They examined 583 men and women with various cholesterol levels. The nuts evaluated included almonds, hazelnuts, pecans, pistachios, walnuts, macadamia nuts and peanuts. The patients in this trial ate approximately 67 grams of nuts per day. The results — a 5.1% reduction in total cholesterol concentration, and a 7.4% reduction in LDL (bad cholesterol). In addition, triglycerides measurements declined by 10.2%.

Nuts should be included in your therapeutic and dietary interventions for improving cholesterol levels. It should not be the sole source of dieting for your cholesterol treatment. Also, moderation is key. Please limit yourself to a maximum of 3 ounces per day because nuts have high calorie density.

The valves work by opening their flaps to allow blood to flow into the ventricles, the heart’s two lower chambers. A brief moment later, the ventricles contract and the mitral and tricuspid valves shut tightly to stop the blood from flowing backward into the atria. With these contractions, they pump blood through the valves and to the pulmonary artery, which carries blood to the lungs to get oxygen.

Heart valves can have 3 basic kinds of problems: regurgitation, stenosis, and atresia. Regurgitation, or backflow, occurs when a valve doesn’t close tightly. Blood leaks back into the chambers rather than flowing forward through the heart. Stenosis occurs when the flaps of a valve thicken, stiffen or fuse together. This prevents the heart valve from fully opening. As a result, not enough blood flows through the valve.  Atresia occurs when a heart valve lacks an opening for blood to pass through.

Currently, there are no medications that cure heart valve disease. However, lifestyle changes and medicines can relieve symptoms and problems. These types of treatments can also lower your risk of develop other life-threatening conditions.

A class I treatment the benefits greatly outweigh the risks. In a Class II treatment the benefits outweigh the risks by a smaller margin. In a class III treatment the benefits and risks are close, and in a class IV treatment, the risks outweigh the benefits. Here is how the task force viewed various treatments for arrhythmias.

Recommendations for Permanent Pacing in Sinus Node Dysfunction (SND)

CLASS I

1. Permanent pacemaker implantation is indicated for SND with documented symptomatic bradycardia, including frequent sinus pauses that produce symptoms. (Level of Evidence: C) (Kay, Estioko, & Wiener, 1982; Kusumoto & Goldschlager, 1996; Rasmussen, 1981)
2. Permanent pacemaker implantation is indicated for symptomatic chronotropic incompetence. (Level of Evidence: C) (Kay, Estioko, & Wiener, 1982; Kusumoto & Goldschlager, 1996; Rasmussen, 1981; Linde-Edelstam et al., 1992; Gammage et al., 1991)
3. Permanent pacemaker implantation is indicated for symptomatic sinus bradycardia that results from required drug therapy for medical conditions. (Level of Evidence: C)

CLASS IIa

1. Permanent pacemaker implantation is reasonable for SND with heart rate less than 40 bpm when a clear association between significant symptoms consistent with bradycardia and the actual presence of bradycardia has not been documented. (Level of Evidence: C) Kay, Estioko, & Wiener, 1982; Kusumoto & Goldschlager, 1996; Rasmussen, 1981; Shaw, Holman, & Gowers, 1980; Dreifus, Michelson, & Kaplinsky, 1983; Rubenstein et al., 1972)
2. Permanent pacemaker implantation is reasonable for syncope of unexplained origin when clinically significant abnormalities of sinus node function are discovered or provoked in electrophysiological studies. (Level of Evidence: C) (Fisher, 1981, Reiffel & Kuehnert, 1994)

CLASS IIb

1. Permanent pacemaker implantation may be considered in minimally symptomatic patients with chronic heart rate less than 40 bpm while awake. (Level of Evidence: C) (Kay, Estioko, & Wiener, 1982; 1996; Rasmussen, 1981; Linde-Edelstam et al., 1992; Shaw, Holman, & Gowers, 1980; Dreifus, Michelson, & Kaplinsky, 1983; Rubenstein et al., 1972)

