How to Keep Your Surgeon Out of Trouble: Perioperative Medicine: Risk Stratification
|
|
|
- Marshall Thornton
- 7 years ago
- Views:
Transcription
1 How to Keep Your Surgeon Out of Trouble: Perioperative Medicine: Risk Stratification Jalal K. Ghali, M.D., F.A.C.C. Professor of Medicine Associate Chair for Clinical Research Chief, Division of Cardiology Department of Medicine Mercer University School of Medicine Macon, GA
2 How to Make Your Surgeon Happy
3 Dear Dr. GS, Your patient Mr. MC has been cleared for the planned surgery. I would like to assure you that no medical complications will arise from the planned surgery and furthermore, should they arise, I take full responsibility for managing them. Our commitment extends for full 30 days post op.
4 How to Keep Your Surgeon Out of Trouble:
5 Impossible
6 Disclosures Internists: Surgeons: Know everything and do no procedures Know nothing and do everything Psychiatrists: Have no clue Pathologists: Know everything, one day late do everything
7 Definition of the Medical Consultant
8 Perioperative Medicine Magnitude of the problem Is there a need for medical consultation? Pathophysiology Predictive models Revised Cardiac Risk Index Thoracic Revised Cardiac Risk Index Vascular Study Group of New England Surgical Mortality Probability Model Risk Calculator for Prediction of Cardiac Risk
9 Perioperative Medicine Clinical Recommendations Special considerations Biomarkers Hypertension PCI Statins Beta Blockers Summary Definition of the medical consultant
10 10 million major noncardiac surgery 4 million in patients 65 years High risk account for 80% of death 250 million procedures worldwide
11 Common preventable complications after non-cardiac surgery that may be prevented by enhanced perioperative care Pneumonia Superficial and deep wound infection Myocardial infarction Arrhythmias Severe pain Pulmonary embolism Acute kidney injury Stroke Respiratory failure Acute confusion or delirium Cardiac arrest Pearse RM, et al. BMJ 2011;343:d5759.
12 84,730 patients who had undergone inpatient general and vascular surgery Very low mortality Very high mortality 3.5% 6.9% Ghaferi AA. N Engl J Med 2009;361:
13 Rates of All Complications, Major Complications, and Death after Major Complications Ghareri AA, et al. N Engl J Med 2009;361:
14 Survival Probability All Patients Patients surviving beyond 30 days postop Days Patients with no complications Patients with 1 or more 30-day postop complications Khuri SF, et al. Ann Surg 2005;242(3):
15 Hospital-specific rates of preoperative medical consultation for major elective noncardiac surgery Wijeysundera DN, et al. Anesthesiology 2012;116:25-34.
16 Associations Between Perioperative Consultation, Quality of Care, and Subsequent Complications Auerbach AD, et al. Arch Intern Med 2007;167:
17 217,082 39% (n = 104,716) underwent anesthesia consultations - Reduced mean hospital length of stay 8.17 vs 8.52 day - No reduction of 30 day or 1 year mortality Wijeysundera DN, et al. Arch Intern Med 2009;169(6):
18 ,866 n = (38.8%) underwent consultation 30 day mortality RR 1.16 ( ) Number needed to harm year mortality RR 1.08 ( ) Number needed to harm 227 Wijeysundera DN, et al. Arch Intern Med 2010;170(15):
19 Pathophysiology
20 Emotional stress Pain Surgical trauma Tissue injury Hypothermia Hypoxemia Immobility Bleeding and anemia Fasting
21 Landesberg G et al. Circulation 2009;119:
22 Landesberg G et al. Circulation 2009;119:
23 Potential triggers of states associated with perioperative elevations in troponin levels, arterial thrombosis and fatal myocardial infarction Devereaux PJ, et al. CMAJ 2005;173(6):
24 Risk Prediction Models
25 Revised Cardiac Risk Index
26 Lee TH, et al. Circulation 1999;100:
27 Risk of Cardiac Death and Nonfatal Myocardial Infarction for Noncardiac Surgical Procedures Risk of procedure High (> 5%) Aortic and major vascular surgery, peripheral vascular surgery Intermediate (1 to 5%) Intraperitoneal or intrathoracic surgery, carotid endarterectomy, head and neck injury, orthopedic surgery, prostate surgery Low (< 1%) Ambulatory surgery, breast surgery, endoscopic procedures, superficial procedures, cataract surgery
28 Thoracic Revised Cardiac Risk Index
29 Thoracic Revised Cardiac Risk Index Ischemic Heart Disease 1.5 CVA or TIA 1.5 Pneumonectomy 1.5 Creatinin >2 mg/dl 1.0 Brunelli A, et al. Ann Thorac Surg 2011;92:445-8.
30 Distribution of Patients in Each Class of the Recalibrated Revised Cardiac Risk Index (ThRCRI) ThRCRI Score Risk Class No. of Cases Major Cardiac Complications 0 A 1, (0.9%) B (4.2%) C 25 2 (8%) >2.5 D (18%) p < Brunelli A, et al. Ann Thorac Surg 2011;92:
31 Rates of cardiac complication according to the Thoracic Revised Cardiac Risk Index classes A, B, C, D Brunelli A, et al. Ann Thorac Surg 2011;92:
32 Vascular Study Group of New England(VSG-CRI)
33 Vascular Surgery Group Cardiac Risk Index (VSG-CRI) scoring system and predicated risk of adverse cardiac events Bertges, et al. J Vasc Surg 2010;52(3):
34 Surgical Mortality Probability Model
35 ASA PS Classification ASA PS I II III IV V Definition A normal healthy patient A patient with mild systemic disease A patient with severe systemic disease A patient with severe systemic disease that is a constant threat to life A moribund patient who is not expected to survive without the operation Glance LG, et al. Ann Surg 2012;255:
36 S-MPM Scoring System for Estimating Risk of 30-Day Mortality After Noncardiac Surgery Glance LG, et al. Ann Surg 2012;255:
37 S-MPM Class Levels and Associated Risk of Mortality Class Point Total Mortality I 0-4 <0.50% II %-4.0% III 7-9 >10% Glance LG, et al. Ann Surg 2012;255:
38 Risk Calculator for Prediction of Cardiac Risk After Surgery
39 Calculator to Predict the risk of myocardial infarction or cardiac arrest (MICA) Type of surgery Functional status Abnormal creatinine American Society of Anesthesiologists class Increasing age The MICA risk calculator is available at Gupta PK, et al. Circulation 2011;124:
40 Clinical Recommendations
41 CCS ACC/ AHA ESC HFSA
42 CCS ACC/AHA ESC HFSA
43 Definition Something that provides direction or advice as to a decision or course of action; A detailed plan or explanation to guide you in setting standards or determining a course of action Collins English Dictionary
44 Definition Systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances 1 To assist health care providers in clinical decision making by describing a range of generally acceptable approaches 2 1. Institute of Medicine. Washington, DC: National Academy PR; Hunt S, et al. Circulation 2005;112:
45 Electrocardiogram
46 Class I Recommendations for Preoperative Resting 12-Lead ECG 1. Patients with at least 1 clinical risk factor who are undergoing vascular surgical procedures. 2. patients with known CHD, peripheral arterial disease, or cerebrovascular disease who are undergoing intermediate-risk surgical procedures. Fleisher LA, et al. Circulation 2009;120:e169-e276.
