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American College of Cardiology/American Heart Association Clinical Practice Guidelines: Part II

2003; Lippincott Williams & Wilkins; Volume: 107; Issue: 24 Linguagem: Inglês

10.1161/01.cir.0000079017.53579.9c

1524-4539

Raymond J. Gibbons, Sidney C. Smith, Elliott M. Antman,

Cardiac pacing and defibrillation studies

HomeCirculationVol. 107, No. 24American College of Cardiology/American Heart Association Clinical Practice Guidelines: Part II Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBAmerican College of Cardiology/American Heart Association Clinical Practice Guidelines: Part IIEvolutionary Changes in a Continuous Quality Improvement Project Raymond J. Gibbons, MD, Sidney C. SmithJr, MD and Elliott Antman, MD Raymond J. GibbonsRaymond J. Gibbons From the Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn (R.J.G.); University of North Carolina/Chapel Hill, Chapel Hill (S.C.S.); and Cardiovascular Division, Brigham and Women's Hospital, Boston, Mass (E.A.). , Sidney C. SmithJrSidney C. SmithJr From the Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn (R.J.G.); University of North Carolina/Chapel Hill, Chapel Hill (S.C.S.); and Cardiovascular Division, Brigham and Women's Hospital, Boston, Mass (E.A.). and Elliott AntmanElliott Antman From the Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn (R.J.G.); University of North Carolina/Chapel Hill, Chapel Hill (S.C.S.); and Cardiovascular Division, Brigham and Women's Hospital, Boston, Mass (E.A.). Originally published24 Jun 2003https://doi.org/10.1161/01.CIR.0000079017.53579.9CCirculation. 2003;107:3101–3107Case Presentation: A 50-year-old male presents to your office for evaluation of a recent episode of atrial fibrillation. The patient had no prior history of atrial fibrillation until 3 days ago. At that time, he was working in his home woodworking shop on a large cabinet. The cabinet slipped out of the clamps holding it and fell on his right great toe. The patient was having moderate to severe toe pain when he noticed that his heart was beating rapidly and irregularly. His palpitations were not associated with any chest pain, shortness of breath, or lightheadedness. He went to his local emergency room. His blood pressure was 135/80, and his pulse was rapid and irregularly irregular. An ECG showed that he was in atrial fibrillation with a ventricular response rate of 160. There were no ST segment changes. Before the patient received any therapy, he converted to normal sinus rhythm. The total duration of his episode of atrial fibrillation was ≈2 hours. A subsequent ECG was entirely normal. X-rays of his right foot did not show any fracture. He was discharged from the local emergency room and advised to see you.The patient is physically active. He denies any history of chest pain or chest pressure. He has no history of hypertension, diabetes, or tobacco use. His only other medical problem is mild asthma, treated with occasional inhalers. Both his mother and father lived into their late 80s and died of cancer. His two siblings are both alive and well without any cardiovascular disease.On physical examination, his blood pressure is 120/80 mm Hg. His heart rate is 70 bpm and regular. His cardiac examination is normal. On lung examination, there are rare wheezes over both lung fields. His right great toe is badly bruised. His ECG from the local emergency room is available and is normal.What are the appropriate next steps in the evaluation of this patient, as outlined in the American College of Cardiology (ACC)/American Heart Association (AHA)/European Society of Cardiology (ESC) Guidelines for the Management of Patients With Atrial Fibrillation?1Appropriate clinical evaluation is shown in Table 1. This patient merits a chest x-ray (to evaluate his rare wheezes), a transthoracic echocardiogram, and blood tests of thyroid function. None of the additional tests listed, ie, exercise testing, Holter monitoring, transesophageal echocardiography, or electrophysiological study, are appropriate at this time. TABLE 1. Minimum and Additional Clinical Evaluation of the AF PatientAF indicates atrial fibrillation; LA, left atrium; LV, left ventricular; MI, myocardial infarction; and RV, right ventricular. Type 1C refers to the Vaughan Williams Classification of antiarrhythmic drugs.