According to the ACC/AHA, a person has a relevant relationship IF: a) the relationship or interest relates to the same or similar subject matter, intellectual property or asset, topic, or issue addressed in the document; or b) the company/entity (with whom the relationship exists) makes a drug, drug class, or device addressed in the document or makes a competing drug or device addressed in the document; or c) the person or a member of the persons household, has a reasonable potential for financial, professional or other personal gain or loss as a result of the issues/content addressed in the document. ACC/AHA statement on cost/value methodology in clinical practice guidelines and performance measures: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and Task Force on Practice Guidelines. Find stories, updates and expert opinion. 2002;39(1):839. internship at Bowman Gray School of Medicine in Winston-Salem, North Carolina. Because the sensor is an electronic device it requires a DC power source.How to Test a 3- Wire Sensor.Locate the ground, the power, and the signal wires using The two studies in heart failure patients measured hospital re-admissions, with both studies reporting a minor Journal of the American College of Cardiology. the ability to identify various adverse heart conditions, Trans-esophageal echo (TEE), produce a detailed graphic outline of your Imaging should be considered in those with new onset or persistent stable chest pain (Figure 13). Only key references are cited. Stress Nuclear (PET or SPECT) Myocardial Perfusion Imaging e387, 3.2.4. Reducing unnecessary testing can provide a means to exert cost savings within the diagnostic evaluation of populations.1 In the same manner, elimination of testing where evidence is lacking and the reduction in testing among low-risk patients for whom deferred testing is appropriate are emphasized in this guideline. Most studies in this review delivered teach-back as part of a simple educational program and compared outcomes against participants receiving general education. The Comprehensive RWI Data Supplement table is available with this article at https://www.ahajournals.org/doi/suppl/10.1161/CIR.0000000000001029. The term guideline-directed medical therapy (GDMT) encompasses clinical evaluation, diagnostic testing, and both pharmacological and procedural treatments. in Psychology from the University of California, San Diego before his medical training at Case Western Reserve University School of Medicine Evidence Gaps and Future Research e419, Appendix 1 Author Relationships With Industry and Other Entities (Relevant) e445, Appendix 2 Reviewer Relationships With Industry and Other Entities (Comprehensive) e448. Dr. He then completed medical school High-risk CAD means left main stenosis 50%; anatomically significant 3-vessel disease (70% stenosis). Clinical Decision Pathway for INOCA Test choice should be guided by local availability and expertise. Anginal symptoms gradually build in intensity over a few minutes. doi: 10.1161/CIR.0000000000001029, Circulation is available at www.ahajournals.org/journal/circ. This concept refers to the extent to which an intervention has been implemented in practice as it was intended to [64]. National Ambulatory Medical Care Survey: 2016 national summary tables. Table 9. in Winston-Salem, North Carolina, and also most recently as the Chair Recent innovations, modifications, and evolution of ACC/AHA Clinical Practice Guidelines: an update for our constituencies: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Comprehensive disclosure information for the Joint Committee is also available online. This article has been copublished in the Journal of the American College of Cardiology. This testing often requires more time than is appropriate for an ED visit. Evidence supports that the improved diagnostic accuracy of PET MPI is helpful in the patient with known CAD. ACS indicates acute coronary syndrome; CAD, coronary artery disease; CCTA, coronary CT angiography; CMR, cardiovascular magnetic resonance; CT, computed tomography; FFR-CT, fractional flow reserve with CT; GDMT, guideline-directed medical therapy; ICA, invasive coronary angiography; INOCA, ischemia and no obstructive coronary artery disease; PET, positron emission tomography; and SPECT, single-photon emission CT. As shown in many secondary