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McMurray Test

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101. Impact of Acarbose on Incident Diabetes and Regression to Normoglycemia in People With Coronary Heart Disease and Impaired Glucose Tolerance: Insights From the ACE Trial

trial participants in China who had impaired glucose tolerance (IGT) and coronary heart disease (CHD). Research design and methods: Participants were randomly assigned to acarbose or placebo and followed with four monthly fasting plasma glucose (FPG) tests and annual oral glucose tolerance tests. Incident diabetes was defined as two successive diagnostic FPG levels ≥7 mmol/L or 2-h plasma glucose (PG) levels ≥11.1 mmol/L while taking study medication or a masked adjudicated confirmation (...) ). Results: Incident diabetes was less frequent with acarbose compared with placebo (3.2 and 3.8 per 100 person-years, respectively; rate ratio 0.82 [95% CI 0.71, 0.94]; P = 0.005), with no evidence of differential effects within the predefined subgroups after accounting for multiple testing. Regression to normoglycemia occurred more frequently in those randomized to acarbose compared with placebo (16.3 and 14.1 per 100 person-years, respectively; 1.16 [1.08, 1.25], P < 0.0001). This effect was greater

2020 EvidenceUpdates

102. Clinical Practice Guidelines on Hypertension

. Grade D, Level 4 22 3 Evaluating high blood pressure No. Recommendation Grade, Level of Evidence CPG page no. 10 Routine clinical evaluation of a patient with elevated BP includes the following: 1. Clinical and family history 2. Full standard physical examination 3. Laboratory investigations, including: a) Urine analysis: Dipstick for hematuria/albumin, microscopic examination, and test for albuminuria b) Measurement of serum concentrations of electrolytes, creatinine, urea, fasting glucose (...) damage in hypertension. Journal of Hypertension. 1987; 5:93-8. 52 Investigators TS. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. New England Journal of Medicine. 1991; 325:293-302. 53 de Vries RJ, van Veldhuisen DJ, Dunselman PH. Efficacy and safety of calcium channel blockers in heart failure: focus on recent trials with second-generation dihydropyridines. American Heart Journal. 2000; 139:185-94. 54 Granger CB, McMurray

2017 Ministry of Health, Singapore

103. Should Beta Blockers be Used in Heart Failure with Preserved Ejection Fraction?

examined the role of beta-blockers in patients with heart failure, 95% of whom had a reduced ejection fraction. This investigation showed that the survival benefit for beta-blockers is associated with the magnitude of the reduction in heart rate but not the drug dosage [10]. Similarly, at least 3 large randomized control studies conducted in the United States, testing bisoprolol, carvedilol, and metoprolol in over 10,000 patients with HFrEF, have confirmed the [11]. In contrast, beta-blockers are more (...) of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines,” Journal of the American College of Cardiology, vol. 62, no. 16, pp. e147-e239, 2013. [8] J. J. V. McMurray, “Systolic heart failure,” New England Journal of Medicine, vol. 362, no. 3, pp. 228-238, 2010. [9] J. J. V. McMurray, S. Adamopoulos, S. D. Anker et al. , “ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012,” European

2017 Clinical Correlations

104. Optimization of Heart Failure Treatment

ejection fraction; HR¼ heart rate; NYHA¼ New York Heart Association. Yancy et al. JACC VOL. -,NO. -,2017 2017 Pathways for Optimization of Heart Failure Treatment -,2017:-–- 6Sacubitril/valsartan (7,8) was tested among patients with chronic HFrEF in a randomized controlled trial, PARADIGM HF (Prospective Comparison of ARNI with ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure). The trial enrolled patients withNYHAclassIItoIVsymptomswithanEF #40% (modi?ed to#35% 1year (...) barrier to care,particularly for ARNI and ivabradine therapy. In such cases, if all solutions are exhausted, optimizing care with the most ?nancially manageable program is recommended (see answer to Issue 7). Clinical Assessment Figure 4 details a reasonable strategy for patient evalua- tion and management following a diagnosis of HFrEF. AfterGDMT isinitiated andtitratedwiththe goal of FIGURE 4 Testing and Medication Titration Following Diagnosis of HFrEF BNP¼B-typenatriureticpeptide;CBC

