Clinical practice guidelines for heart failure.
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Development of guidelines can be a difficult process; each organization or institution must establish the rules and criteria for including specific therapies and the level of complexity needed. Specific outcomes must be incorporated, including maintenance of comfort and functionality, freedom from hospitalization, and survival. In existing guidelines for the management of heart failure, angiotensin-converting enzyme (ACE) inhibitor therapy is clearly the gold standard. However, there is still a high mortality with ACE inhibitor therapy; the key may be choosing the right patients. Current guidelines reflect the uncertainty regarding digoxin before the Digitalis Investigation Group (DIG) trial; obviously, these guidelines should be revisited. Clinical practice guidelines for the management of heart failure need to be revised to include a better consensus on beta-blockade, the new data on digoxin, emerging data on angiotensin II receptor antagonists, and current thinking on anticoagulant therapy. (+info)
Evaluation of the American Heart Association Stroke Outcome Classification.
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BACKGROUND AND PURPOSE: The purpose of this study was to evaluate the concurrent validity of the American Heart Association Stroke Outcome Classification (AHA.SOC) and compare performance of its function classification with that of the Modified Rankin Scale. METHODS: The individuals in this study included the last 105 consecutive subjects who were part of a cohort of 459 stroke patients in the Kansas City Stroke Study. The patients were evaluated with a variety of standardized assessments at enrollment (within 14 days of stroke onset) and followed at 1, 3, and 6 months after stroke. Specifically, we examined validity of AHA.SOC by comparing its 3 domains (ie, Domain, Severe, and Function) with stroke severity. We correlated AHA.SOC-Function with scores of the Barthel Index, Lawton Instrumental Activities of Daily Living (IADL) Scale, and Medical Outcome Study 36-Item Short-Form Health Survey (SF-36) measures of physical function and mental health. Finally, we compared the discriminant ability of AHA.SOC-Function and the Modified Rankin Scale in assessing disability and handicap. These data were analyzed with the use of Spearman rank correlations and Kruskal-Wallis tests. RESULTS: All 3 domains of the AHA.SOC were significantly associated with stroke severity and scores of Barthel Index, Lawton IADL, and SF-36 physical function (all P<0.001). Both AHA.SOC-Function and the Modified Rankin Scale discriminated well the disabilities and handicap measured by Barthel Index, Lawton IADL, and SF-36 physical function (all P<0.001). CONCLUSIONS: The AHA.SOC was able to capture impairments, disabilities, and handicap after stroke. The AHA. SOC-Function performed equally as well as the Modified Rankin Scale in assessing disabilities related to basic activities of daily living but differentiated slightly better than the Modified Rankin Scale in assessing disabilities/handicap related to instrumental activities of daily living. Neither the AHA.SOC-Function nor the Modified Rankin Scale captured differences in mental health after stroke. (+info)
Pediatric advanced life support: a review of the AHA recommendations. American Heart Association.
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The etiologies of respiratory failure, shock, cardiopulmonary arrest and dysrhythmias in children differ from those in adults. In 1988, the American Heart Association implemented the pediatric advanced life support (PALS) program. Major revisions to the program were made in 1994, with further revisions in 1997. The PALS program teaches a systematic, organized approach for the evaluation and management of acutely ill or injured children. Early identification and treatment of respiratory failure and shock in children improve survival, from a dismal 10 percent to an encouraging 85 percent. Family physicians who care for acutely ill or injured children have a tremendous opportunity to save lives through implementation of the PALS information. (+info)
Development and implementation of a decision support system for carotid artery stenosis: the Carotid Ultrasound Report Enhancement (CURE).
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The management of carotid artery stenosis is an art evolving into a science, increasingly informed by clinical trials of medical management versus carotid endarterectomy (CEA). Ideas about optimal management depend on the confluence of patient-specific variables, surgical expertise, and the state of medical knowledge. In this complex and progressing setting, an up-to-date decision support system could help physicians apply the latest evidence to patient care. Carotid ultrasonography (US) studies provide an excellent opportunity to aid in the therapy of carotid stenosis. We developed a Carotid US Report Enhancement (CURE) to augment carotid US reports with treatment-specific prognostic information and patient-specific portions of the American Heart Association's 1998 guideline for the management of carotid artery stenosis. In the process of designing and implementing the CURE software, we encountered and eventually solved a variety of problems. The first problem was that US test was not always precise enough to distinguish between a moderate and mild carotid stenosis. Likewise, the standard US reports did not elucidate several technical problems that decreased the reliability of the US result. Third, although 17 of 18 physicians agreed to receive the CURE reports, they requested non-incriminating wording. Fourth, vascular surgeons supervising the US laboratories were reluctant to support the CURE report if they thought it would be construed as prompting self-referral. Finally, information about some comorbid conditions (e.g. a history of atrial fibrillation) could not be obtained reliably from the patients. The result of responding to these problems is a decision support program that is increasingly robust, able to detect many of its own limitations, and capable of integrating data from multiple sources. A randomized controlled trial now in progress will evaluate the clinical impact of the CURE program. (+info)
AHA Science Advisory. Stanol/sterol ester-containing foods and blood cholesterol levels. A statement for healthcare professionals from the Nutrition Committee of the Council on Nutrition, Physical Activity, and Metabolism of the American Heart Association.
