Top Ten Clinical Issues PPT

Definition
0 Complex clinical syndrome
0 Any structural or functional impairment of ventricular
filling or ejection of blood
0 Cardinal s/sx
0 Dyspnea and fatigue
0 Fluid retention
0 Pts may c/o exercise intolerance with little fluid
retention.
0 Others may c/o the peripheral edema, SOB, or fatigue
Etiology
0 The clinical syndrome of HF may result from
0 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,
0
0
0
0
therefore, the term “HEART FAILURE” is preferred over
“CONGESTIVE HEART FAILURE.”
No single diagnostic test for HF.
HF is largely a clinical diagnosis based on a careful history
and physical examination.
**HF is not synonymous with either cardiomyopathy or LV
dysfunction; these latter terms describe possible structural
or functional reasons for the development of HF.
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 Fraction
0 HFpEF = Heart Failure with preserved Ejection Fraction
0 Most pts with HF with have systolic and diastolic.
0 Reasons why EF is important
0 Demographics
0 Comorbidities
0 Prognosis
0 Response to therapies
0 **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.
Epidemiology
0 20% lifetime risk for Americans ≥ 40 yo.
0 Incidence stable over last several decades.
0 >650,000 new diagnoses yearly
0 Prevalence: ~5.1 million.
0 1 in 5 will be >65 yo by 2050.
0 Highest HF prevalence.
Disparities Identified
0 Blacks - highest risk for HF.
0 White women – lowest incidence.
0 Black men – highest incidence.
0 5-year mortality rate – blacks > whites.
0 Prevalence:
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%
Diagnostic Tests: Class I
0 Initial laboratory evaluation
0 CBC, CMP, Magnesium, FLP, TSH, urinalysis. (C)
0 Serial monitoring
0 Serum electrolytes and renal function. (C)
0 Initial 12-lead electrocardiogram. (C)
Diagnostic Tests: Class IIa
0 Screening:
0 Hemochromatosis or HIV - reasonable in selected
patients. (C)
0 Other tests:
0 Rheumatologic diseases.
0 Amyloidosis.
0 Pheochromocytoma.
0 Reasonable if clinical suspicion. (C)
Outpatient Biomarkers: Class I
0 Ambulatory patients with dyspnea, it is useful to
measure B-type natriuretic peptide (BNP) or Nterminal pro-B-type natriuretic peptide (NT-proBNP).
It supports clinical decision. Especially if uncertain.(A)
0 Measure BNP or NT-proBNP to establish prognosis or
disease severity in chronic HF. (A)
Outpatient Biomarkers: Class IIa
0 Well-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 IIb
0 Serial BNP:
0 Usefulness in reducing hospitalization or mortality is
not well established. (B)
0 Other clinically available tests
0 Biomarkers of myocardial injury or fibrosis - additive
for risk stratification in chronic HF. (B)
Hospitalized/Acute: Class I
0 Measurement of BNP or NT-proBNP
0 Useful to support clinical judgment for the diagnosis of
acutely decompensated HF. (A)
0 Measurement of BNP or NT-proBNP and/or cardiac
troponin
0 Useful for establishing prognosis or disease severity in
acutely decompensated HF. (A)
Hospitalized/Acute: Class IIb
0 Usefulness of BNP- or NT-proBNP−guided therapy for
acutely decompensated HF is not well established. (C)
Noninvasive Cardiac Imaging:
Class I
0 Patients 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)
0 2D echocardiogram with Doppler
0 Initial evaluation to assess ventricular function, size,
wall thickness, wall motion, and valve function. (C)
Noninvasive Cardiac Imaging:
Class I
0 Repeat 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 function
0 Those who may be candidates for device therapy
0 (Level of Evidence: C)
Noninvasive Cardiac Imaging:
Class III
No Benefit
0 Routine repeat measurement of LV function in pt w/o
a change in clinical status or treatment interventions
should not be performed. (B)
Treatment of Stage A to D:
Recommendations: Stage A Class
I
0 Treat Hypertension and Hyperlipidemia, according to
guidelines, to lower the risk of HF. (A)
0 Control or avoid other conditions that may lead to or
contribute to HF
0 Obesity
0 Diabetes mellitus
0 Tobacco use
0 Known cardiotoxic agents
0 (Level of Evidence: C)
Treatment of Stage A to D:
Recommendations: Stage B Class
I
0 Recent or remote h/o MI or ACS and reduced EF = ACEI.
0
0
0
0
0
(A)
ACEI prevent symptomatic HF and reduce mortality.