*One or several tests may be necessary.Minimum Evaluation History and physical examination to define: Presence and nature of symptoms associated with AF Clinical type of AF (first episode, paroxysmal, persistent, or permanent) Onset of the first symptomatic attack or date of discovery of AF Frequency, duration, precipitating factors, and modes of termination of AF Response to any pharmacological agents that have been administered Presence of any underlying heart disease or other reversible conditions (eg, hyperthyroidism or alcohol consumption) Electrocardiogram to identify: Rhythm (verify AF) LV hypertrophy P-wave duration and morphology or fibrillatory waves Pre-excitation Bundle-branch block Prior MI Other atrial arrhythmias To measure and follow the RR, QRS, and QT intervals in conjunction with antiarrhythmic drug therapy Chest radiograph to evaluate: Lung parenchyma, when clinical findings suggest an abnormality Pulmonary vasculature, when clinical findings suggest an abnormality Echocardiogram to identify: Valvular heart disease Left and right atrial size LV size and function Peak RV pressure (pulmonary hypertension) LV hypertrophy LA thrombus (low sensitivity) Pericardial disease Blood tests of thyroid function For a first episode of AF, when the ventricular rate is difficult to control or when AF recurs unexpectedly after cardioversionAdditional Testing* Exercise testing If the adequacy of rate control is in question (permanent AF) To reproduce exercise-induced AF To exclude ischemia before treatment of selected patients with a type 1C antiarrhythmic drug Holter monitoring or event recording If diagnosis of the type of arrhythmia is in question As a means of evaluating rate control Transesophageal echocardiography To identify LA thrombus (in the LA appendage) To guide cardioversion Electrophysiological study To clarify the mechanism of wide–QRS-complex tachycardia To identify a predisposing arrhythmia such as atrial flutter or paroxysmal supraventricular tachycardia Seeking sites for curative ablation or AV conduction block/modificationEvolution of the ACC/AHA GuidelinesThis illustrative case example is intended to demonstrate the evolution of the ACC/AHA practice guidelines in recent years. Part I of this review2 provided an overview of the guidelines process and its fundamental principles. This review will describe the further evolution of the guidelines process, including the increasing focus on patient conditions rather than procedures, efforts to provide more rapid updates, its international extension, and its interface with efforts at implementation and overall quality improvement.As outlined in Part I of this series,2 the ACC/AHA effort began with procedure-based guidelines, such as those regarding the implantation of permanent pacemakers. This led to a series of guidelines about procedures including radionuclide imaging, exercise testing, echocardiography, and coronary angiography. However, these procedure-based guidelines did not provide sufficient help to practicing clinicians, who more often confronted patients with clinical problems rather than questions about procedures. The publication of the ACC/AHA/ESC Guidelines on the Management of Patients with Atrial Fibrillation in 2001 was the first attempt to provide the practicing clinician with useful steps in the evaluation and management of such patients. It is an example of the shift in focus of the ACC/AHA Guidelines effort to patient conditions rather than procedures. These new disease-based guidelines have priority from the standpoint of resources; their recommendations take precedence over older or less comprehensive recommendations in the procedure-based guidelines. The procedure-based guidelines are still maintained and updated. They serve as a single repository of all the potential applications of procedures such as echocardiography, and they include both additional technical information and applications to less common patient conditions, eg, pericarditis, for which there are not any current disease-based guidelines. Inevitably, there is overlap between the recommendations that appear in disease-based guidelines such as those for atrial fibrillation and procedure-based guidelines such as those for echocardiography; the ACC/AHA Task Force on Practice Guidelines follows a series of steps in an attempt to make sure this overlapping information is consistent across guidelines to avoid confusion. As mentioned above, the recommendations of the writing committees for the disease-based guidelines have precedence unless the procedure-based guidelines are more recent and provide compelling new evidence for a given application of a procedure.Acceleration of the Revision ProcessAnother important step in the evolution of the ACC/AHA Guidelines process has been to shorten the time required for updates and revisions. In the late 1980s and the early 1990s, revision of any practice guideline required the formation of a new writing committee and completion of the exhaustive process outlined in Part I of this series. This usually led to a considerable time interval between guidelines. The