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Coronary Risk Stratification of Chest Pain

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121. Gut microbiota-dependent trimethylamine N-oxide in acute coronary syndromes: a prognostic marker for incident cardiovascular events beyond traditional risk factors. Full Text available with Trip Pro

, the prognostic value of TMAO in the setting of acute coronary syndromes (ACS) remains unknown.We investigated the relationship of TMAO levels with incident cardiovascular risks among sequential patients presenting with ACS in two independent cohorts. In the Cleveland Cohort, comprised of sequential subjects (n = 530) presenting to the Emergency Department (ED) with chest pain of suspected cardiac origin, an elevated plasma TMAO level at presentation was independently associated with risk of major adverse (...) patients presenting with chest pain predict both near- and long-term risks of incident cardiovascular events, and may thus provide clinical utility in risk stratification among subjects presenting with suspected ACS.Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For permissions, please email: journals.permissions@oup.com.

2017 European Heart Journal

122. Transcatheter Aortic Valve Implantation in Patients With Severe, Symptomatic Aortic Valve Stenosis at Intermediate Surgical Risk

is an open-heart surgery that requires cardiopulmonary bypass (using a heart– lung machine) and is performed under general anesthesia. 2 Patients undergoing SAVR who require revascularization may be considered for SAVR combined with a coronary artery bypass graft (CABG). March 2020 Ontario Health Technology Assessment Series; Vol. 20: No. 2, pp. 1–121, March 2020 11 In North America, a patient’s surgical risk is assessed by a multidisciplinary heart team informed by the Society of Thoracic Surgeons (STS (...) (the heart’s lower left chamber) and the aorta (the main artery that distributes blood from the heart to the body). Aortic valve stenosis is a narrowing of the aortic valve, which prevents it from opening completely and reduces blood flow from the heart. This causes the heart to work harder to pump blood to the body and may lead to symptoms such as chest pain, shortness of breath, and fatigue. Surgical aortic valve replacement (SAVR) is the usual treatment for people who have severe, symptomatic aortic

2020 Health Quality Ontario

123. Chronic Heart Failure in Congenital Heart Disease Full Text available with Trip Pro

cardiac complications, including heart failure (HF). HF management in the setting of CHD is challenged by the wide range of ages at which HF occurs, the heterogeneity of the underlying anatomy and surgical repairs, the wide spectrum of HF causes, the lack of validated biomarkers for disease progression, the lack of reliable risk predictors or surrogate end points, and the paucity of evidence demonstrating treatment efficacy. The purposes of this statement are to review the literature pertaining (...) . Although nuances and specific details may be controversial, the broad definition from the Heart Failure Society of America guidelines states the following: “In physiologic terms, HF is a syndrome characterized by either or both pulmonary and systemic venous congestion and/or inadequate peripheral oxygen delivery, at rest or during stress, caused by cardiac dysfunction.” The definition of chronic HF in this document concurs with that of the European Society of Cardiology guidelines, which emphasize

2016 American Heart Association

124. Heart Failure Full Text available with Trip Pro

in patients with either a suspected diagnosis or new diagnosis of heart failure, to assess cardiac rhythm, QRS duration, and the presence of underlying conditions such as myocardial ischaemia or LV hypertrophy. Strong FOR Low A chest X-ray is recommended in patients with either a suspected diagnosis or new diagnosis of heart failure, to detect signs of pulmonary congestion and to identify alternative cardiac or non-cardiac causes for the patient’s symptoms. Strong FOR Very low Plasma B-type natriuretic (...) . Strong FOR Low Invasive coronary angiography should be considered in patients with heart failure associated with refractory angina, resuscitated cardiac arrest, sustained ventricular arrhythmias, or with evidence of ischaemic heart disease on other investigations, or an intermediate-to-high pretest probability for coronary artery disease, to determine the need for coronary revascularisation. Strong FOR Low Either computed tomography (CT) coronary angiography or cardiac magnetic resonance imaging (CMR

