Top Clinical Issues Eltanya A. Patterson, MD. Heart Failure Guidelines Eltanya A. Patterson, MD.
-
Upload
egbert-lawson -
Category
Documents
-
view
213 -
download
0
Transcript of Top Clinical Issues Eltanya A. Patterson, MD. Heart Failure Guidelines Eltanya A. Patterson, MD.
Top Clinical Issues
Eltanya A. Patterson, MD
Heart Failure Guidelines
Eltanya A. Patterson, MD
Definition
0Complex clinical syndrome0Any structural or functional impairment of ventricular
filling or ejection of blood0Cardinal s/sx
0 Dyspnea and fatigue0 Fluid retention0 Pts may c/o exercise intolerance with little fluid
retention.0 Others may c/o the peripheral edema, SOB, or fatigue
Etiology
0The clinical syndrome of HF may result from0 disorders of the pericardium, myocardium,
endocardium, heart valves, or great vessels, 0 or from certain metabolic abnormalities, 0 but most patients with HF have symptoms due to
impaired left ventricular (LV) myocardial function.
Definition
0 Some patients present without s/sx of fluid overload, therefore, the term “HEART FAILURE” is preferred over “CONGESTIVE HEART FAILURE.”
0 No single diagnostic test for HF.0 HF is largely a clinical diagnosis based on a careful history
and physical examination. 0 **HF is not synonymous with either cardiomyopathy or LV
dysfunction; these latter terms describe possible structural or functional reasons for the development of HF.
0 is preferable to use the terms preserved or reduced EF over preserved or reduced systolic function.
New Terminology
0 HFrEF = Heart Failure with reduced Ejection Fraction0 HFpEF = Heart Failure with preserved Ejection Fraction
0 Most pts with HF with have systolic and diastolic.0 Reasons why EF is important
0 Demographics0 Comorbidities0 Prognosis0 Response to therapies0 **Most clinical trials selected pts based on EF
Definition: Redefining HF
Classification EF Description
HFrEF ≤ 40% Synonymous with systolic HF. Demonstrated efficacious therapy.
HFpEF ≥ 50% Synonymous with diastolic HF. No efficacious therapy.
HFpEF, borderline 41-49% Intermediate/borderline group. Characteristics, treatment, and outcome similar to HFpEF.
HFpEF, improved > 40% Pertains to subset of pts who were prev HFrEF. These pts have recovered their EF. Further studies needed.
ACCF/AHA Stages of HF Stage Description
A At high risk for HF but without structural heart None disease or symptoms of HF
B Structural heart disease but without signs or symptoms of HF
C Structural heart disease with prior or current symptoms of HF
D Refractory HF requiring specialized interventions
NYHA Functional Classification
Classification Description
I No limitation of physical activity. Ordinary physical activity does not cause symptoms of HF.
II Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF.
III Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF.
IV Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest.
020% lifetime risk for Americans ≥ 40 yo.0 Incidence stable over last several decades.
0 >650,000 new diagnoses yearly0Prevalence: ~5.1 million.01 in 5 will be >65 yo by 2050.