CLASS III

1. Permanent pacemaker implantation is not indicated for SND in asymptomatic patients. (Level of Evidence: C)
2. Permanent pacemaker implantation is not indicated for SND in patients for whom the symptoms suggestive of bradycardia have been clearly documented to occur in the absence of bradycardia. (Level of Evidence: C)
3. Permanent pacemaker implantation is not indicated for SND with symptomatic bradycardia due to nonessential drug therapy. (Level of Evidence: C)

Recommendations for Acquired Atrioventricular (AV) Block in Adults

CLASS I

1. Permanent pacemaker implantation is indicated for third-degree and advanced second-degree AV block at any anatomic level associated with bradycardia with symptoms (including heart failure) or ventricular arrhythmias presumed to be due to AV block. (Level of Evidence: C) (Dreifus, Michelson, & Kaplinsky, 1983; Friedberg, Donoso, & Stein, 1964; British Pacing and Electrophysiology Group, 1991; Kastor, 1975)
2. Permanent pacemaker implantation is indicated for third-degree and advanced second-degree AV block at any anatomic level associated with arrhythmias and other medical conditions that require drug therapy that results in symptomatic bradycardia. (Level of Evidence: C) (Dreifus, Michelson, & Kaplinsky, 1983; Friedberg, Donoso, & Stein, 1964; British Pacing and Electrophysiology Group, 1991; Kastor, 1975)
3. Permanent pacemaker implantation is indicated for third-degree and advanced second-degree AV block at any anatomic level in awake, symptom-free patients in sinus rhythm, with documented periods of asystole greater than or equal to 3.0 seconds (Ector, Rolies, & De Geest, 1983) or any escape rate less than 40 bpm, or with an escape rhythm that is below the AV node. (Level of Evidence: C)(Kay, Estioko, & Wiener, 1982; Shaw, Holman, & Gowers, 1980)
4. Permanent pacemaker implantation is indicated for third-degree and advanced second-degree AV block at any anatomic level in awake, symptom-free patients with atrial fibrillation (AF) and bradycardia with 1 or more pauses of at least 5 seconds or longer. (Level of Evidence: C)
5. Permanent pacemaker implantation is indicated for third-degree and advanced second-degree AV block at any anatomic level after catheter ablation of the AV junction. (Level of Evidence: C) (Gallagher et al., 1982; Langberg et al., 1989)
6. Permanent pacemaker implantation is indicated for third-degree and advanced second-degree AV block at any anatomic level associated with postoperative AV block that is not expected to resolve after cardiac surgery. (Level of Evidence: C) (Kim et al., 2001; Kastor, 1975; Glikson et al., 1997; Koplan et al., 2003)
7. Permanent pacemaker implantation is indicated for third-degree and advanced second-degree AV block at any anatomic level associated with neuromuscular diseases with AV block, such as myotonic muscular dystrophy, Kearns-Sayre syndrome, Erb dystrophy (limb-girdle muscular dystrophy), and peroneal muscular atrophy, with or without symptoms. (Level of Evidence: B) (Perloff et al., 1984; Hiromasa et al., 1987; Stevenson et al., 1990; James & Fisch, 1963; Roberts, Perloff, & Kark, 1979; Charles et al., 1981; James, 1962)
8. Permanent pacemaker implantation is indicated for second-degree AV block with associated symptomatic bradycardia regardless of type or site of block. (Level of Evidence: B) (Strasberg et al., 1981)
9. Permanent pacemaker implantation is indicated for asymptomatic persistent third-degree AV block at any anatomic site with average awake ventricular rates of 40 bpm or faster if cardiomegaly or left ventricular (LV) dysfunction is present or if the site of block is below the AV node. (Level of Evidence: B) (British Pacing and Electrophysiology Group, 1981; Shaw et al., 1985)
10. Permanent pacemaker implantation is indicated for second- or third-degree AV block during exercise in the absence of myocardial ischemia. (Level of Evidence: C) (Chokshi et al., 1990; Barold & Mugica, 1991)