If intolerant to ACEIs  ARBs. (A)
Beta blockers to reduce mortality. (B)
In recent or remote history of MI or ACS  statins to
prevent symptomatic HF and cardiovascular events. (A)
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
0 Beta 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
IIa
0 Placement of an implantable cardioverter-
defibrillator (ICD)
0 To prevent sudden death
0 Is reasonable in patients with
0 asymptomatic ischemic cardiomyopathy
0 who are at least 40 days post-MI,
0 have an LVEF of 30% or less,
0 are on appropriate medical therapy,
0 and have reasonable expectation of survival
0 with a good functional status for more than 1 year.
0 (Level of Evidence: B)
Treatment of Stage A to D:
Recommendations: Stage B Class
III Harm
0 Nondihydropyridine 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)
Anticoagulants
0 Heparins
0 Vitamin K Antagonists
0 Fondaparinux
0 Direct Thrombin Inhibitors (DTI)
0 Direct Factor Xa Inhibitors (DFXaI)
Thrombin
0 Final enzyme in clotting cascade that produces fibrin.
0 Activates other procoagulant factors.
0 Active in both circulating and clot-bound forms.
0 DTI block action of both forms of thrombin.
0 Heparins only inactivate thrombin in fluid phase via
antithrombin
Factor Xa
0 Acts at convergence point of intrinsic and extrinsic
coagulation pathway.
0 One molecule of factor 10a can cleave over 1000
molecules of prothrombin to thrombin.
0 Active in circulating and clot-bound forms.
0 DXa 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
0 Anithrombotic Agent
0 Antiplatelet
0 anticoagulant
0 Antiplatelet
0 ASA
0 Clopidogrel
0 Anticoagulant
0 DTI
0 DFXaI
Anticoagulant Terminology
0 Other Acronyms
0 TSOACs
0 DOACs
0 ODI
0 NOACs
0 Newer
0 Nonvitamin K antagonists
Comparison
0 Anticoagulants differ in efficacy depending on clinical
setting.
0 There are differences in dosing, monitoring, cost, and
risk.
0 Advantages and disadvantages of each agent must be
individualized.
Comparison
Coumadin
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
Reversal Agents
Vitamin K, FFP, PCC,
rFVIIa
None. PCC for lifethreatening bleeding
Monitor - Reversal
PT/INR
TT – dabigatran
Anti-factor Xa apixaban
Therapeutic Time
Comorbid Conditions
Renal functions affects
phrmacokinetics
Unclear dosing for
those with obesity
Contraindications
0 Pregnancy
0 Prosthetic Heart Valve
0 Renal Impairment
0 Compliance
0 GI Disease
Indications
0 DVT prophylaxis and treatment
0 Afib
0 Unstable angina
0 MI
0 Coronary Stenting
0 Heparin –Induced Thrombocytopenia
Bleeding
0 Warfarin - Vitamin K
0 Dabigatran – Clotting factor products, i.e. FFP
0 Rivaroxaban - Clotting factor products, i.e. FFP
0 Apixaban - Clotting factor products, i.e. FFP
Surgery/Invasive Procedure
0 Warfarin - Stopped 5 days before surgery
0 Dabigatran – Stopped 2-3 days before surgery
0 Rivaroxaban - Stopped 2-3 days before surgery
0 Apixaban - Stopped 2-3 days before surgery
Dabigatran – Overview
0 Orally administered prodrug. Converted in the liver.
0 Active DTI
0 Inhibits clot-bound and circulating thrombin
0 T1/2 ~12 to 17 hours
0 Max anticoag effect @ 2-3 hrs of ingestion
0 Renal excretion. Not used if CrCl <15
0 **Capsules in original bottle only!!!
