Guidelines for Percutaneous Coronary Intervention

If you are wondering what the procedure and guidelines are for the percutaneous coronary intervention, the National Guideline Clearinghouse of the U.S. Department of Health and Human Services has provided a thorough summary. Below is a brief excerpt from the guideline:

Target Population

Patients with coronary artery disease

Management/Treatment

  1. Percutaneous coronary interventions (PCI), including percutaneous transluminal coronary angioplasty (PTCA), balloon expandable stents, drug-eluting stents, extraction atherectomy, directional coronary atherectomy, rotational atherectomy, rheolytic thrombectomy catheter, proximal and distal embolic protection devices, excimer laser coronary atherectomy, and local radiation devices to reduce in-stent restenosis
  2. Insurance of institutional and operator competency in performing PCI (quality assurance programs, high-volume operators in high-volume institutions, availability of onsite cardiac surgical back-up or access to cardiac surgical back-up)
  3. Antiplatelet and antithrombotic adjunctive therapies (aspirin, clopidogrel, glycoprotein IIb/IIIa Inhibitors, unfractionated heparin, low-molecular-weight heparin, bivalirudin) in patients undergoing PCI
  4. Special considerations (for example, management of clinical restenosis, ad hoc PCI, PCI in the cardiac transplant patient, and restenosis after stent implantation)
  5. Post-PCI management (postprocedural evaluation of ischemia, risk factor modification, exercise testing, follow-up coronary angiography)

Evaluation/Follow-up

  1. Angiographic assessment
  2. Use of adjunctive technologies
    • Coronary intravascular ultrasound imaging (IVUS)
    • Measurement of coronary flow velocity and coronary vasodilatory reserve
    • Measurement of coronary artery pressure and fractional flow reserve (FFR)
  3. Measurement of creatine kinase-MB isoenzyme and troponins I or T

For a complete guideline, please visit the website here.

Guidelines for Management of Myocardial Infraction

If you are wondering what the procedure and guidelines are for the management of myocardial infraction, the National Guideline Clearinghouse of the U.S. Department of Health and Human Services has provided a thorough summary. Below is a brief excerpt from the guideline:

Target Population
  • Adults with ST-elevation myocardial infarction (STEMI)
  • Adults at risk of STEMI

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.

Guidelines for Device-based Therapy for Arrhythmias

If you are wondering what the procedure and guidelines are for a doctor’s diagnostic exam for abnormal heart beats, the National Guideline Clearinghouse of the U.S. Department of Health and Human Services has provided a thorough summary. Below is a brief excerpt from the guideline:
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Guidelines for Atrial Fibrillation Diagnostic

If you are wondering what the procedure and guidelines are for a doctor’s diagnostic exam for atrial fibrillation, the National Guideline Clearinghouse of the U.S. Department of Health and Human Services has provided a thorough summary. Below is a brief excerpt from the guideline:

Target Population

Patients with atrial fibrillation

Clinical Evaluation

  1. History and physical examination
  2. Electrocardiogram
  3. Transthoracic echocardiography
  4. Blood tests including thyroid, renal, and hepatic function
  5. Additional tests, as needed, including
    • Six-minute walk test
    • Exercise testing
    • Holter monitoring
    • Transesophageal echocardiography (TEE)
    • Electrophysiological study
    • Chest radiography

Management

  1. Rate control
    • Pharmacological control, using calcium channel blockers (diltiazem and verapamil), beta-blockers (esmolol, metoprolol, propranolol), digoxin, amiodarone
    • Atrioventricular nodal ablation
  2. Prevention of thromboembolism
    • Risk stratification
    • Anticoagulants (Vitamin K antagonists, aspirin, unfractionated heparin, low molecular weight heparin)
  3. Cardioversion
    • Pharmacological cardioversion
    • Direct-current (DC) cardioversion including pharmacological enhancement and prevention of thromboembolism
  4. Maintenance of sinus rhythm after cardioversion
    • Treatment of precipitating or reversible causes of atrial fibrillation
    • Pharmacological therapy, including propafenone, flecainide, or sotalol
    • Catheter ablation
  5. Consideration of special circumstances, including
    • Postoperative atrial fibrillation
    • Acute myocardial infarction
    • Wolff-Parkinson White preexcitation syndromes
    • Hyperthyroidism
    • Pregnancy
    • Hypertrophic cardiomyopathy
    • Pulmonary diseases

