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Coronary Risk Stratification of Chest Pain


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761. Guidelines for the Prevention of Stroke in Women

the appropriate prevention strategies. Despite the importance of stroke in women, there has never been an American Heart Association (AHA)/American Stroke Association guideline dedicated to stroke risk and preven- tion in women. This endeavor is important because women differ from men in a multitude of ways, including genetic differences in immunity, 14,15 coagulation, 16,17 hormonal fac- tors, 18 reproductive factors including pregnancy and child- birth, and social factors, 5,9 all of which can influence (...) of their pregnancy (although only 1 study has suggested an increased risk for CVD after a pregnancy complicated by ges- tational diabetes; CVD was defined as a composite outcome of admission to hospital for acute MI, coronary bypass, coronary angioplasty, stroke, or carotid endarterectomy [CEA]). 180–182 A 2012 study of long-term risk for CVD reported that 18.2% of women with a history of preeclampsia versus 1.7% of women with uncomplicated pregnancies had a CVD event in 10 years (OR, 13.08; 95% CI, 3.38–85.5

2014 Congress of Neurological Surgeons

762. Squamous cell carcinoma

ulcers or inflammation), clinical size (> 2 cm), histological depth extension (beyond the subcutaneous tissue), histologic type (acantho- lytic, spindle, and desmoplastic subtypes), degree of differentiation (poorly differentiated or un- differentiated), recurrence, and immunosuppression. Rate of growth (rapidly versus slowly grow- ing tumors) has been also included in several risk stratification schemes. In addition, margin- positive re-excision (positive re-excision) of incompletely removed cSCC (...) margin of 5 mm even for low-risk tumors. For tumors, with histological thickness of > 6 mm or in tumors with high risk pathological features, e.g., high histological grade, subcutaneous invasion, perineural invasion, recurrent tumors, and/or tumors at high risk locations an extended margin of 10 mm is recom- mended. As lymph node involvement by cutaneous SCC increases the risk of recurrence and mortality, a lymph node ultrasound is highly recommended, particularly in tumors with high-risk

2014 European Dermatology Forum

763. Transitions of Care for Children with Special Health Care Needs

transferring from pediatric clinics experiencing increased episodes of pain and greater mortality, 86-88 premature deaths after transfer for young people with congenital heart disease, 63 and high rates of rejection and allograft loss among youth with transplants immediately following transfer. 42,63,81,89,90 10 Some subgroups of patients may be at increased risk for poorer outcomes. For example, a retrospective review of administrative and survey data of young adults with diabetes found that individuals (...) for young adults with special health care needs is to maximize lifelong functioning and potential through the provision of high-quality, developmentally appropriate health care services that continue uninterrupted as the individual moves from adolescence to adulthood.” 1 This process can be challenging, particularly for children and youth with special health care needs (CSHCN), defined as individuals having or being at risk of “a chronic physical, developmental, behavioral, or emotional condition

2014 Effective Health Care Program (AHRQ)

764. Unraveling The Mysteries of Prinzmetal?s Angina: What Is It And How Do We Diagnose It?

exercise capacity without ST segment changes, even at target heart rate. Given the history, a diagnosis of coronary artery spasm was suggested. The patient was given a trial of diltiazem therapy, with marked improvement in his chest pain episodes thereafter. In his landmark article in 1959, Dr. Myron Prinzmetal described a distinct type of “variant angina,” termed Prinzmetal’s angina. This chest pain tended to occur at rest (i.e. was not associated with increased cardiac work), waxed and waned (...) clinical risk score to aid in prognostic stratification of patients with coronary artery spasm [30]. A multicenter registry study of 1429 patients, median age 66 years, with a median follow-up period of 32 months, was performed. The primary endpoint was defined as major adverse cardiac events (MACE), including cardiac death, nonfatal myocardial infarction, hospitalization due to unstable angina pectoris, heart failure, and appropriate ICD shocks during the follow-up period that began at the date

