Initiation of beta-blocker therapy is recommended after optimization of volume status and successful discontinuation of IV diuretics, vasodilators, and inotropic agents. Beta-blocker therapy should be initiated at a low dose and only in stable pts. Particular caution should be used when initiating beta-blockers in pts who have required inotropes during their hospital course. New New
39. The Hospitalized Patient Urgent Cardiac Catheterization and Revascularization When pts present with acute HF and known or suspected acute myocardial ischemia due to occlusive coronary disease, especially when there are signs and symptoms of inadequate systemic perfusion, urgent cardiac catheterization and revascularization is reasonable where it is likely to prolong meaningful survival. New I IIa IIb III
40. The Hospitalized Patient In pts with evidence of severely symptomatic fluid overload in the absence of systemic hypotension, vasodilators such as IV NTG, nitroprusside or neseritide can be beneficial when added to diuretics and/or in those who do not respond to diuretics alone. Severe Symptomatic Fluid Overload New I IIa IIb III
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42. The Hospitalized Patient Ultrafiltration is reasonable for pts with refractory congestion not responding to medical therapy. IV inotropic drugs such as dopamine, dobutamine or milrinone might be reasonable for those pts presenting with documented severe systolic dysfunction, low BP and evidence of low cardiac output, with or without congestion, to maintain systemic perfusion and preserve end-organ performance. Ultrafiltration and Intravenous Inoptropic Drugs New New I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III B