Showing papers by "Kim A. Eagle published in 1999"
2,115 citations
TL;DR: Coronary Angiography: A Treatise on Morbidity and Mortality 1757-1764.
1,036 citations
TL;DR: The guidelines have been updated to include the most significant advances that have occurred in the management of patients with acute myocardial infarction (AMI) during that time frame and were developed to keep the guidelines current without republishing the entire document.
Abstract: The American College of Cardiology/American Heart Association (ACC/AHA) Guidelines for the Management of Patients With Acute Myocardial Infarction have been reviewed over the past 2.5 years since their initial publication in the Journal of the American College of Cardiology (1996;28:1328–1428) to ensure their continued relevancy. The guidelines have been updated to include the most significant advances that have occurred in the management of patients with acute myocardial infarction (AMI) during that time frame. This update was developed to keep the guidelines current without republishing the entire document. This effort represents a new procedure of the ACC/AHA Task Force on Practice Guidelines. These guidelines will be reviewed and updated as necessary until it is deemed appropriate to revise and republish the entire document.
The guidelines, incorporating the update, are available on the Web sites of both the American College of Cardiology (www.acc.org) and the American Heart Association (www.americanheart.org). In the Web site version, deleted text is indicated by strikeout, and new/revised text is presented as double-underlined type. Reprints of the original document with the revised sections appended are available from both organizations (see information below).
The following is a listing of the recommendations made by the ACC/AHA Task Force on Practice Guidelines in the ACC/AHA Task Force Report “ACC/AHA Guidelines for the Management of Patients With Acute Myocardial Infarction.” More detailed information regarding the evidence and the rationale for these recommendations can be found in the full text of the guidelines themselves, which appears in the November 1996 and September 1999 (update) issues of the Journal of the American College of Cardiology.
As in previous guidelines, the American College of Cardiology and the American Heart Association have used the following classification system in which indications for a diagnostic procedure, a particular therapy, or intervention are designated as:
Class I: Conditions for …
749 citations
TL;DR: It is important that the medical profession play a significant role in critically evaluating the use of diagnostic procedures and therapies in the management or prevention of disease states.
667 citations
TL;DR: These revised guidelines are based on a computerized search of the English literature since 1989, a manual search of final articles, and expert opinion and describe the most consistent predictors of mortality after coronary artery surgery.
Abstract: The American College of Cardiology/American Heart Association (ACC/AHA) Task Force on Practice Guidelines was formed to make recommendations regarding the appropriate use of diagnostic tests and therapies for patients with known or suspected cardiovascular disease. Coronary artery bypass graft (CABG) surgery is among the most common operations performed in the world and accounts for more resources expended in cardiovascular medicine than any other single procedure. Since the original Guidelines were published in 1991, there has been considerable evolution in the surgical approach to coronary disease, and at the same time there have been advances in preventive, medical, and percutaneous catheter approaches to therapy. These revised guidelines are based on a computerized search of the English literature since 1989, a manual search of final articles, and expert opinion.
As with other ACC/AHA guidelines, this document uses ACC/AHA classifications I, II, and III as summarized below:
Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective.
Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness or efficacy of a procedure.
Class IIa: Weight of evidence/opinion is in favor of usefulness/efficacy.
Class IIb: Usefulness/efficacy is less well established by evidence/opinion.
Class III: Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective and in some cases may be harmful.
### A. Hospital Outcomes
Seven core variables (priority of operation, age, prior heart surgery, sex, left ventricular [LV] ejection fraction [EF], percent stenosis of the left main coronary artery, and number of major coronary arteries with significant stenoses) are the most consistent predictors of mortality after coronary artery surgery. The greatest risk is correlated with the urgency of operation, advanced age, and 1 or more prior coronary bypass surgeries. Additional variables that are related …
432 citations
TL;DR: This document revises and updates the original “Guidelines for Coronary Angiography,” published in 1987, and uses the ACC/AHA classifications of class I, II, and III.
Abstract: This document revises and updates the original “Guidelines for Coronary Angiography,” published in 1987. This executive summary and recommendations appears in the May 4, 1999, issue of Circulation . The guidelines in their entirety, including the American College of Cardiology/American Heart Association (ACC/AHA) class I, II, and III recommendations, are published in the May 1999 issue of the Journal of the American College of Cardiology . Reprints of both the full text and executive summary and recommendations are available from both organizations.
The frequent and still growing use of coronary angiography, its relatively high costs, its inherent risks, and the ongoing evolution of its indications provide the reasons for this revision. The committee appointed to develop this document included private practitioners and academicians who were selected to represent both experts in coronary angiography and senior clinician consultants. Representatives from the family practice and internal medicine professions were also included on the committee. In addition to reviewing the original document, the committee conducted a search of the literature for the 10 years preceding development of these guidelines. Evidence was compiled and ranked by the committee. Whereas randomized trials are often available for reference in the development of treatment guidelines, randomized trials regarding the use of diagnostic procedures such as coronary angiography are rarely available.
This document uses the ACC/AHA classifications of class I, II, and III. These classes summarize the indications for coronary angiography as follows:
Class I: Conditions for which there is evidence and/or general agreement that this procedure is useful and effective.
Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of performing the procedure.
Class IIa: Weight of evidence/opinion is in favor of usefulness/ efficacy.
Class IIb: Usefulness/efficacy is less well established by evidence/opinion.
Class III: Conditions for which there …
407 citations
TL;DR: A meter drive circuit includes a signal input circuit through which an input signal is applied to a peak hold circuit for producing an output signal which indicates an instantaneous peak value of the input signal.
275 citations
TL;DR: Analysis of the Medicare Claims database suggests that vascular surgery is associated with substantial perioperative and long-term mortality and reinforces the need for a prospective evaluation of these practices.
