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41. Cardiovascular Disease: Primary Prevention

ASCVD shared decision making tool in Epic. No shared decision making tool. Atorvastatin and rosuvastatin are now the preferred statins for primary prevention. Simvastatin was the preferred statin for primary prevention. Annual LDL monitoring is no longer required for people on a statin or with diabetes. Annual LDL monitoring was recommended for all patients on a statin. Non-fasting lipid panel is now the preferred cholesterol test. Fasting lipoprotein panel or direct LDL cholesterol were (...) the preferred cholesterol tests. Updated blood pressure targets: • 190 mg/dL, or diabetes. • Aspirin not recommended for patients with 190 mg/dL. • Statins not recommended for patients with 50%. • Cerebrovascular disease, such as transient ischemic attack, ischemic stroke, and carotid artery stenosis > 50%. • Peripheral artery disease, such as claudication. • Aortic atherosclerotic disease, such as abdominal aortic aneurysm and descending thoracic aneurysm. Primary prevention refers to the effort to prevent

2018 Kaiser Permanente Clinical Guidelines

43. Patients Hospitalized with Heart Failure: Risk Assessment, Management, and Clinical Trajectory

College of Physicians. Rheumatologic diseases Treat according to current guidelines, recognize that some biological agents may have cardiotoxicity or adverse effects in HF patients. 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis Amyloidosis Screen for cardiac or systemic amyloidosis with or without polyneuropathy, with genetic testing as appropriate; consider treatment for ATTR and AL. Guidelines on the management of AL amyloidosis Cancer Assess for cardiac (...) TRAJECTORY CHECK The near-term clinical trajectory during hospitalization represents responsiveness to therapy in terms of clinical HF symptoms and signs and laboratory and diagnostic tests. This trajectory helps de?ne the next steps for management, care coordination, health outcomes risk and prognosis, and disposition. We have also highlighted a long-term trajectory assessment as a speci?c evaluation of progress toward resolution of symptoms and signs of congestion, ade- quacy of perfusion, stability

2019 American College of Cardiology

44. Management of Acute ST Segment Elevation Myocardial Infarction (STEMI) – (4th Edition)

with chest pain or chest pain equivalent, a 12 lead ECG should be done and interpreted 0.5 mm (= 1 mm in men 95% as a single test on admission and almost 100% when repeated after 3 hours. 26 Sex-dependent values are recommended for hs-troponin assays. 27-29 MANAGEMENT OF ACUTE ST SEGMENT ELEVATION MYOCARDIAL INFARCTION (STEMI) 2019 50 CK-MB (measured by mass assay) is the next best alternative. It is less tissue- specific than troponins and values differ between the gender. The criterion most commonly (...) grounds, a = 20% increase in the value of either troponins or CK-MB between 2 samples 3-6 hours apart supports the diagnosis. 29-31 To ensure the reliability of these tests, each individual laboratory should maintain high quality laboratory practice and confirm the range of reference values in their specific setting. Total CK measurement is also not recommended owing to its poor specificity and large distribution in skeletal muscles. 29MANAGEMENT OF ACUTE ST SEGMENT ELEVATION MYOCARDIAL INFARCTION

2019 Ministry of Health, Malaysia

45. Management of Heart Failure (4th Edition)

Practice Guidelines, Ministry of Health Malaysia and key health personnel in the major hospitals of the Ministry of Health and the private sector for review and feedback.8 Clinical Questions Addressed: There were several topics and subtopics that were formulated addressing the diagnosis and management of HF. For diagnosis: In a person presenting with shortness of breath: ? What features in the history and clinical examination would make one suspect this patient is having a HF? ? What diagnostic tests (...) (by either CABG or PCI) should be considered in patients with HF and suitable coronary anatomy. Key Recommendation # 10: ? In managing patients with HFpEF: ? Hypertension is an important cause and should be treated according to guidelines. ? Treat volume overload with diuretics ? Manage comorbidities.28 Flow Chart I: Algorithm for the Diagnosis of Heart Failure or LV Dysfunction * Section 6, Page 39 Tests Normal but clinical suspicion is high Echocardiography TREAT ACCORDINGLY Tests Abnormal Tests

2019 Ministry of Health, Malaysia

46. 2019 HRS expert consensus statement on evaluation, risk stratification, and management of arrhythmogenic cardiomyopathy (Full text)