first 2 echocardiography guidelines were separated by 7 years. Successive guidelines for percutaneous transluminal coronary angiography (PTCA),3,4 radionuclide imaging,5,6 and exercise testing7,8 were separated by 8, 9, and 11 years, respectively.The Task Force on Practice Guidelines recognized in the mid-1990s that this time lag was no longer acceptable; it initiated the concept of a "living committee" for each writing group. The writing committee was instructed that its work was not complete when a guideline was published. It was directed to monitor ongoing literature that was pertinent to the subject of the guideline with the assistance of the ACC scientific staff. When the writing committee felt that new evidence warranted a limited number of either revised or new recommendations, the Task Force would initiate a guideline "update." At the start of this process, one third of the membership of the original writing committee is replaced to ensure new input. The principles outlined in Part I of this review2 for the election of the original writing committee members are again followed in the selection of the new members. The new committee then holds a series of meetings and conference calls to identify specific portions of the guideline that merit new or revised recommendations. Minor changes in text, tables, and references are discouraged. One of the first examples of such an update occurred in the myocardial infarction guidelines. In 1996, primary PTCA was in a Class IIa recommendation for the treatment of patients with cardiogenic shock. The 1999 update of this guideline altered this recommendation in response to the publication of the SHOCK Trial.9 Patients with cardiogenic shock, ST elevation, or left bundle branch block; age <75 years; and revascularization within 18 hours were now appropriately considered to have a Class I indication for primary PTCA on the basis of that trial (Figure 1). Guideline updates, along with their focus, are listed in Table 2. These updates should be distinguished from "revisions," which are more extensive rewrites of the entire guideline when the magnitude of new evidence is greater. The process for a guideline revision includes formation of a new writing committee. Download figureDownload PowerPointFigure 1. The relative risk of death and reinfarction inpatients from various subgroups in the SHOCK trial. Relative risks of 1 indicate benefit from medical therapy. MI indicates myocardial infarction. Reprinted with permission from reference 9.TABLE 2. Recent Updates of ACC/AHA GuidelinesGuideline SubjectDate of Update PublicationMajor Subjects in UpdateInternetSummary ArticleICD indicates implantable cardioverter-defibrillator; CAD, coronary artery disease; EF, ejection fraction; MI, myocardial infarction; and AV, atrioventricular.Perioperative evaluation for noncardiac surgery12/012/02Comorbid diseasesFunctional status and testingPerioperative medical therapyImplanted pacemakers and ICDsUnstable angina/non–ST-segment elevation myocardial infarction3/0210/02Risk assessmentAntiplatelet therapyAnticoagulant therapyEarly conservative vs early invasive strategyRisk factor modificationExercise testing8/0210/02Confounders of stress ECG interpretationRisk stratificationAsymptomatic individuals without known CADValvular heart diseasePacemaker/ICD9/0211/02ICD in patients with EF 163 hospitals.GAP and GWTG both provide information about adherence to guidelines and about problems with "real-world" applications that is fed back to the Task Force on Practice Guidelines and, when appropriate, to the writing committees.The ACC and AHA are not the only organizations interested in improving the quality of care. Medicare has encouraged its state peer review organizations under the Health Care Financing Administration Healthcare Quality Improvement Program. Details of successful efforts for lipid evaluation in management of myocardial infarction patients and in coronary artery bypass surgery improvement have now been published.14,15 Data standards and performance measures are critical to these efforts. The ACC and AHA have separate joint task forces on performance measures, and on data standards, to help define the appropriate standards and measures for quality improvement efforts.Future Challenges for the Guideline EffortThere is a growing recognition of the importance of evidence-based clinical practice guidelines in the delivery of cardiovascular care. The ACC/AHA Task Force receives numerous suggestions to develop clinical practice guidelines in a broad range of topics. The need for these guidelines must be balanced against the limited financial, staff, and volunteer resources that are available for this purpose. Both organizations have made