47 Recommendations for Preoperative Resting 12-Lead ECG Class III 1. Preoperative and postoperative resting 12-lead ECGs are not indicated in asymptomatic persons undergoing low-risk surgical procedures. Fleisher LA, et al. Circulation 2009;120:e169-e276.
48 Suggested algorithm for performing preoperative electrocardiography Feely MA, et al. Am Fam Physician 2013;87(6):414-8.
49 Echocardiography
50 264, 823 patients undergoing elective intermediate to high risk noncardiac surgery Echocardiography 40,084 (15.1%) 70, day mortality 1 year mortality 1.14 ( ) 1.07 ( ) Wijeysundera DN, et al. BMJ 2011;342:d3695.
51 Recommendations for Preoperative Noninvasive Evaluation of LV Function Class IIa 1. It is reasonable for patients with dyspnea of unknown origin. 2. It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical status if not performed within 12 months. Fleisher LA, et al. Circulation 2009;120:e169-e276.
52 Recommendations for Preoperative Noninvasive Evaluation of LV Function Class IIb 1. Reassessment of LV function in clinically stable patients with previously documented cardiomyopathy is not well established. Class III 1. Routine perioperative evaluation of LV function in patients is not recommended. Fleisher LA, et al. Circulation 2009;120:e169-e276.
53 Stress Testing
54 Association of preoperative stress testing with one year survival in the subgroup analyses Wijeysundera DN, et al. BMJ 2010;340:b5526.
55 Active Cardiac Conditions for Which the Patient Should Undergo Evaluation and Treatment Before Noncardiac Surgery Unstable coronary symptoms Decompensated HF (NYHA functional class IV: worsening or new-onset HF) Significant arrythmias Severe valvular disease Fleisher LA, et al. Circulation 2009;120:e169-e276.
56 Recommendations for Noninvasive Stress Testing Before Noncardiac Surgery Class I 1. Patients with active cardiac conditions. Class IIa 1. 3 or more clinical risk factors and poor functional capacity (less than 4 METs) who require vascular surgery is reasonable if it will change management. Fleisher LA, et al. Circulation 2009;120:e169-e276.
57 Recommendations for Noninvasive Stress Testing Before Noncardiac Surgery Class IIb 1. may be considered for patients with at lease 1 to 2 clinical risk factors and poor functional capacity (less than 4 METs) who require intermediate risk or vascular surgery if it will change management. Class III 1. Noninvasive testing is not useful for patients with no clinical risk factors undergoing low or intermediate-risk noncardiac surgery. Fleisher LA, et al. Circulation 2009;120:e169-e276.
58 Long-Term Survival among Patients Assigned to Undergo Coronary-Artery Revascularization or No Coronary-Artery Revascularization before Elective Major Vascular Surgery McFalls EO, et al. NEJM 2004;351:
59 American College of Cardiology (ACC)/ American Heart Association (AHA) 2007 Guidelines Open Vascular Surgery Required Emergent No Yes Active Cardiac Condition No Known Functional Capacity No Proceed with planned procedure Yes Class I: Non-Invasive Stress Testing Class I: Coronary Revascularization indications same as in patients not undergoing surgery < 3 Clinical Risk Factors Class I: No Further Testing Class I: Continue β-blocker if currently prescribed No Yes Class IIa: Consider Non-Invasive Stress Testing
60 Biomarkers
61 Postoperative NT-proBNP Thresholds and the Incidence of Mortality or Nonfatal MI at 30 Days after Surgery Rodseth et al. Anesthesiology 2013;119:
62 Postoperative BNP Thresholds and the Incidence of Mortality or Nonfatal MI at 30 Days after Surgery Rodseth et al. Anesthesiology 2013;119:
63 Risk of death for patients with estimated glomerular filtration rate <60 ml-min-1.73 m -2 compared with 60 mil-min-1.73 m -2 at both short-term and long-term follow up Mooney et al. Anesthesiology 2013;118:
64 Kaplan-Meier estimates of 30-Day mortality based on peak Troponin T values 15,133 noncardiac surgery ( ) The Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (VISION) Study Investigators. JAMA 2013;307:
65 Le Manach, et al. Anesthesiology 2005;102:
66 Le Manach, et al. Anesthesiology 2005;102:
67 Kikura M, et al. J Thromb Haemost 2008;6:
68 Kikura M, et al. J Thromb Haemost 2008;6:
69 Statins
70 Effect of perioperative statins on myocardial infarction, atrial fibrillation, and death. Chopra V, et al. Arch Surg 2012;147(3):181-9.
71 Effect of perioperative statins on hospital and intensive care unit length of stay. Chopra V, et al. Arch Surg 2012;147(3):181-9.