0 Used within 4 months.
Dabigatran - Indicator
0 DVT prophylaxis and treatment.
0 Stroke prevention in Afib
0 PE
Dabigatran vs Coumadin
0 Meta-analyses an dlarge observational studies
0 Overall bleeding rates are similar
0 Dabigatran may be assoc’d with a slightly lower rate
of ICH and death
0 Dabigatran may be assoc’d with a slightly higher rate
of GIB
0 Lacks a specific antidote
0 Dyspepsia – common SE
Rivaroxaban - Overview
0 DFXaI
0 T1/2 ~7 to 17 hours
0 Indicator: DVT prophylaxis and treatment and stroke
0
0
0
0
0
prevention in Afib.
Contraindicated in pregnancy, prosthetic heart valve
Taken with food
Not recommended for use in CrCl <30. Not used if CrCl <15
or significant hepatic impairment (Child-Pugh Class B and
C with coagulopathy)
Rivaroxaban interacts with CYP-3A4 and P-glycoprotein
inh
Drug levels are relatively predictable
Apixaban - Overview
0 DFXaI
0 T1/2 ~5 to 9 hours
0 Indicator: DVT prophylaxis and treatment and stroke
prevention in Afib.
0 Contraindicated in pregnancy or those with prosthetic
heart valve
0 Drug levels are relatively predictable
CYP-3A4 and P-glycoprotein
inh
0 Ketoconazole
0 Itraconazole
0 Voriconazole
0 Posaconazole
0 Ritonavir
Purpose
0 The 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
0 Atherosclerotic cardiovascular disease
0 ASCVD includes
0 coronary heart disease (CHD)
0 stroke
0 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
0 Strategies for using drug therapy
0 Treat-to-cholesterol target
0 Lower cholesterol is better
0 Risk-based treatment approaches.
0 Only 1 approach evaluated in multiple RCTs
0 Using fixed doses of cholesterol-lowering drugs to
reduce the ASCVD risk.
0 Bulk of evidence from statin trials
0 Expert Panel focused on statin RCTs to develop the
evidence-based guidelines
RCTs
0 Either compared fixed doses of statins with placebo or
untreated controls,
0 Or compared fixed doses of higher-intensity statins
with moderate-intensity statins.
0 The 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
0 No RCT evidence to support titrating cholesterol-
lowering drug therapy to achieve target LDL–C or
non-HDL-C levels (as recommended by ATP III).
0 No 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.
0 Extensive RCT evidence that the appropriate intensity
of statin therapy should be used to reduce ASCVD risk
in those most likely to benefit.
0 The difficulty of giving up the treat-to-goal paradigm
was deliberated extensively over a 3-year period.
Example
0 FH with LDL–C >190 mg/dL.
0 Individuals with FH are unable to achieve an LDL–C
goal <100 mg/dL.
0 They may only achieve an LDL–C of 120 mg/dL
despite use of 3 cholesterol-lowering drugs.
0 Did this patient fall short of the 100 mg/dL goal?
0 No, they have decreased their LDL–C by >50%.
0 May have started from an untreated LDL–C level of
~325-400 mg/dL.
0 Not treatment failures.
Age
0 A person aged 70 years without other risk factors will
receive statin treatment on the basis of age alone.
0 The estimated 10-year risk is still ≥7.5%, a risk
threshold for which a reduction in ASCVD risk events
has been demonstrated in RCTs.
0 Most ASCVD events occur after age 70 years, giving
individuals >70 years of age the greatest potential for
absolute risk reduction.
Lifestyle Modification
0 Emphasized
0 Adhering to a heart healthy diet
0 Regular exercise
0 Avoidance of tobacco products
0 Maintenance of a healthy weight
0 Critical component of health promotion and ASCVD
risk reduction
0 Before and with the use of cholesterol- lowering drug
therapy
Statin Therapy
Statins
0 3 types of statin therapy
0 High-intensity
0 Moderate-intensity
0 Lower-intensity
0 Designations were developed from RCTs
0 Evidence: The relative reduction in ASCVD risk is related
to the degree LDL-C is lowered.
