Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery.

/pdf/guidelines-for-pre-operative-cardiac-risk-assessment-and-24w6qyo5uf.pdf

Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery

Background:UnlikemedicinesprescribedforFoodand DrugAdministration–approvedindications,off-labeluses may lack rigorous scientific scrutiny. Despite concerns aboutpatientsafetyandcoststothehealthcaresystem,little is known about the frequency of off-label drug use or the degree of scientific evidence supporting this practice. Methods: We used nationally representative data from the 2001 IMS Health National Disease and Therapeutic Index (NDTI) to define prescribing patterns by diagnosis for 160 commonly prescribed drugs. Each reported drug-diagnosis combination was identified as Food andDrugAdministration–approved,off-labelwithstrong scientific support, or off-label with limited or no scientific support. Outcome measures included (1) the proportion of uses that were off-label and (2) the proportion of off-label uses supported by strong scientific evidence. Multivariate analyses were used to identify drug-specific characteristics predictive of increased off-label use. Results: In 2001, there were an estimated 150 million (95%confidenceinterval,127-173million)off-labelmentions (21% of overall use) among the sampled medications. Off-label use was most common among cardiac medications(46%,excludingantihyperlipidemicandantihypertensiveagents)andanticonvulsants(46%),whereas gabapentin(83%)andamitriptylinehydrochloride(81%) had the greatest proportion of off-label use among specificmedications.Mostoff-labeldrugmentions(73%;95% confidence interval, 61%-84%) had little or no scientific support. Although several functional classes were associatedwithincreasedoff-labeluse(P.05),fewotherdrug characteristics predicted off-label prescription. Conclusions:Off-labelmedicationuseiscommoninoutpatient care, and most occurs without scientific support. Efforts should be made to scrutinize underevaluatedoff-labelprescribingthatcompromisespatientsafety or represents wasteful medication use. Arch Intern Med. 2006;166:1021-1026

https://jamanetwork.com/journals/jamainternalmedicine/articlepdf/410250/ioi50251.pdf

Off-label prescribing among office-based physicians.

This is the first of 2 articles evaluating cardiac events in patients undergoing noncardiac surgery. In this article, we review the magnitude of the problem, the pathophysiology of these events, approaches to risk assessment and communication of risk. The number of patients undergoing noncardiac surgery worldwide is growing, and annually 500,000 to 900,000 of these patients experience perioperative cardiac death, nonfatal myocardial infarction (MI) or nonfatal cardiac arrest. Although the evidence is limited, a substantial proportion of fatal perioperative MIs may not share the same pathophysiology as nonoperative MIs. A clearer understanding of the pathophysiology is needed to direct future research evaluating prophylactic, acute and long-term interventions. Researchers have developed tools to facilitate the estimation of perioperative cardiac risk. Studies suggest that the Lee index is the most accurate generic perioperative cardiac risk index. The limitations of the studies evaluating the ability of noninvasive cardiac tests to predict perioperative cardiac risk reveals considerable uncertainty as to the role of these popular tests. Similarly, there is uncertainty as to the predictive accuracy of the American College of Cardiology/American Heart Association algorithm for cardiac risk assessment. Patients are likely to benefit from improved estimation and communication of cardiac risk because the majority of noncardiac surgeries are elective and accurate risk estimation is important to allow informed patient and physician decision-making.

/pdf/perioperative-cardiac-events-in-patients-undergoing-4162glvbiy.pdf

Perioperative cardiac events in patients undergoing noncardiac surgery: a review of the magnitude of the problem, the pathophysiology of the events and methods to estimate and communicate risk

ESC Committee for Practice Guidelines (CPG): Alec Vahanian (Chairperson) (France), Angelo Auricchio (Switzerland), Jeroen J. Bax (The Netherlands), Claudio Ceconi (Italy), Veronica Dean (France), Gerasimos Filippatos (Greece), Christian Funck-Brentano (France), Richard Hobbs (UK), Peter Kearney (Ire

/pdf/guidelines-for-pre-operative-cardiac-risk-assessment-and-3e1g51y1fb.pdf

Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery: the Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery of the European Society of Cardiology (ESC) and endorsed by the European Society of Anaesthesiology (ESA)

