Preface: In an effort to respond to the need for thoughtful and objective use of healthcare services in the delivery of high-quality care; the American College of Radiology (ACR) and the American College of Cardiology Foundation (ACCF) have taken on the important process of jointly determining the appropriate use of cardiovascular imaging modalities for specific important clinical scenarios in patients with heart failure (HF). The ultimate objective of an Appropriate Utilization of Imaging (AUI) document is to improve patient care and health outcomes. The ACR, ACCF, and the collaborators in this document believe that careful balancing of a broad range of clinical experiences and available evidence-based information will help guide a more effective, efficient and equitable allocation of healthcare resources.
Introduction: The European Society of Cardiology (ESC) has recently published practice guidelines for the management of grown-up congenital heart disease (GUCH).1 For the sake of space, this document did not include recommendations for the organization of care for adults with congenital heart disease (CHD) nor for training in the subspecialty of adult CHD, although emphasis was given to their importance and the need for a separate recommendations paper in the future.1 This publication is a position paper from the ESC Working Group on Grown-up Congenital Heart Disease, which makes recommendations for the standards and organization of care for adults with CHD, as well as for training in GUCH within Europe. Obviously, there is a lack of solid scientific data to support such recommendations and the majority of them must remain based on expert consensus.
Abstract: The benefits of cardiac imaging are immense, and modern medicine requires the extensive and versatile use of a variety of cardiac imaging techniques. Cardiologists are responsible for a large part of the radiation exposures every person gets per year from all medical sources. Therefore, they have a particular responsibility to avoid unjustified and non-optimized use of radiation, but sometimes are imperfectly aware of the radiological dose of the examination they prescribe or practice. This position paper aims to summarize the current knowledge on radiation effective doses (and risks) related to cardiac imaging procedures. We have reviewed the literature on radiation doses, which can range from the equivalent of 1–60 milliSievert (mSv) around a reference dose average of 15 mSv (corresponding to 750 chest X-rays) for a percutaneous coronary intervention, a cardiac radiofrequency ablation, a multidetector coronary angiography, or a myocardial perfusion imaging scintigraphy. We provide a European perspective on the best way to play an active role in implementing into clinical practice the key principle of radiation protection that: ‘each patient should get the right imaging exam, at the right time, with the right radiation dose’.
Introduction: The radial approach to angiography and intervention has emerged internationally as the preferred alternative to the traditional femoral approach [1]. Multiple observational and randomized trials performed to date have shown an association between radial access and reduced risk for bleeding and vascular complications [2]. Other studies have shown an association between radial approach and reduced costs [3], increased patient satisfaction [4, 5], and reduced mortality in high-risk patient subgroups like those with ST-segment elevation myocardial infarction (STEMI) [6]. Disadvantages include increased radiation exposure to the operator during the learning curve, limitation of guide catheter size in some patients, and radial artery occlusion. The increased understanding of the potentially favorable risk:benefit ratio of transradial procedures has led to a near 10-fold increase in the adoption of radial access in the United States between 2007 and 2011 [7]. Concomitant with this surge in radial approach has been a proliferation of studies that have examined various technical aspects and outcomes from transradial procedures. Transradial angiography and intervention was once largely guided by anecdote and case series reports, but now there is a solid evidence base to guide some aspects of radial practice. The purpose of this document is to provide consensus opinion on what is considered "best practice" for facets of radial procedures where there is supportive evidence in order to maximize the benefits, standardize certain practices to minimize complications, and summarize areas that need further study.
Introduction: The rationale for use of intracoronary physiology assessment and imaging arises from the limitations of coronary angiography, the traditional method for determining the severity of coronary stenoses. The visual assessment of percent diameter reduction has significant interobserver variability [1-3], even among experienced angiographers [4]. Computer-assisted quantitative coronary angiography only marginally improves diagnostic accuracy and its estimate of functional significance [5].
Abstract: Cardiovascular magnetic resonance (CMR) imaging is a rapidly developing technology that is becoming increasingly important in the diagnostic assessment of heart disease. Recognizing the need for recommendations to optimize the use of this technique, the Canadian Society for Cardiovascular Magnetic Resonance developed a task force to generate recommendations on the clinical use of parameters acquired by CMR imaging and how they should be reported. This article is the consensus report generated by the task force. The online material of this report provides such parameters for all relevant clinical settings, including pediatric and congenital applications. It considers the current clinical role of CMR, general requirements for CMR imaging, components of CMR studies, quantitative CMR image analysis, and appropriate contents of CMR reports. The recommendations are based on previously published recommendations on analysis and reporting and are the first of their kind. It is hoped that the use of these recommendations to guide daily clinical routine will help institutions offering CMR to adhere to high standards of quality according to the present state of the art.
Abstract: The 2013 Canadian Cardiovascular Society Heart Failure Management Guidelines Update provides focused discussions on the management recommendations on 2 topics: (1) exercise and rehabilitation; and (2) surgical coronary revascularization in patients with heart failure. First, all patients with stable New York Heart Association class I-III symptoms should be considered for enrollment in a tailored exercise training program, to improve exercise tolerance and quality of life. Second, selected patients with suitable coronary anatomy should be considered for bypass graft surgery. As in previous updates, the topics were chosen in response to stakeholder feedback. The 2013 Update also includes recommendations, values and preferences, and practical tips to assist the clinicians and health care workers manage their patients with heart failure.
Abstract: The American College of Cardiology Foundation in collaboration with the Heart Rhythm Society and key specialty and subspecialty societies conducted a review of common clinical scenarios where implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy (CRT) are frequently considered. The clinical scenarios covered in this document address secondary prevention, primary prevention, comorbidities, generator replacement at elective replacement indicator, dual-chamber ICD, and CRT.