0 High-intensity > Moderate-intensity > lower-intensity
Comparison of Statin Intensity
High-Intensity
Moderate-Intensity
Lower-Intensity
Lowering ≥ 50%
of LDL-C
30% to <50%
<30%
Statins
Atorvastatin 10 (20)
mg
Rosuvastatin (5)
10mg
Simvastatin 20-40mg
Pravastatin 40 (80)
mg
Lovastatin 40mg
Fluvastatin XL 80mg
Fluvastatin 40mg bid
Pitavastatin 2-4mg
Simvastatin 10mg
Pravastatin 1020mg
Lovastatin 20mg
Fluvastatin 2040mg
Pitavastatin 1mg
Atorvastatin 4080mg
Rosuvastatin 20 (40)
mg
0 Bold statins and doses = Evaluated in RCTs.
0 Italic statins and doses = Approved by FDA, not tested in RCTs that were reviewed.
Primary Prevention
0 Adult ≥21 yo with LDL-C ≥190mg/dL
0 High lifetime risk for ASCVD events
0 Initiate High-intensity statin
0 Goal: to achieve at least 50% reduction
0 May require nonstatin cholesterol-lowering medication
also.
0 Consider screening family members
0 Screen for secondary causes
Secondary Causes
Elev 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
0 40-75yo with DM and LDL-C 70-189mg/dL
0 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 therapy
0 Evaluate for ASCVD benefits
0 Evaluate for AE
0 Discuss with patient
0 (E)
Primary Prevention
0 40-75yo without DM and LDL-C 70-189mg/dL
0 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:
0 History of intolerance
0 Drug-drug interactions
0 Patient preference
0 >75yo with clinical ASCVD  Moderate-intensity (E)
** Note **
0 No recommendation for or against specific LDL-C or
non-HDL-C targets, irregardless of primary or
secondary prevention.
HF and HD
0 No 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
0 For identification of candidates for statin therapy
0 http://my.americanheart.org/cvriskcalculator
0 http://www.cardiosource.org/science-and-
quality/practice-guidelines-and-qualitystandards/2013-prevention-guideline-tools.aspx
0 App from iTunes or Google Play or launch from
website
0 Age, gender, race, HDL, TC, SBP, HTN/DM/Smoker
Statin Maintenance
0 If predisposed to AE, initiate therapy with the nextv
lower intensity level. (A)
0 To 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 Maintenance
0 If mild to moderate muscle symptoms develop during statin therapy:
0–
0–
Discontinue the statin until the symptoms can be evaluated.
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
0 Multiple or serious comorbidities, including impaired
renal or hepatic function.
0 History of previous statin intolerance or muscle
disorders.
0 Unexplained ALT elevations >3 times ULN.
0 Patient characteristics or concomitant use of
0 drugs affecting statin metabolism.
0 >75 years of age.
0 History of hemorrhagic stroke.
0 Asian ancestry.
4 Major Statin Groups
0 Individuals with clinical ASCVD
0 Individuals with primary elevations of LDL–C >190
mg/dL
0 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
0 Fasting lipid panel (FLP) is preferred.
0 If nonfasting TG >500, a FLP is required.
0 ALT
0 CK (if necessary)
0 Hemoglobin A1c (If not DM)
Labwork - Maintenance
0 Do not routinely measure CK. (A)
0 Baseline CK is reasonable if concerns. (E)
0 Measure CK and hepatic function when AE is
suspected. (E)
0 Consider decreasing statin dose when 2 consecutive
LDL-C <40mg/dL. (C/Weak)
0 Initial FLP
0 F/U in 4-12 weeks
0 Then every 3 to 12 months as clinically indicated.
Further Studies
0 To determine the optimal age for initiation of therapy
0 To determine duration of therapy
Hydrocodone Combination
Products (HCPs)
0 Previously listed as schedule III
0 Now listed as schedule II
History of Change
0 2004 – DEA received petition requesting a schedule
change for HCPs.
0 DEA submitted request for “HHS to provide the DEA
with a scientific and medical evaluation of available
information and a scheduling recommendation for
HCPS.”
0 2008 – HHS provided DEA with necessary info –
recommendation for HCPs to remain as they were in
schedule III.