72 Forest plot of comparison: I Statin versus placebo/no treatment, outcome: 1.2 All-Cause mortality Sanders RD, et al. Cochrane Database Syst Rev 2013;7.
73 Forest plot of comparison: I Statin versus placebo/no treatment, outcome: 1.4 Myocardial Infarction (non-fatal) Sanders RD, et al. Cochrane Database Syst Rev 2013;7.
74 PCI
75 The highest-risk period for ST after PCI with either BMS or DES following NCS is the first 4 weeks. Therefore, it seems reasonable to withhold NCS, if possible, for at least 4 weeks after PCI. Singla S, et al. JACC 2012;60:
76 Proposed approach to the management of patients with previous PCI requiring noncardiac surgery Fleisher LA, et al. Circulation 2009;120:e169-e276.
77 Proposed treatment for patients requiring percutaneous coronary intervention (PCI) who need subsequent surgery Fleisher LA, et al. Circulation 2009;120:e169-e276.
78 Perioperative Hypertension
79 No link between perioperative complications with either preexistant hypertension or an elevated blood pressure Types of surgery: CABG, AA, CEA, PVS, intraperitoneal or intrathoracic Perioperative cardiac complications are associated with hemodynamic lability (>20% change in mean BP)
80 Consider lowering the dose of ACE inhibitors or AR antagonist 24 hours ( at least 10 hours) before surgery
81 Perioperative Beta Blockers
82 8,351 patients with, or at risk of, atherosclerotic disease received extended-release metoprolol succinate (n=4174) or placebo (n=4177) started 2-4 h before surgery and continued for 30 days. Perioperative Ischemic Evaluation Study (POISE) Group. Lancet 2008;371:
83 Kaplan-Meier estimates of the primary outcome (A), myocardial infarction (B), stroke (C) and death (D) Perioperative Ischemic Evaluation Study (POISE) Group. Lancet 2008;371:
84 Metoprolol (n = 4179) Placebo (n = 4177) Death Strokes Perioperative Ischemic Evaluation Study (POISE) Group. Lancet 2008;371:
85 Meta-analysis of β-blocker trials in patients undergoing noncardiac surgery Perioperative Ischemic Evaluation Study (POISE) Group. Lancet 2008;371:
86 Comparison of effect of perioperative β-blockade on nonfatal strokes in secure and non-secure trials. Bouri S et al. Heart 2013.
87 Meta-analysis of nine secure randomised controlled trials showing a significant increase in mortality with perioperative β-blockade. Bouri S et al. Heart 2013.
88 Prevalence of hypotension in β-blocker and control groups. Bouri S et al. Heart 2013.
89 Thirty-Day Mortality Propensity Model London MJ, et al. JAMA 2013;309(16):
90 Beta Blockers 28,263 adults with IHD who underwent noncardiac surgery MACE Mortality Heart Failure 22% 18% MI within 2 years 46% 20% MI 2 5 years 29% 26% MI > 5 years 35% 33% No MI or HF 44% 30% Anderson C et al. Annual Congress of the European Society of Cardiology. September 18, 2013.
91 Summary of ACC/AHA Guideline Recommendations Beta-Blocker Medical Therapy Class I Class III Beta-blockers should be continued in patients undergoing surgery who are receiving betablockers to treat angina, symptomatic arrhythmias, hypertension, or other ACC/AHA class I guideline indications Routine administration of high-dose betablockers in the absence of dose titration is not useful and may be harmful to patients not currently taking beta-blockers who are undergoing noncardiac surgery
92 Fleisher LA. Cleve Clin J Med 2009;76:S9-15.
93 Fleisher LA. Cleve Clin J Med 2009;76:S9-15.
94 Medical Consultant Provide informed clinical judgment based on knowledge, experience and the individual patient s data to optimize short and long term outcomes.
Perioperative Cardiac Evaluation
Perioperative Cardiac Evaluation Caroline McKillop Advisor: Dr. Tam Psenka 10-3-2007 Importance of Cardiac Guidelines -Used multiple times every day -Patient Safety -Part of Surgical Care Improvement Project
Objectives. Preoperative Cardiac Risk Stratification for Noncardiac Surgery. History
Preoperative Cardiac Risk Stratification for Noncardiac Surgery Kimberly Boddicker, MD FACC Essentia Health Heart and Vascular Center 27 th Heart and Vascular Conference May 13, 2011 Objectives Summarize
Perioperative Risk Stratification for Noncardiac Surgical Patients with Cardiac Diagnosis. Michael A. Blazing
Perioperative Risk Stratification for Noncardiac Surgical Patients with Cardiac Diagnosis Michael A. Blazing Outline The coming crush A practical approach to clinical risk assessment Classic approach to
Cardiac Assessment for Renal Transplantation: Pre-Operative Clearance is Only the Tip of the Iceberg
Cardiac Assessment for Renal Transplantation: Pre-Operative Clearance is Only the Tip of the Iceberg 2 nd Annual Duke Renal Transplant Symposium March 1, 2014 Durham, NC Joseph G. Rogers, M.D. Associate
ECG may be indicated for patients with cardiovascular risk factors
eappendix A. Summary for Preoperative ECG American College of Cardiology/ American Heart Association, 2007 A1 2002 A2 European Society of Cardiology and European Society of Anaesthesiology, 2009 A3 Improvement,
PREOPERATIVE CARDIAC RISK FOR NONCARDIAC SURGERY Review of 2014 ACC/AHA Guidelines and Implications for Clinical Care
PREOPERATIVE CARDIAC RISK FOR NONCARDIAC SURGERY Review of 2014 ACC/AHA Guidelines and Implications for Clinical Care Ronald L Walsh, D.O., MACOI, FACC ACOI Clinical Challenges in Inpatient Care March
CARDIAC RISKS OF NON CARDIAC SURGERY
CARDIAC RISKS OF NON CARDIAC SURGERY N E W S T U D I E S & N E W G U I D E L I N E S W. B. C A L H O U N, M D, F A C C 2014 ACC/AHA Guideline on perioperative cardiovascular evaluation and management
In patients undergoing noncardiac surgery, preoperative
LEE A. FLEISHER, MD Robert D. Dripps Professor and Chair, Department of Anesthesiology and Critical Care, and Professor of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA Cardiac
2/20/2015. Cardiac Evaluation of Potential Solid Organ Transplant Recipients. Issues Specific to Transplantation. Kidney Transplantation.