2018 Cardiac Society of Australia and New Zealand

125. Stable Coronary Artery Disease (2nd Edition)

testing 56 7.5.1 Coronary Calcium (CAC) Score 56 7.5.2 Computed Tomography Angiography (CTA) 57 7.5.3 Risk Stratification by Invasive Coronary Angiography (ICA) 58 7.5.4 Risk assessment by Physiological Assessment of the functional severity of coronary lesions 58 7.6 Guidelines for referral to a tertiary cardiac center 60 8. MANAGEMENT (Fig 2, pg 25) 62 8.1 Behavioural modification therapy (BMT) 63 8.1.1 Patient education 63 8.1.2 Diet 63 8.1.3 Physical activity 63 8.1.4 Smoking Cessation 67 8.1.5 (...) of Stable CAD by Anatomic testing 56 7.5.1 Coronary Calcium (CAC) Score 56 7.5.2 Computed Tomography Angiography (CTA) 57 7.5.3 Risk Stratification by Invasive Coronary Angiography (ICA) 58 7.5.4 Risk assessment by Physiological Assessment of the functional severity of coronary lesions 58 7.6 Guidelines for referral to a tertiary cardiac center 60 8. MANAGEMENT (Fig 2, pg 25) 62 8.1 Behavioural modification therapy (BMT) 63 8.1.1 Patient education 63 8.1.2 Diet 63 8.1.3 Physical activity 63 8.1.4

2018 Ministry of Health, Malaysia

126. Sirens to Scrubs: Acute Coronary Syndrome – Beyond Door-to-Balloon

, depending on where you read this from) is not a diagnostic tool so do not use it as such. Pain caused by ACS may be refractory to nitroglycerin therapy, whilst the pain caused by oesophageal spasm (for example), can be relieved with nitrates. 12 13 For a good review of the positive and negative predictive values of clinical exam findings for myocardial infarction, see the JAMA Rational Clinical Examination series, What if the ECG is Normal!? Time for risk stratification! Scores such as the HEART Score (...) Sirens to Scrubs: Acute Coronary Syndrome – Beyond Door-to-Balloon Sirens to Scrubs: Acute Coronary Syndromes, Part One - Beyond Door-to-Balloon - CanadiEM Sirens to Scrubs: Acute Coronary Syndromes, Part One – Beyond Door-to-Balloon In , by Richard Armour September 27, 2018 Emergency Medical Services receives a 9-1-1 call for a 52-year-old female suffering with chest pain. As Paramedics rush to the scene, they discuss the physiology of Acute Coronary Syndromes… About Sirens to Scrubs Sirens

2018 CandiEM

127. Adults With Congenital Heart Disease

innominate vein, and right upper pulmonary vein(s) connecting high on the superior vena cava. Long-term sequelae of anomalous pulmonary venous connections reflect the impact of right heart volume overload and are similar to the sequelae of ASDs. Surgical repair can be challenging as low-velocity venous flow imparts risk of thrombosis of the surgically operated vein. See Section 3.3 for recommendations on who should perform surgeries, cardiac catheterization, and other procedures in these patients (...) , the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline, was conducted from April 2014 to November 2014. Key search words included but were not limited to the following: adult congenital heart disease, anesthesia, aortic aneurysm, aortic stenosis, atrial septal defect, arterial switch operation, bradycardia, bicuspid aortic valve, cardiac catheterization, cardiac imaging, cardiovascular magnetic resonance, cardiac reoperation, cardiovascular surgery, chest

2018 American College of Cardiology

128. Management of Valvular Heart Disease Full Text available with Trip Pro

; MSCT = multislice computed tomography; PCI = percutaneous coronary intervention; TAVI = transcatheter aortic valve implantation; VHD = valvular heart disease. a Class of recommendation. b Level of evidence. c MSCT may be used to exclude CAD in patients who are at low risk of atherosclerosis. d Chest pain, abnormal non-invasive testing. e ≥50% can be considered for left main stenosis. 3.1.3.2 Cardiac catheterization The measurement of pressures and cardiac output or the assessment of ventricular (...) 3.1.2.1 Stress testing 2744 3.1.2.2 Cardiac magnetic resonance 2745 3.1.2.3 Computed tomography 2745 3.1.2.4 Cinefluoroscopy 2745 3.1.2.5 Biomarkers 2745 3.1.3 Invasive investigations 2745 3.1.3.1 Coronary angiography 2745 3.1.3.2 Cardiac catheterization 2746 3.1.4 Assessment of comorbidity 2746 3.2 Risk stratification 2746 3.3 Special considerations in elderly patients 2746 3.4 Endocarditis prophylaxis 2746 3.5 Prophylaxis for rheumatic fever 2746 3.6 Concept of the Heart Team and heart valve centres