0 Highest HF prevalence.
Epidemiology
0Blacks - highest risk for HF. 0White women – lowest incidence.0Black men – highest incidence.05-year mortality rate – blacks > whites.0Prevalence:
0 Non-Hispanic black males - 4.5%0 Non-Hispanic females – 3.8%0 Non-Hispanic white males - 2.7% 0 Non-Hispanic white females - 1.8%
Disparities Identified
0 Initial laboratory evaluation 0 CBC, CMP, Magnesium, FLP, TSH, urinalysis. (C)
0Serial monitoring0 Serum electrolytes and renal function. (C)
0 Initial 12-lead electrocardiogram. (C)
Diagnostic Tests: Class I
0Screening:0 Hemochromatosis or HIV - reasonable in selected
patients. (C)0Other tests:
0 Rheumatologic diseases.0 Amyloidosis.0 Pheochromocytoma.0 Reasonable if clinical suspicion. (C)
Diagnostic Tests: Class IIa
0Ambulatory patients with dyspnea, it is useful to measure B-type natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NT-proBNP). It supports clinical decision. Especially if uncertain.(A)
0Measure BNP or NT-proBNP to establish prognosis or disease severity in chronic HF. (A)
Outpatient Biomarkers: Class I
0Well-structured HF disease management program: BNP- or NT-proBNP−guided HF therapy can be useful to achieve optimal dosing of GDMT in select clinically euvolemic patients. (B)
Outpatient Biomarkers: Class IIa
0Serial BNP:0 Usefulness in reducing hospitalization or mortality is
not well established. (B)
0Other clinically available tests 0 Biomarkers of myocardial injury or fibrosis - additive for
risk stratification in chronic HF. (B)
Outpatient Biomarkers: Class IIb
0Measurement of BNP or NT-proBNP0 Useful to support clinical judgment for the diagnosis of
acutely decompensated HF. (A)0Measurement of BNP or NT-proBNP and/or cardiac
troponin0 Useful for establishing prognosis or disease severity in
acutely decompensated HF. (A)
Hospitalized/Acute: Class I
0Usefulness of BNP- or NT-proBNP−guided therapy for acutely decompensated HF is not well established. (C)
Hospitalized/Acute: Class IIb
0Patients with suspected or new-onset HF, or those presenting with acute decompensated HF, should undergo 0 CXR - to assess heart size and pulmonary congestion and
to detect alternative cardiac, pulmonary, and other diseases that may cause or contribute to the patient’s symptoms. (C)
02D echocardiogram with Doppler 0 Initial evaluation to assess ventricular function, size,
wall thickness, wall motion, and valve function. (C)
Noninvasive Cardiac Imaging: Class I
0Repeat measurement of EF and severity of structural remodeling is useful when:0 There’s significant change in clinical status; 0 In those who have experienced or recovered from a
clinical event; 0 In those who have received treatment that might have
had a significant effect on cardiac function0 Those who may be candidates for device therapy0 (Level of Evidence: C)
Noninvasive Cardiac Imaging: Class I
0Routine repeat measurement of LV function in pt w/o a change in clinical status or treatment interventions should not be performed. (B)
Noninvasive Cardiac Imaging: Class IIINo Benefit
0Treat Hypertension and Hyperlipidemia, according to guidelines, to lower the risk of HF. (A)
0Control or avoid other conditions that may lead to or contribute to HF0 Obesity0 Diabetes mellitus0 Tobacco use0 Known cardiotoxic agents0 (Level of Evidence: C)
Treatment of Stage A to D: Recommendations: Stage A Class I
0 Recent or remote h/o MI or ACS and reduced EF = ACEI. (A)
0 ACEI prevent symptomatic HF and reduce mortality.0 If intolerant to ACEIs ARBs. (A)0 Beta blockers to reduce mortality. (B)0 In recent or remote history of MI or ACS statins to
prevent symptomatic HF and cardiovascular events. (A)0 ACE inhibitors in all patients with a reduced EF to
prevent symptomatic HF, regardless of history of MI. (A)
Treatment of Stage A to D: Recommendations: Stage B Class I
0Beta blockers in all patients with a reduced EF to prevent symptomatic HF, even if no history of MI. (C)
Treatment of Stage A to D: Recommendations: Stage B Class I
0Placement of an implantable cardioverter-defibrillator (ICD)0 To prevent sudden death0 Is reasonable in patients with
0asymptomatic ischemic cardiomyopathy 0who are at least 40 days post-MI, 0have an LVEF of 30% or less, 0are on appropriate medical therapy, 0and have reasonable expectation of survival 0with a good functional status for more than 1 year.
0 (Level of Evidence: B)
Treatment of Stage A to D: Recommendations: Stage B Class IIa
0Nondihydropyridine calcium channel blockers with negative inotropic effects may be harmful in asymptomatic patients with low LVEF and no symptoms of HF after MI. (Level of Evidence: C)
Treatment of Stage A to D: Recommendations: Stage B Class III Harm
Oral Anticoagulants
Anticoagulants
0Heparins0Vitamin K Antagonists0Fondaparinux0Direct Thrombin Inhibitors (DTI)0Direct Factor Xa Inhibitors (DFXaI)
Thrombin
0Final enzyme in clotting cascade that produces fibrin.0Activates other procoagulant factors.0Active in both circulating and clot-bound forms.0DTI block action of both forms of thrombin.0Heparins only inactivate thrombin in fluid phase via
antithrombin
Factor Xa
0Acts at convergence point of intrinsic and extrinsic coagulation pathway.
0One molecule of factor 10a can cleave over 1000 molecules of prothrombin to thrombin.