DISCLOSURES I have no relevant financial relationships to disclose. Cardiac Evaluation of Potential Solid Organ Transplant Recipients Michele Hamilton, MD Director, Heart Failure Program Cedars Sinai Heart
Pre-Operative Cardiac Evaluation Kalpana Jain, MD
Pre-Operative Cardiac Evaluation Kalpana Jain, MD Cardiac evaluation is an integral part of pre-op evaluation. Perioperative cardiac events are common causes of mortality. Major cardiac complications associated
Review of 2014 ACC/AHA Guidelines and Implications for Clinical Care
Review of 2014 ACC/AHA Guidelines and Implications for Clinical Care Guideline on Perioperative Cardiovascular Evaluation Dr.Kevin Kannan, Dept. of Cardiology, OhioHealth Conflict of Interest No relevant
Listen to your heart: Good Cardiovascular Health for Life
Listen to your heart: Good Cardiovascular Health for Life Luis R. Castellanos MD, MPH Assistant Clinical Professor of Medicine University of California San Diego School of Medicine Sulpizio Family Cardiovascular
Antiplatelet and Antithrombotics From clinical trials to guidelines
Antiplatelet and Antithrombotics From clinical trials to guidelines Ashraf Reda, MD, FESC Prof and head of Cardiology Dep. Menofiya University Preisedent of EGYBAC Chairman of WGLVR One of the big stories
DISCLOSURES RISK ASSESSMENT. Stroke and Heart Disease -Is there a Link Beyond Risk Factors? Daniel Lackland, MD
STROKE AND HEART DISEASE IS THERE A LINK BEYOND RISK FACTORS? D AN IE L T. L AC K L AN D DISCLOSURES Member of NHLBI Risk Assessment Workgroup RISK ASSESSMENT Count major risk factors For patients with
Measure #257 (NQF 1519): Statin Therapy at Discharge after Lower Extremity Bypass (LEB) National Quality Strategy Domain: Effective Clinical Care
Measure #257 (NQF 1519): Statin Therapy at Discharge after Lower Extremity Bypass (LEB) National Quality Strategy Domain: Effective Clinical Care 2016 PQRS OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
NAME OF THE HOSPITAL: 1. Coronary Balloon Angioplasty: M7F1.1/ Angioplasty with Stent(PTCA with Stent): M7F1.3
1. Coronary Balloon Angioplasty: M7F1.1/ Angioplasty with Stent(PTCA with Stent): M7F1.3 1. Name of the Procedure: Coronary Balloon Angioplasty 2. Select the Indication from the drop down of various indications
Perioperative myocardial infarction. for Perioperative Cardiac Events. Paul Lee, M.D., M.P.H. Perioperative Cardiac Risk in Non-Cardiac Surgery
Perioperative Cardiac Risk in Non-Cardiac Surgery Perioperative Cardiac Risk in Non-Cardiac Surgery Paul Lee, M.D., M.P.H. Associate Clinical Professor of Medicine Medical Director, Section of Hospital
Treating AF: The Newest Recommendations. CardioCase presentation. Ethel s Case. Wayne Warnica, MD, FACC, FACP, FRCPC
Treating AF: The Newest Recommendations Wayne Warnica, MD, FACC, FACP, FRCPC CardioCase presentation Ethel s Case Ethel, 73, presents with rapid heart beating and mild chest discomfort. In the ED, ECG
None. Dual Antiplatelet Therapy Plus Systemic Anticoagulation: Bleeding Risk and Management. 76 year old male LINGO 1/5/2015
Financial Disclosure Information Dual Antiplatelet Therapy Plus Systemic Anticoagulation: Bleeding Risk and Management Robert D. McBane, M.D. Division of Cardiology Mayo Clinic Rochester Dual Antiplatelet
Duration of Dual Antiplatelet Therapy After Coronary Stenting
Duration of Dual Antiplatelet Therapy After Coronary Stenting C. DEAN KATSAMAKIS, DO, FACC, FSCAI INTERVENTIONAL CARDIOLOGIST ADVOCATE LUTHERAN GENERAL HOSPITAL INTRODUCTION Coronary artery stents are
9/6/2012 25% 25% 25% 25%
Objectives Risky (Factor) Business: Preoperative Evaluation for the Primary Care Physician David M Schneider, MD Faculty Physician, Santa Rosa Family Medicine Residency 9/6/12 By the end of this conference,
Main Effect of Screening for Coronary Artery Disease Using CT
Main Effect of Screening for Coronary Artery Disease Using CT Angiography on Mortality and Cardiac Events in High risk Patients with Diabetes: The FACTOR-64 Randomized Clinical Trial Joseph B. Muhlestein,
Efficient Evaluation of Chest Pain
Efficient Evaluation of Chest Pain Vikranth Gongidi, DO FACC FACOI Indian River Medical Center Vero Beach, FL No Disclosures Outline Background Chest pain pathway Indications for stress test Stress test
PRECOMBAT Trial. Seung-Whan Lee, MD, PhD On behalf of the PRECOMBAT Investigators
Premier of Randomized Comparison of Bypass Surgery versus Angioplasty Using Sirolimus-Eluting Stent in Patients with Left Main Coronary Artery Disease PRECOMBAT Trial Seung-Whan Lee, MD, PhD On behalf
Atrial Fibrillation 2014 How to Treat How to Anticoagulate. Allan Anderson, MD, FACC, FAHA Division of Cardiology
Atrial Fibrillation 2014 How to Treat How to Anticoagulate Allan Anderson, MD, FACC, FAHA Division of Cardiology Projection for Prevalence of Atrial Fibrillation: 5.6 Million by 2050 Projected number of
Coronary Artery Disease leading cause of morbidity & mortality in industrialised nations.
