At the first meeting, members of the Writing Committee were given assignments to provide descriptions and analyses of coronary artery calcium (CAC) measurement for identifying and modifying coronary event risk in the asymptomatic patient, for modifying the clinical care and outcomes of symptomatic patients suspected of having coronary artery disease (CAD), and for understanding the role of CAC measurement in selected patient subgroups.

Considerable discussion among the group focused on the best and most proper way to assess clinical appropriateness of tests such as CAC measurement since there have been no clinical trials to evaluate the impact of CAC testing on clinical outcomes in either symptomatic or asymptomatic patients. The Writing Committee agreed uniformly that the ideal assessment of cardiac tests would require clinical trials that utilize important patient outcomes such as improving the quality or quantity of a patient’s life. However, recognizing that this standard is not available for CAC measurement, the Committee considered other standards of evidence in reaching a consensus opinion.

Two committee members evaluated the quality of each included report with the results of this analysis being included in Table 2 in the original guideline document. The quality assessment criteria included: 1) documentation of prospective data collection; 2) inclusion of self-referred patient series or from a population sample; 3) reporting of coronary heart disease (CHD) events; 4) reporting of outcome data by gender and ethnicity; 5) sample size greater than 1000 individuals; 6) avoiding potential for limited challenge (i.e., an inclusion of very low to very high-risk patients resulting in a wide spread in the outcome results) by not reporting data within strata of clinical risk; 7) reporting measured versus historical or self-reported risk factor data; and 8.) reporting univariable and multivariable prognostic models (i.e., ascertaining the incremental value of CAC scores). A review of the highlighted reports reveals that all studies identified for inclusion were of at least moderate-high quality.

For the complete guideline, please visit the website.

Diagnosis/Evaluation

1. Medical history and review of symptoms (ROS)
2. Diagnostic methods
   • Ankle-brachial index (ABI) and toe-brachial index
   • Segmental pressure examination
   • Pulse volume recoding
   • Continuous-wave Doppler ultrasound
   • Duplex ultrasound
   • Treadmill exercise testing with and without ankle-brachial index assessments and 6-minute walk test
   • Computed tomographic angiography (CTA)
   • Magnetic resonance angiography (MRA)
   • Contrast angiography

Management/Treatment/Prevention

1. Cardiovascular risk reduction
   • Lipid-lowering drugs (statins, fibric acid derivatives)
   • Antihypertensive drugs (beta-blockers, angiotensin-converting enzyme [ACE] inhibitors)
   • Diabetes management (foot inspection, skin cleansing, glucose control)
   • Smoking cessation (behavioral therapy, nicotine replacement therapy, bupropion)
   • Antiplatelet and antithrombotic drugs
   • Note: The following drugs were considered but not recommended: homocysteine-lowering drugs, such as folic acid, vitamin B₁₂
2. Treatment of claudication
   • Supervised exercise programs
   • Pharmacological treatment (cilostazol, pentoxifylline)
   • Note: The following agents were considered but not recommended: L-arginine, propionyl-L-carnitine, ginkgo biloba, oral prostaglandins, vitamin E, chelation
   • Endovascular treatment (e.g., stenting, lasers, atherectomy, percutaneous transluminal angioplasty [PTA], thermal angioplasty)
   • Surgery (inflow and outflow procedures)
3. Treatment for limb salvage (critical limb ischemia [CLI])
   • Parenteral prostaglandins (limited efficacy)
   • Angiogenic growth factors (considered but not recommended outside of clinical trials)
   • Endovascular treatment
   • Thrombolysis
   • Surgery
4. Prevention: vascular ROS and prompt use of the ABI test, comprehensive pulse examination, feet inspection, and review of family history of abdominal aortic aneurysm for patients at risk for lower extremity peripheral arterial disease

For the complete guideline, please visit the website.

General Interventions for Evaluation of Valvular Heart Diseases

1. Echocardiography (imaging, spectral, and color Doppler): transesophageal, transthoracic
2. Electrocardiography
3. Chest X-ray
4. Cardiac catheterization
5. Exercise testing
6. Radionuclide angiography
7. Intraoperative transesophageal echocardiography

Interventions for Specific Valvular Diseases

Aortic Stenosis

1. Aortic valve replacement
2. Aortic balloon valvotomy

Aortic Regurgitation

1. Cardiac catheterization with aortic root angiography
2. Vasodilator therapy
3. Aortic valve replacement
4. Repair of thoracic aorta in patients with bicuspid aortic valves

Bicuspid Aortic Valve with Dilated Ascending Aorta

1. Serial evaluation by echocardiography, cardiac magnetic resonance imaging, or computed tomography
2. Surgery to repair the aortic root or replace the ascending aorta
3. Beta-adrenergic drug therapy

Mitral Stenosis

1. Anticoagulation
2. Percutaneous mitral balloon valvotomy
3. Mitral valve repair
4. Mitral valve replacement
5. Open commissurotomy

Mitral Valve Prolapse

1. Aspirin therapy
2. Warfarin therapy

Mitral Regurgitation

1. Left ventriculography and hemodynamic measurements
2. Mitral valve repair
3. Mitral valve replacement

Tricuspid Regurgitation

Tricuspid valve repair, replacement, or annuloplasty

Pulmonic Stenosis

Intervention in the adolescent or young adult with pulmonic stenosis (balloon valvotomy or surgery)

For the complete guideline, please visit the website.

Management before ST-elevation Myocardial Infarction (STEMI)

1. Identification of patients at risk of STEMI
2. Patient education for early recognition and response to STEMI

Management after Onset of STEMI

1. Management of out-of-hospital cardiac arrest
   • Activation of Emergency Medical System (EMS)
   • Early defibrillation
   • Early advanced cardiac life support
   • Cardiopulmonary resuscitation training program for families

Prehospital Issues

1. Training of emergency medical services systems personnel to respond to patients with chest pain and/or cardiac arrest
2. Prehospital chest pain evaluation and treatment
3. Prehospital fibrinolysis
4. Prehospital destination protocols

Initial Recognition and Management in the Emergency Department (ED)

1. Optimal strategies for ED triage
2. Initial patient evaluation
   • History
   • Physical examination
   • Electrocardiogram
   • Laboratory examinations
   • Measurement of biomarkers of cardiac damage
   • Imaging
3. Management
   • Oxygen
   • Nitroglycerin
   • Analgesia
   • Aspirin
   • Beta-blockers
   • Reperfusion (pharmacological reperfusion, percutaneous coronary intervention, acute surgical perfusion)
   • Ancillary reperfusion therapy, including aspirin, clopidogrel, glycoprotein IIb/IIIa inhibitors
   • Other pharmacological measures, including angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers, strict glucose control (e.g., insulin for people with diabetes), magnesium, calcium channel blockers (e.g., verapamil, diltiazem)

For the entire guideline, please visit the website here.

For more information, please visit the complete guideline here.

For the complete version of the guideline, please visit this website.