John W. Beasley

ACC/AHA Guidelines for the Management of Patients With Unstable Angina and Non–ST-Segment Elevation Myocardial Infarction: Executive Summary and Recommendations A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina)

The American College of Cardiology (ACC)/American Heart Association (AHA) Task Force on Practice Guidelines was formed to make recommendations regarding the diagnosis and treatment of patients with known or suspected cardiovascular disease. Coronary artery disease (CAD) is the leading cause of death in the United States. Unstable angina (UA) and the closely related condition non–ST-segment elevation myocardial infarction (NSTEMI) are very common manifestations of this disease. These life-threatening disorders are a major cause of emergency medical care and hospitalizations in the United States. In 1996, the National Center for Health Statistics reported 1 433 000 hospitalizations for UA or NSTEMI. In recognition of the importance of the management of this common entity and of the rapid advances in the management of this condition, the need to revise guidelines published by the Agency for Health Care Policy and Research (AHCPR) and the National Heart, Lung and Blood Institute in 1994 was evident. This Task Force therefore formed the current committee to develop guidelines for the management of UA and NSTEMI. The present guidelines supersede the 1994 guidelines.nnThe customary ACC/AHA classifications I, II, and III summarize both the evidence and expert opinion and provide final recommendations for both patient evaluation and therapy:nnClass I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective .nnClass II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment. nnClass IIa: Weight of evidence/opinion is in favor of usefulness/efficacy. nnClass IIb: Usefulness/efficacy is less well established by evidence/opinion. nnClass III: Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective and in some cases may be harmful. nnThe weight of the evidence was ranked highest (A) if the data …

ACC/AHA Guidelines for Exercise Testing: Executive Summary A Report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing)

The American College of Cardiology/American Heart Association Task Force on Practice Guidelines was formed to make recommendations regarding the appropriate use of testing in the diagnosis and treatment of patients with known or suspected cardiovascular disease. Exercise testing is widely available and relatively low in cost. For the purposes of these guidelines, exercise testing is a cardiovascular stress test using treadmill or bicycle exercise and electrocardiographic and blood pressure monitoring. Pharmacological stress testing and imaging modalities (radionuclide imaging, echocardiography) are beyond the scope of these guidelines.nnThese guidelines have been endorsed by the American College of Sports Medicine, the American Society of Echocardiography, and the American Society of Nuclear Cardiology.nnThis executive summary appears in the July 1, 1997, issue of Circulation. The guidelines in their entirety are published in the July 1997 issue of the Journal of the American College of Cardiology. Reprints of both the executive summary and the full text are available from both organizations.nnExercise testing is a well-established procedure that has been in widespread clinical use for many decades. It is described in detail in previous publications of the AHA, to which interested readers are referred.nnAlthough exercise testing is generally a safe procedure, both myocardial infarction and death have been reported and can be expected to occur at a rate of up to 1 per 2500 tests. Good clinical judgment should therefore be used in deciding which patients should undergo exercise testing. Absolute and relative contraindications to exercise testing are summarized in Table 1⇓.nnView this table:nn Table 1. nContraindications to Exercise Testing nnnnThe vast majority of treadmill exercise testing is performed in adults with symptoms of known or suspected ischemic heart disease. Special groups who are exceptions to this norm are discussed in detail in sections VI and VII. Sections II through IV illustrate the variety …

ACC/AHA Guideline Update for the Management of Patients With Unstable Angina and Non–ST-Segment Elevation Myocardial Infarction—2002: Summary Article

