Tag Archives: Linee guida

“Best Practice” preospedaliera: Arresto cardiaco da trauma

4 Ago

Tra tutte le “Best Practices”, quella che rappresenta più di tutte un cambio radicale di mentalità nell’approccio clinico e terapeutico, è la gestione dell’arresto cardiaco da causa traumatica. Vi prego quindi di leggere attentamente le raccomandzioni raccolte nel documento sottostante e di non esitare a esprimere le vostre riflessioni nei commenti.

Arresto cardiaco adulto traumatico

Chi è interessato ad approfondire il razionale che sta alla base  delle raccomandazioni può scaricare e leggere il documento completo: Arresto cardiaco nell’adulto da causa traumatica full text

 

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“Best Practice” preospedaliera: Arresto cardiaco nel neonato

29 Lug

Continua la pubblicazione di una serie di monografie dedicate alle Best Practices per l’emergenza preospedaliera.

La quarta della serie riguarda l’arresto cardiaco nel neonato.

Potete scaricare il documento cliccando sull’icona sottostante.

Arresto cardiaco neonato

 

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“Best Practice” preospedaliera: Arresto cardiaco in età pediatrica

16 Lug

Continua la pubblicazione di una serie di monografie dedicate alle Best Practices per l’emergenza preospedaliera.

La terza della serie riguarda l’arresto cardiaco in età pediatrica.

Potete scaricare il documento cliccando sull’icona sottostante.Arresto cardiaco pediatrico

 

 

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“Best Practice” preospedaliera: Arresto cardiaco in gravidanza

1 Lug

Continua la pubblicazione di una serie di monografie dedicate alle Best Practices per l’emergenza preospedaliera.

La seconda della serie riguarda l’arresto cardiaco in gravidanza.

Potete scaricare il documento cliccando sull’icona sottostante.

Arresto cardiaco gravidanza_Page_1

 

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“Best Practice” preospedaliera

25 Giu

Da oggi inizia la pubblicazione di una serie di monografie dedicate alle Best Practices per l’emergenza preospedaliera.

La prima riguarda l’arresto cardiaco nel paziente adulto da causa non traumatica.

Potete scaricare il documento cliccando sull’icona sottostante.

Arresto cardiaco adulto non traumatico_Page_1

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Endovascular therapy in Stroke: the 2015 AHA/ASA Updated Guidelines establish new eligibility criteria.

30 Giu

New evidences aroused in treatment of ischemic stroke from early 2015. Large and well conducted trials demonstrated the benefit of endovascular therapy (in association with thrombolysis) on primary clinical endpoints.

MEDEST post on Endovascular Treatment of Ischemic Stroke

Today AHA and ASA  updated the 2013 Stroke Guidelines for the Early Management of Patients With Acute Ischemic Stroke regarding Endovascular Treatment on the basis of this recent evidences.

Let’s resume the recommendations on Endovascular Interventions:

  • Patients who are elegible for intravenous r-tPA should receive r-tPA and in addition endovascular therapy with a stent retriever if they meet all the following criteria (Class I; Level of Evidence A). (New recommendation):
  1. Prestroke modified Ranking Scale score 0 to 1
  2. Acute ischemic stroke receiving intravenous r-tPA within 4.5 hours of onset according to guidelines from professional medical societies
  3. Causative occlusion of the internal carotid artery or proximal MCA (M1)
  4. Age ≥18 years
  5. NIHSS score of ≥6
  6. ASPECTS of ≥6
  7. Treatment can be initiated (groin puncture) within 6 hours of symptom onset
  • To ensure benefit, reperfusion should be achieved as early as possible and within 6 hours of stroke onset (Class I; Level of Evidence B-R). (Revised from the 2013 guideline); if treatment is initiated beyond 6 hours from symptom onset, the effectiveness of endovascular therapy is uncertain (Class IIb; Level of Evidence C). (New recommendation)
  • The benefits are uncertain, on carefully selected patients with acute ischemic stroke in whom treatment
    can be initiated (groin puncture) within 6 hours of symptom onset and who have causative occlusion of the M2 or M3 portion of the MCAs, anterior cerebral arteries, vertebral arteries, basilar artery, or posterior cerebral arteries. (Class IIb; Level of Evidence C). (New recommendation)
  • Endovascular therapy with stent retrievers may be reasonable for some patients <18 years of age with acute ischemic stroke who have demonstrated large vessel occlusion in whom treatment can be initiated (groin puncture) within 6 hours of symptom onset, but the benefits are not established in this age group (Class IIb; Level of Evidence C). (New recommendation)