0 2009 – DEA requested a re-evaluation from HHS
History of Change
0 July 9, 2012 – President Obama signed the FDA Safety and
Innovation Act
0 “Directed” FDA to have public hearing on HCPs
0 Required the Secretary to engage stakeholders
0 Health benefits and risks
0 Potential for abuse
0 Impact of up-scheduling
0 January 24-25, 2013 – Meeting of the Drug Safety and Risk
Management Advisory Committee (DSaRM)
0
0
0
0
0
DEA
NIDA (Nat’l Institute on Drug Abuse)
CDC
General Public
Vote 19/10
History of Change
0 Dec 16, 2013 – HHS submitted recommendation for
schedule II.
0 Stated reasons for recommendation.
0 HCPs are taken in amounts enough to create a safety
hazard for themselves, others, and the community
0 Significant diversion
0 Individuals take HCPs on their own accord rather than
as advised by their physician
History of Change
0 Feb 27, 2014 – Notification of proposed change in
Federal Register.
0 Comments were solicited and reviewed.
0 Mcv sdf – HCPs officially became schedule II
0 Cannot be called over the phone.
Tramadol
0 DEA 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
IV
0 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
0 DEA decision:
0 Tramadol to be placed in schedule IV.
0 Effective: August 18, 2014
USPSTF Grading
Grade
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 Current evidence is insufficient to assess the
I
who Have Ever Smoked
balance of benefits and harms of screening for
AAA.
Women Who Have Never
Smoked
Release Date: June 2014
Against.
D
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
I
balance of benefits and harms of screening for
chlamydia and gonorrhea in men.
Release Date: September 2014
Sexually Transmitted Infections:
Behavioral Counseling
Population
Recommendation
Sexually Active Adolescents
and Adults
Intensive behavioral counseling for ALL
B
sexually active adolescents and for adults who
are at increased risk for sexually transmitted
infections (STIs).
Release Date: September 2014
Grade
Cognitive Impairment in Older
Adults: Screening
Population
Recommendation
Older Adults
Current evidence is insufficient to assess the
I
balance of benefits and harms of screening for
cognitive impairment.
Release Date: March 2014
Grade
Dental Caries in Children from
Birth Through Age 5 Years:
Screening
Population
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
Current evidence is insufficient to assess the
Women, Before 24 Weeks of balance of benefits and harms of screening.
Gestation
Release Date: January 2014
I
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
Persons at High Risk for
Infection
Screen for hepatitis B virus (HBV) infection in B
persons at high risk for infection.
Release Date: May 2014
Grade
Low-Dose Aspirin Use for the
Prevention of Morbidity and
Mortality From Preeclampsia:
Preventive Medication
Population
Recommendation
Pregnant Women Who Are
At High Risk for
Preeclampsia
Use of low-dose ASA (81 mg/d) as preventive B
medication after 12 weeks of gestation in
women who are at high risk for preeclampsia.
Release Date: September 2014
Grade
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:
Counseling
Products
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 β-carotene or Vitamin Against the use of β-carotene or vitamin E
E for Prevention of
supplements for the prevention of
Cardiovascular Disease or
cardiovascular disease or cancer.
Cancer
Release Date: May 2014
D
References
0 Federal Register. http://www.gpo.gov/fdsys/pkg/FR-2014-08-
0
0
0
0
0
22/pdf/2014-19922.pdf. Accessed October 2014.
Federal Register. http://www.gpo.gov/fdsys/pkg/FR-2014-0702/pdf/2014-15548.pdf. Accessed October 2014.
Leung, Lawrence LK. Anticoagulation with direct thrombin inhibitors and
direct factor Xa inhibitors. www.uptodate.com. Updated 10/07/2014.
Accessed 10/17/2014.
Stone, NJ, et al. 2013 ACC/AHA Blood Cholesterol
Guideline.http://circ.ahajournals.org/content/early/2013/11/11/01.cir.00
00437738.63853.7a.full.pdf. Downloaded 10/19/2014.
USPSTF. http://www.uspreventiveservicestaskforce.org/BrowseRec/Index.
Accessed 10/24/2014.
Yancey et al. 2013 ACCF/AHA Heart Failure Guideline: Executive Summary.
http://circ.ahajournals.org/content/128/16/e240. Downloaded October 24,
2014.