Abstract: UNLABELLED Debate continues regarding the value of cardiovascular testing and coronary revascularization before major vascular surgery. Whereas recent guidelines have advocated selective preoperative testing, several authors have suggested that it is no longer necessary in an era of low perioperative cardiac morbidity and mortality. We used data from a random sample of Medicare beneficiaries to determine the mortality rate after vascular surgery, based on the use of preoperative cardiac testing. A 5% nationally random sample of the aged Medicare population for the final 6 mo of 1991 and first 11 mo of 1992 was used to identify a cohort of patients who underwent elective infrainguinal or abdominal aortic reconstructive surgery. Use within the first 6 mo of 1991 was reviewed to determine if preoperative noninvasive cardiovascular imaging or coronary revascularization was performed. Thirty-day (perioperative) and 1-yr mortalities were assessed. Perioperative mortality was significantly increased for aortic surgery (209 of 2865 or 7.3%), compared with infrainguinal surgery (232 of 4030 or 5.8%); however, 1-yr mortality was significantly increased for infrainguinal surgery (16.3% vs 11.3%, P < 0.05). Stress testing, with or without coronary revascularization, was associated with improved short-and long-term survival in aortic surgery. The use of stress testing with coronary revascularization was not associated with reduced perioperative mortality after infrainguinal surgery. Stress testing alone was associated with reduced long-term mortality in patients undergoing infrainguinal revascularization. IMPLICATIONS Analysis of the Medicare Claims database suggests that vascular surgery is associated with substantial perioperative and long-term mortality. The reduced long-term mortality in patients who had previously undergone preoperative testing and coronary revascularization reinforces the need for a prospective evaluation of these practices.
126 citations
TL;DR: The accuracy of the two models tested in adjusting for the relatively high mortality rate observed in this patient group supports their application in quality assessment or quality improvement efforts.
59 citations
TL;DR: Patients who are less ill, those who are seen early, and those who received thrombolytic therapy are more often transferred from community hospitals, while patients with greater comorbidity rates are treated at community hospitals and not transferred.
57 citations
TL;DR: In this paper, the authors describe the design of an ongoing randomized trial intended to test whether patients who require elective vascular surgery would benefit from preoperative coronary artery revascularization prior to the vascular procedure.
TL;DR: It is concluded that a chest pain management algorithm in achest pain center can be safe, yet effective, for identifying high-risk patients for admission and low- risk patients for discharge.
Abstract: The iterative lessons from our studies suggest that creation of a chest pain center alone will not change the practice of chest pain management by most physicians. In 1993 we established a chest pain center; in mid-1995 we established a patient management algorithm directing intermediate-risk patients to the chest pain center rather than admit them to the hospital. The creation of a chest pain center did not reduce the rate of chest pain admission by mid-1995. After the patient management algorithm was created, admittances dropped by a rate of 21% (p <0.001) and chest pain center usage increased by +1,726% (p <0.001). Among the 473 patients treated and discharged in the chest pain center after mid-1995, 333 (70%) were considered intermediate risk. No patient died after discharge from the chest pain center and there was 1 non-Q-wave myocardial infarction. We conclude that a chest pain management algorithm in a chest pain center can be safe, yet effective, for identifying high-risk patients for admission and low-risk patients for discharge.
TL;DR: The recent editorial by Greenland and colleagues highlights the utility of cardiac risk prediction algorithms and points to several important advantages and disadvantages of existing risk equations based on the Framingham Heart Study.
Abstract: To the Editor:
The recent editorial by Greenland and colleagues1 highlights the utility of cardiac risk prediction algorithms and points to several important advantages and disadvantages of existing risk equations based on the Framingham Heart Study. Although the excellent observational data obtained from Framingham may be useful for absolute risk estimation, it may not be the best source of information to estimate risk reduction. …
TL;DR: This simple clinical prediction rule has a positive predictive value of 86% when applied in the community hospital setting, and when a technology-based assessment of left ventricular function is considered in patients after an MI, this prediction rule may allow for a more cost-effective patient selection.
Abstract: Background A previous study showed that patients with previous myocardial infarction (MI) who meet 4 simple clinical and/or electrocardiographic criteria have a left ventricular ejection fraction (LVEF) of 40% or greater, with a positive predictive value of 98%. The objective of this study was to validate this clinical rule in the community hospital setting. Methods Retrospective chart review in a 330-bed community hospital. Two hundred thirteen consecutive patients with MI were identified between June 1, 1993, and March 31, 1995. Left ventricular ejection fraction was predicted in a blinded fashion by means of the clinical rule before the actual LVEF test was reviewed. Results We identified 213 patients admitted with the primary discharge diagnosis of acute MI. All patients met standard clinical and enzymatic definitions for acute MI and had at least 1 measure of LVEF, such as echocardiography, ventricular angiography, or gated blood pool scan. The clinical rule predicted that 83 patients (39.0%) would have an LVEF of 40% or greater. Of these 83 patients, 71 had an ejection fraction of 40% or greater, for a positive predictive value of 86%. Of the 12 patients who were incorrectly predicted to have a preserved LVEF, 6 (50%) had an index non–Q-wave anterior MI ( P Conclusions This simple clinical prediction rule has a positive predictive value of 86% when applied in the community hospital setting. Patients with anterior non–Q-wave MI may be 1 group in whom the rule is inaccurate, and expanding the clinical rule to 5 variables may increase the positive predictive value. When a technology-based assessment of left ventricular function is considered in patients after an MI, this prediction rule may allow for a more cost-effective patient selection, and as many as 40% of patients who have had acute MIs may require no testing at all.
01 Jun 1999
Journal Article•