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Implantable cardioverter defibrillators for the treatment of arrhythmias and cardiac resynchronisation therapy for the treatment of heart failure: systematic review and economic evaluation

Study found that implantable cardiac defibrillators reduced all-cause mortality in people at increased risk of sudden cardiac death as a result of previous ventricular arrhythmias or cardiac arrest, remote myocardial infarction or ischaemic/non-ischaemic heart failure and LVEF ≤ 35%. Cardiac resynchronisation therapy reduced all-cause mortality and improved other outcomes in people with heart failure as a result of left ventricular systolic dysfunction and cardiac dyssynchrony when compared with optimal pharmacological therapy. The devices were cost-effective at a willingness-to-pay threshold of £30,000 when compared with optimal pharmacological therapy.

Health Technology Assessment - NIHR Journals Library.

Version: August 2014
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Catheter ablation would be an alternative to inhibit recurrence of paroxysmal or persistent atrial fibrillation

Atrial fibrillation is a common arrhythmic disease where the heart beats rapidly and irregularly. This can occur for separate brief or long episodes (paroxysmal) or it may become continuous (persistent). This review's aim was to establish whether catheter ablation was better than medical therapies to control heart rate or rhythm for paroxysmal and persistent AF. If catheter ablations were found to be better, the aim was to determine which ablation method was superior to the other. In catheter ablation, a thin tube is passed through a vein to the heart through which instruments can target the misfiring parts of the tissue that control the hearts rhythm. A total of thirty two randomised controlled trials (RCTs) were included in this review. Catheter ablation may be superior to medical treatment but the data is inconclusive in inhibiting recurrence of AF. Embolic complications were commonly caused by catheter ablation. Although these complications and death rate of catheter ablation were similar to that of medical therapies, catheter ablation may cause adverse events of radiation exploration. We were also unable to determine which catheter ablation technique was the best as most RCTs were small scale. Evidence from RCTs cannot yet support catheter ablation as the first line of treatment for paroxysmal and persistent AF.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2012

Thioridazine for schizophrenia

About 1% of people will get schizophrenia and it often begins early in life. Schizophrenia is typically characterised by hallucinations (perceptions without a cause), delusions (fixed and false beliefs), disordered thinking, and emotional withdrawal. The outcomes vary, but antipsychotic drugs generally help; thioridazine is one such drug. It had been thought to be effective and less prone to cause the movement disorders that can happen particularly with the older generation antipsychotics. Largely thioridazine has been withdrawn due to its links with abnormal heart rhythm but is still used in special circumstances.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2011

Monitoring for Atrial Fibrillation in Discharged Stroke and Transient Ischemic Attack Patients: A Clinical and Cost-Effectiveness Analysis and Review of Patient Preferences [Internet]

The aim of this health technology assessment (HTA) is to inform decision-making about the appropriate use of outpatient atrial fibrillation (AF) monitoring in patients who have experienced a stroke and/or transient ischemic attacks (TIA) . Policy issues such as determining the most appropriate device or sequence of devices for AF monitoring, identifying and selecting the appropriate patient population for ambulatory monitoring, and decisions on anticoagulant therapy initiation based on ambulatory monitoring results are in need of evidence-based support. This HTA will address these issues by evaluating the clinical effectiveness, and cost-effectiveness of AF ambulatory monitoring devices in outpatient stroke and/or TIA patients. This HTA will also identify patient perspectives regarding the value and impact of outpatient cardiac monitoring devices for AF monitoring on their health, health care, and quality of life.

CADTH Optimal Use Report - Canadian Agency for Drugs and Technologies in Health.

Version: September 2015

Systematic Review of Decision Tools and Their Suitability for Patient-Centered Decisionmaking Regarding Electronic Cardiac Devices [Internet]

1) Identify validated decision aids available for insertion, continuation, or deactivation of electronic cardiac devices (ECDs); 2) Review evidence on the effectiveness of decision aids for promoting informed decisionmaking and their relevance to the Medicare population; 3) Identify barriers to use of decision aids.

Technology Assessment Report - Agency for Healthcare Research and Quality (US).

Version: May 23, 2012
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Systematic review and modelling of the cost-effectiveness of cardiac magnetic resonance imaging compared with current existing testing pathways in ischaemic cardiomyopathy

Study found that late gadolinium-enhanced cardiac magnetic resonance imaging, stress echocardiography, single photon emission computed tomography and positron emission tomography were all cost-effective strategies to test patients prior to revscularisation of patients with ischaemic cardiomyopathy. However, the cost-effectiveness analyses suggested that late gadolinium-enhanced cardiac magnetic resonance imaging and revascularising everyone without prior screening were the optimal strategies.

Health Technology Assessment - NIHR Journals Library.