The American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for the management of unstable angina and non–ST-segment elevation myocardial infarction (UA/NSTEMI) were published in September 2000.1 Since then, a number of clinical trials and observational studies have been published or presented that, when taken together, alter significantly the recommendations made in that document. Therefore, the ACC/AHA Committee on the Management of Patients With Unstable Angina, with the concurrence of the ACC/AHA Task Force on Practice Guidelines, revised these guidelines. These revisions were prepared in December 2001, reviewed and approved, and then published on the ACC World Wide Web site (www.acc.org) and AHA World Wide Web site (www.americanheart.org) on March 15, 2002. The present article describes these revisions and provides further updates in this rapidly moving field. Minor clarifications in the wording of three recommendations that now appear differently from those that were previously published on the ACC and AHA Web sites are noted in footnotes.nnThe ACC/AHA classifications I, II, and III are used to summarize indications as follows:nnClass I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective.nnClass II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment.nnIIa: Weight of evidence/opinion is in favor of usefulness/efficacy.nnIIb: Usefulness/efficacy is less well established by evidence/opinion.nnClass III: Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective and in some cases may be harmful.nnThe weight of the evidence was ranked highest (A) if the data were derived from multiple randomized clinical trials that involved large numbers of patients and intermediate (B) if the data were derived from a limited number of randomized trials that involved small numbers of …

ACC/AHA guidelines for the management of patients with unstable angina and non–st-segment elevation myocardial infarction: A report of the american college of cardiology/ american heart association task force on practice guidelines (committee on the management of patients with unstable angina)

Preamble......971nnI.nnIntroduction ......972nnA.nnOrganization of Committee and Evidence Review......972nnB.nnPurpose of These Guidelines......973nnC.nnOverview of the Acute Coronary Syndrome......973nn1.nnDefinition of Terms......973nn2.nnPathogenesis of UA/NSTEMI ......974nn3.nnPresentations of

ACC/AHA Guidelines for the Management of Patients With Unstable Angina and Non–ST-Segment Elevation Myocardial Infarction: Executive Summary and Recommendations

The American College of Cardiology (ACC)/American Heart Association (AHA) Task Force on Practice Guidelines was formed to make recommendations regarding the diagnosis and treatment of patients with known or suspected cardiovascular disease. Coronary artery disease (CAD) is the leading cause of death in the United States. Unstable angina (UA) and the closely related condition non–ST-segment elevation myocardial infarction (NSTEMI) are very common manifestations of this disease. These life-threatening disorders are a major cause of emergency medical care and hospitalizations in the United States. In 1996, the National Center for Health Statistics reported 1 433 000 hospitalizations for UA or NSTEMI. In recognition of the importance of the management of this common entity and of the rapid advances in the management of this condition, the need to revise guidelines published by the Agency for Health Care Policy and Research (AHCPR) and the National Heart, Lung and Blood Institute in 1994 was evident. This Task Force therefore formed the current committee to develop guidelines for the management of UA and NSTEMI. The present guidelines supersede the 1994 guidelines.nnThe customary ACC/AHA classifications I, II, and III summarize both the evidence and expert opinion and provide final recommendations for both patient evaluation and therapy:nnClass I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective .nnClass II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment. nnClass IIa: Weight of evidence/opinion is in favor of usefulness/efficacy. nnClass IIb: Usefulness/efficacy is less well established by evidence/opinion. nnClass III: Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective and in some cases may be harmful. nnThe weight of the evidence was ranked highest (A) if the data …

ACC/AHA guidelines for the management of patients with unstable angina and non–st-segment elevation myocardial infarction

Preamble......971nnI.nnIntroduction ......972nnA.nnOrganization of Committee and Evidence Review......972nnB.nnPurpose of These Guidelines......973nnC.nnOverview of the Acute Coronary Syndrome......973nn1.nnDefinition of Terms......973nn2.nnPathogenesis of UA/NSTEMI ......974nn3.nnPresentations of

American College of Cardiology/American Heart Association Clinical Competence statement on stress testing: a report of the American College of Cardiology/American Heart Association/American College of Physicians--American Society of Internal Medicine Task Force on Clinical Competence.