prevention trials, such as the Veterans Affairs Non-Q-Wave myocardial infarction (VANQUISH), COURAGE and ISCHEMIA, GDMT should be assessed in all patients with known CAD and optimized when symptomatic.2,22,23. In patients with submaximal exercise or for those with an ischemic ECG 1.0 mm ST depression, additional stress imaging may improve risk detection and guide clinical management.41 Marked ischemia (eg, 2.0 mm at reduced workloads) or high Duke or Lauer scores signify increased risk among women and men13,41,42,44; such patients may benefit from additional testing (anatomic or stress testing). From the ORBITA (Objective Randomized Blinded Investigation With Optimal Medical Therapy in Stable Angina) trial, there was a greater reduction in the stress echocardiographic wall motion score among patients with single-vessel CAD treated with PCI compared with placebo (P<0.0001).68 In a secondary analysis, there was an interaction between the baseline stress echocardiographic wall motion score and the efficacy of PCI for improved angina at 6 weeks of follow-up.69 That is, PCI-treated patients with a wall motion score 1 were more often angina-free compared with those in the placebo arm. Tachycardia + dyspnea>90% of patients; pain with inspiration, Connective tissue disorders (eg, Marfan syndrome), extremity pulse differential (30% of patients, type A>B), Emesis, subcutaneous emphysema, pneumothorax (20% patients), unilateral decreased or absent breath sounds, AS: Characteristic systolic murmur, tardus or parvus carotid pulse, Fever, pleuritic chest pain, increased in supine position, friction rub, Esophagitis, peptic ulcer disease, gall bladder disease, Fever, localized chest pain, may be pleuritic, friction rub may be present, regional dullness to percussion, egophony, Dyspnea and pain on inspiration, unilateral absence of breath sounds, Pain in dermatomal distribution, triggered by touch; characteristic rash (unilateral and dermatomal distribution), Abnormal ST changes on resting ECG, digoxin, left bundle branch block, Wolff-Parkinson-White pattern, ventricular paced rhythm (unless test is performed to establish exercise capacity and not for diagnosis of ischemia), High-risk unstable angina, complicated ACS or AMI (<2 d), Limited acoustic windows (eg, in COPD patients), Suspected ACS, CP >5 min, planned serial troponin, Suspected ACS, CP >5 min, planned observation, ED discharge without increasing missed 30-d or 1-y MACE, ED discharge rate without increasing missed 30-d MACE, Low-risk classification without increasing missed 30-d MACE, Patients with primary outcome in study population, %, Initial hs-cTn is very low and Sx onset >3 h ago, Initial hs-cTn is between low and high, ED discharges by 21% (40% versus 18%), More patients identified as low risk versus ADAPT (42% versus 31%), ADAPT: More discharged 6 h (19% versus 11%), hs-cTn accuracy: 30-d MACE sensitivity, %, Normal stress test (given adequate stress), T-0 hs-cTn below the assay limit of detection or very low threshold if symptoms present for at least 3 h, T-0 hs-cTn and 1- or 2-h delta are both below the assay low thresholds (>99% NPV for 30-d MACE), HEART score 3, initial and serial cTn/hs-cTn < assay 99th percentile, EDACS score 16; initial and serial cTn/hs-cTn < assay 99th percentile, TIMI score 0, initial and serial cTn/hs-cTn < assay 99th percentile, TIMI score 0/1, initial and serial cTn/hs-cTn < assay 99th percentile, Gastroesophageal reflux disease/gastritis/esophagitis, Adverse effect of certain medications (eg, 5-fluorouracil), The University of Arizona PhoenixProfessor of Medicine & Chief of Cardiology, Wayne State UniversityProfessor and Associate Chair for Research, Department of Emergency Medicine; Assistant Vice President for Translational Science and Clinical Research Innovation, Texas Tech University Health Sciences Center El PasoChairman, Department of Medicine, UC Davis Medical CenterProfessor, Department of Internal Medicine, Brigham and Womens Hospital Heart & Vascular CenterExecutive Director of Interventional Cardiovascular Programs; Harvard Medical SchoolProfessor of Medicine, University of Houston College of PharmacyClinical Professor. These patients should be transferred to an acute care setting by EMS when there is clinical suspicion of ACS. Pain that can be localized to a very limited area and pain radiating to below