INTRODUCTION Coronary Artery Disease leading cause of morbidity & mortality in industrialised nations. Although decrease in cardiovascular mortality still major cause of morbidity & burden of disease.
Updated guidelines on cardiovascular evaluation before noncardiac surgery: A view from the trenches
REVIEW CME CREDIT EDUCATIONAL OBJECTIVE: Readers will interpret the latest guidelines when evaluating patients for cardiovascular risk before noncardiac surgery STEVEN L. COHN, MD, FACP, SFHM Medical Director,
Hot Line Session at European Society of Cardiology (ESC) Congress 2014:
Investor News Not intended for U.S. and UK Media Bayer AG Investor Relations 51368 Leverkusen Germany www.investor.bayer.com Hot Line Session at European Society of Cardiology (ESC) Congress 2014: Once-Daily
Stroke Risk Scores. CHA 2 DS 2 -VASc. CHA 2 DS 2 -VASc Scoring Table 2
Bleeding/Clotting Risk Evaluation Tools for Atrial Fibrillation Patients Before prescribing anticoagulants, providers should weigh the risk of thrombosis against the risk of bleeding. The tools below can
Journal Club: Niacin in Patients with Low HDL Cholesterol Levels Receiving Intensive Statin Therapy by the AIM-HIGH Investigators
Journal Club: Niacin in Patients with Low HDL Cholesterol Levels Receiving Intensive Statin Therapy by the AIM-HIGH Investigators Shaikha Al Naimi Doctor of Pharmacy Student College of Pharmacy Qatar University
Cardiac Rehabilitation: An Under-utilized Resource Making Patients Live Longer, Feel Better
Cardiac Rehabilitation: An Under-utilized Resource Making Patients Live Longer, Feel Better Marian Taylor, M.D. Medical University of South Carolina Director, Cardiac Rehabilitation I have no disclosures.
Cardiac Rehabilitation The Best Medicine for Your CAD Patients. James A. Stone
James A. Stone BPHE, BA, MSc, MD, PhD, FRCPC, FAACVPR, FACC Clinical Professor of Medicine, University of Calgary Total Cardiology, Calgary Acknowledgements and Disclosures Acknowledgements Jacques Genest
1/12/2016. What s in a name? What s in a name? NO.Anti-Coagulation. DOACs in clinical practice. Practical aspects of using
What s in a name? Practical aspects of using DOACs (Direct Oral Anticoagulants) James L. Sebastian, MD, MACP Professor of Medicine (GIM) Medical College of Wisconsin February 5, 2016 DOAC NOAC NOAC ODI
New Real-World Evidence Reaffirms Low Major Bleeding Rates for Bayer s Xarelto in Patients with Non-Valvular Atrial Fibrillation
Investor News Not intended for U.S. and UK Media Bayer AG Investor Relations 51368 Leverkusen Germany www.investor.bayer.com Late-Breaking Science at ESC Congress 2015: New Real-World Evidence Reaffirms
The author has no disclosures
Mary Bradbury, PharmD, BCPS Clinical Pharmacy Specialist, Cardiac Surgery September 18, 2012 Mary.bradbury@inova.org This presentation will discuss unlabeled and investigational use of products The author
Rivaroxaban for acute coronary syndromes
Northern Treatment Advisory Group Rivaroxaban for acute coronary syndromes Lead author: Nancy Kane Regional Drug & Therapeutics Centre (Newcastle) May 2014 2014 Summary Current long-term management following
Medical management of CHF: A New Class of Medication. Al Timothy, M.D. Cardiovascular Institute of the South
Medical management of CHF: A New Class of Medication Al Timothy, M.D. Cardiovascular Institute of the South Disclosures Speakers Bureau for Amgen Background Chronic systolic congestive heart failure remains
FOR THE PREVENTION OF ATRIAL FIBRILLATION RELATED STROKE
www.bpac.org.nz keyword: warfarinaspirin FOR THE PREVENTION OF ATRIAL FIBRILLATION RELATED STROKE Key Concepts In atrial fibrillation (AF) warfarin is more effective than aspirin for stroke prevention.
Dual Antiplatelet Therapy. Stephen Monroe, MD FACC Chattanooga Heart Institute
Dual Antiplatelet Therapy Stephen Monroe, MD FACC Chattanooga Heart Institute Scope of Talk Identify the antiplatelet drugs and their mechanisms of action Review dual antiplatelet therapy in: The medical
4/7/2015. Cardiac Rehabilitation: From the other side of the glass door. Chicago, circa 1999. Objectives. No disclosures, no conflicts
Cardiac Rehabilitation: From the other side of the glass door No disclosures, no conflicts Charles X. Kim, MD, FACC, ABVM Objectives 1. Illustrate common CV benefits of CV rehab in real world practice.
