specialty referral guidelines for cardiovascular...

Specialty ReferralGuidelines forCardiovascularEvaluation andManagement

V.1 ©2002 American Healthways, Inc. All rights reserved.

*A committee of Johns Hopkins faculty and professional staff have reviewed theseguidelines and found them appropriate for use by primary care physicians and otherhealth professionals. Johns Hopkins acted independently of and received compensationfrom American Healthways for this review. Johns Hopkins bears no responsibility forclinical outcomes that result from applying these guidelines.

These clinical referral guidelines were developed with input from representatives ofthe American College of Cardiology, but are not an official document of the ACC.


able of ContentsTIntroduction............................................................................................................................i

Goal, Definition of Referral, Use and Caveats ....................................................................ii

Conference Participants.......................................................................................................iii

Referral Guidelines ...............................................................................................................1

Chest Pain and Coronary Artery Disease...................................................................2

Abnormal Screening Tests ..........................................................................................4

Preoperative Evaluation ..............................................................................................5

Hypertension................................................................................................................6

Lipids and Metabolic Syndrome.................................................................................7

Heart Failure................................................................................................................8

Arrhythmias or Syncope..............................................................................................9

Valvular Heart Disease...............................................................................................12

Congenital Heart Disease..........................................................................................13

Pregnant or Contemplating Pregnancy ...................................................................14

Other ..........................................................................................................................15

Appendix..............................................................................................................................17

Bibliography ...............................................................................................................18

Abbreviations..............................................................................................................19

Selected Clinical Targets ...........................................................................................20

Physician Input/Feedback Request..........................................................................22

Registration and Version Update Request ...............................................................23

Index.....................................................................................................................................25

V.1 ©2002 American Healthways, Inc. All rights reserved. i

Specialty Referral Guidelines for Cardiovascular Evaluation and Management

It is estimated that over 60 million Americans have one or more types of cardiovascular disease (CVD). Given thismagnitude, it is easy to appreciate the impact of CVD on the health and health care cost of Americans. Alarmingly, thescale of this problem has grown rapidly over the last decade. Even more significant growth in the prevalence of CVD, as aresult of the aging of America’s Baby Boomers, is likely to further challenge an ailing health care delivery system.

Fortunately, important technological and pharmacological advances have been made in the treatment of acute andchronic heart disease. Significant improvements have also occurred in primary and secondary prevention of CVD. Theseadvancements are frequently cited as the reason for the decline in the death rates from CVD seen over the last decade.Regrettably, many of these interventions have involved not only costly procedures, but also expensive long-term drugtherapy, further fueling the ever-increasing cost of health care.

Rapidly expanding costs of health care associated with these and other medical interventions stimulated costcontainment efforts in the 1990s that usually focused on utilization of services and appropriateness of specialty care referral.Whether real or perceptual, these steps seemed to result in restriction of access to either physician or medical treatments.While both cost and patient outcomes associated with utilization management approaches were often disappointing, or atbest inconsistent, these practices have dramatically increased the frustrations of patients and physicians.

Data show that physicians have been slow and inconsistent in adopting treatment strategies that have been tested inclinical trials and subsequently incorporated in clinical practice guidelines. Classic examples include the use of beta-blockers in acute myocardial infarction and ACE inhibitors for heart failure. The lackluster penetration of suchestablished evidence-based medicine into practice makes it obvious that current approaches are not a practical solution tothe more global problem.

In view of these issues, focus is shifting away from rigorous utilization management to processes that improve theapplication of evidence-based medicine. This includes such initiatives as the ACC/AHA clinical guidelines. These practiceguidelines have been published and widely circulated for a number of years. Issues with the application of these guidelineshave also been recognized. The ACC has started a Guidelines Applied in Practice (GAP) Program, and the AmericanHeart Association’s Get with the Guidelines project is in place in over 200 hospitals. Both of these efforts have shownpromising results in improving clinical guideline adherence by both cardiologists and primary care physicians.

What has not been clearly addressed is the matter of appropriate referral of patients with CVD to physicianspecialists. To facilitate this process, American Healthways convened a Consensus Conference in which physicianrepresentatives from primary care, cardiology and a variety of other medical specialties, together with representatives frommanaged care organizations, developed the following guidelines. The collaborative effort involved in their creation isintended to provide a set of referral guidelines that are balanced and appropriate from the perspectives of the majormembers of a patient’s health care team.