Read the full text on AHA/ASA website:

2015 AHA/ASA Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment

Read also:

Medscape article: Groups Issue Guidance on Endovascular Repair of Ischemic Stroke (subscription required)

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2014 NICE Guidelines. Acute heart failure: diagnosing and managing acute heart failure in adults

18 Ott

L’uscita di nuove linee guida è sempre un’occasione importante per chi ogni giorno si prende cura di pazienti critici in regime di emergenza-urgenza.

Quando poi l’argomento di cui trattano è importante, e per alcuni aspetti anche controverso, fa ancora più piacere l’uscita di un documento di consenso che permette di avere un riferimento affidabile per la pratica clinica giornaliera.

D’altra parte per i professionisti sanitari le linee guida non devono essere una gabbia professionale, bensì il valore aggiunto che guida le scelte cliniche ma la cui interpretazione critica prelude anche a scelte diverse, ma conseapevoli, da quele indicate.

Le nuove linee guida NICE (National Institute for Healthcare and Ecellence) sulla diagnosi e cura dello scompenso cardiaco acuto (2014 Acute heart failure NICE Full text Guidelines) pongono da questo punto di vista alcuni spunti interessanti quando si tratta di indicazioni per il trattamento iniziale.

Avevamo già trattato in un precedente post il trattamento dell’edema polmonare acuto affrontando le evidenze attuali ed i retaggi culturali che ancora persistono nel suo trattamento.

Vediamo se queste linee guida accolgono o meno i cambiamenti culturali che le nuove evidenze ci propongono.

1.3 Initial pharmacological treatment
1.3.2 Do not routinely offer opiates to people with acute heart failure.
 
Assolutamente d’accordo che il trattamento con oppiacei (se non per aumentare la compliance nel paziente in NIV) è inutile ed a volte dannoso. La somministrazione sistematica di Morfina quindi dovrebbe essere eliminata dall’algoritmo sulla gestione dello scompenso acuto di cuore.
References:
 
1.3.3 Offer intravenous diuretic therapy to people with acute heart failure. Starttreatment using either a bolus or infusion strategy.
 
Ci aspettavamo una scelta più coraggiosa e moderna a questo proposito da parte degli autori. La netta distinzione in termini fisiopatologici ha oramai evidenziato come molti delle presentazioni acute più drammatiche dello scompenso cardiaco non sono assolutamente determinate dal meccanismo del “volume overload” ma piuttosto sul “fluid shift”. Al contrario le presentazioni dovute ad un sovraccarico di volume sono di genesi più refratta nel tempo e quindi con sintomi meno drammatici, e molto spesso si giovano di un trattamento a lungo termine (anche con diuretici) e non sicuramente d’urgenza.
L’utilizzo di diuretici in emergenza per il paziente con scompenso cardiaco ha una utilità molto limitata, è potenzialmente  dannoso e dovrebbe essere riservato solo ad un selezionato selezionato gruppo di pazienti in una fase successiva della del trattamento.
References:
1.3.7 Do not routinely offer nitrates to people with acute heart failure.
1.3.8 If intravenous nitrates are used in specific circumstances, such as for people with concomitant myocardial ischaemia, severe hypertension or regurgitant aortic or mitral valve disease, monitor blood pressure closely in a setting where at least level
2 care can be provided.
 
La pratica clinica quotidiana, specie dopo l’avvento della NIV, ci conferma che l’utilizzo dei nitrati (specie in infusione continua) ha assunto un ruolo ed una priorità secondaria rispetto al trattamento non farmacologico, ma relegare il loro uso solo ad alcune situazioni particolari sembra inutilmente riduttivo per una terapia che presenta molti benefici in questa condizione patologica (elencati nella tabella seguente)
 
