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Patients with left bundle branch block pattern and high cardiac risk myocardial SPECT: does the current management suffice?

INTRODUCTION: Myocardial perfusion SPECT (MPS) is frequently used for cardiovascular risk stratification. The significance of MPS in patients with abnormal electrical ventricular activation is often questionable. This review assesses the value of MPS for risk stratification of patients with intrinsic left bundle branch block or that due to right ventricular apical pacing.

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

Version: 2013

Electrocardiographic criteria for detecting acute myocardial infarction in patients with left bundle branch block: a meta-analysis

This review evaluated the Sgarbossa electrocardiogram algorithm. The authors concluded that an algorithm score of 3 or more was useful for diagnosing acute myocardial infarction (AMI) and that patients with symptoms suggesting AMI should receive immediate intervention when this score is reached. Methodological limitations in the review and possible over-interpretation of the data suggested that the authors’ conclusions may be overstated.

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

Version: 2008

The Management of Inadvertent Perioperative Hypothermia in Adults [Internet]

Inadvertent perioperative hypothermia is a common but preventable complication of perioperative procedures, which is associated with poor outcomes for patients. Inadvertent perioperative hypothermia should be distinguished from the deliberate induction of hypothermia for medical reasons, which is not covered by this guideline.

NICE Clinical Guidelines - National Collaborating Centre for Nursing and Supportive Care (UK).

Version: April 2008
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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
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Drug Class Review: Beta Adrenergic Blockers: Final Report Update 4 [Internet]

Beta blockers inhibit the chronotropic, inotropic, and vasoconstrictor responses to the catecholamines, epinephrine, and norepinephrine. Beta blockers differ in their duration of effect (3 hours to 22 hours), the types of beta receptors they block (β1-selective or β1/β2-nonselective), whether they are simultaneously capable of exerting low level heart rate increases (intrinsic sympathomimetic activity [ISA]), and in whether they provide additional blood vessel dilation effects by also blocking alpha-1 receptors. All beta blockers are approved for the treatment of hypertension. Other US Food and Drug Administration-approved uses are specific to each beta blocker and include stable and unstable angina, atrial arrhythmias, bleeding esophageal varices, coronary artery disease, asymptomatic and symptomatic heart failure, migraine, and secondary prevention of post-myocardial infarction. The objective of this review was to evaluate the comparative effectiveness and harms of beta blockers in adult patients with hypertension, angina, coronary artery bypass graft, recent myocardial infarction, heart failure, atrial arrhythmia, migraine or bleeding esophageal varices.

Drug Class Reviews - Oregon Health & Science University.

Version: July 2009
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Transient Loss of Consciousness (‘Blackouts’) Management in Adults and Young People [Internet]

There are a number of existing guidelines, for epilepsy, falls and cardiac arrhythmias; which all relate to transient loss of consciousness (TLoC), but there is no guideline which addresses the initial assessment and management of patients who blackout. As such patients may come under the care of a range of clinicians, the lack of a clear pathway contributes to their misdiagnosis, and inappropriate treatment.

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

Version: August 2010
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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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Screening Asymptomatic Adults for Coronary Heart Disease With Resting or Exercise Electrocardiography: Systematic Review to Update the 2004 U.S. Preventive Services Task Force Recommendation [Internet]

Coronary heart disease is the leading cause of death in the United States in adults. Traditional risk factors do not account for all of the excess risk associated with coronary heart disease. Screening for abnormalities with resting or exercise electrocardiography (ECG) could help identify persons at higher risk for coronary heart disease who might benefit from interventions to reduce cardiovascular risk.

Evidence Syntheses - Agency for Healthcare Research and Quality (US).

Version: September 2011
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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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Systematic review of the effectiveness and cost-effectiveness, and economic evaluation, of myocardial perfusion scintigraphy for the diagnosis and management of angina and myocardial infarction

Coronary heart disease (CHD), secondary to coronary artery disease (CAD), is the most common cause of death in the UK, resulting in over 120,000 deaths in 2001. Prevalence, which varies across the UK, increases with age; it is estimated that around 2.65 million people in the UK have CHD. Over 378,000 people received inpatient treatment for CHD in NHS hospitals in 2000-01, representing 5% of all inpatient cases in men and 2% in women.

NIHR Health Technology Assessment programme: Executive Summaries - NIHR Journals Library.