CLASS IIa

1. Permanent pacemaker implantation is reasonable for persistent third-degree AV block with an escape rate greater than 40 bpm in asymptomatic adult patients without cardiomegaly. (Level of Evidence: C) (Dreifus, Michelson, & Kaplinsky et al., 1983; Friedberg, Donoso, & Stein, 1964; Gadboys, Wisoff, & Litwak, 1964; British Pacing and Electrophysiology Group, 1991; Barold & Mugica, 1991; Kastor, 1975)
2. Permanent pacemaker implantation is reasonable for asymptomatic second-degree AV block at intra- or infra-His levels found at electrophysiological study. (Level of Evidence: B) (Strasberg et al., 1981; British Pacing and Electrophysiology Group, 1991; Shaw et al., 1985)
3. Permanent pacemaker implantation is reasonable for first- or second-degree AV block with symptoms similar to those of pacemaker syndrome or hemodynamic compromise. (Level of Evidence: B) (Barold, 1996; Kim et al., 1993)
4. Permanent pacemaker implantation is reasonable for asymptomatic type II second-degree AV block with a narrow QRS. When type II second-degree AV block occurs with a wide QRS, including isolated right bundle-branch block, pacing becomes a Class I recommendation. (See Section 2.1.3, “Chronic Bifascicular Block” in the original guideline document.) (Level of Evidence: B) (Barold, 1996; British Pacing and Electrophysiology Group, 1991; Zipes, 1979; Kastor, 1975)

CLASS IIb

1. Permanent pacemaker implantation may be considered for neuromuscular diseases such as myotonic muscular dystrophy, Erb dystrophy (limb-girdle muscular dystrophy), and peroneal muscular atrophy with any degree of AV block (including first-degree AV block), with or without symptoms, because there may be unpredictable progression of AV conduction disease. (Level of Evidence: B) (Perloff et al., 1984; Hiromasa et al., 1987; Stevenson et al., 1990; James & Fisch, 1963; Roberts, Perloff & Kark, 1979; Charles et al., 1981; James, 1962)
2. Permanent pacemaker implantation may be considered for AV block in the setting of drug use and/or drug toxicity when the block is expected to recur even after the drug is withdrawn. (Level of Evidence: B) (Zeltser et al., 2004; Shohat-Zabarski et al., 2004)

CLASS III

1. Permanent pacemaker implantation is not indicated for asymptomatic first-degree AV block. (Level of Evidence: B) (Mymin et al., 1986) (See Section 2.1.3, “Chronic Bifascicular Block” in the original guideline document.)
2. Permanent pacemaker implantation is not indicated for asymptomatic type I second-degree AV block at the supra-His (AV node) level or that which is not known to be intra- or infra-Hisian.(Level of Evidence: C) (Strasberg et al., 1981)
3. Permanent pacemaker implantation is not indicated for AV block that is expected to resolve and is unlikely to recur (McAlister, et al., 1989) (e.g., drug toxicity, Lyme disease, or transient increases in vagal tone or during hypoxia in sleep apnea syndrome in the absence of symptoms). (Level of Evidence: B) (Shohat-Zabarski et al., 2004; McAlister et al., 1989)

Recommendations for Permanent Pacing in Chronic Bifascicular Block

CLASS I

1. Permanent pacemaker implantation is indicated for advanced second-degree AV block or intermittent third-degree AV block. (Level of Evidence: B) (Friedberg, Donoso, & Stein, 1964; Gadboys, Wisoff, & Litwak, 1964; Johansson, 1966; Hindman et al., 1978; Donmoyer, DeSanctis, & Austen, 1967; Edhag & Swahn, 1976)
2. Permanent pacemaker implantation is indicated for type II second-degree AV block. (Level of Evidence: B) (Dhingra et al., “The significance,” 1974; Donoso, Adler, & Friedberg, 1964; Ranganathan et al., 1972; Dhingra et al.,”Syncope,” 1974)
3. Permanent pacemaker implantation is indicated for alternating bundle-branch block. (Level of Evidence: C) (Josephson, 1993)

