2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction

Rs, Wright; Jl, Anderson; Cd, Adams; Cr, Bridges; Casey, Donald E.; Sm, Ettinger; Fm, Fesmire; Tg, Ganiats; Jneid, Hani; Lincoff, A. Michael; Peterson, ED; Gj, Philippides; Théroux, Pierre; Nk, Wenger; Jp, Zidar; Em, Antman; Califf, RM; We, Chavey; Hochman, Judith S.; Tn, Levin

doi:10.1016/j.jacc.2011.02.011

Cited by 388 publications

(119 citation statements)

References 915 publications

(350 reference statements)

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“…4,5 Several CPGs have followed this route. 28 Empirical evidence suggests that data from nonrandomized and randomized designs are not in profound disagreement, [29][30][31][32] but nonrandomized studies are generally more susceptible to biases. 33 For example, propensity score methods attempt to emulate randomized comparisons by making contrasts between patient groups that are on average similar on all observed confounders.…”

Section: Engage the Cpg Workgroup To Identify Critical Or Important Cmentioning

confidence: 99%

Addressing Multimorbidity in Evidence Integration and Synthesis

2014

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To minimize bias, clinical practice guidelines (CPG) for managing patients with multiple conditions should be informed by well-planned syntheses of the totality of the relevant evidence by means of systematic reviews and meta-analyses. However, deficiencies along the entire evidentiary pathway hinder the development of evidence-based CPGs. Published reports of trials and observational studies often do not provide usable data on treatment effect heterogeneity, perhaps because their design, analysis and presentation is seldom geared towards informing on how multimorbidity modifies the effect of treatments. Systematic reviews and meta-analyses inherit all the limitations of their building blocks and introduce additional of their own, including selection biases at the level of the included studies, ecological biases, and analytical challenges. To generate recommendations to help negotiate some of the challenges in synthesizing the primary literature, so that the results of the evidence synthesis is applicable to the care of those with multiple conditions. Informal group process. We have built upon established general guidance, and provide additional recommendations specific to systematic reviews that could improve the CPGs for multimorbid patients. We suggest that following the additional recommendations is good practice, but acknowledge that not all proposed recommendations are of equal importance, validity and feasibility, and that further work is needed to test and refine the recommendations. INTRODUCTIONMost current clinical practice guidelines (CPG) are typically developed for managing individuals with a single disease, and also apply to patients with multiple conditions, provided that each can be managed separately from the others.1,2 Some patients, however, have conditions that must be considered jointly, perhaps because the management of one affects the management or the course of other. Uncritical adherence to guideline-recommended management of their isolated conditions can be impractical or even harmful for such patients. Tailored guidance is needed at least for specific combinations of conditions. Very few examples of CPGs providing such guidance exist, 1,2 perhaps because developing such guidance is hindered by deficiencies along the entire evidentiary pathway. Pivotal trials or observational studies often exclude individuals with multimorbidity. 4,5 Even when these individuals are included, the treatment effect is typically averaged over all participants, without report of whether and how it is modified in those with important multimorbid conditions. 6 Thus, systematic reviews that inform CPG recommendations often do not or cannot describe the pertinent evidence base. 7This manuscript describes the outcomes of a working session conducted with the goal of generating recommendations to help overcome some of the challenges in synthesizing the primary literature so that the results of the evidence synthesis are applicable to the care of those with multiple conditions that must be considered jointly, or in...

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Section: Engage the Cpg Workgroup To Identify Critical Or Important Cmentioning

confidence: 99%

Addressing Multimorbidity in Evidence Integration and Synthesis

2014

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“…Nevertheless myoglobin has been regarded as the most sensitive biomarker of myocardial damage in the past. In fact, high diagnostic sensitivity is still reported as the major strength of myoglobin in a recent guideline [7] . Even some recent studies adding myoglobin to conventional cTn suggest an improved diagnostic value [18] .…”

Section: Myoglobinmentioning

confidence: 99%

“…There is now ample evidence that CK-MB mass determination is inferior to conventional cTn so that its use has not been advocated any more before the advent of hs-cTn. In fact, guidelines recommend CK-MB only, if cTn is not available [6,7] . Thus, for the diagnosis of acute MI in the setting of an emergency room or chest pain unit, CK-MB cannot be recommended.…”

Section: Creatine Kinase Mb (Ck-mb)mentioning

confidence: 99%

“…This is clearly the case for all patients with non-cardiac chest pain in whom the diagnosis of MI and ACS has to be ruled out, but also for many patients with unstable angina or non-ST-elevation myocardial infarction. Therefore, guidelines for the appropriate diagnosis and treatment in these cases have been issued and are regularly updated by the American and European professional associations [6,7] .…”

Section: Introductionmentioning

confidence: 99%

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Laboratory diagnostics of myocardial infarction – troponins and beyond

Lackner

2012

Clinical Chemistry and Laboratory Medicine (CCLM)

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In the case of suspected acute coronary syndrome and myocardial infarction positive diagnosis or exclusion strongly depend on the use of biomarkers and in particular cardiac troponins (cTn). Especially in the early phase of myocardial infarction the sensitivity of cTn assays has been unsatisfactory. This has led to the investigation of many other potential markers for the early diagnosis of myocardial infarction. In addition, several traditional markers have been advocated, e.g., myoglobin, as these were considered to be more sensitive than cTn. With the advent of high-sensitive (hs) cTn assays the value and practical use of the alternative or additional markers has to be reassessed. According to the currently available data, no single marker is superior to hs-cTn for the diagnosis of acute myocardial infarction. In particular, the notion of superior sensitivity of myoglobin compared to cTn no longer holds true. There are two protein markers, hearttype fatty acid binding protein and copeptin, and plasma free fatty acids that may increase the diagnostic value and specifically the negative predictive value when determined on admission in combination with hs-cTn. However, the incremental gain, if any, is small. Further data are needed to determine, whether these markers can in fact improve diagnosis and if they are superior to the recommended use of the relative or absolute change of hs-cTn after 3 h.

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“…The American College of Cardiology recommends imipramine for treatment of CMVD in patients who have failed treatment with risk factor reduction, beta blockers, calcium channel blockers or nitrates (Wright et al, 2011).…”

mentioning

confidence: 99%