2017 European Society of Cardiology

129. AIM Clinical Appropriateness Guidelines for Advanced Imaging of the Heart

? Patients awaiting solid organ transplantation who have not undergone evaluation for coronary artery disease within the preceding one (1) year Suspected coronary artery disease in symptomatic patients who have not had evaluation of coronary artery disease (MPI, stress echo, cardiac PET, coronary CTA or cardiac catheterization) within the preceding sixty (60) days ? Chest pain ? With intermediate or high pretest probability of CAD (Table 1); OR ? With low or very low pretest probability of CAD (Table 1 (...) ) and high risk of CAD (SCORE) ? Atypical symptoms: syncope, shortness of breath (dyspnea), neck, jaw, arm, epigastric or back pain, or sweating (diaphoresis) ? With moderate or high risk of CAD (SCORE) ? Other symptoms; palpitation, dizziness, lightheadedness, near syncope, nausea, vomiting, anxiety, weakness, fatigue, etc. ? With high risk of CAD (SCORE) ? Patients with any cardiac symptom who have diseases/conditions with which coronary artery disease commonly coexists such as: ? Diabetes mellitus

2018 AIM Specialty Health

130. Suspected New-Onset and Nonacute Heart Failure

changes in static images (ie, CTA; or, without the use ACR Appropriateness Criteria ® 6 Suspected New-Onset and Known Nonacute Heart Failure of intravenous contrast for coronary calcification, calcium scoring for risk stratification). Delayed imaging helps further the detection of fibrous or fatty tissue replacement in cardiac structures (eg, LV wall) [26,29,30]. Despite marked improvements, prevailing concerns about potential complications are still limitations to the use of this modality (...) ???? Tc-99m SPECT/CT MPI rest and stress Usually Not Appropriate ???? US echocardiography transthoracic stress Usually Not Appropriate O Radiography chest Usually Not Appropriate ?ACR Appropriateness Criteria ® 3 Suspected New-Onset and Known Nonacute Heart Failure Variant 3: Confirmed new-onset heart failure with reduced ejection fraction of uncertain etiology: ischemic versus nonischemic. Procedure Appropriateness Category Relative Radiation Level CTA coronary arteries with IV contrast Usually

2018 American College of Radiology

131. Length of stay following percutaneous coronary intervention: An expert consensus document update from the society for cardiovascular angiography and interventions

imbalance, or ongoing pain, bleeding, ischemia, or dysrhythmia after the procedure. In addition, some patients may be considered higher risk for complications based on coronary anatomy, left ventricular dysfunction, procedural complexity, and comorbidities. Finally, there may be appropriate logistical reasons that require a patient to remain in the hospital overnight, such as procedures that end too late in the day for a safe discharge the same day, lack of transportation, or inadequate social support (...) shock/salvage 54 43 37 22 11 0 NYHA class within 2 weeks NYHA class IV NYHA class Cardiac arrest within 24 hr No Yes 0 13 BMI, body mass index; CVD, cerebrovascular disease; EF, ejection fraction; GFR, glomerular filtration rate; PAD, peripheral artery disease; NYHA, New York Heart Association. The very low rates of in‐hospital mortality and complications after elective PCI are reassuring for the development of SDD policies. The main challenge with risk scores is deciding how

2018 Society for Cardiovascular Angiography and Interventions

132. Cardiopulmonary Resuscitation in Infants and Children With Cardiac Disease Full Text available with Trip Pro

or de- velop new problems over time, with an increased risk of cardiac arrest. This population commonly develops myocardial dysfunction, arrhythmia, and unbalanced pulmonary and systemic circulation. Specific drugs and the indications for administration and dosing can differ for infants and children with heart disease. In addition, there are many variations of CHD, and the underlying physiological substrates can have a significant impact on systemic perfusion and pulmonary blood flow (PBF (...) Management Risk Factors for Cardiac Arrest and Death The following factors have been identified as contributing to early death in the neonate or infant with single ven- tricle: (1) anatomic diagnosis of HLHS, total anomalous pulmonary venous connection (TAPVC), and pulmonary atresia with intact ventricular septum with RV-dependent coronary circulation; (2) decreased ventricular function; (3) hemodynamically significant semilunar or atrio- ventricular valve insufficiency; and (4) comorbidities including