2014 Clinical Correlations

765. General practice management of type 2 diabetes 2014-15

unwell. Patients with claudication need to be encouraged to continue physical activity. When advising on physical activity, the GP should explain: • the risks and benefits of physical activity for the individual • the importance of varying intensity of exercise levels • the importance of following the chest pain/discomfort and/or diabetes symptom management plan. 48 Clinical advice should be given to stop physical activity if the patient experiences symptoms of hypoglycaemia and to discontinue (...) with diabetes is to develop a whole-person assessment and discover which factors are affecting the patient’s health and quality of life. Many people with diabetes are dealing with or have other medical conditions (not necessarily related to diabetes) and family, work or financial stresses. Some are also dealing with lifestyle factors including poor sleep, smoking, lack of exercise and pain that will affect their priorities for management. People with type 2 diabetes are at risk of impaired emotional

2014 Clinical Practice Guidelines Portal

766. Multiple myeloma from diagnosis to treatment

with a two-week history of sudden onset lower back pain. X-ray revealed a thoracic vertebral crush fracture, and he was prescribed analgesia. He was previously well with no significant medical history, including no history of corticosteroid use, and denied a history of trauma. He presented to the emergency department four weeks later with ongoing back pain, and was prescribed additional analgesia and discharged. He re-presented to the emergency department within a week due to uncontrolled pain, and blood (...) gammopathy of undetermined significance (MGUS) and smouldering multiple myeloma (SMM): novel biological insights and development of early treatment strategies. Blood 2011;117:5573–81. 8. Kyle RA, Rajkumar SV. Criteria for diagnosis, staging, risk stratification and response assessment of multiple myeloma. Leukemia 2009;23:3–9. 9. Rajkumar SV. Multiple myeloma: 2013 update on diagnosis, risk-stratifica- tion, and management. Am J Hematol 2013;88:226–35 10. The International Myeloma Working Group. Criteria

2014 Clinical Practice Guidelines Portal

767. Royal Flying Doctor Service Western Operations Clinical manual part 1.Clinical guidelines

transport of ACS *May need to stage through regional centre Figure 6. Disposition and Prioritisation Interhospital Transfer NSTEMI +ve troponin 12 hours pain, arrhythmia, failure free, no GTN infusion No doctor required NSTEACS –ve troponin Pain, arrhythmia, heart failure, GTN infusion Doctor to accompany Primary Chest pain Doctor to accompany No pain No doctor required STEMI Doctor to accompany STEMI NSTEMI NSTEACS Coronary Care Unit Coronary Care Unit* High risk Low risk Regional Hospital (...) of the flight. This is vital to maintain supply. Medical Chest Items GTN spray (Item 190), Aspirin 300mg tabs (Item 62), Morphine 10mg amps (Item 188) References National Heart Foundation of Australia “Guidelines for Management of Acute Coronary Syndromes” 2006 MJA Vol 184 No. 8 Supplement. 2011 Addendum to National Heart Foundation of Australia, Cardiac Society of Australia and NewZealand “Guidelines for The Management of Acute Coronary Syndromes 2006” March 2011 Australian Resuscitation Council. Acute

2014 Clinical Practice Guidelines Portal

768. EANM procedural guidelines for radionuclide myocardial perfusion imaging with SPECT and SPECT/CT

for which he or she was referred, administration of the radiopharmaceutical should be considered despite the suboptimal increase in heart rate. Absolute contraindications to maximal, dynamic exercise are: ? Acute coronary syndrome, until the patient has been stable for at least 48 h and the risk is clinically assessed as acceptable ? Acute pulmonary embolism ? Severe pulmonary hypertension ? Acute aortic dissection ? Symptomatic severe aortic stenosis ? Hypertrophic, obstructive cardiomyopathy (...) including unstable angina, vasodilator stress test may be considered when the patient has been stable for at least 48 h and the clinically assessed risk is deemed acceptable In addition the following conditions contraindicate a vasodilator test: ? Severe chronic obstructive (in particular bronchospastic) pulmonary disease (COPD) ? Greater than first-degree heart block or sick sinus syndrome, without a pacemaker ? Symptomatic aortic stenosis and hypertrophic obstructive cardiomyopathy 30 ? Systolic blood

