The National High Blood Pressure Education Program presents the complete Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Like its predecessors, the purpose is to provide an evidence-based approach to the prevention and management of hypertension. The key messages of this report are these: in those older than age 50, systolic blood pressure (BP) of greater than 140 mm Hg is a more important cardiovascular disease (CVD) risk factor than diastolic BP; beginning at 115/75 mm Hg, CVD risk doubles for each increment of 20/10 mm Hg; those who are normotensive at 55 years of age will have a 90% lifetime risk of developing hypertension; prehypertensive individuals (systolic BP 120-139 mm Hg or diastolic BP 80-89 mm Hg) require health-promoting lifestyle modifications to prevent the progressive rise in blood pressure and CVD; for uncomplicated hypertension, thiazide diuretic should be used in drug treatment for most, either alone or combined with drugs from other classes; this report delineates specific high-risk conditions that are compelling indications for the use of other antihypertensive drug classes (angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, beta-blockers, calcium channel blockers); two or more antihypertensive medications will be required to achieve goal BP (<140/90 mm Hg, or <130/80 mm Hg) for patients with diabetes and chronic kidney disease; for patients whose BP is more than 20 mm Hg above the systolic BP goal or more than 10 mm Hg above the diastolic BP goal, initiation of therapy using two agents, one of which usually will be a thiazide diuretic, should be considered; regardless of therapy or care, hypertension will be controlled only if patients are motivated to stay on their treatment plan. Positive experiences, trust in the clinician, and empathy improve patient motivation and satisfaction. This report serves as a guide, and the committee continues to recognize that the responsible physician's judgment remains paramount.

Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure

The rapid technological developments of the past decade and the changes in echocardiographic practice brought about by these developments have resulted in the need for updated recommendations to the previously published guidelines for cardiac chamber quantification, which was the goal of the joint writing group assembled by the American Society of Echocardiography and the European Association of Cardiovascular Imaging. This document provides updated normal values for all four cardiac chambers, including three-dimensional echocardiography and myocardial deformation, when possible, on the basis of considerably larger numbers of normal subjects, compiled from multiple databases. In addition, this document attempts to eliminate several minor discrepancies that existed between previously published guidelines.

https://biblio.ugent.be/publication/5953422/file/5953443.pdf

Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.

https://caltcm.memberclicks.net/assets/documents/acc_aha_chf_2013_guidelines.pdf

2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines

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It is important that the medical profession play a significant role in critically evaluating the use of diagnostic procedures and therapies as they are introduced in the detection, management,

/pdf/acc-aha-2006-guidelines-for-the-management-of-patients-with-27qfh9fc7i.pdf

ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease

Although considerable improvement has occurred in the process of care for patients with ST-elevation myocardial infarction (STEMI), room for improvement exists.[1–3][1][][2][][3] The purpose of the present guideline is to focus on the numerous advances in the diagnosis and management of patients

/pdf/acc-aha-guidelines-for-the-management-of-patients-with-st-3d4n2zt04k.pdf

ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction—Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction)

Presentation of Case A 62-year-old woman was admitted to the hospital because of increasing peripheral edema. There was a four-year history of Sjogren's syndrome, with a dry mouth and Raynaud's phe...