2017 American College of Cardiology

105. Periprocedural Management of Anticoagulation in Patients With Nonvalvular Atrial Fibrillation

cannot be extrapolated to these populations. For all patients taking anticoagulant therapy for stroke prophylaxis in NVAF who are scheduled for a procedure, it is important to carefully review the medical history; medication list, including over-the-counter medications and any supplements and herbal prepara- tions; and laboratory test results to identify factors that may increase bleed risk. On the basis of these ?ndings and the type of procedure to be performed, the risks and bene?ts of TI should (...) be used if appropriate. For some patients, there may be a need to provide prophylactic doses of anticoagulation prior to the resumption of therapeutic anticoagulation. During TI of DOAC therapy, it is reasonable in these cases to use pro- phylactic doses of an LMWH or UFH starting 6 to 8 hours followingtheprocedureforVTEprophylaxisprovidedthat adequatehemostasishasbeenachieved(46).Inthesetting of NVAF, only dabigatran has been speci?cally tested at a prophylactic dose after low bleed-risk procedures

2017 American College of Cardiology

106. Management of Bleeding in Patients on Oral Anticoagulants

Measurement of DOACs When Specialized Assays are Available Drug Clinical Objective Exclude Clinically Relevant* Drug Levels Measure On-Therapy or Above On-Therapy Drug Levels Suggested Test Interpretation Suggested test Dabigatran Dilute TT ECT ECA Normal result probably excludes clinically relevant* levels Dilute TT ECT ECA Apixaban, edoxaban, or rivaroxaban Anti-Xa Absent chromogenic anti-Xa assay activity probably excludes clinically relevant* levels Anti-Xa† *The term “clinically relevant” refers (...) acid for trauma patients within the ?rst 3 hours of pre- sentation is associated with decreased bleeding and overall mortality, and should be considered (32).The writing committee recommends further resuscitation using a goal-directed strategy guided by the results of laboratory testing. Careful attention should be given to comorbidities that could worsen bleeding and subsequent outcome.Because of their dependence on renal function for clearance, all of the DOACs have higher blood levels and longer

2017 American College of Cardiology

107. Management of Cardiac Involvement Associated With Neuromuscular Diseases: A Scientific Statement From the American Heart Association Full Text available with Trip Pro

involvement are dissociated from or occur late after the development of skeletal myopathy, and poor correlation exists between genotype and phenotypes at the cardiac and skeletal muscle levels. The importance of genetic testing in the diagnosis of NMDs must be noted. Because there can be significant phenotypic overlap among NMDs at initial presentation, genetic testing is crucial to the diagnostic workup of NMDs, commonly allowing for a definitive diagnosis. , Although typical disease inheritance patterns (...) is confirmed by genetic testing, with affected individuals having >35 trinucleotide repeats. In general, longer repeat expansion correlates with higher penetrance, earlier onset, and increased severity of disease. Clinically, DM1 is characterized by progressive development of facial, neck, and distal limb muscle weakness and myotonia. Other degenerative symptoms include cataracts, neurological/neuropsychiatric deficits, and endocrine/metabolic abnormalities. There is a tendency for successive generations