, Treatments, and Diagnostic Testing in Patient Care.* Reproduced with permission of the American College of Cardiology and the American Heart Association. x 2 Halperin, J.L., Levine, G.N., Al-Khatib, S.M. et al. Further evolution of the ACC/AHA clinical practice guideline recommendation classification system: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation . 2016 ; 133 : 1426–1428 | | | ---- | ---- Figure 2 Algorithm (...) Modified Task Force Criteria for arrhythmogenic right ventricular cardiomyopathy (ARVC) showing the diagnostic categories for major and minor criteria according to the 2010 ARVC Task Force Criteria. These criteria are sensitive and specific in differentiating patients with ARVC from control populations but have not been adequately tested in relation to other arrhythmogenic cardiomyopathies (ACMs) with overlapping phenotypes (eg, cardiac sarcoidosis, myocarditis). x 48 Cox, M.G., van der Smagt, J.J

2019 International Society for Heart and Lung Transplantation PubMed abstract

47. Treatment of Diabetes in Older Adults (Full text)

|⊕⊕⊕⊕) Technical remark: The measurement of HbA1c may be inaccurate in some people in this age group because of comorbidities that can affect the lifespan of red blood cells in the circulation. Although the optimal screening frequency for patients whose initial screening test is normal remains unclear, the writing committee advocates repeat screening every 2 years thereafter. As with any health screening, the decision about diabetes and prediabetes screening for an individual patient depends on whether some (...) action will be taken as a result and the likelihood of benefit. For example, such screening may not be appropriate for an older patient with end-stage cancer or organ system failure. In these situations, shared decision-making with the patient is recommended. 2.2 In patients aged 65 years and older without known diabetes who meet the criteria for prediabetes by fasting plasma glucose or HbA1c, we suggest obtaining a 2-hour glucose post–oral glucose tolerance test measurement. (2|⊕⊕⊕O) Technical

2019 The Endocrine Society PubMed abstract

48. Primary Prevention of ASCVD and T2DM in Patients at Metabolic Risk (Full text)

of blood pressure, waist circumference, fasting lipid profile, and blood glucose. Individuals identified at metabolic risk should undergo 10-year global risk assessment for ASCVD or coronary heart disease to determine targets of therapy for reduction of apolipoprotein B–containing lipoproteins. Hypertension should be treated to targets outlined in this guideline. Individuals with prediabetes should be tested at least annually for progression to diabetes and referred to intensive diet and physical (...) glucose, or 2-hour glucose with a second test for confirmation using a new blood sample. Testing for additional biological markers ( e.g., high-sensitivity C-reactive protein) associated with metabolic risk should be limited to subpopulations. This recommendation is specifically for adults aged 40 to 75 years, those for whom the interventions have the greatest impact and evidence for efficacy. This does not restrict screening for appropriate individuals outside of this age range, especially those who

2019 The Endocrine Society PubMed abstract

49. BTS/SIGN British Guideline on the Management of Asthma

Acute asthma 8 2.8 Difficult asthma 9 2.9 Asthma in pregnancy 9 2.10 Occupational asthma 9 3 Diagnosis 10 3.1 Definition and overarching principles 10 3.2 Predictive value of individual symptoms, signs and diagnostic tests 11 3.3 Practical approach to diagnosis 20 3.4 Organisation of diagnostic services 28 3.5 Wheezing in preschool children and the future risk of developing persistent asthma 29 4 Monitoring asthma 30 4.1 Targeting care 31 4.2 Monitoring current asthma symptom control 31 4.3 (...) . The grade of recommendation relates to the strength of the supporting evidence on which the recommendation is based. It does not reflect the clinical importance of the recommendation. 2.1 Diagnosis C Compare the results of diagnostic tests undertaken whilst a patient is asymptomatic with those undertaken when a patient is symptomatic to detect variation over time. D Carry out quality-assured spirometry using the lower limit of normal to demonstrate airway obstruction, provide a baseline for assessing