Benefits of Nitrate Therapy in Heart Failure

S-nitrosylation of effector proteins (8,13)
 Activates ryanodine receptors to improve myocardial contractility
 Regulates endothelial function
 Inhibits smooth muscle hyperplasia
 Regulates blood flow with changes in tissue oxygen tension matching flow to demand
 Protects myocytes by preventing oxidative damage
 Scavenges superoxide anions
 Regulates energy metabolism
 Protects cells from apoptosis
Guanylyl cyclase activation (8,17)
 Promotes venous and arterial smooth muscle relaxation decreasing preload and afterload
 Inhibits platelet aggregation by inhibiting platelet adhesion to vascular endothelium
 Has anti-inflammatory effects by preventing leukocyte adhesion to vascular endothelium
 Has antiapoptotic effects
 Has antiremodeling effects
Hemodynamic conditions (12,18,19)
 Decreased pulmonary capillary wedge pressure
 Decreased left ventricular end diastolic pressure
 Decreased pulmonary vascular resistance and right ventricular afterload
 Decreased systemic vascular resistance and left ventricular afterload
 Increased venous capacitance
 Decreased right atrial pressure
 Decreases myocardial oxygen demand
Divya Gupta, MD; Vasiliki V. Georgiopoulou, MD; Andreas P. Kalogeropoulos, MD Nitrate Therapy for Heart FailureBenefits and Strategies to Overcome Tolerance JCHF. 2013;1(3):183-191. doi:10.1016/j.jchf.2013.03.003
La somministrazione di Nitrati rimane quindi  (considerando anche i contesti in cui la NIV no è disponibile) un’utile opzione nel trattamento farmacologico dello scompenos cardiaco
1.4 Initial non-pharmacological treatment
1.4.1Do not routinely use non-invasive ventilation (continuous positive airways pressure [CPAP] or non-invasive positive pressure ventilation [NIPPV]) in people with acute heart failure and cardiogenic pulmonary oedema.
1.4.2 If a person has cardiogenic pulmonary oedema with severe dyspnoea and acidaemia consider starting non-invasive ventilation without delay at acute presentation or as an adjunct to medical therapy if the person’s condition has failed to respond
1.4.3 Consider invasive ventilation in people with acute heart failure that, despite treatment, is leading to or is complicated by:
respiratory failure or reduced consciousness or physical exhaustion
 
L’emergenza preospedaliera ha oramai adottato in modo stabile l’utilizzo della ventilazione non invasiva per il trattamento dello scompenso cardiaco. Le linee guida NICE raccomandano il suo utilizzo solo per pazienti che presentano “cardiogenic pulmonary oedema with severe dyspnoea and acidaemia“.
Mentre il criterio clinico sembra molto generico (manca infatti un riferimento ai parametri clinici per definire la dispnea grave, e mancano tutti i criteri di esclusione) risulta per la maggior parte delle nostre realtà territoriali non utilizzabile il parametro strumentale dell’acidemia.
La NIV è attualemnte uno dei cardini fondamentali della terapia non farmacologica dello scompenso cardiaco e il suo utilizzo dovrebbe essere implementato fin dalle prime fasi del soccorso.
References:
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Queste sono solo alcune alcune considerazioni.  Per approfondire l’argomento, potete comunque leggere

Aggiornate le linee guida sulla diagnosi ed il trattamneto della BPCO: GOLD 2014.

25 Giu

GOLD

Aggiornamento linee guida GOLD sulla diagnosi ed il trattamento della BPCO.

Highlights:

Trattamento delle riacutizzazioni

  • Short acting Beta 2 (associati o meno agli anticolinergici) trattamento di scelta

  • L’aggiunta Magnesio Solfato al Salbutamolo per via inalatoria, non migliora il FEV1

  • Corticosteroidi somministrati per via parenterale od orale (unico consigliato per via inalatoria è la Budesonide, ma occhio al costo!). Consiglio: prednisone 40 mg/die

  • La somministrazione precoce di antibiotici migliora i sintomi e la frequenza delle riacutizzazioni. Indicati in caso di:

    • Peggioramento della dispnea

    • Aumento dell’espettorato

    • Espettorato purulento

  • O2 terapia con maschera di Venturi (alti flussi e FiO2 variabile) con target di SaO2 tra 88-92%

Ma all’interno del documento troverete molto di più. Il consiglio è, come al solito, di leggerlo in modo accurato.