Version: 2004

Systematic Review of ECG-based Signal Analysis Technologies for Evaluating Patients With Acute Coronary Syndrome [Internet]

To summarize the clinical and scientific evidence for commercially available ECG-based signal analysis technologies used or proposed to be used to evaluate patients at low to intermediate risk for coronary artery disease (CAD) who have chest pain or other symptoms suggestive of acute coronary syndrome (ACS).

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

Version: June 2012
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Adjunctive Devices for Patients With Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention [Internet]

This is a Comparative Effectiveness Review examining the benefits to harms of adjunctive devices to remove thrombi or protect against embolization in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) of native vessels.

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

Version: December 2011
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Atrial Fibrillation: The Management of Atrial Fibrillation

Atrial fibrillation (AF) is a very common problem. In England alone, approximately 835,000 people have AF.321 Through its effects on rate and rhythm, it is a major cause of morbidity. Through increasing susceptibility to stroke, it is a major cause of both morbidity and mortality.

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

Version: June 2014
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Depression: The Treatment and Management of Depression in Adults (Updated Edition)

This clinical guideline on depression is an updated edition of the previous guidance (published in 2004). It was commissioned by NICE and developed by the National Collaborating Centre for Mental Health, and sets out clear, evidence- and consensus-based recommendations for healthcare staff on how to treat and manage depression in adults.

NICE Clinical Guidelines - National Collaborating Centre for Mental Health (UK).

Version: 2010
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Eplerenone (Inspra) (25 mg Tablet and 50 mg Tablet): As an Adjunct to Standard Therapy to Reduce the Risk of Cardiovascular Mortality and Hospitalization for Heart Failure in Patients With NYHA Class II Systolic Chronic Heart Failure and Left Ventricular Systolic Dysfunction [Internet]

The objective of this systematic review was to evaluate the beneficial and harmful effects of eplerenone 25 mg to 50 mg daily for the treatment of patients with New York Heart Association (NYHA) class II systolic chronic heart failure (HF) and left ventricular systolic dysfunction.

Common Drug Review - Canadian Agency for Drugs and Technologies in Health.

Version: October 2014
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Heavy Menstrual Bleeding

Heavy menstrual bleeding (HMB) has an adverse effect on the quality of life of many women. It is not a problem associated with significant mortality. Many women seek help from their general practitioners and it is a common reason for referral into secondary care.

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

Version: January 2007
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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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Systematic review, meta-analysis and economic modelling of diagnostic strategies for suspected acute coronary syndrome

Study found that hospital admission for 10-hour troponin testing to diagnose myocardial infarction was unlikely to be cost-effective compared with high-sensitivity troponin testing at presentation, unless rapid decision-making and discharge was possible. There was insufficient evidence to support the routine use of alternative biomarkers alongside troponin or routine investigation with exercise ECG or CTCA in troponin-negative patients.

Health Technology Assessment - NIHR Journals Library.

Version: January 2013
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Transitional Care Interventions To Prevent Readmissions for People With Heart Failure [Internet]

To conduct a systematic review and meta-analysis of the efficacy, comparative effectiveness, and harms of transitional care interventions that aim to reduce readmissions and mortality for adults hospitalized with heart failure (HF). We also sought to describe the components of interventions that showed efficacy.

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

Version: May 2014
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Drug Class Review: Direct Renin Inhibitors, Angiotensin Converting Enzyme Inhibitors, and Angiotensin II Receptor Blockers: Final Report [Internet]

The renin-angiotensin system is a complex biologic system between the heart, brain, blood vessels, and kidneys that leads to the production of biologically active agents, including angiotensin I and II and aldosterone, which act together to impact a variety of bodily functions including blood vessel tone, sodium balance, and glomerular filtration pressure. The multiple and varied effects of these agents allows the renin-angiotensin system to play a wide role in the pathology of hypertension, cardiovascular health, and renal function. Our ability to begin to intervene upon the complex cycle of hormone and other biochemical agent production within the renin-angiotensin system began with the advent of the first orally active ACE-I (angiotensin converting enzyme inhibitor), captopril, in 1981. AIIRAs (angiotensin II receptor blockers) were developed as an alternative to ACE-I, and block the interaction between angiotensin II and the angiotensin receptor. Losartan, the first commercially available AIIRA, was approved for clinical use in 1995. The goal of this report is to compare the effectiveness and harms between aliskiren and placebo and between AIIRAs and ACEIs in the treatment of diagnosed coronary heart disease, hypertension, left ventricular dysfunction, heart failure, nondiabetic chronic kidney disease, or diabetic nephropathy.

Drug Class Reviews - Oregon Health & Science University.

Version: January 2010
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