Treatment of cardiogenic shock
ACUTE HEART FAILURE AND COMORBIDITY IN THE ELDERLY Treatment of cardiogenic shock Christian J. Wiedermann, M.D., F.A.C.P. Associate Professor of Internal Medicine, Medical University of Innsbruck, Austria
Cardiac Rehabilitation An Underutilized Class I Treatment for Cardiovascular Disease
Cardiac Rehabilitation An Underutilized Class I Treatment for Cardiovascular Disease What is Cardiac Rehabilitation? Cardiac rehabilitation is a comprehensive exercise, education, and behavior modification
Systolic Blood Pressure Intervention Trial (SPRINT) Principal Results
Systolic Blood Pressure Intervention Trial (SPRINT) Principal Results Paul K. Whelton, MB, MD, MSc Chair, SPRINT Steering Committee Tulane University School of Public Health and Tropical Medicine, and
Managing Mitral Regurgitation: Repair, Replace, or Clip? Michael Howe, MD Traverse Heart & Vascular
Managing Mitral Regurgitation: Repair, Replace, or Clip? Michael Howe, MD Traverse Heart & Vascular Mitral Regurgitation Anatomy Mechanisms of MR Presentation Evaluation Management Repair Replace Clip
DUAL ANTIPLATELET THERAPY. Dr Robert S Mvungi, MD(Dar), Mmed (Wits) FCP(SA), Cert.Cardio(SA) Phy Tanzania Cardiac Society Dar es Salaam Tanzania
DUAL ANTIPLATELET THERAPY Dr Robert S Mvungi, MD(Dar), Mmed (Wits) FCP(SA), Cert.Cardio(SA) Phy Tanzania Cardiac Society Dar es Salaam Tanzania DUAL ANTIPLATELET THERAPY (DAPT) Dual antiplatelet regimen
Cilostazol versus Clopidogrel after Coronary Stenting
Cilostazol versus Clopidogrel after Coronary Stenting Seong-Wook Park, MD, PhD, FACC Division of Cardiology, Asan Medical Center University of Ulsan College of Medicine Seoul, Korea AMC, 2004 Background
ESC Guidelines on the diagnosis and treatment of peripheral artery diseases Lower extremity artery disease. Erich Minar Medical University Vienna
ESC Guidelines on the diagnosis and treatment of peripheral artery diseases Lower extremity artery disease Erich Minar Medical University Vienna for the Task Force on the Diagnosis and Treatment of Peripheral
AANA Journal Course 4
AANA Journal Course 4 Update for nurse anesthetists Preoperative cardiac evaluation *6 CE Credits Bob Halliburton, CRNA, DNSc Saint Louis, Missouri Donald Bell, CRNA, DNSc John Preston, CRNA, DNSc Knoxville,
Inpatient Heart Failure Management: Risks & Benefits
Inpatient Heart Failure Management: Risks & Benefits Dr. Kenneth L. Baughman Professor of Medicine Harvard Medical School Director, Advanced Heart Disease Section Brigham & Women's Hospital Harvard Medical
Investor News. Not intended for U.S. and UK media
Investor News Not intended for U.S. and UK media Bayer AG Investor Relations 51368 Leverkusen Germany www.investor.bayer.com Bayer s Xarelto (Rivaroxaban) Approved for the Treatment of Pulmonary Embolism
Making Sense of the New Statin guidelines. They are more than just lowering your cholesterol!
Making Sense of the New Statin guidelines They are more than just lowering your cholesterol! No Disclosures Margaret (Peg) O Donnell DNPs, FNP, ANP B-C, FAANP Senior Nurse Practitioner South Nassau Communities
Antiplatelet and anticoagulation treatment of patients undergoing carotid and peripheral artery angioplasty
Round Table: Antithrombotic therapy beyond ACS Antiplatelet and anticoagulation treatment of patients undergoing carotid and peripheral artery angioplasty M. Matsagkas, MD, PhD, EBSQ-Vasc Associate Professor
STROKE PREVENTION IN ATRIAL FIBRILLATION
STROKE PREVENTION IN ATRIAL FIBRILLATION OBJECTIVE: To guide clinicians in the selection of antithrombotic therapy for the secondary prevention of ischemic stroke and arterial thromboembolism in patients
Evidence-Based Secondary Stroke Prevention and Adherence to Guidelines
Evidence-Based Secondary Stroke Prevention and Adherence to Guidelines Mitchell S.V. Elkind, MD, MS Associate Professor of Neurology Columbia University New York, NY Presenter Disclosure Information Mitchell
Atrial Fibrillation The Basics
Atrial Fibrillation The Basics Family Practice Symposium Tim McAveney, M.D. 10/23/09 Objectives Review the fundamentals of managing afib Discuss the risks for stroke and the indications for anticoagulation
3/2/2010 Post CABG R h e bili a i tat on Ahmed Elkerdany Professor o f oof C ardiac Cardiac Surgery Ain Shams University 1
Post CABG Rehabilitation i Ahmed Elkerdany Professor of Cardiac Surgery Ain Shams University 1 Definition Cardiac rehabilitation services are comprehensive, long-term programs involving : medical evaluation.
ABOUT XARELTO CLINICAL STUDIES
ABOUT XARELTO CLINICAL STUDIES FAST FACTS Xarelto (rivaroxaban) is a novel, oral direct Factor Xa inhibitor. On September 30, 2008, the European Commission granted marketing approval for Xarelto for the
Sudden Cardiac Arrest in a Low-Risk Patient During Elective Spinal Surgery
Case Report J Lipid Atheroscler 2012;1(1):35-39 JLA Sudden Cardiac Arrest in a Low-Risk Patient During Elective Spinal Surgery Kyung Hoon Cho, Myung Ho Jeong, Min Chul Kim, Min Goo Lee, Keun Ho Park, Doo
How can registries contribute to guidelines? Nicolas DANCHIN, HEGP, Paris
How can registries contribute to guidelines? Nicolas DANCHIN, HEGP, Paris Pros and cons of registers Prospective randomised trials constitute the cornerstone of "evidence-based" medicine, and they therefore
8-9-2012. In hospital diabetes care background and challenges. Duality of interest. One of the goals may be...