Objective To examine whether racial disparities in usage and outcomes of total knee and total hip arthroplasty (TKA and THA) have declined over time. Methods We used data from the US Medicare Program (MedPAR data) for years 1991–2008 to identify four separate cohorts of patients (primary TKA, revision TKA, primary THA, revision THA). For each cohort, we calculated standardised arthroplasty usage rates for Caucasian and African–American Medicare beneficiaries for each calendar year, and examined changes in disparities over time. We examined unadjusted and adjusted outcomes (30-day readmission rate, discharge disposition etc.) for Caucasians and African–Americans, and whether disparities decreased over time. Results In 1991, the use of primary TKA was 36% lower for African–Americans compared with Caucasians (20.6 per 10 000 for African–Americans; 32.1 per 10 000 for Caucasians; p Conclusions In an 18-year analysis of US Medicare data, we found little evidence of declines in racial disparities for joint arthroplasty usage or outcomes.

/pdf/racial-disparities-in-knee-and-hip-total-joint-arthroplasty-1ze582teyr.pdf

Racial disparities in knee and hip total joint arthroplasty: an 18-year analysis of national medicare data

Over the past decade, the conceptual understanding of heart failure has changed significantly. Several large clinical trials have demonstrated that pharmacologic interventions can dramatically reduce the morbidity and mortality associated with heart failure. These trials have extended the therapeutic paradigm for treating heart failure beyond the goal of limiting congestive symptoms of volume overload. This two-part article presents an evidence-based guideline to assist primary care physicians in evaluating and treating patients with heart failure. Part I describes the new paradigm of heart failure and offers guidance for diagnostic testing. Part II presents a treatment guideline.

Guideline for the management of heart failure caused by systolic dysfunction: Part I. Guideline development, etiology and diagnosis.

Background: The American College of Cardiology/American Heart Association (ACC/AHA) publishes recommendations for cardiac assessment of patients undergoing noncardiac surgery with t

Implementation of the ACC/AHA guidelines for preoperative cardiac risk assessment in a general medicine preoperative clinic: improving efficiency and preserving outcomes.

Several large clinical trials conducted over the past decade have shown that pharmacologic interventions can dramatically reduce the morbidity and mortality associated with heart failure. These trials have modified and enhanced the therapeutic paradigm for heart failure and extended treatment goals beyond limiting congestive symptoms of volume overload. Part II of this two-part article presents treatment recommendations for patients with left ventricular systolic dysfunction. The authors recommend that, if tolerated and not contraindicated, the following agents be used in patients with left ventricular systolic dysfunction: an angiotensin-converting enzyme inhibitor in all patients; a beta blocker in all patients except those who have symptoms at rest; and spironolactone in patients who have symptoms at rest or who have had such symptoms within the past six months. Diuretics and digoxin should be reserved, as needed, for symptomatic management of heart failure. Other treatments or treatment programs may be necessary in individual patients.

Guideline for the management of heart failure caused by systolic dysfunction: part II. Treatment.

Heart failure caused by systolic dysfunction affects more than 5 million adults in the United States and is a common source of outpatient visits to primary care physicians. Mortality rates are high, yet a number of pharmacologic interventions may improve outcomes. Other interventions, including patient education, counseling, and regular self-monitoring, are critical, but are beyond the scope of this article. Angiotensin-converting enzyme inhibitors and beta blockers reduce mortality and should be administered to all patients unless contraindicated. Diuretics are indicated for symptomatic patients as needed for volume overload. Aldosterone antagonists and direct-acting vasodilators, such as isosorbide dinitrate and hydralazine, may improve mortality in selected patients. Angiotensin receptor blockers can be used as an alternative therapy for patients intolerant of angiotensin-converting enzyme inhibitors and in some patients who are persistently symptomatic. Digoxin may improve symptoms and is helpful for persons with concomitant atrial fibrillation, but it does not reduce cardiovascular or all-cause mortality. Serum digoxin levels should not exceed 1.0 ng per mL (1.3 nmol per L), especially in women.

Sean K. Kesterson

Papers

Guideline for the management of heart failure caused by systolic dysfunction: Part I. Guideline development, etiology and diagnosis.

Implementation of the ACC/AHA guidelines for preoperative cardiac risk assessment in a general medicine preoperative clinic: improving efficiency and preserving outcomes.

Guideline for the management of heart failure caused by systolic dysfunction: part II. Treatment.

Pharmacologic management of heart failure caused by systolic dysfunction.

Chapter 27 – The Executive Male