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

Guidelines for Unstable Angina Diagnostic

If you are wondering what the procedure and guidelines are for a doctor’s diagnostic exam in unstable angina, the National Guideline Clearinghouse of the U.S. Department of Health and Human Services has provided a thorough summary. Below is a brief excerpt from the guideline:

Initial Evaluation and Management

  1. Clinical assessment, including 12-lead electrocardiogram, biomarker determination, physical examination, and stress test
  2. Instructions to call 9-1-1 if signs of acute coronary syndrome
  3. Pre-hospital aspirin (ASA) and nitroglycerin (NTG) as appropriate
  4. Risk stratification

Early Hospital Care

  1. Anti-ischemic and analgesic therapy, including NTG, beta blockers, angiotensin-converting enzyme (ACE) inhibitors, calcium channel blockers, angiotensin receptor blocker (ARB), morphine sulfate, long-acting nondihydro0pyridine calcium antagonists, supplemental oxygen
  2. Anti-platelet and anticoagulant therapy, including ASA, clopidogrel, glycoprotein (GP) IIb/IIIa inhibitors, enoxaparin, unfractionated heparin (UFH)
  3. Consideration of conservative versus invasive initial strategies
  4. Risk stratification at discharge

Revascularization

  1. Percutaneous coronary intervention (PCI)
  2. Coronary artery bypass graft (CABG) surgery

Post-Discharge Care

  1. Continuation of medications to control ischemia
  2. Long-term medical therapy, including anti-platelet therapy, beta blockers, inhibitors of the rennin-angiotensins-aldosterone system (ACE inhibitors, ARBs), NTG, calcium channel blockers, warfarin
  3. Secondary prevention, including lipid management, blood pressure control, treatment of diabetes mellitus, smoking cessation, weight management, physical activity, patient education, influenza immunization, depression screening, and pain relief
  4. Post-discharge follow-up and cardiac rehabilitation
  5. Consideration of special groups

For the rest of the guideline, please click here.

Guidelines for Heart Failure Diagnosis

If you are wondering what the procedure and guidelines are for a doctor’s diagnostic exam in chronic adult heart failure, the National Guideline Clearinghouse of the U.S. Department of Health and Human Services has provided a thorough summary. Below is a brief excerpt from the guideline:

Guideline Objective(s)

To assist health care providers in clinical decision-making by describing a range of generally acceptable approaches for the prevention, diagnosis, and management of heart failure

Target Population

  • Adults with chronic heart failure associated with normal or low left ventricular ejection fraction , including consideration of the following special populations:
    • Women and men
    • High-risk ethnic minority groups (e.g., blacks)
    • Elderly patients
  • Adults at high risk of developing heart failure

Initial Assessments

  1. Thorough history and physical examination, including history of current and past alcohol and drug use, orthostatic blood pressure changes, weight and height, and calculation of body mass index
  2. Assessment of ability to perform routine and desired activities of daily living
  3. Laboratory testing: complete blood count, urinalysis, serum electrolytes (including calcium and magnesium), blood urea nitrogen, serum creatinine, fasting blood glucose, lipid profile, liver function tests, and thyroid-stimulating hormone.
  4. 12-lead electrocardiography
  5. Chest radiography (PA and lateral)
  6. Two-dimensional echocardiogram coupled with Doppler flow studies
  7. Coronary arteriography in appropriate patients
  8. Maximal exercise testing with or without measurement of respiratory gas exchange and/or blood oxygen saturation in appropriate patients
  9. Screening for hemochromatosis, sleep-disturbed breathing, or human immunodeficiency virus, in selected patients
  10. Diagnostic tests for rheumatologic diseases, amyloidosis, or pheochromocytoma, if indicated
  11. Endomyocardial biopsy, when specific diagnosis is suspected that would influence therapy
  12. Holter monitoring, if indicated.

The rest of the summary can be found here.

Calcium Channel Blockers

Calcium channel blockers are heart disease drugs that increase the blood and oxygen supply to the heart, while lessening the heart’s workload. Examples of brand name calcium channel blockers include: Norvasc, Plendil, Cardizem, Calan, Adalat, Cardene, Sular, Vascor, Virapin and Isoptin.

What Conditions Do These Blockers Help?

For a variety of heart conditions including: coronary artery disease, coronary spasm, angina, abnormal heart rhythms, hypertrophic cardiomyopathy, diastolic heart failure, and migraine headaches.