Scaricate i documenti completi:

GOLD Guidelines 2014 Full Report

GOLD Guidelines 2014 Pocket Manual

GOLD Guidelines 2014 Slideset

Troverai queste e molte altre linee guida alla pagina dedicata

Linee Guida

MEDEST you tube

 

Linee Guida 2014 sulla gestione del paziente con Fibrillazione Atriale

11 Giu

Rinnovata attenzione al rischio cardioembolico anche nei pazienti con insorgenza databile entro le 48 ore, attenta anamnesi cardiologica per la scelta del farmaco giusto, e molto altro ancora.

Una veloce (e spero completa) guida per il medico d’emergenza al trattamento della FA dal territorio al DEA.

o visualizza la presentazione cliccando qui

References:

2014 AHA_ACC_HRS Guideline for the Management of Patients With Atrial Fibrillation

MEDEST you tube

Highlights from 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation

24 Apr

2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation

Sono state pubblicate le linee guida 2014 sul trattamento dei pazienti con Fibrillazione Atriale.

Ecco i punti  d’interesse per la medicina d’urgenza.

Per approfondire scaricate il full text nella sezione Linee Guida

Definitions:

  • “Paroxysmal AF”    “AF that terminates spontaneously or with intervention within 7 d of onset. Episodes may recur with variable frequency.”
  • “Persistent AF”    “Continuous AF that is sustained >7 d.”
  • “Longstanding persistent AF”    “Continuous AF of >12 mo duration.”
  • “Permanent AF”    “Permanent AF is used when there has been a joint decision by the patient and clinician to cease further attempts to restore and/or maintain sinus rhythm.
  • “Nonvalvular AF”    “AF in the absence of rheumatic mitral stenosis, a mechanical or bioprosthetic heart valve, or mitral valve repair.”
  • “Lone AF” is a historical descriptor that has been variably applied to younger individuals without clinical or echocardiographic evidence of cardiopulmonary disease, hypertension, or diabetes mellitus (4-7).
    Because definitions are variable, the term “lone AF’” is potentially confusing and should not be used to guide
    therapeutic decisions.
Types of AF

AF Types

Clinical Evaluation: Recommendation

Class I
  • Electrocardiographic documentation is recommended to establish the diagnosis of AF. (Level of Evidence: C)

Rate control in AF

Class I
  • Control of the ventricular rate using a beta blocker or nondihydropyridine calcium channel antagonist is recommended for patients with paroxysmal, persistent, or permanent AF (260-262). (Level of Evidence: B)
  • Intravenous administration of a beta blocker or nondihydropyridine calcium channel blocker is  recommended to slow the ventricular heart rate in the acute setting in patients without pre-excitation. In hemodynamically unstable patients, electrical cardioversion is indicated. (Level of Evidence: B)
  • In patients who experience AF-related symptoms during activity, the adequacy of heart rate control should be assessed during exertion, adjusting pharmacological treatment as necessary to keep the ventricular rate within the physiological range. (Level of Evidence: C)
Class IIa
  • A heart rate control (resting heart rate <80 bpm) strategy is reasonable for symptomatic management of AF. (Level of Evidence: B)
  • Intravenous amiodarone can be useful for rate control in critically ill patients without preexcitation. (Level of Evidence: B)
Class IIb
  • A lenient rate-control strategy (resting heart rate <110 bpm) may be reasonable as long as patients remain asymptomatic and LV systolic function is preserved. (Level of Evidence: B)
  • Oral amiodarone may be useful for ventricular rate control when other measures are unsuccessful or contraindicated. (Level of Evidence: C)
Class III: Harm
  • Nondihydropyridine calcium channel antagonists should not be used in patients with decompensated HF as these may lead to further hemodynamic compromise. (Level of Evidence: C)
  • In patients with pre-excitation and AF, digoxin, nondihydropyridine calcium channel antagonists, or intravenous amiodarone should not be administered as they may increase the ventricular response and may result in ventricular fibrillation (274). (Level of Evidence: B)