In hospital diabetes care background and challenges Duality of interest Nothing to disclose within the framework of this presentation My own fasting BG is 4.6 mmol/l, HbA1c 5.4% Bruce H.R. Wolffenbuttel
National Imaging Associates, Inc. Clinical guidelines
National Imaging Associates, Inc. Clinical guidelines Original Date: February 2010 STRESS ECHOCARDIOLOGY Page 1 of 15 CPT Codes: 93350, 93351, + 93352 Last Reviewed Date: June 2012 Guideline Number: NIA_CG_026
Therapeutic Approach in Patients with Diabetes and Coronary Artery Disease
Home SVCC Area: English - Español - Português Therapeutic Approach in Patients with Diabetes and Coronary Artery Disease Martial G. Bourassa, MD Research Center, Montreal Heart Institute, Montreal, Quebec,
James F. Kravec, M.D., F.A.C.P
James F. Kravec, M.D., F.A.C.P Chairman, Department of Internal Medicine, St. Elizabeth Health Center Chair, General Internal Medicine, Northeast Ohio Medical University Associate Medical Director, Hospice
Utilizing the Cath Lab for Cardiac Arrest
Utilizing the Cath Lab for Cardiac Arrest Khaled M. Ziada, MD Director, Cardiovascular Catheterization Laboratories Gill Heart Institute, University of Kentucky UK/AHA Strive to Revive Symposium May 2013
Tranexamic Acid. Tranexamic Acid. Overview. Blood Conservation Strategies. Blood Conservation Strategies. Blood Conservation Strategies
Overview Where We Use It And Why Andreas Antoniou, M.D., M.Sc. Department of Anesthesia and Perioperative Medicine University of Western Ontario November 14 th, 2009 Hemostasis Fibrinolysis Aprotinin and
Preoperative Laboratory and Diagnostic Studies
Preoperative Laboratory and Diagnostic Studies Preoperative Labratorey and Diagnostic Studies The concept of standardized testing in all presurgical patients regardless of age or medical condition is no
ACC/AHA Pocket Guidelines
ACC/AHA Pocket Guidelines Perioperative Cardiovascular Evaluation for Noncardiac Surgery A Report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines ACC/AHA
To Bridge or Not to Bridge. Periop Anticoagulation Management. Don Weinshenker, MD Ambulatory Care Denver VAMC
To Bridge or Not to Bridge Periop Anticoagulation Management Don Weinshenker, MD Ambulatory Care Denver VAMC Financial Disclosure Information Nothing to report Periop AC Management Chronically anti-coagulated
ΠΟΙΟ ΑΝΤΙΠΗΚΤΙΚΟ ΓΙΑ ΤΟΝ ΑΣΘΕΝΗ ΜΟΥ? ΚΛΙΝΙΚΑ ΠΑΡΑΔΕΙΓΜΑΤΑ. Σωκράτης Παστρωμάς Καρδιολόγος Νοσοκομείο Ερρίκος Ντυνάν
ΠΟΙΟ ΑΝΤΙΠΗΚΤΙΚΟ ΓΙΑ ΤΟΝ ΑΣΘΕΝΗ ΜΟΥ? ΚΛΙΝΙΚΑ ΠΑΡΑΔΕΙΓΜΑΤΑ Σωκράτης Παστρωμάς Καρδιολόγος Νοσοκομείο Ερρίκος Ντυνάν The AF epidemic Mayo Clinic data (assuming a continued increase in the AF incidence) Mayo
Failure or significant adverse effects to all of the alternatives: Eliquis and Xarelto
This policy has been developed through review of medical literature, consideration of medical necessity, generally accepted medical practice standards, and approved by the IEHP Pharmacy and Therapeutics
CARDIOLOGY ROTATION GOALS AND OBJECTIVES
CARDIOLOGY ROTATION GOALS AND OBJECTIVES PGY-1 Core Medicine Rotation The trainee will have the opportunity to develop clinical skills, the ability to analyze patients problems, and make treatment plans
6/5/2014. Objectives. Acute Coronary Syndromes. Epidemiology. Epidemiology. Epidemiology and Health Care Impact Pathophysiology
Objectives Acute Coronary Syndromes Epidemiology and Health Care Impact Pathophysiology Unstable Angina NSTEMI STEMI Clinical Clues Pre-hospital Spokane County EMS Epidemiology About 600,000 people die
Palpitations & AF. Richard Grocott Mason Consultant Cardiologist THH NHS Foundation Trust & Royal Brompton & Harefield NHS Foundation Trust
Palpitations & AF Richard Grocott Mason Consultant Cardiologist THH NHS Foundation Trust & Royal Brompton & Harefield NHS Foundation Trust Palpitations Frequent symptom Less than 50% associated with arrhythmia
RATE VERSUS RHYTHM CONTROL OF ATRIAL FIBRILLATION: SPECIAL CONSIDERATION IN ELDERLY. Charles Jazra
RATE VERSUS RHYTHM CONTROL OF ATRIAL FIBRILLATION: SPECIAL CONSIDERATION IN ELDERLY Charles Jazra NO CONFLICT OF INTEREST TO DECLARE Relationship Between Atrial Fibrillation and Age Prevalence, percent
Common Surgical Procedures in the Elderly
Common Surgical Procedures in the Elderly From hip and knee replacements to cataract and heart surgery, America s elderly undergo 20% of all surgical procedures. For a group that comprises only 13% of
Bayer Initiates Rivaroxaban Phase III Study to Support Dose Selection According to Individual Benefit-Risk Profile in Long- Term VTE Prevention
Investor News Not intended for U.S. and UK Media Bayer AG Investor Relations 51368 Leverkusen Germany www.investor.bayer.com Long-term prevention of venous blood clots (VTE): Bayer Initiates Rivaroxaban
Universitätsklinik für Kardiologie. Test. Thomas M. Suter Akute Herzinsuffizienz Diagnostik und Therapie thomas.suter@insel.ch 1
Test Thomas M. Suter Akute Herzinsuffizienz Diagnostik und Therapie thomas.suter@insel.ch 1 Heart Failure - Definition European Heart Journal (2008) 29, 2388 2442 Akute Herzinsuffizienz Diagnostik und
New Cholesterol Guidelines: Carte Blanche for Statin Overuse Rita F. Redberg, MD, MSc Professor of Medicine
New Cholesterol Guidelines: Carte Blanche for Statin Overuse Rita F. Redberg, MD, MSc Professor of Medicine Disclosures & Relevant Relationships I have nothing to disclose No financial conflicts Editor,
Getting smart about dyspnea and life saving drug therapy in ACS patients. Kobi George Kaplan Medical Center Rehovot
Getting smart about dyspnea and life saving drug therapy in ACS patients Kobi George Kaplan Medical Center Rehovot 78 year old female Case description Presented with resting chest pain and dyspnea Co morbidities:
Perioperative Cardiovascular Evaluation for Noncardiac Surgery. Pocket Guideline Update