2018 American Heart Association

133. Chest pain: if it hurts a lot, is heart attack more likely? (Abstract)

Chest pain: if it hurts a lot, is heart attack more likely? In previous studies including patients with suspected cardiac chest pain, those who had acute myocardial infarction (AMI) reported more severe chest pain than those without AMI. However, many patients with AMI present with very mild pain or discomfort. We aimed to investigate whether peak pain severity, as reported by patients in the Emergency Department, has any potential role in the risk stratification of patients with suspected (...) cardiac chest pain.In this secondary analysis from a prospective diagnostic cohort study, we included patients presenting to the Emergency Department with suspected cardiac chest pain. Patients were asked to report their maximum pain severity using a 11-point numeric rating scale at the time of initial presentation. The primary outcome was a diagnosis of AMI, adjudicated by two independent investigators on the basis of reference standard (12 h) troponin testing.Of the 455 patients included

2014 European Journal of Emergency Medicine

134. Diagnostic importance of admission platelet volume indices in patients with acute chest pain suggesting acute coronary syndrome Full Text available with Trip Pro

be of benefit to detect chest pain resulting in MI from that of non-cardiac one, and also for risk stratification of patients who suffered from an acute chest discomfort.Copyright © 2014 Cardiological Society of India. Published by Elsevier B.V. All rights reserved. (...) Diagnostic importance of admission platelet volume indices in patients with acute chest pain suggesting acute coronary syndrome Acute coronary syndrome (ACS) is a challenging issue in cardiovascular medicine. Given platelet role in atherothrombosis, we sought to determine whether platelet indices can be used as diagnostic tests for patients who suffered from an acute chest discomfort.We prospectively enrolled 862 patients with an acute chest pain and 184 healthy matched controls. They were

2014 Indian heart journal

135. Admission glycaemia and its association with acute coronary syndrome in Emergency Department patients with chest pain. (Abstract)

Admission glycaemia and its association with acute coronary syndrome in Emergency Department patients with chest pain. This study aims to evaluate admission blood glucose level (BGL) in patients presenting to the emergency department (ED) as a risk factor for a major adverse cardiac event (MACE) on presentation and up to 30 days post discharge. Admission BGL is a prognostic indicator in patients with confirmed acute coronary syndrome (ACS). It is unclear if admission BGL improves the diagnosis (...) and stratification of patients presenting to the ED with suspected ACS.This study is an analysis of data collected from a prospective observational study. The study population consisted of ED patients from Brisbane, Australia and Christchurch, New Zealand. Patients were enrolled between November 2007 and February 2011. Admission BGL was taken as part of routine admission blood with fasting status unknown. The primary end point for this study was a MACE at presentation and up to 30 days post discharge. Logistic

2014 Emergency Medicine Journal

136. Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU Full Text available with Trip Pro

with preoperative anxiety or depression have a higher level of self-reported pain intensity ( ). One large cohort of 5,176 medical ICU adults reported the following baseline predictors of higher self-reported pain intensity during the ICU admission: younger age; need for support to conduct daily living activities; number of comorbidities such as cardiac and pulmonary diseases; depression; anxiety; and an expectation of a future poor quality of life ( ). Clinicians should make an effort to obtain information (...) , Nashville, TN. 9 Division of Sleep Medicine, Vanderbilt University Medical Center, Nashville, TN. 10 Division of Pulmonary and Critical Care, Brigham and Women’s Hospital and School of Medicine, Harvard University, Boston, MA. 11 Division of Anesthesiology, Perioperative Care and Pain Medicine, New York University Langone Health, New York, NY. 12 Division of Medicine, New York University Langone Health, New York, NY. 13 Division of Neurology, New York University Langone Health, New York, NY. 14 Division