Drugs

Beta blockers
  • Metoprolol tartrate 2.5–5.0 mg IV bolus over 2 min; up to 3 doses 25–100 mg BID
  • Atenolol  25–100 mg QD
  • Esmolol 500 mcg/kg IV bolus over 1 min, then 50–300 mcg/kg/min IV
  • Propranolol 1 mg IV over 1 min, up to 3 doses at 2 min intervals 10–40 mg TID or QID
  • Nadolol 10–240 mg QD
  • Carvedilol 3.125–25 mg BID
  • Bisoprolol 2.5–10 mg QD
Nondihydropyridine calcium channel antagonists
  • Verapamil (0.075-0.15 mg/kg) IV bolus over 2 min, may give an additional 10.0 mg after 30 min if no response, then 0.005 mg/kg/min infusion 180–480 mg QD (ER)
  • Diltiazem 0.25 mg/kg IV bolus over 2 min, then 5-15 mg/h 120–360 mg QD (ER)
Digitalis glycosides
  • Digoxin 0.25 mg IV with repeat dosing to a maximum of 1.5 mg over 24 h 0.125–0.25 mg QD
Others
  • Amiodarone 300 mg IV over 1 h, then 10–50 mg/h over 24 h 100–200 mg QD

AF indicates atrial fibrillation; BID, twice daily; ER, extended release; IV, intravenous; N/A, not applicable; QD, once
daily; QID, four times a day; and TID, three times a day

Rate-control-strategy-in-AF

Approach to Selecting Drug Therapy for Ventricular Rate Control

Rhythm Control

Electrical and Pharmacological Cardioversion of AF and Atrial Flutter

Thromboembolism Prevention: Recommendations
Class I
  • For patients with AF or atrial flutter of 48-hour duration or longer, or when the duration of AF is unknown, anticoagulation with warfarin (INR 2.0 to 3.0) is recommended for at least 3 weeks prior to and 4 weeks after cardioversion, regardless of the CHA2DS2-VASc score and the method (electrical or pharmacological) used to restore sinus rhythm (313-316). (Level of Evidence: B)
  • For patients with AF or atrial flutter of more than 48 hours or unknown duration that requires immediate cardioversion for hemodynamic instability, anticoagulation should be initiated as soon as possible and continued for at least 4 weeks after cardioversion unless contraindicated. (Level of Evidence: C)
  • For patients with AF or atrial flutter of less than 48-hour duration and with high risk of stroke, intravenous heparin or LMWH, or administration of a factor Xa or direct thrombin inhibitor, is recommended as soon as possible before or immediately after cardioversion, followed by longterm anticoagulation therapy. (Level of Evidence: C)
  • Following cardioversion for AF of any duration, the decision regarding long-term anticoagulation therapy should be based on the thromboembolic risk profile (Section 4). (Level of Evidence: C)
Direct-Current Cardioversion:

A number of technical factors influence cardioversion efficacy, including energy, waveform, and electrode placement. A biphasic waveform is more effective than a monophasic waveform. Anteroposterior electrode placement is superior to anterolateral placement in some but not all studies. If an attempt at cardioversion using 1 electrode placement fails, another attempt using the alternative placement is recommended. The initial use of a higher-energy shock is more effective and may minimize the number of
shocks required as well as the duration of sedation. The risks associated with cardioversion include thromboembolism, sedation-related complications, ventricular tachycardia and fibrillation, bradyarrhythmias, skin burn or irritation from electrodes, muscle soreness, and reprogramming or altering implanted cardiac device function. Elective cardioversion should not be performed in patients with evidence of digoxin toxicity, severe hypokalemia, or other electrolyte imbalances until these factors are corrected.

Recommendations
Class I
  • In pursuing a rhythm-control strategy, cardioversion is recommended for patients with AF or atrial flutter as a method to restore sinus rhythm. If cardioversion is unsuccessful, repeated direct-current cardioversion attempts may be made after adjusting the location of the electrodes or applying pressure over the electrodes, or following administration of an antiarrhythmic medication (320). (Level of Evidence: B)
  • Cardioversion is recommended when a rapid ventricular response to AF or atrial flutter does not respond promptly to pharmacological therapies and contributes to ongoing myocardial ischemia, hypotension, or HF. (Level of Evidence: C)
  • Cardioversion is recommended for patients with AF or atrial flutter and pre-excitation when tachycardia is associated with hemodynamic instability. (Level of Evidence: C)
Pharmacological Cardioversion: Recommendations
Class I
  • Flecainide, dofetilide, propafenone, and intravenous ibutilide are useful for pharmacological cardioversion of AF or atrial flutter provided contraindications to the selected drug are absent. (Level of Evidence: A)
Class IIa

 