CLASS IIa

1. Permanent pacemaker implantation is reasonable for syncope not demonstrated to be due to AV block when other likely causes have been excluded, specifically ventricular tachycardia (VT). (Level of Evidence: B) (Fisch, Zipes, & Fisch, 1980; McAnulty et al., 1982; Kulbertus & Collignon, 1969; DePasquale & Bruno, 1973; Denes, 1977; McAnulty et al., 1978; Peters et al., 1979; Scheinman et al., 1982; Morady et al., 1984; Click et al., 1987; Ezri et al., 1983; Twidale et al., 1988; Englund et al., 1995; Scheinman et al., 1977; Probst et al., 1979; Dhingra et al., 1979; Cheng, 1971; Dhingra et al., “Syncope,” 1974; Brignole et al., 2001)
2. Permanent pacemaker implantation is reasonable for an incidental finding at electrophysiological study of a markedly prolonged HV interval (greater than or equal to 100 milliseconds) in asymptomatic patients. (Level of Evidence: B) (Scheinman et al., 1982)
3. Permanent pacemaker implantation is reasonable for an incidental finding at electrophysiological study of pacing-induced infra-His block that is not physiological. (Level of Evidence: B) (Dhingra et al., 1979)

CLASS IIb

1. Permanent pacemaker implantation may be considered in the setting of neuromuscular diseases such as myotonic muscular dystrophy, Erb dystrophy (limb-girdle muscular dystrophy), and peroneal muscular atrophy with bifascicular block or any fascicular block, with or without symptoms. (Level of Evidence: C) (Perloff et al., 1984; Hiromasa et al., 1987; Stevenson et al., 1990; James & Fisch, 1963; Roberts, Perloff, & Kark, 1979; Charles et al., 1981; James, 1962)

CLASS III

1. Permanent pacemaker implantation is not indicated for fascicular block without AV block or symptoms. (Level of Evidence: B) (McAnulty et al., 1982; McAnulty et al.,1978; Scheinman et al., 1982; Scheinman et al., 1977)
2. Permanent pacemaker implantation is not indicated for fascicular block with first-degree AV block without symptoms. (Level of Evidence: B) (McAnulty et al., 1982; McAnulty et al.,1978; Scheinman et al., 1982; Scheinman et al., 1977)

Recommendations for Permanent Pacing After the Acute Phase of Myocardial Infarction (MI)

CLASS I

1. Permanent ventricular pacing is indicated for persistent second-degree AV block in the His-Purkinje system with alternating bundle-branch block or third-degree AV block within or below the His-Purkinje system after ST-segment elevation MI. (Level of Evidence: B) (Ranganathan et al., 1972; Col & Weinberg, 1972; Ritter et al., 1976; Ginks et al., 1977; Domenighetti & Perret, 1980; Lamas et al., 1986)
2. Permanent ventricular pacing is indicated for transient advanced second- or third-degree infranodal AV block and associated bundle-branch block. If the site of block is uncertain, an electrophysiological study may be necessary. (Level of Evidence: B) (Col & Weinberg, 1972; Ritter et al., 1976)
3. Permanent ventricular pacing is indicated for persistent and symptomatic second- or third-degree AV block. (Level of Evidence: C)

CLASS IIb

1. Permanent ventricular pacing may be considered for persistent second- or third-degree AV block at the AV node level, even in the absence of symptoms. (Level of Evidence: B) (Shaw, Holman, & Gowers, 1980)

CLASS III

1. Permanent ventricular pacing is not indicated for transient AV block in the absence of intraventricular conduction defects. (Level of Evidence: B) (Col & Weinberg, 1972)
2. Permanent ventricular pacing is not indicated for transient AV block in the presence of isolated left anterior fascicular block. (Level of Evidence: B) (Ginks et al., 1977)
3. Permanent ventricular pacing is not indicated for new bundle branch block or fascicular block in the absence of AV block. (Level of Evidence: B) (Hindman et al., 1978; Col & Weinberg, 1972)
4. Permanent ventricular pacing is not indicated for persistent asymptomatic first-degree AV block in the presence of bundle branch or fascicular block. (Level of Evidence: B) (Col & Weinberg, 1972)

*These recommendations are consistent with the “ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction” (Antman et al., 2004).