Version: September 2014

MI - Secondary Prevention: Secondary Prevention in Primary and Secondary Care for Patients Following a Myocardial Infarction: Partial Update of NICE CG48 [Internet]

Myocardial infarction (MI) remains one of the most dramatic presentations of coronary artery disease (CAD). Complete occlusion of the artery often produces myocardial necrosis and the classical picture of a heart attack with severe chest pain, electrocardiographic (ECG) changes of ST-segment elevation, and an elevated concentration of myocardial specific proteins in the circulation. Such people are described as having a ST-segment elevation myocardial infarction (STEMI). Intermittent or partial occlusion produces similar, but often less severe clinical features, although no or transient and undetected ST elevation. Such cases are described as a non-ST segment elevation myocardial infarction (NSTEMI). People who have suffered from either of these conditions are amenable to treatment to reduce the risk of further MI or other manifestations of vascular disease, secondary prevention.

NICE Clinical Guidelines - National Clinical Guideline Centre (UK).

Version: November 2013
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Chest Pain of Recent Onset: Assessment and Diagnosis of Recent Onset Chest Pain or Discomfort of Suspected Cardiac Origin [Internet]

Chest pain or discomfort caused by acute coronary syndromes (ACS) or angina has a potentially poor prognosis, emphasising the importance of prompt and accurate diagnosis. Treatments are available to improve symptoms and prolong life, hence the need for this guideline.

NICE Clinical Guidelines - National Clinical Guideline Centre for Acute and Chronic Conditions (UK).

Version: March 2010
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Use of Cardiac Resynchronization Therapy in the Medicare Population [Internet]

To assess the benefits and harms of cardiac resynchronization with (CRT-D) and compared to an ICD alone, CRT without a defibrillator (CRT-P) compared with optimal medical therapy and CRT-D compared with CRT-P in patients with an EF ≤35% and a QRS duration ≥120 ms. We also sought to assess predictors of response to CRT-D and CRT-P.

Technology Assessment Report - Agency for Healthcare Research and Quality (US).

Version: March 24, 2015

Assessment on Implantable Defibrillators and the Evidence for Primary Prevention of Sudden Cardiac Death [Internet]

Implantable cardioverter–defibrillators (ICDs) are battery-powered implantable devices that monitor heart rhythm and deliver therapy in the form of either electric shock or antitachycardia pacing (ATP) when a life-threatening ventricular arrhythmia is detected. ICDs have been used in patients who survived sustained ventricular arrhythmias to prevent sudden cardiac death (SCD). In recent years, ICDs have also been implanted for primary prevention (prevention of SCD in a patient who has not had yet had sustained ventricular tachyarrhythmia but has risk factors for it). ICDs may also include cardiac resynchronization therapy (CRT) for additional treatment of heart failure in patients with dyssynchronous ventricles.

Technology Assessment Report - Agency for Healthcare Research and Quality (US).

Version: June 26, 2013
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Myocardial Infarction with ST-Segment Elevation: The Acute Management of Myocardial Infarction with ST-Segment Elevation [Internet]

When myocardial blood flow is acutely impaired (ischaemia), and often not provoked by exertion, a person will commonly suffer more prolonged pain; this is referred to as acute coronary syndrome (ACS). The underlying common pathophysiology of ACS involves the erosion or sudden rupture of an atherosclerotic plaque within the wall of a coronary artery. Exposure of the circulating blood to the cholesterol-rich material within the plaque stimulates blood clotting (thrombosis), which obstructs blood flow within the affected coronary artery. This coronary obstruction may be of short duration, and may not result in myocardial cell damage (necrosis), in which case the clinical syndrome is termed unstable angina. Unstable angina may result in reversible changes on the electrocardiogram (ECG) but does not cause a rise in troponin, a protein released by infarcting myocardial cells. Ischaemia which causes myocardial necrosis (infarction) will result in elevated troponin. When the ischaemia-causing infarction is either short-lived or affects only a small territory of myocardium the ECG will often show either no abnormality or subtle changes. This syndrome is termed non-ST-segment elevation myocardial infarction (NSTEMI). The diagnosis and immediate management of STEMI and the management of unstable angina and NSTEMI is addressed in other NICE Clinical Guidelines (CG95 and CG94).

NICE Clinical Guidelines - National Clinical Guideline Centre (UK).

Version: July 2013
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Venous Thromboembolism: Reducing the Risk of Venous Thromboembolism (Deep Vein Thrombosis and Pulmonary Embolism) in Patients Admitted to Hospital

Venous thromboembolism (VTE) is a term used to include the formation of a blood clot (a thrombus) in a vein which may dislodge from its site of origin to travel in the blood, a phenomenon called embolism. A thrombus most commonly occurs in the deep veins of the legs; this is called deep vein thrombosis. A dislodged thrombus that travels to the lungs is known as a pulmonary embolism.

NICE Clinical Guidelines - National Clinical Guideline Centre – Acute and Chronic Conditions (UK).