0Active in circulating and clot-bound forms.0DXa inhibitors block the action in both forms.0 Indirect Factor Xa inhibitors (heparin and
fondaparinux) only able to inactivate Xa in the fluid phase.
Anticoagulant Terminology
0Anithrombotic Agent0 Antiplatelet0 anticoagulant
0Antiplatelet0 ASA0 Clopidogrel
0Anticoagulant 0 DTI0 DFXaI
Anticoagulant Terminology
0Other Acronyms0TSOACs0DOACs0ODI0NOACs0Newer0Nonvitamin K antagonists
Comparison
0Anticoagulants differ in efficacy depending on clinical setting.
0There are differences in dosing, monitoring, cost, and risk.
0Advantages and disadvantages of each agent must be individualized.
ComparisonCoumadin TSOACs
Dose Once daily Once or twice daily
Diet Vitamin K foods Rivaroxaban: take with food
Monitor - Therapy PT/INR plus None required
Drug Interactions Numerous Rivaroxaban – CYP-3A4 and P-glycoprotein inh
Therapeutic Time
Reversal Agents Vitamin K, FFP, PCC, rFVIIa
None. PCC for life-threatening bleeding
Monitor - Reversal PT/INR TT – dabigatranAnti-factor Xa - apixaban
Comorbid Conditions Renal functions affects phrmacokineticsUnclear dosing for those with obesity
Contraindications
0Pregnancy0Prosthetic Heart Valve0Renal Impairment0Compliance0GI Disease
Indications
0DVT prophylaxis and treatment0Afib0Unstable angina0MI0Coronary Stenting0Heparin –Induced Thrombocytopenia
Bleeding
0Warfarin - Vitamin K0Dabigatran – Clotting factor products, i.e. FFP0Rivaroxaban - Clotting factor products, i.e. FFP0Apixaban - Clotting factor products, i.e. FFP
Surgery/Invasive Procedure
0Warfarin - Stopped 5 days before surgery0Dabigatran – Stopped 2-3 days before surgery0Rivaroxaban - Stopped 2-3 days before surgery0Apixaban - Stopped 2-3 days before surgery
Dabigatran – Overview
0Orally administered prodrug. Converted in the liver.0Active DTI0 Inhibits clot-bound and circulating thrombin0T1/2 ~12 to 17 hours0Max anticoag effect @ 2-3 hrs of ingestion0Renal excretion. Not used if CrCl <150 **Capsules in original bottle only!!!0Used within 4 months.
Dabigatran - Indicator
0DVT prophylaxis and treatment.0Stroke prevention in Afib0PE
Dabigatran vs Coumadin
0Meta-analyses an dlarge observational studies0Overall bleeding rates are similar0Dabigatran may be assoc’d with a slightly lower rate
of ICH and death0Dabigatran may be assoc’d with a slightly higher rate
of GIB0Lacks a specific antidote0Dyspepsia – common SE
Rivaroxaban - Overview
0 DFXaI0 T1/2 ~7 to 17 hours0 Indicator: DVT prophylaxis and treatment and stroke
prevention in Afib.0 Contraindicated in pregnancy, prosthetic heart valve0 Taken with food0 Not recommended for use in CrCl <30. Not used if CrCl <15
or significant hepatic impairment (Child-Pugh Class B and C with coagulopathy)
0 Rivaroxaban interacts with CYP-3A4 and P-glycoprotein inh0 Drug levels are relatively predictable
Apixaban - Overview
0DFXaI0T1/2 ~5 to 9 hours0 Indicator: DVT prophylaxis and treatment and stroke
prevention in Afib.0Contraindicated in pregnancy or those with prosthetic
heart valve0Drug levels are relatively predictable
CYP-3A4 and P-glycoprotein inh
0Ketoconazole0 Itraconazole0Voriconazole0Posaconazole0Ritonavir
2013 ACC/AHA Blood Cholesterol Guideline
Purpose
0The American College of Cardiology (ACC) and the American Heart Association (AHA) have collaborated with the National Heart, Lung, and Blood Institute (NHLBI) and stakeholder and professional organizations to:0 to provide a strong evidence-based foundation for the
treatment of cholesterol 0 for the primary and secondary prevention of ASCVD in
women and men.
ASCVD
0Atherosclerotic cardiovascular disease 0ASCVD includes
0 coronary heart disease (CHD)0 stroke0 peripheral arterial disease
The Research
0 Based on the highest quality evidence available. 0 Expert panel did not consider evidence beyond 2011. 0 Recommendations were derived from randomized trials,
meta-analyses, and observational studies evaluated for quality.
