General Considerations...e70 Risk Assessment Using Clinical Parameters...e71 Advanced Testing: Resting and Stress Noninvasive Testing...e72 Resting Imaging to Assess Cardiac Structure and Function: ...Recommendations...e72 Stress Testing and Advanced Imaging in Patients With Known SIHD Who Require Noninvasive Testing for Risk Assessment: Recommendations...e74 Risk Assessment in Patients Able to Exercise...e74 Risk Assessment in Patients Unable to Exercise...e74 Risk Assessment Regardless of Patients' Ability to Exercise...e74 Exercise ECG...e75 Exercise Echocardiography and Exercise Nuclear MPI...e76 Dobutamine Stress Echocardiography and Pharmacological Stress Nuclear MPI...e77 Pharmacological Stress CMR Imaging...e77 Special Patient Group: Risk Assessment in Patients Who Have an Uninterpretable ECG Because of LBBB or Ventricular Pacing...e77 Prognostic Accuracy of Anatomic Testing to Assess Risk in Patients With Known CAD...e78 Coronary CT Angiography...e78 Coronary Angiography...e78 Coronary Angiography as an Initial Testing Strategy to Assess Risk: Recommendations...e78 Coronary Angiography to Assess Risk After Initial Workup With Noninvasive Testing: Recommendations...e78 Treatment...e80 Definition of Successful Treatment...e80 General Approach to Therapy...e82 Factors That Should Not Influence Treatment Decisions...e83 Assessing Patients' Quality of Life...e84 Patient Education: Recommendations...e84 Guideline-Directed Medical Therapy...e86 Risk Factor Modification: Recommendations...e86 Lipid Management...e86 Blood Pressure Management...e88 Diabetes Management...e89 Physical Activity...e91 Weight Management...e92 Smoking Cessation Counseling...e92 Management of Psychological Factors...e93 Alcohol Consumption...e94 Avoiding Exposure to Air Pollution...e94 Additional Medical Therapy to Prevent MI and Death: Recommendations...e95 Antiplatelet Therapy...e95 Beta-Blocker Therapy...e96 Renin-Angiotensin-Aldosterone Blocker Therapy...e97 Influenza Vaccination...e98 Additional Therapy to Reduce Risk of MI and Death...e99 Medical Therapy for Relief of Symptoms...e100 Use of Anti-ischemic Medications: Recommendations...e100 Alternative Therapies for Relief of Symptoms in Patients With Refractory Angina: Recommendations...e104 Enhanced External Counterpulsation...e104 Spinal Cord Stimulation...e105 Acupuncture...e105 CAD Revascularization...e106 Heart Team Approach to Revascularization Decisions: Recommendations...e106 Revascularization to Improve Survival: Recommendations...e108 Revascularization to Improve Symptoms: Recommendations...e109 CABG Versus Contemporaneous Medical Therapy...e109 PCI Versus Medical Therapy...e110 CABG Versus PCI...e110 CABG Versus Balloon Angioplasty or BMS...e110 CABG Versus DES...e111 Left Main CAD...e111 CABG or PCI Versus Medical Therapy for Left Main CAD...e111 Studies Comparing PCI Versus CABG for Left Main CAD...e111 Revascularization Considerations for Left Main CAD...e112 Proximal LAD Artery Disease...e112 Clinical Factors That May Influence the Choice of Revascularization...e113 Completeness of Revascularization...e113 LV Systolic Dysfunction...e113 Previous CABG...e113 Unstable Angina/Non-ST-Elevation Myocardial Infarction...e113 DAPT Compliance and Stent Thrombosis: Recommendation...e113 Transmyocardial Revascularization...e114 Hybrid Coronary Revascularization: Recommendations...e114 Special Considerations...e114 Women...e115 Older Adults...e115 Diabetes Mellitus...e116 Obesity...e117 Chronic Kidney Disease...e118 HIV Infection and SIHD...e118 Autoimmune Disorders...e119 Socioeconomic Factors...e119 Special Occupations...e119 Patient Follow-Up: Monitoring of Symptoms and Antianginal Therapy...e119 Clinical Evaluation, Echocardiography During Routine, Periodic Follow-Up: Recommendations...e120 Follow-Up of Patients With SIHD...e121 Focused Follow-Up Visit: Frequency...e121 Focused Follow-Up Visit: Interval History and Coexisting Conditions...e121 Focused Follow-Up Visit: Physical Examination...e122 Focused Follow-Up Visit: Resting 12-Lead ECG...e122 Focused Follow-Up Visit: Laboratory Examination...e122 Noninvasive Testing in Known SIHD...e122 Follow-Up Noninvasive Testing in Patients With Known SIHD:
An organized and directed approach to a thorough review of evidence has resulted in the production of clinical practice guidelines that assist physicians in selecting the best management strategy for ...an individual patient. ...clinical practice guidelines can provide a foundation for other applications, such as performance measures, appropriate use criteria, and both quality improvement and clinical decision support tools. For certain conditions for which inadequate data are available, recommendations are based on expert consensus and clinical experience and are ranked as LOE C.\n Sanborn Official Reviewer--SCAI None The Medicines Company Merck None St. Jude Medical (DSMB) None None Jeffrey L. Anderson Content Reviewer--ACCF/AHA Task Force on Practice Guidelines BMS/sanofi-aventis Daiichi-Sankyo Eli Lilly None None None None None William E. Boden Content Reviewer Abbott CV Therapeutics/Gilead* Sanofi-aventis Schering-Plough Medicure Pharma None None None None Matthew Budoff Content Reviewer--ACCF Imaging Council None None None None None None Kim A. Eagle Content Reviewer None None None None None None Gordon A. Ewy Content Reviewer None None None None None None Victor Ferrari Content Reviewer--ACCF Imaging Council None None None None None None Raymond J. Gibbons Content Reviewer Cardiovascular Clinical Studies Lantheus Medical Imaging Medscape Molecular Insight TherOx None None Velomedix* None None Linda Gillam Content Reviewer--ACCF Imaging Council Abbott Vascular Edwards Lifesciences None None None Core Lab Services None Robert A. Guyton Content Reviewer--ACCF/AHA Task Force on Practice Guidelines None None None Edwards Lifesciences None None L. David Hillis Content Reviewer None None None None None None David R. Holmes Content Reviewer--ACCF Interventional Scientific Council None None None None None None Hani Jneid Content Reviewer-- AHA Council on Clinical Cardiology None None None None None None Sanjay Kaul Content Reviewer None None None None None None Howard C. Lewin Content Reviewer--ACCF Imaging Council None None Positron Imaging Partners None None None Todd D. Miller Content Reviewer--AHA Council on Clinical Cardiology The Medicines Company TherOx None None Kai Pharmaceuticals King Pharmaceuticals Lantheus Medical Imaging Molecular Insight Pharmaceuticals None None L. Kristin Newby Content Reviewer-- AHA Council on Clinical Cardiology Adolor Biovascular CV Therapeutics Inverness Medical Johnson & Johnson Novartis Roche Diagnostics Daiichi-Sankyo None AstraZeneca BG Medicine Carvio Dx* GlaxoSmithKline* Medicare* Millennium Pharmaceuticals Schering-Plough* None None Elizabeth Ross Content Reviewer None None None None None None William S. Weintraub Content Reviewer AstraZeneca* Bayer* Bristol-Myers Squibb Cardionet Eli Lilly Pfizer* Sanofi-aventis Shionogi None None Abbott* AstraZeneca* Bristol-Myers Squibb* Otsuka* Sanofi-aventis* None 2004; Defendant; Aprotinin 2008; Defendant; Quetiapine 2008; Defendant; Celebrex * This table represents the relationships of reviewers with industry and other entities that were disclosed at the time of peer review. Relationships noted in this table are modest unless otherwise noted.AATS indicates American Association for Thoracic Surgery; ACCF, American College of Cardiology Foundation; ACP, American College of Physicans; AHA, American Heart Association; NIH, National Institutes of Health; PCNA, Preventive Cardiovascular Nurses Association; SCAI, Society for Cardiovascular Interventions and Angiography; and STS, Society of Thoracic Surgeons.
Valvular heart diseases are not usually regarded as a major public-health problem. Our aim was to assess their prevalence and effect on overall survival in the general population.
We pooled ...population-based studies to obtain data for 11 911 randomly selected adults from the general population who had been assessed prospectively with echocardiography. We also analysed data from a community study of 16 501 adults who had been assessed by clinically indicated echocardiography.
In the general population group, moderate or severe valve disease was identified in 615 adults. There was no difference in the frequency of such diseases between men and women (p=0·90). Prevalence increased with age, from 0·7% (95% CI 0·5–1·0) in 18–44 year olds to 13·3% (11·7–15·0) in the 75 years and older group (p<0·0001). The national prevalence of valve disease, corrected for age and sex distribution from the US 2000 population, is 2·5% (2·2–2·7). In the community group, valve disease was diagnosed in 1505 (1·8% adjusted) adults and frequency increased considerably with age, from 0·3% (0·2–0·3) of the 18–44 year olds to 11·7% (11·0–12·5) of those aged 75 years and older, but was diagnosed less often in women than in men (odds ratio 0·90, 0·81–1·01; p=0·07). The adjusted mortality risk ratio associated with valve disease was 1·36 (1·15–1·62; p=0·0005) in the population and 1·75 (1·61–1·90; p<0·0001) in the community.
Moderate or severe valvular diseases are notably common in this population and increase with age. In the community, women are less often diagnosed than are men, which could indicate an important imbalance in view of the associated lower survival. Valve diseases thus represent an important public-health problem.