Recommendations for Permanent Pacing in Hypersensitive Carotid Sinus Syndrome and Neurocardiogenic Syncope

CLASS I

1. Permanent pacing is indicated for recurrent syncope caused by spontaneously occurring carotid sinus stimulation and carotid sinus pressure that induces ventricular asystole of more than 3 seconds. (Level of Evidence: C) (Brignole et al., 1992; Brignole et al., 1991)

CLASS IIa

1. Permanent pacing is reasonable for syncope without clear, provocative events and with a hypersensitive cardioinhibitory response of 3 seconds or longer. (Level of Evidence: C) (Brignole et al., 1992)

CLASS IIb

1. Permanent pacing may be considered for significantly symptomatic neurocardiogenic syncope associated with bradycardia documented spontaneously or at the time of tilt-table testing. (Level of Evidence: B) (Sutton et al., 2000; Ammirati, Colivicchi, & Santini, 2001; Connolly et al., 2003; Sheldon et al., 1998)

CLASS III

1. Permanent pacing is not indicated for a hypersensitive cardioinhibitory response to carotid sinus stimulation without symptoms or with vague symptoms. (Level of Evidence: C)
2. Permanent pacing is not indicated for situational vasovagal syncope in which avoidance behavior is effective and preferred. (Level of Evidence: C)

Recommendations for Pacing After Cardiac Transplantation

CLASS I

1. Permanent pacing is indicated for persistent inappropriate or symptomatic bradycardia not expected to resolve and for other Class I indications for permanent pacing. (Level of Evidence: C)

CLASS IIb

1. Permanent pacing may be considered when relative bradycardia is prolonged or recurrent, which limits rehabilitation or discharge after postoperative recovery from cardiac transplantation. (Level of Evidence: C)
2. Permanent pacing may be considered for syncope after cardiac transplantation even when bradyarrhythmia has not been documented. (Level of Evidence: C)

Recommendations for Permanent Pacemakers That Automatically Detect and Pace to Terminate Tachycardias

CLASS IIa

1. Permanent pacing is reasonable for symptomatic recurrent supraventricular tachycardia (SVT that is reproducibly terminated by pacing when catheter ablation and/or drugs fail to control the arrhythmia or produce intolerable side effects. (Level of Evidence: C) (Peters et al., 1985; Fisher et al., 1987; Den et al., 1984; Saksena et al., 1986; Barold et al., 1987)

CLASS III

1. Permanent pacing is not indicated in the presence of an accessory pathway that has the capacity for rapid anterograde conduction. (Level of Evidence: C)

Recommendations for Pacing to Prevent Tachycardia

CLASS I

1. Permanent pacing is indicated for sustained pause-dependent VT, with or without QT prolongation. (Level of Evidence: C) (Eldar et al., 1987; Eldar et al., 1992)

CLASS IIa

1. Permanent pacing is reasonable for high-risk patients with congenital long-QT syndrome. (Level of Evidence: C) (Eldar et al., 1987; Eldar et al., 1992)

CLASS IIb

1. Permanent pacing may be considered for prevention of symptomatic, drug-refractory, recurrent AF in patients with coexisting SND. (Level of Evidence: B) (Lamas et al., 2000; Saksena et al., 1996; Saksena et al, 1998)

CLASS III

1. Permanent pacing is not indicated for frequent or complex ventricular ectopic activity without sustained VT in the absence of the long-QT syndrome. (Level of Evidence: C) (Fisher et al., 1987)
2. Permanent pacing is not indicated for torsade de pointes VT due to reversible causes. (Level of Evidence: A) (Moss & Robinson, 1992; Viskin et al., 1996)

Recommendation for Pacing to Prevent Atrial Fibrillation

CLASS III

1. Permanent pacing is not indicated for the prevention of AF in patients without any other indication for pacemaker implantation. (Level of Evidence: B) (Knight et al., 2005)

Recommendations for Cardiac Resynchronization Therapy in Patients With Severe Systolic Heart Failure

CLASS I

1. For patients who have left ventricular ejection fraction (LVEF) less than or equal to 35%, a QRS duration greater than or equal to 0.12 seconds, and sinus rhythm, cardiac resynchronization therapy (CRT) with or without an ICD is indicated for the treatment of NYHA functional Class III or ambulatory Class IV heart failure symptoms with optimal recommended medical therapy. (Level of Evidence: A) (Abraham et al., 2002; Bristow et al., 2004; Cleland et al., 2005; Hunt, 2005)