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Considerable attention in the recent past has focused on the potential benefits or adverse effects of butter versus different types of margarines, usually with respect to their relative content of polyunsaturated, saturated, and trans fatty acids, and the impact of these on low-density lipoprotein (LDL) cholesterol levels. Recently, a new class of margarines and other fat-derived products (eg, salad dressings, mayonnaise) containing plant-derived sterols that are intended for use to lower blood cholesterol levels have been introduced into the food supply. These products are being marketed as adjuncts to low-saturated-fat and low-cholesterol diets to maximize reductions in LDL cholesterol levels achievable by dietary means. (+info)
Circulation Research: origin and early years.
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Circulation Research, first published in 1953, was created by the American Heart Association as "the authoritative new journal for investigators of the basic sciences as they apply to the heart and circulation." This review of the early years of the journal highlights the contributions of the first four Editors: Carl J. Wiggers, Carl F. Schmidt, Eugene M. Landis, and Julius H. Comroe, Jr. The success of Circulation Research is seen not only in the high quality of the articles published in its pages but also in the remarkable improvements in prevention and treatment of cardiovascular disease that have occurred over the past half century. (+info)
Dietary protein and weight reduction: a statement for healthcare professionals from the Nutrition Committee of the Council on Nutrition, Physical Activity, and Metabolism of the American Heart Association.
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High-protein diets have recently been proposed as a "new" strategy for successful weight loss. However, variations of these diets have been popular since the 1960s. High-protein diets typically offer wide latitude in protein food choices, are restrictive in other food choices (mainly carbohydrates), and provide structured eating plans. They also often promote misconceptions about carbohydrates, insulin resistance, ketosis, and fat burning as mechanisms of action for weight loss. Although these diets may not be harmful for most healthy people for a short period of time, there are no long-term scientific studies to support their overall efficacy and safety. These diets are generally associated with higher intakes of total fat, saturated fat, and cholesterol because the protein is provided mainly by animal sources. In high-protein diets, weight loss is initially high due to fluid loss related to reduced carbohydrate intake, overall caloric restriction, and ketosis-induced appetite suppression. Beneficial effects on blood lipids and insulin resistance are due to the weight loss, not to the change in caloric composition. Promoters of high-protein diets promise successful results by encouraging high-protein food choices that are usually restricted in other diets, thus providing initial palatability, an attractive alternative to other weight-reduction diets that have not worked for a variety of reasons for most individuals. High-protein diets are not recommended because they restrict healthful foods that provide essential nutrients and do not provide the variety of foods needed to adequately meet nutritional needs. Individuals who follow these diets are therefore at risk for compromised vitamin and mineral intake, as well as potential cardiac, renal, bone, and liver abnormalities overall. (+info)
Guideline compliance improves stroke outcome: a preliminary study in 4 districts in the Italian region of Lombardia.
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BACKGROUND AND PURPOSE: Guidelines for medical practice in stroke have been proposed in different countries, but their impact on stroke outcome has not been verified to date. The aim of this study was to evaluate the impact of the American Heart Association guidelines for acute stroke and for transient ischemic attack on first-ever stroke patients. METHODS: Three hundred eighty-six first-ever ischemic stroke patients were admitted to the study. Those observed within 6 hours from stroke onset were eligible for the acute clinical phase of the study, while all were admitted to the early clinical phase. The follow-up lasted 6 months. Primary end points were survival and the effectiveness of treatment on disability, measured as the proportion of potential improvement in the Barthel Index score achieved during treatment. A rating of noncompliance with the guideline recommendations was calculated for each patient, and its association with the end points was investigated. The Kaplan-Meier method and log-rank test were used to estimate and compare survival curves between groups; Cox proportional hazards model and logistic regression were used to identify risk factors for mortality; and correlation tests and regression analysis were used to evaluate the influence of guideline compliance on disability. Both univariate and multivariate statistical analyses were performed. RESULTS: Survival and treatment effectiveness were directly correlated with guideline compliance. The relative risk of death for patients with a noncompliance rating > or =5 was 2.26 with respect to patients with a noncompliance rating <5 (95% CI, 1.51 to 4.67; P<0.0007). In this latter group, at 6 months we detected a 15% decrease in mortality (95% CI, 9.1% to 17.5%). Treatment effectiveness showed a Spearman's rank correlation with the noncompliance rating of -0.3 (P<0.001). At discharge we observed a 13% increase in treatment effectiveness, while no significant differences were detectable at 3 and 6 months. These associations were confirmed by the multivariate analysis, in which we included, together with the noncompliance rating, all the variables previously identified as independent predictors of mortality and disability. CONCLUSIONS: This study demonstrates an association between adherence to guidelines and stroke outcome, and it can be viewed as a study that prepares the way for a randomized controlled trial in this area. It also emphasizes the need to develop personnel and structures devoted to stroke care because an evidence-based clinical approach could significantly reduce the risk of death. (+info)