Case 40-1988

The past decade and a half has witnessed a culture change in perioperative cardiovascular evaluation and management. On the basis of landmark studies such as the Coronary Artery Revascularization Project (CARP)1 and the PeriOperative ISchemic Evaluation (POISE) trial,2 we have learned that practices such as routine preoperative coronary angiography and one-size-fits-all β-blockade are not beneficial (and, in the latter case, appear to be harmful). The most recent iteration of the American College of Cardiology/American Heart Association (ACC/AHA) perioperative guidelines advocates a relatively parsimonious approach to preoperative stress testing and advises caution with regard to initiating and titrating β-blockers.3 Now that the “less is more” approach has grown deeper roots in the clinical cardiology community, it seems that this is a fitting time to take stock of perioperative outcomes on a national scale. Smilowitz and colleagues4 have used the National Inpatient Sample to review trends in major adverse cardiovascular and cerebrovascular events (MACCE) from 2004 to 2013. The overall frequency of MACCE declined significantly over the study period, as did perioperative death and acute myocardial infarction (AMI). These findings are encouraging, as they suggest that patients have not been harmed (and perhaps have avoided harm) because of contemporary preoperative evaluation practices. However, the perioperative stroke rate increased over this time period. This held true after adjustment for a multitude of variables, although the trend was attenuated somewhat in patients undergoing nonvascular surgery. In an era when stroke incidence is decreasing nationwide, and stroke mortality is also declining,5 albeit at a slower rate than in the past,6 it is concerning that perioperative stroke does not appear to be following suit. What might be unique about the perioperative population that could increase their risk? Patients subjected to anesthesia and fluid shifts may be prone to hypoperfusion-related strokes, or so-called watershed infarcts, more commonly than the general population. Smilowitz and colleagues4 suggest that an increase in perioperative β-blocker use may have contributed to the stroke rate increase, though the curve does not appear to level off at 2008 or 2009 as one might expect, given the publication of POISE at the time.2 Is it likely that perioperative β-blockade is still overprescribed? Unfortunately, medication data was not available in the data set used by Smilowitz and colleagues, and this is perhaps the most significant limitation of the study. In addition to β-blockers, it would have been very useful to know how many of these patients were taking statins and aspirin. Given the recent expansion of indications for statins in primary prevention, as per the 2013 ACC/AHA lipid guidelines,7 it will be interesting to see if perioperative stroke rates decline in future studies. In an administrative data set like the National Inpatient Sample, there is no clinical narrative, or even a timeline, for any given admission. Therefore, it was not possible for the authors to determine with certainty how many of the reported MACCE were truly perioperative events, despite the sensitivity analyses that were performed. Introduction of a new International Classification of Diseases, Ninth Revision (ICD-9) code for prior stroke or transient ischemic attack in 2007 may have somehow increased recognition of cerebrovascular events. Conversely, perioperative AMI rates may have appeared to decrease because clinicians obtained fewer routine postoperative electrocardiograms and cardiac biomarkers over time. While many trials and cohort studies in cardiovascular medicine include heart failure admissions or heart failure with clinical worsening under the umbrella of MACCE, heart failure was not included in this study, likely because heart failure exacerbations or incident heart failure would have been difficult to distinguish from chronic heart failure based on ICD-9 codes alone. With our aging population, it will be especially important to understand the relationship between perioperative care and acute on chronic heart failure, and the relative specificity of ICD-10 codes may help with this in the future. Smilowitz and colleagues4 showed that the downward trend in overall perioperative MACCE and upward trend in stroke was consistent between sexes and across racial groups. There were strikingly higher perioperative death and stroke rates among non-Hispanic black patients than among other groups. Although the gaps appear to have narrowed slightly over time, these findings suggest that further concerted efforts to identify and reduce disparities in care are badly needed. It is also important to note that despite adjustment for many identifiable risk factors, 3 types of surgery—vascular, thoracic, and transplant—were associated with higher risks of all types of MACCE. This may be a reflection in part of procedural complexity, but more likely, a consequence of multiple comorbidities in these patient populations. While major vascular surgery and thoracic surgery have long been considered higher risk than most other general surgical procedures, as recognized by the Revised Cardiac Risk Index,3 the current results imply that solid organ transplant surgery should be given equal consideration in perioperative risk assessment. However, it remains somewhat unclear how these patients should be risk stratified and treated to prevent perioperative MACCE effectively. Many liver and kidney transplant programs in this country mandate annual stress testing for patients to maintain actively listed status, but there is no compelling evidence to suggest that this practice improves outcomes. On the basis of idiosyncratic presurgical testing protocols, which vary greatly among centers, patients with no cliniRelated article Trends in Perioperative Cardiovascular Events Invited Commentary

Trends in Perioperative Cardiovascular Events: Mostly Sunny, With Showers.

Improving quality of cardiovascular care in the real world: how can we remove the barriers?

• Objective: To review secondary prevention strategies for patients with acute coronary syndrome. • Methods: Review of the literature. • Results: Patients with acute myocardial infarction represent an important high-risk cohort in which secondary vascular disease prevention is likely to be particulary effective and cost-effective. Lifestyle modification such as regular exercise, weight management, and smoking cessation should be encouraged. Tight glucose control in diabetics and optimal blood pressure control are important goals. Effective pharmacologic therapies include statins, antiplatelet agents, β blockers, and angiotensin-converting enzyme inhibitors. Attention to disease management opportunities may improve quality of care for acute myocardial infarction patients. • Conclusion: Aggressive risk factor and lifestyle modification and pharmacologic therapies improve patient survival, reduce recurrent events, and improve quality of life in post‐myocardial infarction patients.

Treatment of the Post-Myocardial Infarction Patient: A Concise Review

Background:Within medical education, there have been recent calls for increased understanding and exposure to poverty to increase trainees’ empathy toward the underserved. Students participating in...

https://journals.sagepub.com/doi/pdf/10.1177/2382120517737995

Kim A. Eagle

Papers

Case 40-1988

Trends in Perioperative Cardiovascular Events: Mostly Sunny, With Showers.

Improving quality of cardiovascular care in the real world: how can we remove the barriers?

Treatment of the Post-Myocardial Infarction Patient: A Concise Review

Increasing Medical Trainees' Empathy Through Volunteerism and Mentorship.