ACC/AHA Pocket Guideline Update Perioperative Cardiovascular Evaluation for Noncardiac Surgery A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines
Cardiac Rehabilitation (Outpatient Phase II) Corporate Medical Policy. Medical Policy
Cardiac Rehabilitation (Outpatient Phase II) Corporate Medical Policy File name: Cardiac Rehabilitation (Outpatient Phase II) File code: UM.REHAB.04 Origination: 08/1994 Last Review: 08/2011 Next Review:
The largest clinical study of Bayer's Xarelto (rivaroxaban) Wednesday, 14 November 2012 07:38
Bayer HealthCare has announced the initiation of the COMPASS study, the largest clinical study of its oral anticoagulant Xarelto (rivaroxaban) to date, investigating the prevention of major adverse cardiac
Cardiology ARCP Decision Aid August 2014
Cardiology ARCP Decision Aid August 2014 The table that follows includes a column for each training year which documents the targets that have to be achieved for a satisfactory ARCP outcome at the end
Update in Perioperative Medicine 2016
Update in Perioperative Medicine 2016 Kurt Pfeifer, MD, FACP, FHM Professor of Medicine Medical College of Wisconsin No conflicts of interest to disclose Learning Objectives Utilize the ACC/AHA guidelines
Endoskopische Venenentnahme der V. saphena in der koronaren Bypasschirurgie - Aktuelle Datenlage - Dr. med. Stefanie Reutter
Endoskopische Venenentnahme der V. saphena in der koronaren Bypasschirurgie - Aktuelle Datenlage - Dr. med. Stefanie Reutter Endoskopische Venenentnahme (EVH) - Einführung 1979 Tevaearai und Kollegen haben
Surgical Site Infection Prevention
Surgical Site Infection Prevention 1 Objectives 1. Discuss risk factors for SSI 2. Describe evidence-based best practices for SSI prevention 3. State principles of antibiotic prophylaxis 4. Discuss novel
The 50-year Quest to Replace Warfarin: Novel Anticoagulants Define a New Era. CCRN State of the Heart 2012 June 2, 2012
The 50-year Quest to Replace Warfarin: Novel Anticoagulants Define a New Era CCRN State of the Heart 2012 June 2, 2012 Disclosures I have I have been involved in trials of new anticoagulants and have received
ACC/AHA Practice Guidelines
ACC/AHA Practice Guidelines ACC/AHA Guideline Update for Perioperative Cardiovascular Evaluation for Noncardiac Surgery Executive Summary A Report of the American College of Cardiology/American Heart Association
Surgeons Role in Atrial Fibrillation
Atrial Fibrillation Surgeons Role in Atrial Fibrillation Steven J Feldhaus, MD, FACS 2015 Cardiac Symposium September 18, 2015 Stages of Atrial Fibrillation Paroxysmal (Intermittent) Persistent (Continuous)
PHARMACOLOGICAL Stroke Prevention in Atrial Fibrillation STROKE RISK ASSESSMENT SCORES Vs. BLEEDING RISK ASSESSMENT SCORES.
PHARMACOLOGICAL Stroke Prevention in Atrial Fibrillation STROKE RISK ASSESSMENT SCORES Vs. BLEEDING RISK ASSESSMENT SCORES. Hossam Bahy, MD (1992 2012), 19 tools have been identified 11 stroke scores 1
Geriatric Cardiology: Challenges and Strategies
Geriatric Cardiology: Challenges and Strategies No financial disclosures Geriatrics -- No Specific Age 'you know it when you see it' Functional Status Polypharmacy Impaired Renal Function Diagnostic Testing:
Long term anticoagulant therapy in patients with atrial fibrillation at high risk of stroke: a new scenario after RE-LY trial
Long term anticoagulant therapy in patients with atrial fibrillation at high risk of stroke: a new scenario after RE-LY trial Camillo Autore Università di Roma Sapienza II Facoltà di Medicina e Chirurgia
A randomized, controlled trial comparing the efficacy of carvedilol vs. metoprolol in the treatment of atrial fibrillation
A randomized, controlled trial comparing the efficacy of carvedilol vs. metoprolol in the treatment of atrial fibrillation Gabriel Sayer Lay Abstract: Atrial fibrillation is a common form of irregular,
Perioperative management of the
Preoperative Cardiac Risk Assessment BERNARD M. KARNATH, M.D., University of Texas Medical Branch at Galveston, Galveston, Texas Heart disease is the leading cause of mortality in the United States. An
Prevention of stroke and systemic embolism in adult patients with non-valvular atrial fibrillation (AF) with one or more risk factors
News Release For use outside the US and UK only Bayer Pharma AG 13342 Berlin Germany Tel. +49 30 468-1111 www.bayerpharma.com Bayer s Xarelto Approved in the EU for the Prevention of Stroke in Patients
How to control atrial fibrillation in 2013 The ideal patient for a rate control strategy
How to control atrial fibrillation in 2013 The ideal patient for a rate control strategy L. Pison, MD Advances in Cardiac Arrhythmias and Great Innovations in Cardiology - Torino, September 28 th 2013
Managing the Patient with Atrial Fibrillation
Pocket Guide Managing the Patient with Atrial Fibrillation Updated April 2012 Editor Stephen R. Shorofsky, MD, Ph.D. Assistant Editors Anastasios Saliaris, MD Shawn Robinson, MD www.hrsonline.org DEFINITION
Revised ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management. Implications for preoperative clinical evaluation
REVIEW Revised ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management. Implications for preoperative clinical evaluation F. 1, R. BALDASSARRI 1, H. J. PRIEBE 2 1Department
4/9/2015. Risk Stratify Our Patients. Stroke Risk in AF: CHADS2 Scoring system JAMA 2001; 285: 2864-71
Anticoagulation in the 21 st Century Adam Karpman, D.O. Saint Francis Medical Center/Oklahoma State University Medical Center Disclosures: None Atrial Fibrillation Most common arrhythmia in clinical practice.
WOEST TRIAL- NO ASPIRIN IN STENTED PATIENTS REQUIRING ANTICOAGULATION. Van Crisco, MD, FACC, FSCAI First Coast
WOEST TRIAL- NO ASPIRIN IN STENTED PATIENTS REQUIRING ANTICOAGULATION Van Crisco, MD, FACC, FSCAI First Coast Conflicts of Interest I have been a paid consultant and speaker for AstraZeneca, makers of