CLASS IIa

1. For patients who have LVEF less than or equal to 35%, a QRS duration greater than or equal to 0.12 seconds, and AF, CRT with or without an ICD is reasonable for the treatment of NYHA functional Class III or ambulatory Class IV heart failure symptoms on optimal recommended medical therapy. (Level of Evidence: B) (Cazeau et al., 2001; Hunt, 2005)
2. For patients with LVEF less than or equal to 35% with New York Heart Association (NYHA) functional Class III or ambulatory Class IV symptoms who are receiving optimal recommended medical therapy and who have frequent dependence on ventricular pacing, CRT is reasonable. (Level of Evidence: C) (Hunt, 2005)

CLASS IIb

1. For patients with LVEF less than or equal to 35% with NYHA functional Class I or II symptoms who are receiving optimal recommended medical therapy and who are undergoing implantation of a permanent pacemaker and/or ICD with anticipated frequent ventricular pacing, CRT may be considered. (Level of Evidence: C) (Hunt, 2005)

CLASS III

1. CRT is not indicated for asymptomatic patients with reduced LVEF in the absence of other indications for pacing. (Level of Evidence: B) (Abraham et al., 2002; Bristow et al., 2004; Cleland et al., 2005; Hunt, 2005)
2. CRT is not indicated for patients whose functional status and life expectancy are limited predominantly by chronic noncardiac conditions. (Level of Evidence: C) (Hunt, 2005)

Recommendations for Pacing in Patients With Hypertrophic Cardiomyopathy (HCM)

CLASS I

1. Permanent pacing is indicated for SND or AV block in patients with HCM as described previously (see Section 2.1.1, “Sinus Node Dysfunction,” and Section 2.1.2, “Acquired Atrioventricular Block in Adults” in the original guideline document). (Level of Evidence: C)

CLASS IIb

1. Permanent pacing may be considered in medically refractory symptomatic patients with HCM and significant resting or provoked LV outflow tract obstruction. (Level of Evidence: A) As for Class I indications, when risk factors for SCD are present, consider a DDD implantable cardioverter defibrillator (ICD) (see Section 3, “Indications for Implantable Cardioverter-Defibrillator Therapy” in the original guideline document). (Fananapazir et al., 1994; Nishimura et al., 1997; Kappenberger et al., 1997; Maron et al., 1999; Nishimura et al., “Effect of,” 1996; Nishimura et al., “Dual-chamber,” 1996)

CLASS III

1. Permanent pacemaker implantation is not indicated for patients who are asymptomatic or whose symptoms are medically controlled. (Level of Evidence: C)
2. Permanent pacemaker implantation is not indicated for symptomatic patients without evidence of LV outflow tract obstruction. (Level of Evidence: C)

Recommendations for Permanent Pacing in Children, Adolescents, and Patients With Congenital Heart Disease

CLASS I

1. Permanent pacemaker implantation is indicated for advanced second- or third-degree AV block associated with symptomatic bradycardia, ventricular dysfunction, or low cardiac output. (Level of Evidence: C)
2. Permanent pacemaker implantation is indicated for SND with correlation of symptoms during age-inappropriate bradycardia. The definition of bradycardia varies with the patient’s age and expected heart rate. (Level of Evidence: B) (Kay, Estioko, & Wiener, 1982; Ector, Rolies, & De Geest, 1983; Beder et al., 1983; Kelly et al., 2001)
3. Permanent pacemaker implantation is indicated for postoperative advanced second- or third-degree AV block that is not expected to resolve or that persists at least 7 days after cardiac surgery. (Level of Evidence: B) (Strasberg et al., 1981; Lillehei et al., 1963)
4. Permanent pacemaker implantation is indicated for congenital third-degree AV block with a wide QRS escape rhythm, complex ventricular ectopy, or ventricular dysfunction. (Level of Evidence: B) (Michaelsson, Jonzon, & Riesenfield , 1995; Moak et al., 2001; Villain et al., 2006)
5. Permanent pacemaker implantation is indicated for congenital third-degree AV block in the infant with a ventricular rate less than 55 bpm or with congenital heart disease and a ventricular rate less than 70 bpm. (Level of Evidence: C) (Pinsky et al., 1982; Jaeggi et al., 2002)