2018 Society of Critical Care Medicine

137. Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications

frequently coexists with mental stress, characterized by a hypercoagulable state, chronic pain patients may be at an increased risk of coronary or cerebrovascular events after discontinuation of protective antiplatelet and anticoagulant medications. This underscores the importance of coordinating the perioperative handling of these medications with the prescribing cardiologist or neurologist. | Nonsteroidal Anti-inflammatory Drugs Nonsteroidal anti-inflammatory drugs inhibit prostaglandin production (...) NSAIDs. | Summary Recommendations for Non-ASA NSAIDs Non-ASA NSAIDs are used for pain control and, unlike ASA, are not required for cardiac and cerebral protection. Therefore, these drugs may be discontinued without negatively affecting cardiac and cerebral function. For interventional pain procedures where the bleeding risks and the consequences of hematoma development may be higher (eg, high-risk procedures; ) consideration should be given to discontinue these medications. Besides ibuprofen

2018 American Society of Regional Anesthesia and Pain Medicine

138. Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Chronic Pain Full Text available with Trip Pro

, and other mechanisms. Parameters such as heart rate, blood pressure, cardiac output, and myocardial oxygen consumption increase even with subanesthetic doses. In the pulmonary system, ketamine causes bronchodilation that appears to be due to circulating catecholamines. Pharyngeal and laryngeal reflexes are mostly preserved, as is respiratory function, and there are increased secretions. The speed of injection may play a role in maintenance of respiratory function, implying that subanesthetic infusions (...) in the setting of hypovolemia, septic shock, or pulmonary disease and have led some experts to recommend and utilize ketamine as a potential first-line treatment for battlefield injuries. The direct, dose-dependent negative inotropic effects on cardiac muscle are typically realized only in catecholamine depleted individuals (eg, long-term trauma or intensive care patients). The dissociative properties associated with ketamine are thought to result from the combination of reduced activation

2018 American Society of Regional Anesthesia and Pain Medicine

139. Low Risk Chest Pain Under Age 40

of the provider EKG shows no ST elevations or depressions Vital signs are stable (no hypotension) No history of known heart disease Cardiac blood tests (troponin or CK-MB), if performed, are negative (normal) Source Document: Christenson et al. A clinical prediction rule for early discharge of patients with chest pain. Ann Emerg Med. 2006;47(1):1–10. Cullen et al. Comparison of Three Risk Stratification Rules for Predicting Patients With Acute Coronary Syndrome Presenting to an Australian Emergency Department (...) . Heart, Lung, and Circulation 2013;22:844-851. Greenslade et al. Validation of the Vancouver Chest Pain Rule using troponin as the only biomarker. Am J Emerg Med. 2013 Jul;31(7):1103-7. Halpern et al. Cardiac risk factors and risk scores vs cardiac computed tomography angiography: a prospective cohort study for triage of ED patients with acute chest American Journal of Emergency Medicine 31 (2013) 1479–1485. Hess et al. Development of a clinical prediction rulefor 30-day cardiac events in emergency

2010 theNNT

140. Low Risk Chest Pain Over Age 40

reviewed In Other Words: After Only An Initial Biomarker: 1 in 80 will have a heart attack After A 2nd Set of Biomarkers (at 6 hours): 1 in 250 will have a heart attack Risk Assessment Criteria Low risk chest pain according to the judgment of the provider EKG shows no ST elevations or depressions Vital signs are stable (no hypotension) Cardiac blood tests (troponin or CK-MB), if performed, are negative (normal) No history of known coronary artery disease Source Document: Christenson et al. A clinical (...) prediction rule for early discharge of patients with chest pain. Ann Emerg Med. 2006;47(1):1–10. Cullen et al. The new Vancouver Chest Pain Rule using troponin as the only biomarker: an external validation study. Amer J Emerg Med. 2014;32(129-134) Cullen et al. Comparison of Three Risk Stratification Rules for Predicting Patients With Acute Coronary Syndrome Presenting to an Australian Emergency Department. Heart, Lung, and Circulation 2013;22:844-851. Goldstein et al. The CT-STAT (Coronary Computed

2010 theNNT

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