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

XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.

Standards of Medical Care in Diabetes

Summary—In 1995 the American College of Sports Medicine and the Centers for Disease Control and Prevention published national guidelines on Physical Activity and Public Health The Committee on Exercise and Cardiac Rehabilitation of the American Heart Association endorsed and supported these recommendations The purpose of the present report is to update and clarify the 1995 recommendations on the types and amounts of physical activity needed by healthy adults to improve and maintain health Development of this document was by an expert panel of scientists, including physicians, epidemiologists, exercise scientists, and public health specialists This panel reviewed advances in pertinent physiologic, epidemiologic, and clinical scientific data, including primary research articles and reviews published since the original recommendation was issued in 1995 Issues considered by the panel included new scientific evidence relating physical activity to health, physical activity recommendations by various organizations in the interim, and communications issues Key points related to updating the physical activity recommendation were outlined and writing groups were formed A draft manuscript was prepared and circulated for review to the expert panel as well as to outside experts Comments were integrated into the final recommendation Primary Recommendation—To promote and maintain health, all healthy adults aged 18 to 65 yr need moderate-intensity aerobic (endurance) physical activity for a minimum of 30 min on five days each week or vigorous-intensity aerobic physical activity for a minimum of 20 min on three days each week [I (A)] Combinations of moderate- and vigorous-intensity activity can be performed to meet this recommendation [IIa (B)] For example, a person can meet the recommendation by walking briskly for 30 min twice during the week and then jogging for 20 min on two other days Moderate-intensity aerobic activity, which is generally equivalent to a brisk walk and noticeably accelerates the heart rate, can be accumulated toward the 30-min minimum by performing bouts each lasting 10 or more minutes [I (B)] Vigorous-intensity activity is exemplified by jogging, and causes rapid breathing and a substantial increase in heart rate In addition, every adult should perform activities that maintain or increase muscular strength and endurance a minimum of two days each week [IIa (A)] Because of the dose-response relation between physical activity and health, persons who wish to further improve their personal fitness, reduce their risk for chronic diseases and disabilities or prevent unhealthy weight gain may benefit by exceeding the minimum recommended amounts of physical activity [I (A)] (Circulation 2007;116:1081-1093)

/pdf/physical-activity-and-public-health-updated-recommendation-5ar650n64d.pdf

Physical Activity and Public Health Updated Recommendation for Adults From the American College of Sports Medicine and the American Heart Association

The aim of this updated guideline is to provide comprehensive and timely evidence-based recommendations on the prevention of future stroke among survivors of ischemic stroke or transient ischemic attack. The guideline is addressed to all clinicians who manage secondary prevention for these patients. Evidence-based recommendations are provided for control of risk factors, intervention for vascular obstruction, antithrombotic therapy for cardioembolism, and antiplatelet therapy for noncardioembolic stroke. Recommendations are also provided for the prevention of recurrent stroke in a variety of specific circumstances, including aortic arch atherosclerosis, arterial dissection, patent foramen ovale, hyperhomocysteinemia, hypercoagulable states, antiphospholipid antibody syndrome, sickle cell disease, cerebral venous sinus thrombosis, and pregnancy. Special sections address use of antithrombotic and anticoagulation therapy after an intracranial hemorrhage and implementation of guidelines.

/pdf/guidelines-for-the-prevention-of-stroke-in-patients-with-4s66xf1dte.pdf

Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association

Background. A number of self-administered questionnaires are available for assessing depression severity, including the 9-item Patient Health Questionnaire depression module (PHQ-9). Because even briefer measures might be desirable for use in busy clinical settings or as part of comprehensive health

The Patient Health Questionnaire-2: validity of a two-item depression screener.

This statement summarizes the current U.S. Preventive Services Task Force (USPSTF) recommendations for screening for depression and the supporting scientific evidence and updates the 1996 USPSTF recommendations on this topic. At that time, the USPSTF concluded that there was insufficient evidence to recommend for or against routine use of standardized questionnaires to screen for depression in primary care patients. The complete information on which the current statement is based, including evidence tables and references, is available in the accompanying article in this issue and in the systematic evidence review on this topic, which can be obtained through the USPSTF Web site (http://www.ahrq.gov/clinic/uspstfix.htm) and in print through the Agency for Healthcare Research and Quality Publications Clearinghouse (800-358-9295).

Screening for depression: recommendations and rationale.