Carotid intima-media thickness (CIMT) is a well-established predictor of cardiovascular disease events. Not well described, however, is the prevalence of plaque and stenosis severity and how this ...varies according to extent of CIMT, age, and gender. We evaluated the extent of carotid plaque and stenosis severity according to CIMT, age, and gender in a large CIMT screening registry. We studied 9,347 women and 12,676 men (n = 22,023) who received carotid ultrasound scans. The presence and severity of both carotid plaque and stenosis was compared according to extent of CIMT (≥1 mm vs <1 mm), age, and gender using the chi-square test of proportions. Among those aged <45 to ≥80 years, the prevalence of CIMT ≥1 mm ranged from 0.13% to 29.3% in women and 0.6% to 40.1% in men, stenosis ≥50% from 0.1% to 14.9% in women and 0.1% to 13.2% in men, and mixed and/or soft plaque from 7.1% to 66.5% in women, and 9.2% to 65.8% in men (all p <0.001 across age groups). Even when CIMT levels were <1 mm, >30% of patients demonstrated mixed or soft plaque potentially prone to rupture. Of those with CIMT ≥1 mm, more than 70% had such mixed or soft plaque and more than 40% demonstrated stenoses of 30% or greater. In conclusion, we describe in a large CIMT registry study a substantial age-related increase in both men and women of increased CIMT, plaque presence, and severity, and stenosis. Even in those with normal CIMT, mixed or soft plaque was common, further demonstrating the value in assessing for plaque when doing carotid ultrasound.
Ventricular arrhythmia (VA) and sudden cardiac death (SCD) remain important problems in patients with heart failure (HF), despite the reduction in VA-associated deaths attributable to implantable ...cardioverter-defibrillators (ICDs) (1). The MADIT-CRT (Multicenter Automatic Defibrillator Implantation Trial With Cardiac Resynchronization Therapy) study demonstrated that in patients with mild HF, left ventricular ejection fraction (LVEF) of <=30%, and QRS duration >=130 ms, the primary endpoint of HF or all-cause mortality occurred in 17.2% of the CRT-ICD group versus 25.3% in the ICD-only group (p = 0.001), a difference driven primarily by a 41% reduction in HF events in the CRT group (2).
Recent evidence indicates that our understanding of the relationship between cardiac function and ischemic stroke remains incomplete. The Cardiovascular Health Study enrolled community-dwelling ...adults ≥ 65 years old. We included participants with speckle-tracking data from digitized baseline study echocardiograms. Exposures were left atrial reservoir strain (primary), left ventricular longitudinal strain, left ventricular early diastolic strain rate, septal e' velocity, and lateral e' velocity. The primary outcome was incident ischemic stroke. Cox proportional hazards models were adjusted for demographics, image quality, and risk factors including left ventricular ejection fraction and incident atrial fibrillation. Among 4,000 participants in our analysis, lower (worse) left atrial reservoir strain was associated with incident ischemic stroke (HR per SD absolute decrease, 1.14; 95% CI 1.04-25). All secondary exposure variables were significantly associated with the outcome. Left atrial reservoir strain was associated with cardioembolic stroke (HR per SD absolute decrease, 1.42; 95% CI 1.21-1.67) and cardioembolic stroke related to incident atrial fibrillation (HR per SD absolute decrease, 1.60; 1.32-1.95). Myocardial dysfunction that can ultimately lead to stroke may be identifiable at an early stage. This highlights opportunities to identify cerebrovascular risk earlier and improve stroke prevention via therapies for early myocardial dysfunction.
This study evaluated the associations of obesity and cardiometabolic traits with incident heart failure with preserved versus reduced ejection fraction (HFpEF vs. HFrEF). Given known sex differences ...in HF subtype, we examined men and women separately.
Recent studies suggest that obesity confers greater risk of HFpEF versus HFrEF. Contributions of associated metabolic traits to HFpEF are less clear.
We studied 22,681 participants from 4 community-based cohorts followed for incident HFpEF versus HFrEF (ejection fraction ≥50% vs. <50%). We evaluated the association of body mass index (BMI) and cardiometabolic traits with incident HF subtype using Cox models.
The mean age was 60 ± 13 years, and 53% were women. Over a median follow-up of 12 years, 628 developed incident HFpEF and 835 HFrEF. Greater BMI portended higher risk of HFpEF compared with HFrEF (hazard ratio HR: 1.34 per 1-SD increase in BMI; 95% confidence interval CI: 1.24 to 1.45 vs. HR: 1.18; 95% CI: 1.10 to 1.27). Similarly, insulin resistance (homeostatic model assessment of insulin resistance) was associated with HFpEF (HR: 1.20 per 1-SD; 95% CI: 1.05 to 1.37), but not HFrEF (HR: 0.99; 95% CI: 0.88 to 1.11; p < 0.05 for difference HFpEF vs. HFrEF). We found that the differential association of BMI with HFpEF versus HFrEF was more pronounced among women (p for difference HFpEF vs. HFrEF = 0.01) when compared with men (p = 0.34).
Obesity and related cardiometabolic traits including insulin resistance are more strongly associated with risk of future HFpEF versus HFrEF. The differential risk of HFpEF with obesity seems particularly pronounced among women and may underlie sex differences in HF subtypes.
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