2015 European Association of Nuclear Medicine

769. A place for pre-hospital troponin testing? A literature review

and critical appraisal of a topic relevant to their future practice. This blog presents the abstract of a literature review on ‘the clinical value of pre-hospital point of care cardiac troponin assays in chest pain patients’. Other . Background and Aim The majority of patients presenting to the ambulance service with chest pain (CP) are transported to the emergency department (ED). However, few are subsequently diagnosed with a life-threatening cardiac pathology, leading to the speculation that this cohort (...) papers were found for inclusion and critically appraised using the . All six were deemed of adequate quality for incorporation in the . Results and Discussion The six studies included one randomised control trial (RCT) and five prospective cohort studies. The thematic analysis identified five themes: acute myocardial infarction (AMI) identification, risk stratification, field triage, accuracy and novel biomarkers. Themes and the interrelationships between themes were discussed in light of UK

2020 Students 4 Best Evidence

770. Potpourri

-hour strategy is similar to a 0/3-hour strategy. Overall, while the disposition of patients is likely to be more rapid from the 0/1 hour strategy, a greater proportion of patients ultimately fall into the “intermediate” zone requiring further observation and diagnostics. Certainly, combinations of hsTnI and other risk-stratification instruments ought to mean the majority of patients with straightforward chest pain presentations may be discharged from the Emergency Department. In this trial (...) observational study evaluated patients with a diagnosis of non-ST elevation acute coronary syndrome using coronary CT angiography prior to invasive coronary angiography. The good news: CT angiography was probably useful at excluding obstructive coronary disease. The bad news: nearly 70% of patients had a coronary stenosis identified on invasive angiography, so patient selection prior to CT angiography will be important to improve the value of using it as a screen to prevent invasive angiography. As we watch

2020 Emergency Medicine Literature of Note

771. Stress testing before discharge is not required for patients with low and intermediate risk of acute coronary syndrome after emergency department short stay assessment. (Abstract)

of chest pain and were diagnosed with non-ST segment elevation myocardial infarctions. Three patients (1%) had abnormal stress testing and were admitted to hospital from ESSU. On review, all three patients were high risk, according to The National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand guidelines.The present study showed that an ED short stay unit can effectively evaluate and manage patients with low and intermediate risk of ACS. The study suggests that patients (...) testing, patients were admitted to the emergency short stay unit (ESSU) for further evaluation using a chest pain protocol that included stress testing as the final risk stratification tool. The primary outcome measure was evidence of myocardial ischaemia at stress testing.Of the 300 patients enrolled and followed up, there were no deaths at 30 days and no myocardial infarcts in patients discharged from the short stay. Two patients (0.67%) had positive serum troponin levels at 6 h after the onset

2010 Emergency medicine Australasia

772. Usefulness of elevations in serum choline and free f(2)-isoprostane to predict 30-day cardiovascular outcomes in patients with acute coronary syndrome (Abstract)

in the determination of clinical outcomes. We evaluated patients presenting with chest pain. ACS was defined by symptoms of cardiac ischemia plus electrocardiographic changes or positive troponin I. Levels of serum troponin I, high sensitivity C-reactive protein, serum choline, and free F(2)-isoprostane were obtained. Patients were followed up for 30 days (n = 108) with determination of nonfatal myocardial infarction, congestive heart failure, need for revascularization, and death. Of the 108 patients, 26 had (...) Usefulness of elevations in serum choline and free f(2)-isoprostane to predict 30-day cardiovascular outcomes in patients with acute coronary syndrome Our objectives were to evaluate the prognostic value of several biomarkers in patients with acute coronary syndrome (ACS) through an evaluation of the 30-day clinical outcomes. Multiple biomarkers have emerged as potentially useful in risk stratification of ACS. Specifically, markers of vascular inflammation and oxidative stress might be helpful

2009 EvidenceUpdates

773. Exercise Standards for Testing and Training Full Text available with Trip Pro

, and during this time additional purposes for testing have evolved. Exercise testing now is used widely for the following: Detection of coronary artery disease (CAD) in patients with chest pain (chest discomfort) syndromes or potential symptom equivalents Evaluation of the anatomic and functional severity of CAD Prediction of cardiovascular events and all-cause death Evaluation of physical capacity and effort tolerance Evaluation of exercise-related symptoms Assessment of chronotropic competence (...) compromise Active endocarditis Symptomatic severe aortic stenosis Decompensated heart failure Acute pulmonary embolism, pulmonary infarction, or deep vein thrombosis Acute myocarditis or pericarditis Acute aortic dissection Physical disability that precludes safe and adequate testing Relative Contraindications Known obstructive left main coronary artery stenosis Moderate to severe aortic stenosis with uncertain relation to symptoms Tachyarrhythmias with uncontrolled ventricular rates Acquired advanced