the umbilicus or hip are unlikely related to myocardial ischemia. Elkind, MD, MS, FAAN, FAHA, President, Mariell Jessup, MD, FAHA, Chief Science and Medical Officer, Radhika Rajgopal Singh, PhD, Senior Vice President, Office of Science and Health, Paul St. Laurent, DNP, RN, Senior Science and Medicine Advisor, Office of Science, Medicine and Health, Jody Hundley, Production and Operations Manager, Scientific Publications, Office of Science Operations. Microsofts Activision Blizzard deal is key to the companys mobile gaming efforts. Evaluation of Acute Chest Pain With Suspected Anxiety and Other Psychosomatic Considerations e405, 4.3.3. Pain, pressure, tightness, or discomfort in the chest, shoulders, arms, neck, back, upper abdomen, or jaw, as well as shortness of breath and fatigue should all be considered anginal equivalents. Exercise electrocardiographic contraindications are reported in Table 5. CABG indicates coronary artery bypass graft; CAD, coronary artery disease; CCTA, coronary CT angiography; CMR, cardiovascular magnetic resonance imaging; CT, computed tomography; ECG, electrocardiogram; FFR-CT, fractional flow reserve with CT; GDMT, guideline-directed medical therapy; ICA, invasive coronary angiography; iFR, instant wave-free ratio; INOCA, ischemia and no obstructive coronary artery disease; MI, myocardial infarction; MPI, myocardial perfusion imaging; PET, positron emission tomography; SIHD, stable ischemic heart disease; and SPECT, single-photon emission CT. SIHD randomized trials reveal a pattern that ischemia-guided percutaneous coronary intervention (PCI) results in an improvement in angina when compared with medical therapy alone.1-4,41 In the ISCHEMIA trial, a total of 5179 patients with stable CAD and site-determined moderate-severe ischemia on stress testing were randomized to invasive versus conservative care strategies.4 No difference in the composite primary MACE endpoint was observed at 3.3 years of follow-up. The diagnostic modality of choice in stable patients is CTA, which is both highly sensitive and specific.4-6 Chest radiographs can show mediastinal widening but may be normal. Patients With Prior Coronary Artery Bypass Surgery With Stable Chest Pain e414, 5.2.2. Pericarditis and myocarditis share overlapping common causes and likely form a continuum.8 In patients with pericarditis, a minimally elevated troponin does not appear to confer a worse prognosis.14 Most cases of pericarditis in developed nations are viral, although tuberculosis is sometimes a consideration. Only one study [48] engaged patients in the development of an implementation plan for the delivery of teach-back. One year after CABG, 10% to 20% of saphenous vein grafts fail, while by 10 years, only about half of saphenous vein grafts are patent.5 In contrast, the internal mammary artery has patency rates of 90% to 95% 10 to 15 years after CABG.6 Compared with the use of saphenous vein grafts, the use of radial artery grafts for CABG also resulted in a higher rate of patency at 5 years of follow-up.7 In addition, knowledge of the native coronary anatomy and type of revascularization (complete or incomplete) is useful for interpretation of functional testing. In the ERIC project, a panel of experts in the field of implementation science and clinical practice compiled a list of 73 implementation strategies and grouped them into 9 categories, with the intention of guiding implementation research and clinical practice (S1 Table). A comprehensive history that captures all the characteristics of chest pain (Table 3), including but not limited to its: 1) nature; 2) onset and duration; 3) location and radiation; 4) precipitating factors; 5) relieving factors; and 6) associated symptoms can help better identify potential cardiac causes and should be obtained from all patients. Prop 30 is supported by a coalition including CalFire Firefighters, the American Lung Association, environmental organizations, electrical workers and businesses that want to improve Californias air quality by fighting and preventing wildfires and reducing air pollution from vehicles. As shown in Fig 1, these components form the zone of translation within the translational research process [32], thus providing a conceptual basis for our research questions. Finally, comprehending medical diagnoses and treatments requires a level of