0 A limited number of expert opinion recommendations were made only when RCT evidence was not present and after a thorough consideration of what the Expert Panel had learned from the RCTs.
0 Plan to begin updating these guidelines starting in 2014.
Lipid Lowering Strategies
0Strategies for using drug therapy 0 Treat-to-cholesterol target0 Lower cholesterol is better0 Risk-based treatment approaches.
0Only 1 approach evaluated in multiple RCTs0 Using fixed doses of cholesterol-lowering drugs to
reduce the ASCVD risk. 0Bulk of evidence from statin trials0Expert Panel focused on statin RCTs to develop the
evidence-based guidelines
RCTs
0Either compared fixed doses of statins with placebo or untreated controls,
0Or compared fixed doses of higher-intensity statins with moderate-intensity statins.
0The trials were not designed to evaluate the effect of titrated (dose-adjusted) statin treatment to achieve a specific LDL–C or non-HDL–C.
RCTs
0No RCT evidence to support titrating cholesterol- lowering drug therapy to achieve target LDL–C or non-HDL-C levels (as recommended by ATP III).
0No RCT evidence that use of therapy (e.g., niacin) to additionally lower non-HDL–C, once an LDL–C target was achieved, further reduce ASCVD.
0Extensive RCT evidence that the appropriate intensity of statin therapy should be used to reduce ASCVD risk in those most likely to benefit.
0The difficulty of giving up the treat-to-goal paradigm was deliberated extensively over a 3-year period.
Example
0FH with LDL–C >190 mg/dL.0 Individuals with FH are unable to achieve an LDL–C
goal <100 mg/dL. 0They may only achieve an LDL–C of 120 mg/dL despite
use of 3 cholesterol-lowering drugs. 0Did this patient fall short of the 100 mg/dL goal?0No, they have decreased their LDL–C by >50%.0May have started from an untreated LDL–C level of
~325-400 mg/dL. 0Not treatment failures.
Age
0A person aged 70 years without other risk factors will receive statin treatment on the basis of age alone.
0The estimated 10-year risk is still ≥7.5%, a risk threshold for which a reduction in ASCVD risk events has been demonstrated in RCTs.
0Most ASCVD events occur after age 70 years, giving individuals >70 years of age the greatest potential for absolute risk reduction.
Lifestyle Modification
0Emphasized 0Adhering to a heart healthy diet0Regular exercise0Avoidance of tobacco products0Maintenance of a healthy weight0Critical component of health promotion and ASCVD
risk reduction0Before and with the use of cholesterol- lowering drug
therapy
Statin Therapy
Statins
03 types of statin therapy0 High-intensity0 Moderate-intensity0 Lower-intensity
0Designations were developed from RCTs0 Evidence: The relative reduction in ASCVD risk is related
to the degree LDL-C is lowered.0High-intensity > Moderate-intensity > lower-intensity
Comparison of Statin Intensity
0 Bold statins and doses = Evaluated in RCTs.0 Italic statins and doses = Approved by FDA, not tested in RCTs that were reviewed.