2017 American Heart Association

108. Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association Full Text available with Trip Pro

syndrome (ACS). Thus, among patients with CS within the appropriate demographic or with risk factors for coronary artery disease, ACS should be the focus of initial diagnostic testing, and this testing should include an ECG within 10 minutes of presentation. Although 5% to 12% of ACS cases are complicated by CS, this presentation is often associated with a large degree of at-risk myocardium. , In patients with a recent ACS, mechanical complications (including papillary muscle rupture, ventricular (...) . Thyroid disorders, both hyperthyroidism and hypothyroidism, can also cause circulatory collapse. , Pregnancy-associated cardiac conditions, including both peripartum cardiomyopathy and acute coronary dissection, may present as CS. Numerous additional causes of CS have been reported, but they typically occur in <1% of patients. , Laboratory Evaluation, Noninvasive Testing, and Hemodynamic Monitoring Laboratory Evaluation Biomarkers of cardiac myonecrosis are useful to gauge the severity of acute

2017 American Heart Association

109. Childhood and Adolescent Adversity and Cardiometabolic Outcomes: A Scientific Statement From the American Heart Association Full Text available with Trip Pro

adversity may increase the risk of cardiometabolic (and other) diseases: behavioral, mental health, and biological. Behavioral Factors Evidence suggests that childhood adversity is associated with adverse health behaviors that increase the risk of cardiometabolic disease, including smoking, overeating, consumption of energy-dense foods, and inactivity. , , The association of childhood adversity with these behaviors was first tested by Felitti et al. In their retrospective ACE study, Felitti et al (...) childbirth would also capture intergenerational adversity and perinatal programming. Limited Identification of Mechanisms As discussed, childhood adversity may provoke unhealthy behaviors and poor mental health or produce neurobiological alterations that initiate relevant pathophysiological processes. Few studies have explicitly tested the mechanisms linking childhood adversity and cardiometabolic disease with comprehensive mediation models. Moreover, no study of which we are aware has tested a range

2017 American Heart Association

110. 2017 AHA/ACC Clinical Performance and Quality Measures for Adults With ST-Elevation and Non?ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures Full Text available with Trip Pro

Short Title: PM-15: Stress Test in Conservatively Treated Patients 27 Short Title: PM-16: Early Troponin Measurement After NSTEMI 28 Short Title: PM-17: AMI Registry Participation 28 Quality Improvement Measures for Inpatient STEMI and NSTEMI Patients 29 Inpatient Measures 29 Short Title: QM-1: Risk Score Stratification for NSTEMI 29 Short Title: QM-2: Early Invasive Strategy for High-Risk NSTEMI 30 Short Title: QM-3: Therapeutic Hypothermia for STEMI Patients 31 Short Title: QM-4: Aldosterone (...) to have the measure tested to identify the consequences of measure implementation. Quality measures may then be promoted to the status of performance measures as supporting evidence becomes available. Gregg C. Fonarow, MD, FACC, FAHA Chair, ACC/AHA Task Force on Performance Measures 1. Introduction In the summer of 2015, the Task Force convened the writing committee to begin the process of revising the existing set of performance measures for adult patients hospitalized with ST-Elevation and Non–ST

2017 American Heart Association

111. High Blood Pressure in Adults: Guideline For the Prevention, Detection, Evaluation and Management

. Laboratory Tests and Other Diagnostic Procedures.. . e159 7.2. Cardiovascular Target Organ Damage . . e159 Whelton et al. JACC VOL. 71, NO. 19, 2018 2017 High Blood Pressure Clinical Practice Guideline MAY 15, 2018:e127–248 e1288.TREATMENT OF HIGH BP . e160 8.1. Pharmacological Treatment ... e160 8.1.1. InitiationofPharmacologicalBPTreatment in the Context of Overall CVD Risk .. .. e160 8.1.2. BP Treatment Threshold and the Use of CVD Risk Estimation to Guide Drug Treatment of Hypertension .. .. e160 (...) include methodologists, epidemiolo- gists, healthcare providers, and biostatisticians. The recommendations developed by the writing committee on the basis of the systematic review are marked with “SR”. Guideline-Directed Management and Therapy The term guideline-directed management and therapy (GDMT) encompasses clinical evaluation, diagnostic testing, and pharmacological and procedural treatments. For these and all recommended drug treatment regi- mens, the reader should con?rmthedosagebyreview- ing