intermediate or proficient health literacy. This study organized a prize-winning knowledge contest among patients each month as an incentive to reinforce the educational effect of teach-back and stimulate interest in patients to participate. In addition, he was the first African American chief medical resident at Grady Memorial Hospital (19841985). In patients of various racial and ethnic subgroups presenting with suspected ACS in whom English may not be their primary language, adequately addressing language barriers with the use of language translation is vital to obtain an accurate and complete history. We are also a part of Trinity Health Mid-Atlantic, which includes Mercy Fitzgerald in Darby, Pa., St. Mary Medical Center in Langhorne, Pa., and Saint Francis Hospital in Wilmington, Del. She at The Armed Forces Medical College of Pune, India. Studies were heterogeneous in terms of setting, population and outcomes. Cumulative diagnostic costs were $1183 for the selective arm and $2755 for the direct referral arm of the CONSERVE trial (57% lower costs). Please feel free to, Talk Title:"Microengineered tissues for regenerative medicine and organs-on-a-chip applications", IEEE CAS Charles Desoer Life Science Systems Student Attendance Grant, Assistive, Rehabilitation, and Quality of Life Technologies, Bio-inspired and Neuromorphic Circuits and Systems, Biofeedback, Electrical Stimulation, and Closed-Loop Systems, Biomedical Imaging Technologies & Image Processing, Innovative Circuits for Medical Applications, Medical Information Systems and Bioinformatics, Wireless and Energy Harvesting/Scavenging Technology. 1-800-AHA-USA-1 Analysis of health care use in this trial showed fewer cardiac imaging tests and lower overall 45-day health care use in patients randomized to the decision aid.7,8. The incidence of PE is estimated at 65 cases per 100000, but some cases are asymptomatic and others undiagnosed.5,6 One-third of deaths are sudden, and 60% are undiagnosed before death.7 Risk factors for PE are the same for venous thromboembolism and include inherited hypercoagulable states and acquired risk factors (recent surgery, trauma, immobilization, malignancy, smoking, obesity, oral contraception). Increased age is a significant risk factor for ACS. Clinical practice guidelines provide recommendations applicable to patients with or at risk of developing cardiovascular disease. Cardiac Testing General Considerations e384, 3.1.1. To promote the translation of teach-back into routine practice, it is important to identify strategies that may address any contextual and interpersonal barriers that support the uptake of this evidence-based intervention. The recommendations listed in this guideline are, whenever possible, evidence based. Accordingly, median adjusted ED charges were nearly 40% lower for CCTA, compared with stress MPI ($2137 for CCTA versus $3458 for stress MPI; P<0.001). Fellowship, University Hospital & Boston University Boston, MA Specialty Board Certification BS, Nazareth College, Rochester, NY MSW, Greater Rochester Collaboration, Rochester, NY. Simply fill in the items below and hit "Calculate"! Transthoracic echocardiography (TTE) can visualize and aid in the differential diagnosis among the numerous causes of acute chest pain such as acute aortic dissection, pericardial effusion, stress cardiomyopathy, and hypertrophic cardiomyopathy.1,2 Although TTE does provide information, for patients with acute chest pain, visualization of left and right ventricular function and regional wall motion abnormalities allows for the assessment of CAD risk and may help to guide clinical decision-making. For risk assessment in stable chest pain, see Figure 11. moving to North Carolina. When actively treated or spontaneously resolving, it dissipates over a few minutes. University in Boiling Springs, NC. postdoctoral training at Emory University and Vanderbilt University Hospitals. Noncardiac Is In. One study in children with asthma found that teach-back was associated with increased patient-centered communication (OR = 4.97; 95% CI: 4.475.53) and increased engagement of parents during pediatric clinical encounters [40]. Follow-up Testing and Intensification of GDMT Guided by Initial Test Results and Persistence / Worsening / Frequency of Symptoms and Shared Decision Making. Medical Center and has completed two