High-Intensity Moderate-Intensity Lower-Intensity
Lowering of LDL-C
≥ 50% 30% to <50% <30%
Statins Atorvastatin 40-80mgRosuvastatin 20 (40) mg
Atorvastatin 10 (20) mgRosuvastatin (5) 10mgSimvastatin 20-40mgPravastatin 40 (80) mgLovastatin 40mgFluvastatin XL 80mgFluvastatin 40mg bidPitavastatin 2-4mg
Simvastatin 10mgPravastatin 10-20mgLovastatin 20mgFluvastatin 20-40mg Pitavastatin 1mg
Primary Prevention
0Adult ≥21 yo with LDL-C ≥190mg/dL0 High lifetime risk for ASCVD events0 Initiate High-intensity statin0 Goal: to achieve at least 50% reduction0 May require nonstatin cholesterol-lowering medication
also.0 Consider screening family members0 Screen for secondary causes
Secondary CausesElev LDL-C Elev TG
Diet Fats (saturated or trans), weight gain, anorexia
Excessive alcohol intake, high amt of refined carbs, very low fat diets, weight gain
Drugs Diuretics, cyclosporine, glucocorticoids, amiodarone
Oral estrogens, glucocorticoids, bile acid sequestrants, protease inhibitors, retinoic acid, anabolic steroids, sirolimus, raloxifene, tamoxifen, BB (not carvedilol), thiazides
Diseases Biliary obstruction, nephrotic syndrome, hypothyroidism, obesity, pregnancy
Nephrotic syndrome, CRF, lipodystrophies, DM (uncontrolled) hypothyroidism, obesity, pregnancy
Primary Prevention
040-75yo with DM and LDL-C 70-189mg/dL0 Moderate-intensity statin is indicated. (A/Strong)0 High-intensity statin is reasonable if 10-yr ASCVD risk
≥7.5% - unless contraindicated. (E)0<40 or >75yo with DM and LDL-C 70-189mg/dL
0 Individualize therapy0 Evaluate for ASCVD benefits0 Evaluate for AE0 Discuss with patient0 (E)
Primary Prevention
040-75yo without DM and LDL-C 70-189mg/dL0 Statin initiation is based on 10-yr ASCVD risk (E)0 If risk ≥7.5% moderate to high-intensity statin (A)0 If risk is 5% - <7.5% moderate-intensity is reasonable
(C/Weak)
Secondary Prevention
0≤ 75yo with clinical ASCVD High-intensity (A/Strong)0 If already on statin at a lower intensity, increase the
intensity.0 Consider:
0History of intolerance0Drug-drug interactions0Patient preference
0>75yo with clinical ASCVD Moderate-intensity (E)
** Note **
0No recommendation for or against specific LDL-C or non-HDL-C targets, irregardless of primary or secondary prevention.
HF and HD
0No recommendation made in regards to initiating or discontinuing statin therapy in those individuals with NYHA class II-IV ischemic systolic HF or patients currently on HD
Risk Assessment
0For identification of candidates for statin therapy0http://my.americanheart.org/cvriskcalculator0http://www.cardiosource.org/science-and-quality/pr
actice-guidelines-and-quality-standards/2013-prevention-guideline-tools.aspx
0App from iTunes or Google Play or launch from website
0Age, gender, race, HDL, TC, SBP, HTN/DM/Smoker
Statin Maintenance
0 If predisposed to AE, initiate therapy with the nextv lower intensity level. (A)
0To avoid unnecessary discontinuation of statins, obtain a history of prior or current muscle symptoms to establish a baseline before initiating statin therapy. (E)
0 If unexplained severe muscle symptoms or fatigue develop during statin therapy, promptly discontinue the statin and address the possibility of rhabdomyolysis by evaluating CK, creatinine, and a urinalysis for myoglobinuria. (E)
Statin Maintenance0 If mild to moderate muscle symptoms develop during statin therapy:
0– Discontinue the statin until the symptoms can be evaluated.
0– Evaluate the patient for other conditions that might increase the risk for muscle symptoms
0 If muscle symptoms resolve, and if no contraindication exists, give the patient the original or a lower dose of the same statin to establish a causal relationship between the muscle symptoms and statin therapy.
0– If a causal relationship exists, discontinue the original statin. Once muscle symptoms resolve, use a low dose of a different statin.
0– Once a low dose of a statin is tolerated, gradually increase the dose as tolerated.
0– If persistent muscle symptoms are determined to arise from a condition unrelated to statin therapy, or if the predisposing condition has been treated, resume statin therapy at the original dose. (E)
Predisposing Characteristics
0Multiple or serious comorbidities, including impaired renal or hepatic function.
0History of previous statin intolerance or muscle disorders.
0Unexplained ALT elevations >3 times ULN. 0Patient characteristics or concomitant use of 0drugs affecting statin metabolism. 0>75 years of age. 0History of hemorrhagic stroke. 0Asian ancestry.
4 Major Statin Groups
0 Individuals with clinical ASCVD0 Individuals with primary elevations of LDL–C >190
mg/dL0 Individuals with diabetes aged 40 to 75 years with
LDL– C 70 to189 mg/dL and without clinical ASCVD 0 Individuals without clinical ASCVD or diabetes with
LDL–C 70 to189 mg/dL and estimated 10-year ASCVD risk >7.5%
Labwork - Initiation
0Fasting lipid panel (FLP) is preferred.0 If nonfasting TG >500, a FLP is required.0ALT0CK (if necessary)0Hemoglobin A1c (If not DM)
Labwork - Maintenance
0Do not routinely measure CK. (A)0Baseline CK is reasonable if concerns. (E)0Measure CK and hepatic function when AE is
suspected. (E)0Consider decreasing statin dose when 2 consecutive
LDL-C <40mg/dL. (C/Weak)0 Initial FLP0F/U in 4-12 weeks0Then every 3 to 12 months as clinically indicated.