2013 American Heart Association

774. Nonischemic Myocardial Disease with Clinical Manifestations (Ischemic Cardiomyopathy Already Excluded)

is an alternative to MRI if the patient has a pacemaker or other contraindication. ???? Arteriography coronary with ventriculography 3 ??? CT chest without IV contrast 2 ??? MRI chest without and with IV contrast 2 O MRI chest without IV contrast 2 O Tc-99m V/Q scan lung 2 ??? X-ray chest 1 ? FDG-PET /CT heart 1 ?? ?? CT coronary calcium 1 ??? US echocardiography transesophageal 1 O Arteriography pulmonary 1 ???? Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate (...) function and morphology without IV contrast 7 O CT heart function and morphology with IV contrast 3 This procedure is an alternative to MRI if the patient has a pacemaker or other contraindication. ???? FDG-PET /CT heart 3 ? ??? CTA chest with IV contrast 2 ??? MRI chest without IV contrast 2 O X-ray chest 1 ? CT chest without IV contrast 1 ??? Tc-99m V/Q scan lung 1 ??? CT coronary calcium 1 ??? MRI chest without and with IV contrast 1 O Arteriography pulmonary 1 ???? Rating Scale: 1,2,3 Usually

2013 American College of Radiology

775. Clinical Practice Guidelines for the Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Patient

folate, homocysteine, methylmalonic acid optional), and 25-vitamin D (vitamins A and E optional); consider more extensive testing in patients undergoing malabsorptive procedures based on symptoms and risks ü Cardiopulmonary evaluation with sleep apnea screening (ECG, CXR, echocardiography if cardiac disease or pulmonary hypertension suspected; DVT evaluation if clinically indicated) ü GI evaluation (H pylori screening in high-prevalence areas; gallbladder evaluation and upper endoscopy if clinically (...) and physical findings (Grade D). r18(29-31). Noninvasive cardiac testing beyond an electrocardiogram is determined on the basis of the indi- vidual risk factors and findings on history and physical examination (Grade b). Patients with known heart disease may require a formal cardiology consultation before bar- iatric surgery (Grade D). Patients at risk for heart disease should undergo evaluation for perioperative b-adrenergic blockade (Grade A; beL 1). r19(32/33)-r. In patients considered for bariatric

2013 American Association of Clinical Endocrinologists

776. Evidence-Based Guideline: Diagnosis and Treatment of Limb-Girdle and Distal Dystrophies

, and associated manifestations (Level B). Clinicians should refer newly diagnosed patients with an LGMD subtype and high risk of cardiac complications for cardiology evaluation even if they are asymptomatic from a cardiac standpoint (Level B). In LGMD patients with a known high risk of respiratory failure, clinicians should obtain periodic pulmonary function testing (Level B). Clinicians should refer patients with muscular dystrophy to a clinic that has access to multiple specialties designed specifically (...) , conduction defects, and dilated cardiomyopathy) were common and may be the only presenting feature of laminopathy. Pacemakers or intracardiac defibrillators were commonly implanted because of arrhythmias and the risk of sudden cardiac death. Cardioembolic stroke occurred because of associated arrhythmias. Many patients also required cardiac transplantation because of congestive heart failure (CHF) from dilated cardiomyopathy. 28 CK levels were normal or slightly elevated—most series had a CK average