fellowships - at Phoenix Regional Relationships in this table are modest unless otherwise noted. with the Center for Advance Practice. In terms of process evaluation, no studies in this review assessed implementation fidelity. Australian Institute for Musculoskeletal Science (AIMSS), The University of Melbourne and Western Health, VIC, Australia, Writing review & editing, * E-mail: alison.beauchamp@unimelb.edu.au, Affiliations at UC Irvine followed by internal medicine residency at the Mayo Clinic We are also a part of Trinity Health Mid-Atlantic, which includes Mercy Fitzgerald in Darby, Pa., St. Mary Medical Center in Langhorne, Pa., and Saint Francis Hospital in Wilmington, Del. at The Chicago Medical School before also serving as the Chief Resident Some may have chronic or minor troponin elevations. These authors also contributed equally to this work. Figure 9. Table 5. This study solicited feedback from recipients through interviews on the teach-back process to inform the delivery of the intervention moving forward. Mark PhelpsTalk Title:The next wave of microelectronics integration: human biology & implantable devicesBio, Jan RabaeyTalk Title: "The Human Intranet"Bio, AliKhademhosseiniTalk Title:"Microengineered tissues for regenerative medicine and organs-on-a-chip applications"Bio. Dr. Gupta has a wealth of academic and practice experience. Given that previous reviews have evaluated teach-back in conjunction with additional strategies (e.g. Atypical chest pain is a problematic term. This table represents all relationships of reviewers with industry and other entities that were reported at the time of peer review, including those not deemed to be relevant to this document, at the time this document was under review. School of Nursing and Midwifery, Deakin University, VIC, Australia, In all cases for a test deemed clinically necessary, the lowest effective dose of ionizing radiation should be used, including considerations for tests with no radiation exposure (eg, echocardiography, CMR imaging).1 Radiation risk to the fetus is very small. The complete policy on relationships with industry and other entities (RWI) can be found online. for both the Echocardiography Laboratory Caromont Regional Medical Center of Cardiovascular Medicine at Deborah Heart and Lung Center in the Greater Evaluation of bypass grafts has been shown to be successful in 93% to 100% of patients.21 In patients who have acute chest pain without features of ACS, CCTA is especially useful for assessing graft patency and is less robust for assessing native coronary vessel stenosis in this population.1-7, There are clinical features and stress imaging test features in patients with prior CABG presenting with acute chest pain with no ACS that may indicate a high likelihood of severe ischemic heart disease such as new resting left ventricular systolic dysfunction (left ventricular ejection fraction <35%) not readily explained by noncoronary causes, stress electrocardiographic findings including 2 mm of ST-segment depression at low workload or persisting into recovery, exercise-induced ST-segment elevation, or exercise-induced VT/ventricular fibrillation (VF), severe stress-induced left ventricular systolic dysfunction, stress-induced perfusion abnormalities involving 10% of the myocardium, or stress-induced left ventricular dilation. Medicine at the Mayo Clinic in Rochester Minnesota. Teach-back was found to be effective across a wide range of settings, populations and outcome measures. Attention to race, ethnicity, and sociocultural differences should be considered in the evaluation and management of such patients. We are a 230-bed community hospital which serves the changing urban population of Northeast Philadelphia. the West Virginia University School of Osteopathic Medicine and graduated Methods to elicit symptoms and clusters of symptoms that provide improved pretest probabilities of symptomatic CAD may be aided with machine-learning algorithms. AACVPR indicates American Association of Cardiovascular and Pulmonary Rehabilitation; AAPA, American Academy of Physician Assistants; AATS, American Association for Thoracic Surgery; ABC, Association of Black Cardiologists; ACC, American College of Cardiology; ACPM, American College of Preventive Medicine; ADA, American Diabetes Association; AGS, American Geriatrics Society; AHA, American