Further Studies
0To determine the optimal age for initiation of therapy0To determine duration of therapy
DEA
Hydrocodone Combination Products (HCPs)
0Previously listed as schedule III0Now listed as schedule II
History of Change
02004 – DEA received petition requesting a schedule change for HCPs.
0DEA submitted request for “HHS to provide the DEA with a scientific and medical evaluation of available information and a scheduling recommendation for HCPS.”
02008 – HHS provided DEA with necessary info – recommendation for HCPs to remain as they were in schedule III.
02009 – DEA requested a re-evaluation from HHS
History of Change
0 July 9, 2012 – President Obama signed the FDA Safety and Innovation Act0 “Directed” FDA to have public hearing on HCPs0 Required the Secretary to engage stakeholders
0 Health benefits and risks0 Potential for abuse0 Impact of up-scheduling
0 January 24-25, 2013 – Meeting of the Drug Safety and Risk Management Advisory Committee (DSaRM)0 DEA0 NIDA (Nat’l Institute on Drug Abuse)0 CDC0 General Public0 Vote 19/10
History of Change
0Dec 16, 2013 – HHS submitted recommendation for schedule II.
0Stated reasons for recommendation.0 HCPs are taken in amounts enough to create a safety
hazard for themselves, others, and the community0 Significant diversion0 Individuals take HCPs on their own accord rather than
as advised by their physician
History of Change
0Feb 27, 2014 – Notification of proposed change in Federal Register.0 Comments were solicited and reviewed.
0Mcv sdf – HCPs officially became schedule II0 Cannot be called over the phone.
Tramadol
0DEA concluded that:0 Tramadol has low potential for abuse when compared to
drugs and substances in schedule III.0 Abuse potential is more aligned with those in schedule
IV0 Tramadol is currently accepted for medical use and
approved for marketing for treatment of moderate to severe pain.
0 Abuse may lead to limited physical or psychological dependence comparable to schedule III.
Tramadol
0DEA decision:0 Tramadol to be placed in schedule IV.0 Effective: August 18, 2014
USPSTF2014 Updates
USPSTF GradingGrade Definition Suggestions for Practice
A Service recommended. High certainty net benefit is substantial.
Offer or provide this service.
B Service recommended. Moderate to high certainty the net benefit is moderate to substantial.
Offer or provide this service.
C Selective recommendation based on professional judgment and patient preferences. At least moderate certainty net benefit is small.
Offer or provide this service for selected patients depending on individual circumstances.
D Recommendation against the service. High or moderate certainty the service has no net benefit or that harms outweigh the benefits.
Discourage the use of this service
I Conclusion: current evidence insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.
If the service is offered, patients should understand the uncertainty about the balance of benefits and harms.
Abdominal Aortic Aneurysm Screening
Population Recommendation Grade
Men Ages 65 to 75 Years who Have Ever Smoked
One-time screening for AAA with US. B
Men Ages 65 to 75 Years who Have Never Smoked
To selectively offer screening for AAA with US. C
Women Ages 65 to 75 Years who Have Ever Smoked
Current evidence is insufficient to assess the balance of benefits and harms of screening for AAA.
I
Women Who Have Never Smoked
Against. D
Release Date: June 2014
Carotid Artery Stenosis: Screening
Population Recommendation Grade
General Adult Population The USPSTF recommends against screening for asymptomatic carotid artery stenosis in the general adult population.
D
Release Date: July 2014
Chlamydia and Gonorrhea: Screening
Population Recommendation Grade
Sexually Active Women Screening for chlamydia in sexually active women age 24 years and younger and in older women who are at increased risk for infection.
B
Sexually Active Women Screening for gonorrhea in sexually active women age 24 years and younger and in older women who are at increased risk for infection.
B
Sexually Active Men Current evidence is insufficient to assess the balance of benefits and harms of screening for chlamydia and gonorrhea in men.
I
Release Date: September 2014
Sexually Transmitted Infections: Behavioral Counseling
Population Recommendation Grade
Sexually Active Adolescents and Adults
Intensive behavioral counseling for ALL sexually active adolescents and for adults who are at increased risk for sexually transmitted infections (STIs).