Preamble: The medical profession should play a central role in evaluating the evidence related to drugs, devices, and procedures for the detection, management, and prevention of disease. When properly applied, expert analysis of available data on the benefits and risks of these therapies and procedures can improve the quality of care, optimize patient outcomes, and favorably affect costs by focusing resources on the most effective strategies. 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. Moreover, 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.
Summary: Each year, the American Heart Association (AHA), in conjunction with the Centers for Disease Control and Prevention, the National Institutes of Health, and other government agencies, brings together the most up-to-date statistics on heart disease, stroke, other vascular diseases, and their risk factors and presents them in its Heart Disease and Stroke Statistical Update. The Statistical Update is a valuable resource for researchers, clinicians, healthcare policy makers, media professionals, the lay public, and many others who seek the best national data available on heart disease, stroke, and other cardiovascular disease–related morbidity and mortality and the risks, quality of care, medical procedures and operations, and costs associated with the management of these diseases in a single document. Indeed, since 1999, the Statistical Update has been cited >10 500 times in the literature, based on citations of all annual versions. In 2011 alone, the various Statistical Updates were cited ≈1500 times (data from ISI Web of Science). In recent years, the Statistical Update has undergone some major changes with the addition of new chapters and major updates across multiple areas, as well as increasing the number of ways to access and use the information assembled.
Summary: Each year, the American Heart Association (AHA), in conjunction with the Centers for Disease Control and Prevention, the National Institutes of Health, and other government agencies, brings together the most up-to-date statistics on heart disease, stroke, other vascular diseases, and their risk factors and presents them in its Heart Disease and Stroke Statistical Update. The Statistical Update is a valuable resource for researchers, clinicians, healthcare policy makers, media professionals, the lay public, and many others who seek the best national data available on heart disease, stroke, and other cardiovascular disease–related morbidity and mortality and the risks, quality of care, medical procedures and operations, and costs associated with the management of these diseases in a single document. Indeed, since 1999, the Statistical Update has been cited >10 500 times in the literature, based on citations of all annual versions. In 2011 alone, the various Statistical Updates were cited ≈1500 times (data from ISI Web of Science). In recent years, the Statistical Update has undergone some major changes with the addition of new chapters and major updates across multiple areas, as well as increasing the number of ways to access and use the information assembled.
Introduction: Thrombosis has long been recognized as a potentially life-threatening complication in children with congenital heart disease (CHD), children with acquired heart disease, and in adults with CHD. High-risk groups include patients with shunt- dependent single ventricles (shunt thrombosis, 8%–12%; 4% risk of death resulting from shunt failure), postoperative central lines (13% thrombosis in central venous lines [CVLs]), Fontan circulation (17%–33% incidence of thrombosis after Fontan), arrhythmias, Kawasaki disease with coronary aneurysms, and cardiomyopathy/myocarditis. Although the prevalence, risk factors, and management of some of these situations have been well described (ie, Kawasaki disease), for the management of others (ie, anticoagulation after the Fontan operation), there is a paucity of data, and controversy exists even among experts. Although as with many pediatric diseases, a lack of randomized, controlled trials limits the ability to make recommendations beyond “expert consensus,” to date there is no published work that focuses solely on the important complication of thrombosis in pediatric and CHD.
Aims: The first aim was to critically evaluate the extent to which familial hypercholesterolaemia (FH) is underdiagnosed and undertreated. The second aim was to provide guidance for screening and treatment of FH, in order to prevent coronary heart disease (CHD).
Preface: Optimizing outcomes after percutaneous coronary intervention (PCI) requires balancing between the risks of thrombotic and bleeding events in individual patients.1–3 However, finding the optimal balance is not always straightforward since the risks of thrombotic and bleeding complications may differ extremely between individuals. In addition, the individual effects of anticoagulant and antiplatelet drugs are not uniform in patients.4 Recent European guidelines1,3 recommend the use of prasugrel or ticagrelor instead of clopidogrel in all PCI-treated acute coronary syndrome (ACS) patients without contraindication, acknowledging that laboratory assessment of P2Y12-receptor inhibition may be considered only in selected cases when clopidogrel is used.1 However, there is no guidance with respect to the appropriate methodology and the suggested interpretation of results. The Working Group on Thrombosis of the European Society of Cardiology aimed to review the available evidence and the clinical relevance of platelet function testing in order to reach a consensus regarding the methodology, evaluation, and clinical interpretation of platelet function in patients undergoing PCI.
Patients presenting for invasive cardiovascular procedures are frequently taking a variety of medications aimed to treat risk factors related to heart and vascular disease. During the procedure, antithrombotic, sedative, and analgesic medications are commonly needed, and after interventional procedures, new medications are often added for primary and secondary prevention of ischemic events. In addition to these prescribed medications, the use of over-the-counter drugs and supplements continues to rise. Most elderly patients, for example, are taking 5 or more prescribed medications and 1 or more supplements, and they often have some degree of renal insufficiency. This polypharmacy might result in drug–drug interactions that affect the balance of thrombotic and bleeding events during the procedure and during long-term treatment. Mixing of anticoagulants, for instance, might lead to periprocedural bleeding, and this is associated with an increase in long-term adverse events. Furthermore, the range of possible interactions with thienopyridine antiplatelets is of concern, because these drugs are essential to immediate and extended interventional success. The practical challenges in the field are great—some drug–drug interactions are likely present yet not well understood due to limited assays, whereas other interactions have well-described biological effects but seem to be more theoretical, because there is little to no clinical impact. Interventional providers need to be attentive to the potential for drug–drug interaction, the associated harm, and the appropriate action, if any, to minimize the potential for medication-related adverse events. This review will focus on drug–drug interactions that have the potential to affect procedural success, either through increases in immediate complications or compromising longer-term outcome.
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