Heart Association; APhA, American Pharmacists Association; ASH, American Society of Hypertension; ASPC, American Society for Preventive Cardiology; CDC, Centers for Disease Control and Prevention; ESC, European Society of Cardiology; HRS, Heart Rhythm Society; NHLBI, National Heart, Lung, and Blood Institute; NLA, National Lipid Association; NMA, National Medical Association; PCNA, Preventive Cardiovascular Nurses Association; SCAI, Society for Cardiovascular Angiography and Interventions; STS, Society of Thoracic Surgeons; and TOS, The Obesity Society. We are excited to hear from the following at the BioCAS 2015 Gala Dinner Forum, "The most important problems to be tackled by the BioCAS community": Join the following at the BioCAS 2015 Parallel Workshop, "Lessons Learned Along the Translational Highway": Steve Maschino,Cyberonics, Inc., Intermedics, Jared William Hansen, North Dakota State University, Johanna Neuber, University of Texas at Austin, Muhammad Awais Bin Altaf, Masdar Institute of Science and Technology, Piyakamal Dissanayaka Manamperi, RMIT University, Mami Sakata, Yokohama National University, Elham Shabani Varaki, University of Western Sydney, Mahdi Rasouli, National University of Singapore, A Smart Homecage System with Behavior Analysis and Closed-Loop Optogenetic Stimulation Capacibilities, Yaoyao Jia, Zheyuan Wang, Abdollah Mirbozorgi, Maysam GhovanlooGeorgia Institute of Technology, A 12-Channel Bidirectional Neural Interface Chip with Integrated Channel-Level Feature Extraction and PID Controller for Closed-Loop Operation, Xilin Liu, Milin Zhang, Andrew Richardson, Timothy Lucas, Jan Van der SpiegelUniversity of Pennsylvania, A Wireless Optogenetic Headstage with Multichannel Neural Signal Compression, Gabriel Gagnon-Turcotte, Yoan Lechasseur, (Doric Lenses Inc.), Cyril Bories, Yves De Koninck, Benoit GosselinUniversit Laval, 32k Channels Readout IC for Single Photon Counting Detectors with 75 m Pitch, ENC of 123 e- rms, 9 e- rms Offset Spread and 2% rms Gain Spread, Pawel Grybos, Piotr Kmon, Piotr Maj, Robert SzczygielAGH University of Science and Technology, BioCAS 2015 - Atlanta, Georgia, USA - October 22-24, 2015. For these older patients, when compared with anatomic noninvasive testing for obstructive CAD with cardiac CT, a positive stress test result was associated with increased risk of cardiovascular death or MI.4, Patients >75 years of age may have symptoms of shortness of breath, syncope, mental impairment, or abdominal pain, or experienced an unexplained fall. For more information about PLOS Subject Areas, click In most studies (n = 15), teach-back was delivered as part of a simple and structured educational approach. Figure 13. Iodinated contrast enters the fetal circulation through the placenta and should be used with caution in a pregnant woman. The most frequently utilized implementation strategies were training and education of stakeholders (e.g. here. Patrick T. OGara, MD, MACC, FAHA, Chair; Joshua A. Beckman, MD, MS, FAHA, FACC, Chair-Elect; Glenn N. Levine, MD, FACC, FAHA, Immediate Past Chair*; Sana M. Al-Khatib, MD, MHS, FACC, FAHA*; Anastasia L. Armbruster, PharmD, FACC; Kim K. Birtcher, MS, PharmD, AACC*; Ralph G. Brindis, MD, MPH, MACC*; Joaquin E. Cigarroa, MD, FACC*; Lisa de las Fuentes, MD, MS, FASE, FAHA; Anita Deswal, MD, MPH, FACC, FAHA; Dave L. Dixon, PharmD, FACC*; Lee A. Fleisher, MD, FACC, FAHA*; Federico Gentile, MD, FACC*; Zachary D. Goldberger, MD, MS, FACC, FAHA*; Bulent Gorenek, MD, FACC; Norrisa Haynes, MD; Adrian F. Hernandez, MD; Mark A. Hlatky, MD, FACC, FAHA*; John S. Ikonomidis, MD, PhD, FAHA*; Jos A. Joglar, MD, FAHA, FACC; W. Schuyler Jones, MD, FACC; Joseph E. Marine, MD, FACC*; Daniel B. For this reason, features more likely to be associated with ischemia have been described as typical versus atypical; however, the latter can be confusing because it is frequently used to describe symptoms considered nonischemic as well as noncardiac. There are only a handful of dermatology nurse practitioner and physician assistant fellowship programs in the United States.. Toggle navigation. CDPs that are based on cTn results have proven valid and useful in clinical practice.1-14 Use of unstructured assessment for clinical decision-making often leads to both under- and over-testing.
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