We are optimistic that appropriate referral and improved application of evidence-based medicine will enhance thequality of care, optimize patient outcomes, and favorably influence the overall cost of care.

ntroductionI


The goal of this document is to provide physicians who deliver primary care ("Primary Physician") to people 18years of age or older who have cardiovascular disease with a set of clinical thresholds that generally indicate the need foradditional professional input. In using these guidelines, primary physicians are urged to take into account such factors astheir own interest, time and expertise, regional practice patterns, availability of specialists and insurance considerations.On balance, it is suggested that it is better to refer in questionable situations than not to refer when indicated,remembering that the purpose of consultation is to add value to the patient’s management.

Referral in this document is defined as, "a request by a physician or other provider for an interaction between apatient and a cardiologist or other appropriate specialist for consultation, evaluation and/or management."

The nature of a referral can only be determined by the referring physician, and follow-up should be mutuallyagreed upon by the specialist and referring physician. Not every referral need be for the purpose of ongoing specialtycare. Appropriate referrals, given the history of other pertinent indicators, might be for testing, consultation, short- orlong-term follow-up, or co-management. Added value may accrue across the entire spectrum of consultant participation.

Finally, because of the chronic, complex and inhomogeneous nature of cardiovascular disease, multipleenvironmental factors may influence the patient’s and physician’s ability to achieve desired goals. These include, but arenot limited to, behavioral issues, psychosocial issues and socioeconomic issues. Since it is impossible to generalize as tothe impact of these factors in an individual situation, physicians are advised to consider any such modifying factors in theirapplication of these referral guidelines.

# # # # #

Variation from these guidelines is always acceptable if, in the opinion of the referring physician or provider,individual circumstances require it.

oal, Definition of Referral, Use and CaveatsGSpecialty Referral Guidelines for Cardiovascular Evaluation and Management

ii

V.1 ©2002 American Healthways, Inc. All rights reserved. iii

Sameer Abu-Samrah, M.D.Darryl Addington, M.D.Iftikhar Ahmad, M.D.Osman Ahmed, M.D., DrPHJohn Anderson, M.D.Timothy Bailey, M.D.Supratim Banerjee, M.D.Denis I. Becker, M.D.Michael Belman, M.D.John Berthiaume, M.D.Sidney Blake, M.D.Charles H. Booras, M.D.Stephen Bradley, M.D.David Buchsbaum, M.D.Arlene Bumbaca, M.D.James Burks, M.D.Timothy Campbell, M.D.Francis X. Campion, M.D.Mark D. Carlson, M.D., FACC*A. Andrew Casano, M.D.Nial Castle, D.O.Larry Chase, M.D.Roy Chen, M.D.David Chess, M.D.Richard S. Chung, M.D.Christopher ColoianKent R. Corral, M.D.William Dang, M.D.Martin Deal, M.D.Craig Dietz, D.O.John Dixon, M.D., FACCLinda DunbarSteven Eisenberg, M.D.Bernie Elliott, M.D.Michael L. Epstein, M.D.*Ronald B. Fiscella, M.D.Kenneth Fishberger, M.D.Neal Friedman, M.D.Ron Y. Fujimoto, D.O.

George Gamblin, M.D.Brian Go, M.D.William R. Gold, M.D.Lee Goldman, M.D.Richard A. Goldstein, M.D.Louis Goolsby, M.D.Bert Groves, M.D., FACC*George Grunberger, M.D.Arvind Gupta, M.D.G. Bruce Head III, M.D.Paul Heidenreich, M.D., FACC*Sharon Hoffarth, M.D.Timothy Howland, M.D.Gregory Hsu, D.O.Joseph Humphry, M.D.Julie L. Johns, M.A.Marjorie King, M.D.Douglas Klink, M.D.Leonard Kryston, M.D.Ken LaBresh, M.D.Lawrence Laslett, M.D., FACC*Virginia T. Latham, M.D.Steven Lefkowitz, M.D.Barry Lewis, D.O., FACC*Howard Lilienfeld, M.D., FACP, FACERodney A. Lorenz, M.D.Steven M. Lum, M.D.Sanford R. Mallin, M.D.Judith Mark, D.O.Linda Marraccini, M.D.Leonard Mastbaum, M.D., FACEKathleen McDarby, RN, MPHJ. Scott McLavy, M.D.John S. Melish, M.D.Carlisle Moore, RNCharles N. Mullican, M.D.Bangalore Murthy, M.D.Allen J. Naftilan, M.D.Michael R. Nagel, M.D., FACC*