B
Release Date: September 2014
Cognitive Impairment in Older Adults: Screening
Population Recommendation Grade
Older Adults Current evidence is insufficient to assess the balance of benefits and harms of screening for cognitive impairment.
I
Release Date: March 2014
Dental Caries in Children from Birth Through Age 5 Years:
ScreeningPopulation Recommendation Grade
Children From Birth Through Age 5 Years
Prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride.
B
Children From Birth Through Age 5 Years
Apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption.
B
Children From Birth Through Age 5 Years
Current evidence is insufficient to assess the balance of benefits and harms of routine screening examinations for dental caries performed by primary care clinicians in children from birth to age 5 years.
I
Release Date: May 2014
Drug Use, Illicit: Primary Care Interventions for Children and
Adolescents
Population Recommendation Grade
Children and Adolescents without a Substance Use Disorder
Current evidence is insufficient to assess the balance of benefits and harms of primary care–based behavioral interventions to prevent or reduce illicit drug or nonmedical pharmaceutical use in children and adolescents.
I
Release Date: March 2014
Gestational Diabetes Mellitus, Screening
Population Recommendation Grade
Asymptomatic Pregnant Women, After 24 Weeks of Gestation
Screen. B
Asymptomatic Pregnant Women, Before 24 Weeks of Gestation
Current evidence is insufficient to assess the balance of benefits and harms of screening.
I
Release Date: January 2014
Healthy Diet and Physical Activity: Counseling Adults with
High Risk of CVD
Population Recommendation Grade
Adults Who Are Overweight or Obese and Have Additional CVD Risk Factors
Offer or refer to intensive behavioral counseling interventions to promote a healthful diet and physical activity for CVD prevention.
B
Release Date: August 2014
Hepatitis B Virus Infection: Screening, 2014
Population Recommendation Grade
Persons at High Risk for Infection
Screen for hepatitis B virus (HBV) infection in persons at high risk for infection.
B
Release Date: May 2014
Low-Dose Aspirin Use for the Prevention of Morbidity and
Mortality From Preeclampsia: Preventive Medication
Population Recommendation Grade
Pregnant Women Who Are At High Risk for Preeclampsia
Use of low-dose ASA (81 mg/d) as preventive medication after 12 weeks of gestation in women who are at high risk for preeclampsia.
B
Release Date: September 2014
Suicide Risk in Adolescents, Adults and Older Adults:
Screening
Population Recommendation Grade
Adolescents, Adults, and Older Adults
Current evidence is insufficient to assess the balance of benefits and harms of screening.
I
Release Date: May 2014
Vitamin Supplementation to Prevent Cancer and CVD:
CounselingProducts Recommendation Grade
Use of Multivitamins to Prevent Cardiovascular Disease or Cancer
Current evidence is insufficient to assess the balance of benefits and harms.
I
Single- or Paired-Nutrient Supplements for Prevention of Cardiovascular Disease or Cancer
Current evidence is insufficient to assess the balance of benefits and harms (except -βcarotene and vitamin E) for the prevention of cardiovascular disease or cancer.
I
Use of -carotene or βVitamin E for Prevention of Cardiovascular Disease or Cancer
Against the use of -carotene or vitamin E βsupplements for the prevention of cardiovascular disease or cancer.
D
Release Date: May 2014
References0 Federal Register. http://www.gpo.gov/fdsys/pkg/FR-2014-08-22/pdf/2014-19922.
pdf. Accessed October 2014.0 Federal Register. http://www.gpo.gov/fdsys/pkg/FR-2014-07-02/pdf/2014-15548.
pdf. Accessed October 2014.0 Leung, Lawrence LK. Anticoagulation with direct thrombin inhibitors and direct
factor Xa inhibitors. www.uptodate.com. Updated 10/07/2014. Accessed 10/17/2014.
0 Stone, NJ, et al. 2013 ACC/AHA Blood Cholesterol Guideline.http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437738.63853.7a.full.pdf. Downloaded 10/19/2014.
0 USPSTF. http://www.uspreventiveservicestaskforce.org/BrowseRec/Index. Accessed 10/24/2014.
0 Yancey et al. 2013 ACCF/AHA Heart Failure Guideline: Executive Summary. http://circ.ahajournals.org/content/128/16/e240. Downloaded October 24, 2014.