Calcium channel blockers should be taken with food. Follow the directions on the prescription label to see how often and how much you should take. While taking the blockers, check your blood pressure regularly either at home, at a pharmacy, or at a doctor’s office. Also, your doctor might also advise you to monitor your pulse daily on taking this medication. If your pulse is slower than it should be, contact your doctor.

Side effects include drowsiness, increased appetite, shortness of breath, slow heartbeat, allergic reaction, constipation, tenderness of gums, swelling of feet, fainting, and gastroesophageal reflux disease. Also, do no eat or drink grapefruit while taking calcium channel blockers. Avoid alcohol, if possible. Pregnant women should double check with their physicians before taking them.

Beta Blockers

Beta blockers are also known as beta-adrenergic blocking agents. They treat a variety of conditions including hypertension (high blood pressure), glaucoma, and migraines. Beta blockers work by blocking the effects of epinephrine, the hormone that produces adrenaline. The beta blockers will reduce heart beats with less force, thus reducing blood pressure. They also help to open up blood vessels to improve blood flow.

Examples of beta blockers include:

  • Acebutolol
  • Atenolol
  • Bisoprolol
  • Carvedilol
  • Metoprolol
  • Nadolol
  • Nebivolol
  • Propranolol

Beta blockers are used to treat and improve symptoms of high blood pressure, irregular heart rhythm, heart failure, chest pain, heart attacks, hyperthyroidism, and much more. Beta blockers aren’t prescribed until other medications haven’t work effectively.

Side effects may occur in taking beta blockers, including fatigue, cold hands, dizziness, and weakness. Beta blockers aren’t used in people with asthma, and requires monitoring for people with diabetes.

This medication can also affect your cholesterol and triglycerides levels, but these changes are only temporary and won’t last.

Below is an image of how beta blockers work:

Anticoagulants

For people with congenital heart defects, anticoagulants are taken to help thin out blood cells. Blood-thinning medicine slows down the blood clotting and prevents blood clots from forming on artificial valves. Valve obstruction and blood clots can travel to the brain and cause strokes.

Anticoagulants are usually given by mouth. In some cases, they’re given by vein or injection. For oral medications, anticoagulants generally include aspirin, clopidogrel, and warfarin. These medicines decrease clotting by interfering with platelets and blocking the body’s production of clotting substances. Aspirin is known to prevent more bleeding complications than clopidogrel or warfarin, however, it may not block clotting as much as the other two. It also can upset the stomach. Clopidogrel could cause bleeding for up to 7-10 days which may require you to avoid certain dental work and operations. Warfarin also increases bleeding and requires careful blood level monitoring by tests. It also requires you to limit some physical activities to reduce the chances of injury.

Intravenous (via the vein) medications works faster to thin blood. However, the effect wears off rapidly if treatment isn’t continued. Subcutaneous (via injection) medications include heparin. This is sometimes done during pregnancy or a certain long period of time, a much better option than oral or intravenous injections.

Anticoagulation and Pregnancy

For women who need anticoagulants during pregnancy, it is important to take special precautions. Warfarin can have significant risk on the fetus, especially in the first trimester. Please consult with your doctor, both your cardiologist and obstetrician, about which medication would best fit your health and your fetus’ health.

Echocardiogram: A Diagnostic Exam

An echocardiogram is a test that creates a moving picture of the heart using sound waves. Unlike an X-ray, the picture is much more detailed and involves no radiation.

How does it work? During an echocardiogram, a sonographer uses a transducer, an instrument that transmits high-frequency waves, to place over the breast bone and directed towards the heart. The transducer picks up the echoes of the sound waves and then transmits them as electrical impulses. The impulses are then converted to moving pictures of the heart. Echocardiograms allow doctors to see many structures of the heart, as well as the beating of the heart.

There is no preparation necessary for the test. You will be asked to remove your clothes from the waist up and lie on the exam table on your back. Small electrodes will be placed on your chest to perform an EKG. Then, a gel will be applied on the chest area and the transducer will start up.

The test is performed for purposes of evaluating the heart in a noninvasive way. It allows doctors to diagnose and evaluate conditions such as heart murmurs, infections, congenital heart disease, atrial fibrillation, pulmonary hypertension, and much more.

An abnormal echocardiogram may show minor or significant signs. However, your doctor will discuss the results of your test in depth so that you are well aware of the information it provides.

Alternative names for an echocardiogram are Doppler ultrasound of the heart, or a surface echo.