2017 American College of Cardiology

113. Valvular Heart Disease (Focused Update): Guidelines For the Management of Patients With

VHD guideline). Outcomes after surgical AVR are excellent in patients who do not have a high procedural risk (43–46,48). Surgical series demonstrate improved symptoms after AVR, and most patients have an improvement in exercise tolerance, as documented in studies with pre- and post-AVR exercise stress testing (43–46,48). The choice of prosthetic valve type is discussed in Section 11.1 of this focused update. IA Surgical AVR or TAVR is recommended for symptomatic patients with severe AS (Stage D

2017 American College of Cardiology

114. 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of Amer

and potential off-target effects may be complex with inhibition of the neprilysin enzyme, which has multiple biological targets. Use of an ARNI is associated with hypotension and a low-frequency incidence of angioedema. To facilitate initiation and titration, the approved ARNI is available in 3 doses that include a dose that was not tested in the HF trial; the target dose used in the trial was 97/103 mg twice daily. 147 Clinical experience will provide further information about the optimal titration (...) with NYHA class II–IV HFrEF and central sleep apnea, adaptive servo-ventilation causes harm. 203 NEW: New data demonstrate a signal of harm when adaptive servo-ventilation is used for central sleep apnea. See Online Data Supplement G. Mortality rate (all cause and cardiovascular) was higher with adaptive servo-ventilation plus GDMT than with GDMT alone in a single RCT to test the addition of adaptive servo-ventilation (=5 hours/night, 7 days/week) to GDMT in patients with HFrEF and central sleep apnea

2017 American Heart Association

115. Management of Patients on Non?Vitamin K Antagonist Oral Anticoagulants in the Acute Care and Periprocedural Setting: A Scientific Statement From the American Heart Association Full Text available with Trip Pro

treatment for AIS patients re- ceiving NOACs must balance the anticoagulant effect of these agents and the ICH risk associated with reperfusion strategies. As has been mentioned previously, routinely performed blood coagulation studies do not reliably ex- clude a significant plasma concentration of the NOACs. Another difficulty in a time-sensitive setting is that the more sensitive blood tests are either not routinely avail- able or have an unacceptably long delay to results. In experimental studies (...) study 76 comprised 78 NOAC-treated patients undergoing intravenous throm- bolysis or intra-arterial therapy a median of 13 hours after the last NOAC dose compared with 441 warfarin- treated patients and 8938 on no anticoagulants. After propensity score matching, there was no significant dif- ference in rate of any ICH, symptomatic ICH, or death among the groups. In the absence of immediately avail- able blood tests sensitive to the presence of NOACs, determining which patients taking these agents

2017 American Heart Association

116. Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: Guideline For the Management of Patients With

OR SUSPECTEDVA ... .. e105 4.1. History and Physical Examination ... . e105 4.2. Noninvasive Evaluation . e106 4.2.1. 12-lead ECG and Exercise Testing .. e106 4.2.2. Ambulatory Electrocardiography .. e107 4.2.3. Implanted Cardiac Monitors . .. e108 4.2.4. Noninvasive Cardiac Imaging .. e108 4.2.5. Biomarkers . .. e109 4.2.6. Genetic Considerations in Arrhythmia Syndromes . .. e109 4.3. Invasive Testing . e110 4.3.1. Invasive Cardiac Imaging: Cardiac Catheterization or CT Angiography .. .. e110 4.3.2 (...) The term guideline-directed management and therapy (GDMT) encompasses clinical evaluation, diagnostic testing,andpharmacologicalandproceduraltreatments. For these and all recommended medication treatment regimens, the reader should con?rm the dosage by reviewing product insert material and evaluate the treat- ment regimen for contraindications and interactions. The recommendationsarelimitedtomedications,devices,and treatments approved forclinical use in the United States. Class of Recommendation

