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Cardiac Tests & Treatments to Avoid

Cardiac Tests & Treatments to Avoid

In collaboration with the American Board of Internal Medicine’s Choosing Wisely campaign, the Society for Cardiovascular Angiography and Interventions (SCAI) has issued a list of five specific, evidence-based recommendations that should be avoided in the care of patients who have cardiovascular disease (CVD) or are at risk for it. “This list should be used to spur conversations between patients and physicians so that wise decisions are made about care based on each patient’s individual situation,” says James C. Blankenship, MD. “It’s hoped that this list will improve care for patients and eliminate unnecessary tests and procedures.” Five Recommendations for Patients with CVD The list of tests and treatments to avoid from SCAI includes the following five recommendations: 1. Avoid routine stress testing after PCI without specific clinical indications. 2. Avoid coronary angiography in post-bypass surgery and post-PCI patients who are asymptomatic or who have normal or mildly abnormal stress tests and stable symptoms that do not limit quality of life. 3. Avoid coronary angiography for risk assessment in patients with stable ischemic CVD who are unwilling to undergo revascularization or who are not candidates for revascularization based on comorbidities or individual preferences. 4. Avoid coronary angiography to assess risk in asymptomatic patients with no evidence of ischemia or other abnormalities on adequate non-invasive testing. 5. Avoid PCI in asymptomatic patients with stable ischemic CVD without the demon­stration of ischemia on adequate stress testing or with abnormal fractional flow reserve testing. The list was based on guidelines and appropriate use criteria developed by SCAI, the American College of Cardiology, the American Heart Asso­ciation, and other professional societies. All of the...

Trends in Acute Kidney Injury in Patients With Acute Myocardial Infarction

Among patients hospitalized with an acute myocardial infarction (AMI), about 20% will develop an acute kidney injury (AKI). This complication has been linked to adverse long-term outcomes, including permanent renal impairment and end-stage renal disease. Minor increases in serum creatinine levels have also been associated with increased mortality, longer hospitalizations, and higher costs. “Experts are increasingly emphasizing the importance of preventing AKI and promptly recognizing it in patients hospitalized with AMI,” says Mikhail N. Kosiborod, MD. “A better understanding of trends may help determine if recent prevention efforts have been successful. This data can also be used to form initiatives aimed at preventing AKI.” Taking a Closer Look at AKI In the February 13, 2012 Archives of Internal Medicine, Dr. Kosiborod and colleagues analyzed data from a registry of patients admitted to 56 hospitals across the United States to examine trends in AKI from 2000 to 2008. AKI was defined as an increase of at least 0.3 mg/dL in creatinine levels or a relative increase of at least 50% during hospitalization. “The database used in our analysis had an extensive collection of laboratory data, including detailed assessments of renal function,” says Dr. Kosiborod. “Using this information, we wanted to understand the incidence trends in AKI and use of AKI prevention strategies among patients hospitalized with AMI.” According to findings, the incidence of AKI declined from 26.6% in 2000 to 19.7% in 2008 (Figure). In-hospital mortality also declined in patients who developed AKI, dropping from 19.9% in 2000 to 13.8% in 2008. This improvement occurred despite a concomitant increase in AKI risk factors, including chronic kidney disease, cardiogenic shock, diabetes,...

A New Guide for Revascularizing Patients With CAD

In the December 6, 2011 Journal of the American College of Cardiology, the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) published guidelines on the management of patients undergoing CABG, one of the most common operations performed in the United States. These guidelines were released at the same time that the ACCF and AHA published recommendations for PCI. According to L. David Hillis, MD, FACP, chair of the ACCF/AHA guidelines committee for CABG, the landscape regarding when surgeons should perform CABG or PCI has been continually changing, particularly in the past 5 to 10 years. “Several recent investigations have shown that PCI and CABG have comparable outcomes when used in patients with certain coronary arterial anatomic features,” he says. “The last guidelines were published in 2004, but clinical trials have continued to improve our understanding of how to optimize the management of patients with coronary artery disease (CAD).” A Collaborative Approach to Determine Revascularization Through a collaboration of two writing committees, the ACCF/AHA guideline update contains the most extensive examination of CABG and PCI use for coronary revascularization. “While one committee was re-writing the CABG guidelines, a separate committee was revising the PCI guidelines,” explains Dr. Hillis. “Our goal was then to develop a consensus between cardiologists and surgeons over patient selection for these two procedures. Busy practitioners have historically been challenged when deciding on which patients should undergo revascularization rather than being treated medically, and whether revascularization should be accomplished with CABG or PCI.” Dr. Hillis says a section of the guidelines has been established to address questions that clinicians may have when deciding...
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