This statement summarizes the current U.S. Preventive Services Task Force (USPSTF) recommendation on screening for colorectal cancer and the supporting scientific evidence and updates the 1995 recommendations contained in the Guide to Clinical Preventive Services, 2nd edition. At that time, the USPSTF recommended screening for colorectal cancer with annual fecal occult blood testing, periodic sigmoidoscopy, or the combination of fecal occult blood testing and sigmoidoscopy but concluded that the evidence was insufficient to recommend for or against colonoscopy or barium enema. The complete USPSTF recommendation and rationale statement on this topic, which includes a brief review of the supporting evidence, is available through the USPSTF Web site (http://www.preventiveservices.ahrq.gov), the National Guideline Clearinghouse (http://www.guideline.gov), and in print through the Agency for Healthcare Research and Quality Publications Clearinghouse (telephone, 800-358-9295; e-mail, ahrqpubs@ahrq.gov). The complete information on which this statement is based, including tables and references, is available in the accompanying article in this issue and in the summary of the evidence and systematic evidence review on the Web sites already mentioned.

Screening for colorectal cancer: recommendation and rationale.

Summary of the Recommendations The U.S. Preventive Services Task Force (USPSTF) recommends screening mammography, with or without clinical breast examination (CBE), every 1 to 2 years for women aged 40 and older. This is a grade B recommendation. (See Appendix Table 1 for a description of the USPSTF classification of recommendations.) The USPSTF found fair evidence that mammography screening every 12 to 33 months significantly reduces mortality from breast cancer. (See Appendix Table 2 for a description of the USPSTF classification of levels of evidence.) Evidence is strongest for women aged 50 to 69, the age group generally included in screening trials. For women aged 40 to 49, the evidence that screening mammography reduces mortality from breast cancer is weaker, and the absolute benefit of mammography is smaller, than it is for older women. Most, but not all, studies indicate a mortality benefit for women undergoing mammography at ages 40 to 49, but the delay in observed benefit in women younger than 50 makes it difficult to determine the incremental benefit of beginning screening at age 40 rather than at age 50. The absolute benefit is smaller because the incidence of breast cancer is lower among women in their 40s than it is among older women. The USPSTF concluded that the evidence is also generalizable to women aged 70 and older (who face a higher absolute risk of breast cancer) if their life expectancy is not compromised by comorbid disease. The absolute probability of benefits of regular mammography increases along a continuum with age, whereas the likelihood of harms from screening (false-positive results and unnecessary anxiety, biopsies, and cost) diminishes from ages 40 to 70. The balance of benefits and potential harms, therefore, grows more favorable as women age. The precise age at which the potential benefits of mammography justify the possible harms is a subjective choice. The USPSTF did not find sufficient evidence to specify the optimal screening interval for women aged 40 to 49 (see Clinical Considerations). The USPSTF concludes that the evidence is insufficient to recommend for or against routine CBE alone to screen for breast cancer. This is a grade I recommendation. No screening trial has examined the benefits of CBE alone (without accompanying mammography) compared to no screening, and design characteristics limit the generalizability of studies that have examined CBE. The USPSTF could not determine the benefits of CBE alone or the incremental benefit of adding CBE to mammography. The USPSTF therefore could not determine whether potential benefits of routine CBE outweigh the potential harms. The USPSTF concludes that the evidence is insufficient to recommend for or against teaching or performing routine breast self-examination (BSE). This is a grade I recommendation. The USPSTF found poor evidence to determine whether BSE reduces breast cancer mortality. The USPSTF found fair evidence that BSE is associated with an increased risk of false-positive results and biopsies. Because of design limitations of published and ongoing studies of BSE, the USPSTF could not determine the balance of benefits and potential harms of BSE. Clinical Considerations The precise age at which the benefits from screening mammography justify the potential harms is a subjective judgment and should take into account patient preferences. Clinicians should inform women about the potential benefits (reduced chance of dying from breast cancer), potential harms (for example, false-positive results, unnecessary biopsies), and limitations of the test that apply to women their age. Clinicians should tell women that the balance of benefits and potential harms of mammography improves with increasing age for women between the ages of 40 and 70. Women who are at increased risk for breast cancer (for example, those with a family history of breast cancer in a mother or sister, a previous breast biopsy revealing atypical hyperplasia, or first childbirth after age 30) are more likely to benefit from regular mammography than women at lower risk. The