2019 British Thoracic Society

51. Atrial Fibrillation (Focused Update)

by the writing committee on the basis of the systematic review are marked “ SR ”. Guideline-Directed Management and Therapy The term guideline-directed management and therapy encompasses clinical evaluation, diagnostic testing, and both pharmacological and procedural treatments. For these and all recommended drug treatment regimens, the reader should confirm dosage with product insert material and evaluate for MANUSCRIPT ACCEPTED ACCEPTED MANUSCRIPT January CT, et al. 2019 Focused Update on Atrial (...) , and consistency of data from clinical trials and other sources (Table 1) (P-5). Glenn N. Levine, MD, FACC, FAHA Chair, ACC/AHA Task Force on Clinical Practice Guidelines MANUSCRIPT ACCEPTED ACCEPTED MANUSCRIPT January CT, et al. 2019 Focused Update on Atrial Fibrillation Page 7 Table 1. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care* (Updated August 2015) MANUSCRIPT ACCEPTED ACCEPTED MANUSCRIPT January CT, et al

2019 American College of Cardiology

52. AIM Clinical Appropriateness Guidelines for Joint Surgery

osteophytes, joint subluxation, avascular necrosis or bone on bone articulations. The degree of joint space narrowing should also be noted. Tobacco Cessation – Adherence to a tobacco-cessation program resulting in abstinence from tobacco for at least six (6) weeks prior to surgery is recommended. Documentation of nicotine-free status by laboratory testing (e.g., cotinine level or carboxyhemoglobin) is recommended. After six (6) weeks of tobacco cessation, labs should be performed with ample time afforded (...) , adherence to a tobacco-cessation program resulting in abstinence from tobacco for at least six (6) weeks prior to surgery is recommended. Documentation of nicotine-free status by laboratory testing (e.g., cotinine level or carboxyhemoglobin) is recommended. After six (6) weeks of tobacco cessation, labs should be performed with ample time afforded to submit this confirmation and complete the prior authorization process. Acute Full Thickness Tear All of the following are required: ? Traumatic injury

2019 AIM Specialty Health

53. Extremity imaging

Administrative Guidelines 6 Ordering of Multiple Studies 6 Simultaneous Ordering of Multiple Studies 6 Repeated Imaging 6 Pre-Test Requirements 7 History 7 Imaging of the Extremities 8 General Information/Overview 8 Scope 8 Technology Considerations 8 Definitions 8 Clinical Indications 10 Congenital and Developmental Conditions 10 Blount disease (Pediatric only) 10 Congenital anomalies of the lower extremity (Pediatric only) 10 Congenital anomalies of the upper extremity (Pediatric only) 11 Coxa vara (...) on persistent symptoms with no clinical change, treatment, or intervention since the previous study ? Repeated imaging of the same anatomical area by different providers for the same member over a short period of time Imaging of the Extremities Copyright © 2019. AIM Specialty Health. All Rights Reserved. 7 Pre-Test Requirements Critical to any finding of clinical appropriateness under the guidelines for specific imaging exams is a determination that the following are true with respect to the imaging request

2019 AIM Specialty Health

54. Statin Safety and Associated Adverse Events: A Scientific Statement From the American Heart Association (Full text)

to the pharmacological properties of the drug. Most clinical trials report the numbers of patients stopping the study medication because of any adverse event. The difference between the test agent and placebo is a good measure of the overall tolerability of the agent, provided that the blind remains secure throughout the trial. 1.2. Randomized Controlled Trials In the evaluation of the safety of a drug used long term, the most reliable data are derived from properly designed and conducted large, long-term, double (...) -blind, placebo-controlled randomized trials. The great advantage of this form of investigation is that bias is controlled by random allocation to treatment. There can still be random error, and sometimes other issues within the control of the investigator such as inadequate follow-up or ineffective blinding, but in a well-planned and executed RCT, the results are determined solely by allocation to the test treatment or the control. Most statin RCTs, especially the largest of such trials, were

2019 American Gastroenterological Association Institute PubMed abstract

56. European Guidelines (S1) on the use of high-dose intravenous immunoglobulin in dermatology

plasma, viral safety issues, methods of biological and pharmacological characterization and the testing of end products for clinical efficacy. The national authorities are responsible for authorizing the preparations, in that they carry out testing and define from which countries blood and plasma may be obtained. The national authorities are also responsible for the regular inspection of the manufacturing process and for virological testing, as well as for the approval of any changes (...) processing includes several independent process steps for virus inactivation/removal. A range of both enveloped and non-enveloped model viruses 4 are used to spike the test preparations in order to quantify and validate the log reduction in virus of each individual step in the process. In addition to the antiviral properties of the manufacturing processes there are a number of dedicated steps for virus inactivation/removal which vary between manufacturers. For each batch of immunoglobulin manufactured

