Critical pathways in cardiology
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Review Comparative Study
Management of non-ST-segment elevation acute coronary syndrome: comparison of the updated guidelines from North America and Europe.
The American College of Cardiology/American Heart Association and the European Society of Cardiology published updated guidelines in 2011 for the management of patients with non-ST-segment elevation acute coronary syndrome. In this article, we highlight the most important new recommendations, review their supporting data, describe differences between the guidelines, and discuss new literature published since the latest guidelines were released. Key updates include detailed guidance regarding early risk stratification, use of coronary computed tomography angiography, selection of initial management strategy, novel antiplatelet agents, and new measures to enhance performance and quality. ⋯ Meanwhile, unique recommendations in the American College of Cardiology/American Heart Association guideline include administration of prasugrel in selected patients before coronary angiography and consideration of continued dual antiplatelet therapy beyond 15 months after drug-eluting stent placement. Both guidelines include new recommendations endorsing platelet function and genetic testing in selected patients on clopidogrel, renal protection strategies, and less aggressive in patient's glycemic control. As these guidelines represent the most evidence-based approach, health care providers should become familiar with these updated recommendations to ensure optimal treatment of their patients with non-ST-segment elevation acute coronary syndrome.
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Natriuretic peptides (B-type natriuretic peptide [BNP] and N-terminal pro-B-type natriuretic peptide [NT]-proBNP) have been proven to be strong diagnostic and prognostic tools in the assessment of acutely decompensated heart failure. The emergence of BNP/NT-proBNP testing as a standard of care in this setting has helped to reduce healthcare costs, and may decrease adverse clinical outcomes. The use of BNP and NT-proBNP to "guide" treatment of acutely destabilized heart failure has recently grown. We present an overview of the value of BNP/NT-proBNP in the context of acute heart failure management and therapy optimization, and present an algorithm for natriuretic peptide-guided treatment of acutely destabilized heart failure.
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In 2003, we published our chest pain protocol for the management of acute coronary syndromes (ACSs) and acute myocardial infarction. Our algorithm was specifically designed for our institution, which was primary percutaneous coronary intervention (PCI) for all ST-elevation myocardial infarctions (STEMIs) and a preferred invasive approach for non-STEMIs. ⋯ We present our updated chest pain algorithm with a brief review of the rapidly evolving changes in adjunctive pharmacotherapy for PCI and provide a rationale for the changes that we have made to our institutional protocol. Clinical pathways need to be consistently updated and revises by incorporating new evidence from clinical trials in order to maintain clinical relevance.
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Global risk assessment is the standard of care for coronary artery disease management. In this setting, sleep apnea syndrome, which includes obstructive sleep apnea and central sleep apnea, is being increasingly recognized as a potentially modifiable risk factor for coronary artery disease. ⋯ Continuous positive airway pressure has been shown to decrease inflammatory markers that are elevated in sleep apnea syndrome. Well-designed randomized controlled clinical trials are needed to better establish the role of sleep apnea in the genesis and progression of coronary artery disease.
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Despite the clinical importance of prompt percutaneous coronary intervention for patients with ST-segment elevation myocardial infarction, many hospitals do not routinely achieve the guideline-recommended 90-minute door-to-balloon times. In this review, we evaluate existing evidence that identifies effective hospital strategies for reducing door-to-balloon time. We performed a computerized search of MEDLINE and Current Contents for studies conducted in the last 10 years of hospital efforts to improve door-to-balloon times. ⋯ Strategies with the strongest evidence include (1) activation of the catheterization laboratory using emergency medicine physicians rather than cardiologists, (2) effective use of prehospital electrocardiograms, (3) performance data monitoring/feedback. Reasonable evidence exists for establishing a single-call system for activating the catheterization laboratory, setting the expectation that the catheterization team be available 20-30 minutes after being paged, and having an organizational environment with strong senior management support and culture to foster changes directed at improving door-to-balloon time. In conclusion, although evidence of "what works" is based on observational studies rather than randomized trials, there is evidence on effective interventions to reduce door-to-balloon time.