The granting of clinical staff privileges is one of the primary mechanisms used by institutions to uphold the quality of care. The Joint Commission on Accreditation of Healthcare Organizations requires that the granting of initial or continuing medical staff privileges be based on assessment of applicants against professional criteria specified in medical staff bylaws. Physicians and other healthcare providers are thus charged with identifying the criteria that constitute professional competence and with evaluating their peers accordingly. The process of evaluating clinical knowledge and competence is often constrained by the evaluator’s own knowledge and ability to elicit the appropriate information, a problem that is compounded by the growing number of highly specialized procedures for which privileges are requested.nnThe American College of Cardiology (ACC)/American Heart Association (AHA)/American College of Physicians–American Society of Internal Medicine (ACP-ASIM) Task Force on Clinical Competence was formed in 1998 to develop recommendations to attain and maintain the cognitive and technical skills necessary for the competent performance of a specific cardiovascular service, procedure, or technology. These documents are evidence based, and where evidence is not available, expert opinion is called upon to formulate recommendations. Indications and contraindications for specific services or procedures are not included in the scope of these documents. Recommendations are intended to assist those who must judge the competence of cardiovascular healthcare providers entering practice for the first time and/or those who are in practice and undergo periodic review of their practice expertise. Because the assessment of competence is complex and multidimensional, isolated recommendations contained herein may not necessarily be sufficient or appropriate for judging overall competence. Board specialty certification is not a required part of these recommendations but is another measure of expertise.nnThis statement is a revision and extension of the previous ACP/ACC/AHA Task Force Statement on Clinical Competence in Exercise Testing. …

American College of Cardiology/American Heart Association Clinical Competence Statement on Stress Testing

The granting of clinical staff privileges is one of the primary mechanisms used by institutions to uphold the quality of care. The Joint Commission on Accreditation of Healthcare Organizations requires that the granting of initial or continuing medical staff privileges be based on assessment of applicants against professional criteria specified in medical staff bylaws. Physicians and other healthcare providers are thus charged with identifying the criteria that constitute professional competence and with evaluating their peers accordingly. The process of evaluating clinical knowledge and competence is often constrained by the evaluator’s own knowledge and ability to elicit the appropriate information, a problem that is compounded by the growing number of highly specialized procedures for which privileges are requested.nnThe American College of Cardiology (ACC)/American Heart Association (AHA)/American College of Physicians–American Society of Internal Medicine (ACP-ASIM) Task Force on Clinical Competence was formed in 1998 to develop recommendations to attain and maintain the cognitive and technical skills necessary for the competent performance of a specific cardiovascular service, procedure, or technology. These documents are evidence based, and where evidence is not available, expert opinion is called upon to formulate recommendations. Indications and contraindications for specific services or procedures are not included in the scope of these documents. Recommendations are intended to assist those who must judge the competence of cardiovascular healthcare providers entering practice for the first time and/or those who are in practice and undergo periodic review of their practice expertise. Because the assessment of competence is complex and multidimensional, isolated recommendations contained herein may not necessarily be sufficient or appropriate for judging overall competence. Board specialty certification is not a required part of these recommendations but is another measure of expertise.nnThis statement is a revision and extension of the previous ACP/ACC/AHA Task Force Statement on Clinical Competence in Exercise Testing. …

ACC/AHA guidelines for the management of patients with unstable angina and non-ST segment elevation myocardial infarction: Executive summary and recommendations: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients with Unstable Angina)

Eugene Braunwald, MD, FACC, Chair; Elliott M. Antman, MD, FACC; John W. Beasley, MD, FAAFP; Robert M. Califf, MD, FACC; Melvin D. Cheitlin, MD, FACC; Judith S. Hochman, MD, FACC; Robert H. Jones, MD, FACC; Dean Kereiakes, MD, FACC; Joel Kupersmith, MD, FACC; Thomas N. Levin, MD, FSCAI, FACC; Carl J. Pepine, MD, FACC; John W. Schaeffer, MD, FACC; Earl E. Smith III, MD, FACEP; David E. Steward, MD, FACP; Pierre Theroux, MD, FACC

ACC/AHA guidelines for the management of patients with unstable angina and non–st-segment elevation myocardial infarction: A report of the american college of cardiology/ american heart association task force on practice guidelines (committee on the management of patients with unstable angina)333

Preamble......971nnI.nnIntroduction ......972nnA.nnOrganization of Committee and Evidence Review......972nnB.nnPurpose of These Guidelines......973nnC.nnOverview of the Acute Coronary Syndrome......973nn1.nnDefinition of Terms......973nn2.nnPathogenesis of UA/NSTEMI ......974nn3.nnPresentations of