2013 American Association of Neuromuscular & Electrodiagnostic Medicine

777. Management of Acute Pancreatitis

increase the risk of AP in patients with anatomic anomalies, such as pancreas divisum ( 48 ). However, the role of genetic testing in AP has yet to be determined, but may be useful in patients with more than one family member with pancreatic disease ( 34 ). Individuals with IAP and a family history of pancreatic diseases should be referred for formal genetic counseling. INITIAL ASSESSMENT AND RISK STRATIFICATION Recommendations 1. Hemodynamic status should be assessed immediately upon presentation (...) such as volume overload, pulmonary edema, and abdominal compartment syndrome ( 91 ). Measurement of the central venous pressure via a centrally placed catheter is most commonly used to determine volume status in this setting. How- ever, data indicate that the intrathoracic blood volume index may have a better correlation with cardiac index than central venous pressure. Measurement of intrathoracic blood volume index may therefore allow more accurate assessment of volume status for patients managed

2013 American College of Gastroenterology

778. Long-term Cardiovascular Toxicity in Children, Adolescents, and Young Adults Who Receive Cancer Therapy: Pathophysiology, Course, Monitoring, Management, Prevention, and Research Directions Full Text available with Trip Pro

survivors diagnosed in childhood or young adulthood who had received >35 Gy of cardiac radiation. All had evidence of radiation-induced cardiac damage, and 6 had at least 1 coronary artery with severe stenosis. Since these early studies, the incidence and risk factors of cardiovascular disease (CVD) have been studied intensely, as described in the present article. Indeed, cardiac-specific disease is the most common noncancer cause of death among long-term childhood cancer survivors (...) cardiomyopathy by testing lower cumulative doses and alternative dosing schedules and methods of administration, , as well as by adding potentially cardioprotective agents. Similarly, to reduce the risk of cardiac disease and second malignant neoplasms (eg, breast cancer), the use, dose, and volume of radiation to the heart has decreased substantially in frontline trials for children with hematological and low-stage, biologically favorable solid malignancies. Current therapy for childhood malignancies has

2013 American Heart Association

779. CIRSE Quality Assurance Guidelines for the Endovascular Treatment of Occlusive Lesions of the Subclavian and Innominate Arteries

in 29% of the patients [6- 10]. These figures reflect the extent and severity of atherosclerotic vascular disease, with two thirds of the patient population having multiple supra-aortic and coronary lesions. Because of their comorbidity, these patients have a high surgical risk, which is responsible for the increased morbidity and mortality rates associated with surgical reconstructions. In 1956 Davis et al. performed the first trans-thoracic innominate artery endarterectomy [11], and prosthetic (...) , Schillinger S, Ahmadi R, Minar E. Risk stratification for subclavian artery angioplasty: is there an increased rate of restenosis after stent implantation? J Endovasc Ther. 2001; 8:550-557 6) Kieffer E, Sabatier J, Koskas, et al. Atherosclerotic innominate artery occlusive disease: early and long-term results of surgical reconstructions. J Vasc Surg. 1995; 2: 326-337 7) Berguer R, Monasch MD, Kline RA. Transthoracic repair of innominate and common carotid artery disease: Immediate and long-term outcome

2013 Cardiovascular and Interventional Radiological Society of Europe

780. Clinical Practice Guidelines for Antimicrobial Prophylaxis in Surgery Full Text available with Trip Pro

or clean-contaminated Cefazolin, ampicillin-sulbactam Clindamycin, vancomycin C Type of Procedure Recommended Agents , Alternative Agents in Pts Withβ-Lactam Allergy Strength of Evidence Cardiac Coronary artery bypass Cefazolin, cefuroxime Clindamycin, vancomycin A Cardiac device insertion procedures (e.g., pacemaker implantation) Cefazolin, cefuroxime Clindamycin, vancomycin A Ventricular assist devices Cefazolin, cefuroxime Clindamycin, vancomycin C Thoracic Noncardiac procedures, including lobectomy (...) Clindamycin, vancomycin A Heart, lung, heart-lung transplantation Heart transplantation Cefazolin Clindamycin, vancomycin A (based on cardiac procedures) Lung and heart-lung transplantation , Cefazolin Clindamycin, vancomycin A (based on cardiac procedures) Liver transplantation , Piperacillin-tazobactam, cefotaxime + ampicillin Clindamycin or vancomycin + aminoglycoside or aztreonam or fluoroquinolone – B Pancreas and pancreas-kidney transplantation Cefazolin, fluconazole (for patients at high risk

2013 Infectious Diseases Society of America

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