CLASS IIa

1. Permanent pacemaker implantation is reasonable for patients with congenital heart disease and sinus bradycardia for the prevention of recurrent episodes of intra-atrial reentrant tachycardia; SND may be intrinsic or secondary to antiarrhythmic treatment. (Level of Evidence: C) (Silka et al., 1990; Stephenson et al., 2003; Pfammatter et al., 1995)
2. Permanent pacemaker implantation is reasonable for congenital third-degree AV block beyond the first year of life with an average heart rate less than 50 bpm, abrupt pauses in ventricular rate that are 2 or 3 times the basic cycle length, or associated with symptoms due to chronotropic incompetence. (Level of Evidence: B) (Dewey, Capeless, & Levy, 1987; Sholler & Walsh, 1989)
3. Permanent pacemaker implantation is reasonable for sinus bradycardia with complex congenital heart disease with a resting heart rate less than 40 bpm or pauses in ventricular rate longer than 3 seconds. (Level of Evidence: C)
4. Permanent pacemaker implantation is reasonable for patients with congenital heart disease and impaired hemodynamics due to sinus bradycardia or loss of AV synchrony. (Level of Evidence: C) (Cohen et al., 2001)
5. Permanent pacemaker implantation is reasonable for unexplained syncope in the patient with prior congenital heart surgery complicated by transient complete heart block with residual fascicular block after a careful evaluation to exclude other causes of syncope. (Level of Evidence: B) (Villain et al., 2006; Banks, Jenson, & Kugler, 2001; Gross et al., 2006; Villain et al., 2003)

CLASS IIb

1. Permanent pacemaker implantation may be considered for transient postoperative third-degree AV block that reverts to sinus rhythm with residual bifascicular block. (Level of Evidence: C) (Krongrad, 1978)
2. Permanent pacemaker implantation may be considered for congenital third-degree AV block in asymptomatic children or adolescents with an acceptable rate, a narrow QRS complex, and normal ventricular function. (Level of Evidence: B) (Sholler & Walsh, 1989; Michaelsson, Jonzon, & Riesenfield, 1995)
3. Permanent pacemaker implantation may be considered for asymptomatic sinus bradycardia after biventricular repair of congenital heart disease with a resting heart rate less than 40 bpm or pauses in ventricular rate longer than 3 seconds. (Level of Evidence: C)

CLASS III

1. Permanent pacemaker implantation is not indicated for transient postoperative AV block with return of normal AV conduction in the otherwise asymptomatic patient. (Level of Evidence: B) (Weindling et al., 1988; Krongrad, 1978)
2. Permanent pacemaker implantation is not indicated for asymptomatic bifascicular block with or without first-degree AV block after surgery for congenital heart disease in the absence of prior transient complete AV block. (Level of Evidence: C)
3. Permanent pacemaker implantation is not indicated for asymptomatic type I second-degree AV block. (Level of Evidence: C)
4. Permanent pacemaker implantation is not

Interventions and Practices Considered

1. Advice and assistance in smoking cessation
2. Avoidance of second-hand smoke
3. Blood pressure control
   • Lifestyle modification
   • Drug therapy (beta-blockers, thiazides, angiotensin-converting enzyme [ACE] inhibitors)
4. Lipid management
   • Diet therapy
   • Addition of plant sterol/stanol
   • Physical activity and weight management
   • Consumption of omega-3 fatty acids
   • Assessment of fasting lipid profile
   • Lipid-lowering drug therapy
5. Encouragement and counseling on physical activity
6. Weight management
   • Assessment of body mass index and waist circumference
   • Encouragement of weight maintenance/reduction
   • Weight loss therapy
7. Diabetes management
   • Lifestyle and pharmacotherapy
   • Risk factor modification
8. Use of antiplatelet agents (aspirin, clopidogrel) and anticoagulants (warfarin)
9. Use of ACE inhibitors, angiotensin receptor blockers, and aldosterone blockers
10. Use of beta-blockers
11. Influenza vaccination

For a complete guideline, please visit the website.

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.