  • Administration of oral amiodarone is a reasonable option for pharmacological cardioversion of AF. (Level of Evidence: A)
  • Propafenone or flecainide (“pill-in-the-pocket”) in addition to a beta blocker or nondihydropyridine calcium channel antagonist is reasonable to terminate AF outside the hospital once this treatment has been observed to be safe in a monitored setting for selected patients.(Level of Evidence: B)
Class III: Harm
  • Dofetilide therapy should not be initiated out of hospital owing to the risk of excessive QT prolongation that can cause torsades de pointes. (Level of Evidence: B)
Strategies for Rhythm Control in Patients with Paroxysmal and Persistent AF
Strategies for Rhythm Control in Patients with Paroxysmal and Persistent AF

AF Complicating ACS: Recommendations

Class I
  • Urgent direct-current cardioversion of new-onset AF in the setting of ACS is recommended for patients with hemodynamic compromise, ongoing ischemia, or inadequate rate control. (Level of Evidence: C)
  • Intravenous beta blockers are recommended to slow a rapid ventricular response to AF in patients with ACS who do not display HF, hemodynamic instability, or bronchospasm. (Level of Evidence: C)
Class IIb
  • Administration of amiodarone or digoxin may be considered to slow a rapid ventricular response in patients with ACS and AF associated with severe LV dysfunction and HF or hemodynamic instability. (Level of Evidence: C)
  • Administration of nondihydropyridine calcium antagonists might be considered to slow a rapid ventricular response in patients with ACS and AF only in the absence of significant HF or hemodynamic instability. (Level of Evidence: C)

Hyperthyroidism: Recommendations

Class I
  • Beta blockers are recommended to control ventricular rate in patients with AF complicating thyrotoxicosis unless contraindicated. (Level of Evidence: C)
  • In circumstances in which a beta blocker cannot be used, a nondihydropyridine calcium channel antagonist is recommended to control the ventricular rate. (Level of Evidence: C)

Pulmonary Disease: Recommendations

Class I
  • A nondihydropyridine calcium channel antagonist is recommended to control the ventricular rate in patients with AF and chronic obstructive pulmonary disease. (Level of Evidence: C)
  • Direct-current cardioversion should be attempted in patients with pulmonary disease who become hemodynamically unstable as a consequence of new onset AF. (Level of Evidence: C)

Pulmonary Disease: Recommendations

Class I
  • A nondihydropyridine calcium channel antagonist is recommended to control the ventricular rate in patients with AF and chronic obstructive pulmonary disease. (Level of Evidence: C)
  • Direct-current cardioversion should be attempted in patients with pulmonary disease who become hemodynamically unstable as a consequence of new onset AF. (Level of Evidence: C)

WPW and Pre-Excitation Syndromes: Recommendations

Class I
  • Prompt direct-current cardioversion is recommended for patients with AF, WPW, and rapid ventricular response who are hemodynamically compromised (64). (Level of Evidence: C)2. Intravenous procainamide or ibutilide to restore sinus rhythm or slow the ventricular rate is recommended for patients with pre-excited AF and rapid ventricular response who are not hemodynamically compromised (64). (Level of Evidence: C)
  • Catheter ablation of the accessory pathway is recommended in symptomatic patients with preexcited AF, especially if the accessory pathway has a short refractory period that allows rapid antegrade conduction (64). (Level of Evidence: C)
Class III: Harm
  • Administration of intravenous amiodarone, adenosine, digoxin (oral or intravenous), or nondihydropyridine calcium channel antagonists (oral or intravenous) in patients with WPW syndrome who have pre-excited AF is potentially harmful as they accelerate the ventricular rate. (Level of Evidence: B)