2017 American College of Cardiology

117. Role of Biomarkers for the Prevention, Assessment, and Management of Heart Failure: A Scientific Statement From the American Heart Association Full Text available with Trip Pro

and to identify areas of inadequacy requiring future research. The panel reviewed the most relevant adult medical literature excluding routine laboratory tests using MEDLINE, EMBASE, and Web of Science through December 2016. The document is organized and classified according to the American Heart Association to provide specific suggestions, considerations, or contemporary clinical practice recommendations. Results: A number of biomarkers associated with HF are well recognized, and measuring (...) peptide testing for the evaluation of patients with suspected or proven heart failure (HF) in the year 2000, interest in biomarkers has grown exponentially. Accordingly, a large number of preclinical and clinical analyses of biomarkers in HF have been completed, and the volume of publications in peer-reviewed literature focused on HF biomarkers has risen dramatically. In addition, after the regulatory approval of the natriuretic peptides for clinical use, a number of newer biomarkers have received

2017 American Heart Association

118. Cardiovascular Health in African Americans: A Scientific Statement From the American Heart Association Full Text available with Trip Pro

, the adjusted odds for incident peripheral arterial disease were 1.67 times higher in African Americans compared with whites. The San Diego Population Study included markers of inflammation in multivariable models to test whether they explained the residual excess risk in African Americans compared with whites but found that, although the RRs for peripheral artery disease between African Americans and whites were further attenuated, they remained statistically significantly higher, ranging from 1.5 to 2.0 (...) duration appears to be a consistent risk factor for stroke, early indications suggest that among diabetic adults, short sleep duration (≤6 hours) is associated with increased stroke risk in whites (OR, 1.38; 95% CI, 1.06–1.80) but not in African Americans (OR, 0.86; 95% CI, 0.58–1.26). Additional research is needed to test the association of objectively determined sleep duration with incident CHD risk in African Americans compared with whites. Summary There are significant disparities in the age

2017 American Heart Association

119. Prioritizing Functional Capacity as a Principal End Point for Therapies Oriented to Older Adults With Cardiovascular Disease

more significantly in older age. Oxygen use is ideally measured by cardiopulmonary exercise testing (CPET). Peak V o 2 is an assessment of maximal aerobic performance that implies that activity has intensified to a point of maximal volition; hence, peak V o 2 is usually assessed as part of a symptom-limited or maximum exercise test. Metabolic equivalents (METs) achieved are a surrogate indicator of exercise performance that are calculated from workload (ie, treadmill speed/grade or Watts) and often (...) et al used the METs calculated from standard ETT and showed that even this relatively less intricate measure of CRF was a powerful predictor of mortality in adults with coronary heart disease and in adults without CVD. In multiple studies, CRF metrics, whether measured by CPET, ETT, or 6-minute walking testing (6MWT), have shown significant prognostic bearing for patients with coronary artery disease (CAD), valvular heart disease, arrhythmia, peripheral arterial diseases, pulmonary hypertension

2017 American Heart Association

120. Dietary Fats and Cardiovascular Disease Full Text available with Trip Pro

, polyunsaturated fat or carbohydrates, differed among trials. Reviewers who evaluate these trials must take into account the specific nutritional experiment that was conducted and the level of its adherence throughout the follow-up period. Low Saturated, High Polyunsaturated Fat Diets In the mid-1950s, 4 research groups reported that replacing saturated fat from animal products with polyunsaturated fat from vegetable oils substantially reduced serum cholesterol levels. Soon, controlled trials followed to test (...) % to 70% of the full effect. , Trials of serum cholesterol–lowering agents show that a reduction in coronary heart disease (CHD) incidence occurs with a lag of 1 to 2 years. These systematic reviews , , together found and analyzed 6 additional trials , , that replaced saturated with polyunsaturated fat but did not have ≥1 of these characteristics crucial to testing the hypothesis. We also discuss these “noncore” trials and evaluate their potential impact on the overall result on dietary saturated

2017 American Heart Association

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