2019 European Dermatology Forum

57. Evaluation and Management of the Child and Adult With Fontan Circulation: A Scientific Statement From the American Heart Association (Full text)

of knowledge on the Fontan circulation and its consequences. A proposed surveillance testing toolkit provides recommendations for a range of acceptable approaches to follow-up care for the patient with Fontan circulation. Gaps in knowledge and areas for future focus of investigation are highlighted, with the objective of laying the groundwork for creating a normal quality and duration of life for these unique individuals. As ever-greater numbers of patients with single-ventricle types of congenital heart (...) and peak oxygen consumption on exercise testing, or chronotropic incompetence, identifies patients at increased risk for early mortality. , These studies emphasize the importance of serial exercise testing in older patients with Fontan circulation and highlight a potential role for consideration of early atrial rate-responsive pacing to augment the heart rate response to exertion. Some surgical studies have reported that the presence of a pacemaker is a risk factor for death, transplantation, or Fontan

2019 American Heart Association PubMed abstract

58. Heart Failure in the Era of Precision Medicine: A Scientific Statement From the American Heart Association

. doi: 10.1371/journal.pgen.1006034 Hershberger RE, Givertz MM, Ho CY, Judge DP, Kantor PF, McBride KL, Morales A, Taylor MRG, Vatta M, Ware SM . Genetic evaluation of cardiomyopathy: a clinical practice resource of the American College of Medical Genetics and Genomics (ACMG). Genet Med . 2018 ; 20:899–909. doi: 10.1038/s41436-018-0039-z Cirino AL, Seidman CE, Ho CY . Genetic testing and counseling for hypertrophic cardiomyopathy. Cardiol Clin . 2019 ; 37:35–43. doi: 10.1016/j.ccl.2018.08.003 Towbin (...) JA, McKenna WJ, Abrams DJ, Ackerman MJ, Calkins H, Darrieux FCC, Daubert JP, de Chillou C, DePasquale EC, Desai MY, et al. . 2019 HRS expert consensus statement on evaluation, risk stratification, and management of arrhythmogenic cardiomyopathy [published online May 9, 2019]. Heart Rhythm . doi: 10.1016/j.hrthm.2019.05.007. . Cirino AL, Harris S, Lakdawala NK, Michels M, Olivotto I, Day SM, Abrams DJ, Charron P, Caleshu C, Semsarian C, et al. . Role of genetic testing in inherited cardiovascular

2019 American Heart Association

59. Is there a role for DOAC level monitoring in clinical practice?

to have the clear advantage in terms of rapid, reliable, widely-available laboratory testing and drug reversal agents. For an anticoagulated patient presenting with an acute bleed, thromboembolic event, and/or a need for an urgent invasive procedure, the evidence and tools available to reliably assess levels of anticoagulation and reverse continue to buoy warfarin’s modern clinical relevance. A DOAC lab measurement analogous to prothrombin time (PT)/international normal ratio (INR) would be a valuable (...) -22 . Additionally, there are other scenarios where DOAC levels would be potentially useful such as with patients at extreme body weight, presence of interacting medications, and confirmation of chronic anticoagulation following initial loading period 10,13,18 . There are two types of tests in the situations outlined above that can help guide management for patients on DOACs: 1) a screening assay for when a clinician needs to determine quickly the presence or absence of the drug (e.g. prior

2019 Clinical Correlations

60. AACE/ACE Comprehensive Type 2 Diabetes Management Algorithm (Full text)

dyslipidemia (triglycerides >200 mg/dL and HDL-C <40 mg/dL) ( ). Niacin lowers apo B, LDL-C, and triglycerides in a dose-dependent fashion and is the most powerful lipid-modifying agent for raising HDL-C currently available ( ), although it may reduce cardiovascular events through a mechanism other than an increase in HDL-C ( ). Two trials designed to test the HDL-C–raising hypothesis (Atherothrombosis Intervention in Metabolic Syndrome with Low HDL/High Triglycerides: Impact on Global Health Outcomes [AIM (...) , and/or niacin to reduce triglyceride levels and to prevent pancreatitis. Blood glucose control is also essential for triglyceride reduction. While no large clinical trials have been designed to test this objective, observational data and retrospective analyses support long-term dietary and lipid management of hypertriglyceridemia for prophylaxis against or treatment of acute pancreatitis ( , ). T2D Pharmacotherapy In patients with T2D, achieving the glucose and A1C targets requires a nuanced approach

2019 American Association of Clinical Endocrinologists PubMed abstract

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