Version: 2010
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Stable Angina: Methods, Evidence & Guidance [Internet]

Angina is pain or constricting discomfort that typically occurs in the front of the chest (but may radiate to the neck, shoulders, jaw or arms) and is brought on by physical exertion or emotional stress. It is the main symptomatic manifestation of myocardial ischaemia and is usually caused by obstructive coronary artery disease restricting oxygen delivery to the cardiac myocytes. Other factors may exacerbate angina either by further restricting oxygen delivery (for example severe anaemia) or by increasing oxygen demand (for example left ventricular hypertrophy). Angina symptoms are associated with other cardiac disease such as aortic stenosis but the management of angina associated with non-coronary artery disease is outside the scope of this guideline.

NICE Clinical Guidelines - National Clinical Guidelines Centre (UK).

Version: July 2011
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Cardiac Troponins Used as Diagnostic and Prognostic Tests in Patients With Kidney Disease [Internet]

To systematically review the literature on the use of cardiac troponin levels in patients with chronic kidney disease (CKD) regarding four Key Questions (KQ): (1) diagnosis of acute coronary syndrome (ACS), (2) management decisions for ACS, (3) prognosis after presenting with ACS, and (4) risk stratification in patients without symptoms of ACS.

Comparative Effectiveness Review - Agency for Healthcare Research and Quality (US).

Version: August 2014
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High-Sensitivity Cardiac Troponin for the Rapid Diagnosis of Acute Coronary Syndrome in the Emergency Department: A Clinical and Cost-Effectiveness Evaluation [Internet]

The objective of this review is to evaluate the clinical and cost-effectiveness of high-sensitivity cardiac troponin T (hs-cTnT) and high-sensitivity cardiac troponin I (hs-cTnI) for the early diagnosis of acute coronary syndrome (ACS) in the emergency department (ED).

CADTH Optimal Use Report - Canadian Agency for Drugs and Technologies in Health.

Version: March 2013

Optimizing Health System Use of Medical Isotopes and Other Imaging Modalities [Internet]

The purpose of this project was to provide national guidance on the optimal use of 99mTc during a situation of reduced supply. To accomplish this, our objective at CADTH was:

Optimal Use Report - Canadian Agency for Drugs and Technologies in Health.

Version: 2012

Unstable Angina and NSTEMI: The Early Management of Unstable Angina and Non-ST-Segment-Elevation Myocardial Infarction

The development of cholesterol-rich plaque within the walls of coronary arteries (atherosclerosis) is the pathological process which underlies ‘coronary artery disease’. However, the clinical manifestations of this generic condition are varied. When the atherosclerotic process advances insidiously the lumen of a coronary artery becomes progressively narrowed blood supply to the myocardium is compromised (ischaemia) and the affected individual will often develop predictable exertional chest discomfort, or ‘stable’ angina. However, at any stage in the development of atherosclerosis, and often when the coronary artery lumen is narrowed only slightly or not at all, an unstable plaque may develop a tear of its inner lining cell layer (intima), exposing the underlying cholesterol rich atheroma within the vessel wall to the blood flowing in the lumen. This exposure stimulates platelet aggregation and subsequent clot (thrombus) formation.

NICE Clinical Guidelines - National Clinical Guideline Centre (UK).

Version: 2010

Antenatal Care: Routine Care for the Healthy Pregnant Woman

The original antenatal care guideline was published by NICE in 2003. Since then a number of important pieces of evidence have become available, particularly concerning gestational diabetes, haemoglobinopathy and ultrasound, so that the update was initiated. This update has also provided an opportunity to look at a number of aspects of antenatal care: the development of a method to assess women for whom additional care is necessary (the ‘antenatal assessment tool’), information giving to women, lifestyle (vitamin D supplementation, alcohol consumption), screening for the baby (use of ultrasound for gestational age assessment and screening for fetal abnormalities, methods for determining normal fetal growth, placenta praevia), and screening for the mother (haemoglobinopathy screening, gestational diabetes, pre-eclampsia and preterm labour, chlamydia).

NICE Clinical Guidelines - National Collaborating Centre for Women's and Children's Health (UK).

Version: March 2008
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Prophylactic amiodarone for prevention of atrial fibrillation after cardiac surgery: a meta-analysis

This review evaluated the effects of amiodarone in post-operative atrial fibrillation. It concluded that amiodarone prophylaxis is associated with a significant reduction in atrial fibrillation after cardiac surgery, as well as a reduction in peri-operative ventricular tachyarrhythmias and strokes and a short but significant reduction in hospital stay. The authors' conclusions reflect the evidence presented and are likely to be reliable.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2006

Nocturnal Enuresis: The Management of Bedwetting in Children and Young People

This guideline aims to provide advice on the assessment and management of children and young people with bedwetting. The guidance is applicable to children and young people up to 19 years with the symptom of bedwetting. It has been common practice to define enuresis as abnormal from 5 years and only to consider children for treatment when they are 7 years. While the prevalence of symptoms decreases with age the guideline scope did not specify a younger age limit in order to consider whether there were useful interventions that might be of benefit to children previously excluded from advice and services.

NICE Clinical Guidelines - National Clinical Guideline Centre (UK).

Version: 2010
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