Heart Failure: Recommendations

Class I
  • Control of resting heart rate using either a beta blocker or a nondihydropyridine calcium channel antagonist is recommended for patients with persistent or permanent AF and compensated HF with preserved EF (HFpEF) (262). (Level of Evidence: B)
  • In the absence of pre-excitation, intravenous beta blocker administration (or a nondihydropyridine calcium channel antagonist in patients with HFpEF) is recommended to slow the ventricular response to AF in the acute setting, with caution needed in patients with overt congestion, hypotension, or HF with reduced LVEF (496-499). (Level of Evidence: B)
  • In the absence of pre-excitation, intravenous digoxin or amiodarone is recommended to control heart rate acutely in patients with HF (270, 497, 500, 501). (Level of Evidence: B)
  • Assessment of heart rate control during exercise and adjustment of pharmacological treatment to keep the rate in the physiological range is useful in symptomatic patients during activity. (Level of Evidence: C)
  • Digoxin is effective to control resting heart rate in patients with HF with reduced EF. (Level of Evidence: C)
Class IIa
  • A combination of digoxin and a beta blocker (or a nondihydropyridine calcium channel antagonist for patients with HFpEF), is reasonable to control resting and exercise heart rate in patients with AF (260, 497). (Level of Evidence: B)
  • It is reasonable to perform AV node ablation with ventricular pacing to control heart rate when pharmacological therapy is insufficient or not tolerated (262, 502, 503). (Level of Evidence: B)
  • Intravenous amiodarone can be useful to control the heart rate in patients with AF when other measures are unsuccessful or contraindicated. (Level of Evidence: C)
  • For patients with AF and rapid ventricular response causing or suspected of causing tachycardiainduced cardiomyopathy, it is reasonable to achieve rate control by either AV nodal blockade or a rhythm-control strategy (52, 300, 504). (Level of Evidence: B)
  • For patients with chronic HF who remain symptomatic from AF despite a rate-control strategy, it is reasonable to use a rhythm-control strategy. (Level of Evidence: C)
Class IIb
  • Oral amiodarone may be considered when resting and exercise heart rate cannot be adequately controlled using a beta blocker (or a nondihydropyridine calcium channel antagonist in patients with HFpEF) or digoxin, alone or in combination. (Level of Evidence: C)
  • AV node ablation may be considered when the rate cannot be controlled and tachycardiamediated cardiomyopathy is suspected. (Level of Evidence: C)
Class III: Harm
  • For rate control, intravenous nondihydropyridine calcium channel antagonists, intravenous beta blockers, and dronedarone should not be administered to patients with decompensated HF. (Level of Evidence: C)

 

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این سایت را به آن دکتوران و محصلین طب که شب و روز برای رفاه نوع انسان فداکاری می کنند ، جوانی و لذایذ زندگی را بدون چشمداشت به امتیاز و نفرین و آفرین قربان خدمت به بشر می کنند و بار سنگین خدمت و اصلاح را بدوش می کشند ، اهداء می کنم This site is dedicated to all Doctors and students that aver the great responsibility of People’s well-being upon their shoulders and carry on their onerous task with utmost dedication and Devotionاولین سایت و ژورنال انتــرنتی علـــمی ،تخـصصی ، پــژوهشــی و آمــوزشــی طبـــی در افغــانســـتان

EmergencyPedia

Free Open Access Medical Education

Little Medic

Learning everything I can from everywhere I can. This is my little blog to keep track of new things medical, paramedical and pre-hospital from a student's perspective.

Prehospital Emergency Medicine Blog

All you want to know about prehospital emergency medicine

Italy Customized Travel Blog

Local Travel Agent, sommelier, food & wine expert in Florence, Italy

GoogleFOAM

The FOAM Search Engine

EM Lyceum

where everything is up for debate . . .

Pediatric EM Morsels

Pediatric Emergency Medicine Education

EM Pills

curiosità-novità-aggiornamenti in medicina d'urgenza

AmboFOAM

Free Open Access Medical Education for Paramedics

FOAM4GP

Free Open Access Meducation 4 General Practice

Rural Doctors Net

useful resources for rural clinicians

Auckland HEMS

Unofficial site for prehospital care providers of the Auckland HEMS service

ECHOARTE

L'ECOGRAFIA: ENTROPIA DELL'IMMAGINE

MEDEST

Prehospital Emergency Medicine

ruralflyingdoc

Just another WordPress.com site

EM Basic

Your Boot Camp Guide to Emergency Medicine

KI Doc

WE HAVE MOVED - VISIT WWW.KIDOCS.ORG FOR NEW CONTENT

Emergency Live

Prehospital Emergency Medicine

AMP EM

Academic Medicine Pearls in Emergency Medicine from THE Ohio State University Residency Program

ERCAST Emergency Medicine Podcasts

Emergency medicine, podcasts, reviews, opinion and curbside consults

Prehospital Emergency Medicine

 Academic Life in Emergency Medicine

Prehospital Emergency Medicine

Prehospital Emergency Medicine

Greater Sydney Area HEMS

The Pre-hospital & Retrieval Medicine Team of NSW Ambulance

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