strong commitments to this effort over the last 2 decades and attempt to accommodate the many requests within the confines of available resources.The Task Force has undertaken an extensive evaluation of the entire guideline development process that was detailed in Part I of this series. This review has been a quality improvement process with a specific focus on literature review, authoring tools, and dissemination of the guidelines. It has led to the development and implementation of a writer's manual, as mentioned in the first part of the series. This manual is available to the public online.16The review has also led to the development of an electronic, Internet-based authoring tool that is currently being used as the foundation of 2 ongoing guideline-writing efforts. Early indications are that this will greatly streamline the process, shorten timelines, reduce travel costs, and improve communication between guideline writers, reviewers, and the leadership of both organizations.There is a clear need to improve the speed of the process to reflect the latest published evidence in existing guidelines. However, this process should never become "instantaneous," as it is on some commercial web sites. The Task Force has recognized that there is a need to balance speed with rigor and deliberation. The initial enthusiasm that accompanies the first presentation of data, as well as the "spin" that commercial interests and protagonists may put on their initial publication, must be balanced with more deliberate consideration by the broader scientific community. The scientific community may judge a trial differently 6 months after publication when perusal and discussion of the data have exposed important themes that were not recognized on the day of publication. The rigor of the review process that was outlined in Part I of this series2 requires several months. Any attempt to compress it further will sacrifice scientific rigor and reduce the quality of the ACC/AHA Guidelines.Practice guidelines are only one part of the quality improvement effort, which some have described as a "great circle" (Figure 4). The guidelines should inspire quality improvement efforts, and those efforts should provide feedback to the guidelines development process.17 Ultimately, the goal is clear—improving cardiovascular care. Download figureDownload PowerPointFigure 4. A proposed model for the integration of quality and for the therapeutic development cycle. Reprinted with permission from reference 17.Guideline-Based Patient ManagementTo return now to our patient, he undergoes a chest x-ray and an echocardiogram, which are both entirely normal. Blood tests of thyroid function are also normal. His appropriate pharmacological management is found in Figure 5, which is taken from the ACC/AHA/ESC Guidelines for the Management of Patients with Atrial Fibrillation.1 Given his paroxysmal atrial fibrillation and the absence of severe symptoms, the only therapy to be considered is anticoagulation. Table 4 shows the recommendations for antithrombotic therapy in patients with atrial fibrillation. In this patient, who is <60 years of age and has no heart disease (this condition is sometimes called lone atrial fibrillation), either aspirin or no therapy is acceptable. The recommendation for no therapy is based on a population-based study referenced in the guidelines.18Download figureDownload PowerPointFigure 5. Suggested pharmacological management of patients with newly discovered atrial fibrillation (AF). HF indicates heart failure. Reprinted with permission from reference 1.TABLE 4. Recommendations for Antithrombotic Therapy in Patients With Atrial Fibrillation Based on Thromboembolic Risk StratificationPatient FeaturesAntithrombotic TherapyClass RecommendationAF indicates atrial fibrillation; CAD, coronary artery disease; INR, international normalized ratio; LV, left ventricular; and TEE, transesophageal echocardiography.*Risk factors for thromboemoblism: Heart failure, LV ejection fraction <0.35, and history of hypertension.Age <60 years with no heart disease (lone AF)Aspirin (325 mg/d) or no therapyIAge 2 million Americans with atrial fibrillation would clearly be enhanced, and multiple strokes would be avoided, if these recommendations were followed uniformly throughout the country.This article is Part II of a 2-part article. Part I appeared in the June 17, 2003, issue of Circulation (Circulation. 2003;107:2979–2986).FootnotesCorrespondence to Raymond J. Gibbons, MD, Division of Cardiovascular Disease, Mayo Clinic, Rochester, MN 55905. E-mail [email protected] References 1 Fuster V, Rydén LE, Asinger RW, et al. ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients With Atrial Fibrillation). Circulation