recommendation for women to begin routine screening in their 40s is strengthened by a family history of breast cancer having been diagnosed before menopause. The USPSTF did not examine whether women should be screened for genetic mutations (BRCA1 and BRCA2) that increase the risk of developing breast cancer, or whether women with genetic mutations might benefit from earlier or more frequent screening for breast cancer. In the trials that demonstrated the effectiveness of mammography in lowering breast cancer mortality, screening was performed every 12 to 33 months. For women aged 50 and older, there is little evidence to suggest that annual mammography is more effective than mammography done every other year. For women aged 40 to 49, available trials also have not reported a clear advantage of annual mammography over biennial mammography. Nevertheless, some experts recommend annual mammography based on the lower sensitivity of the test and on evidence that tumors grow more rapidly in this age group. The precise age at which to discontinue screening mammography is uncertain. Only two randomized, controlled trials enrolled women older than 69, and no trials enrolled women older than 74. Older women face a higher probability of developing and dying of breast cancer but also have a greater chance of dying of other causes. Women with comorbid conditions that limit their life expectancy are unlikely to benefit from screening. Clinicians should refer patients to mammography screening centers with proper accreditation and quality assurance standards to ensure accurate imaging and radiographic interpretation. Clinicians should adopt office systems to ensure timely and adequate follow-up of abnormal results. A listing of accredited facilities is available at www.fda.gov/cdrh/mammography/certified.html. Clinicians who advise women to perform BSE or who perform routine CBE to screen for breast cancer should understand that there is currently insufficient evidence to determine whether these practices affect breast cancer mortality and that they are likely to increase the incidence of clinical assessments and biopsies. The brief review of the evidence that is normally included in USPSTF recommendations is available in the complete recommendation and rationale statement on the USPSTF Web site (www.preventiveservices.ahrq.gov). Recommendations of Others Nearly all North American organizations support mammography screening, although groups vary in the recommended age to begin screening, the interval for screening, and the role of CBE. The American Medical Association (AMA) (1), the American College of Radiology (ACR) (2), and the American Cancer Society (ACS) (3) all support screening with mammography and CBE beginning at age 40. The American College of Obstetricians and Gynecologists (ACOG) (4) supports screening with mammography beginning at age 40 and CBE beginning at age 19. The Canadian Task Force on Preventive Health Care (CTFPHC) (5), the American Academy of Family Physicians (AAFP) (6), and the American College of Preventive Medicine (ACPM) (7) recommend beginning mammography for average-risk women at age 50. The AAFP and ACPM recommend that mammography in high-risk women begin at age 40, and the AAFP recommends that all women aged 40 to 49 be counseled about the risks and benefits of mammography before making decisions about screening (6, 7). A 1997 Consensus Development Panel convened by the U.S. National Institutes of Health concluded that the evidence was insufficient to determine the benefits of mammography among women aged 40 to 49. This panel recommended that women aged 40 to 49 should be counseled about potential benefits and harms before making decisions about mammography (8). In 2001, the CTFPHC concluded there was insufficient evidence to recommend for or against mammography in women 40 to 49 (9). Organizations differ on their recommendations for the appropriate interval for mammography. Annual mammography is recommended by the AMA, ACR, and ACS (1-3). Mammography every 1 to 2 years is recommended by the CTFPHC, AAFP, and ACPM (5-7). The ACOG recommends mammography every 1 to 2 years for women aged 40 to 49 and annually for women aged 50 and older (4). In its 2001 report, the CTFPHC recommends against teaching BSE to women aged 40 to 69 (10). The AMA, ACS, ACOG, and AAFP support teaching BSE (1, 3, 4, 6).

Screening for breast cancer: recommendations and rationale.

This statement summarizes the U.S. Preventive Services Task Force (USPSTF) recommendations on genetic risk assessment and BRCA mutation testing for breast and ovarian cancer susceptibility, along with the supporting scientific evidence. The complete information on which this statement is based, including evidence tables and references, is included in the evidence synthesis available through the USPSTF Web site (http://www.preventiveservices.ahrq.gov). The recommendation is also posted on the Web site of the National Guideline Clearinghouse (http://www.guideline.gov).

U.S. Preventive Services Task Force

Papers

Screening for depression: recommendations and rationale.

Screening for colorectal cancer: recommendation and rationale.

Screening for colorectal cancer: recommendation and rationale.

Screening for breast cancer: recommendations and rationale.

Genetic risk assessment and BRCA mutation testing for breast and ovarian cancer susceptibility: recommendation statement.