Alexander Newman, M.D.Carlos A. Pacheco, M.D.Arun Palkhiwala, M.D.Mary G. Pixler, M.D.James E. Pope, M.D.John O. Pastore, M.D., FACC*Thomas J. Quam, M.D., MBAJeffrey J. Rice, M.D., JDMark Ridinger, M.D.David Rollo, M.D., Ph.D.Mary Elizabeth Roth, M.D.William E. Rush, M.D.Laurie RussellTodd B. Seto, M.D., MPHRobert E. Sevier, M.D.Bonnie Shanis, M.D.David G. Sharp, M.D.Roger Shell, M.D.Dennis Shuman, M.D.Bryan Sitzmann, M.D.James W. Snyder, M.D.Stephen A. South, M.D.Paul Southall, M.D.John L. Stone, M.D.Hemant Thawani, M.D.Stanley Thompson, M.D.Nancy Tilson-Mallett, M.D.Fred G. Toffel, M.D.Dan J. Ullyot, M.D., MACC*Paul Vescovo, M.D.Victor Villagra, M.D.Sylvan Weinberg, M.D., MACC*Kersey Winfree, M.D.Stuart Winston, D.O., FACC*Gordon Wong, M.D., Ph.D., MPHJanet S. Wright, M.D., FACC*Richard F. Wright, MD, FACC*Lin Yong, M.D.

onference ParticipantsC

* Representative of the American College of Cardiology

V.1 ©2002 American Healthways, Inc. All rights reserved. 1

Specialty Referral Guidelinesfor Cardiovascular

Evaluation and Management

V.1 ©2002 American Healthways, Inc. All rights reserved.2

GROUPS/CLASSES/CATEGORIES TRIGGERS REFERRAL GUIDELINE

Acute coronary syndrome

Patients post-revascularization(PTCA/stent/coronary arterybypass) < 12 months

Patient with known coronary arterydisease, including those withrevascularization procedures

• Unstable angina• Acute myocardial infarction• Patients with elevated markers

of cardiac injury

• Asymptomatic

• Emergence of symptoms similar topreoperative ischemia equivalents or symptoms suggesting "new" ischemia

• Failure to readily achieve goals for preventive therapy

• Stable• LVEF < 45%

• Progression of symptoms• Significant changes in EKG• New congestive heart failure or

declining LVEF• Emergence of significant

arrhythmia• Clinical or imaging evidence

of significant inducible ischemia

• Failure to readily achieve goalsfor preventive therapy

➢ Refer to cardiologist.

➢ Cardiologist evaluation or follow-up as determined jointly by primary physician and specialist.

➢ Refer to cardiologist for earlier than scheduled evaluation.

➢ Consider referral to appropriate specialist.

➢ Consider referral to cardiologist on annual basis for overview of risk factor management and reassessment of adequacy ofpreventive therapy.


➢ Consider referral toappropriate specialist.

Variation from this guideline is always acceptable if, in the opinion of the referring physician or provider, individual circumstances require it.

CHEST PAIN AND CORONARY ARTERY DISEASE(Includes stable angina and acute coronary syndrome [unstable angina and MI])


CHEST PAIN AND CORONARY ARTERY DISEASE(Includes stable angina and acute coronary syndrome [unstable angina and MI])


Chest discomfort of uncertainetiology or other symptomssuggestive of myocardial ischemia

• Multiple ER visits for chestdiscomfort without a definitive diagnosis, but has clinicalsuspicion of CAD

• Chest discomfort, atypical for ischemia, in a patient with two or more major coronary risk factors

• Chest discomfort suspicious for angina

• Symptoms suggestive of myocardialischemia




ABNORMAL SCREENING TESTS(This referral guideline should not be construed as supporting the use of routine screeningfor coronary calcium.)


Abnormal screening tests for cardio-vascular disease

• Abnormal stress test

• Presence of multiple risk factors• Change in ECG• Evidence of significant

cerebrovascular or peripheralvascular disease

• Abnormal result of coronarycalcium score in upper quartileof age-adjusted results


➢ Consider referral to cardiologist or other appropriate specialist based on individual patient needs.




Patients at increased perioperativerisk

High-risk surgery with greater than5% cardiovascular mortality (e.g.emergent major operations, aorticand major vascular, peripheralvascular, prolonged surgery withlarge fluid shifts or blood loss)

Patients at low perioperative risk

• Angina (CCS class 2, 3 or 4)• Recent MI (within six months) • Significant aortic stenosis (AS),

valve area < 1.5 cm2

• Uncontrolled arrhythmias• Malignant hypertension• Atrial fibrillation (AF) with

uncontrolled ventricular response • Patients undergoing vascular

surgery• Implanted defibrillator• Unexplained syncope• Congestive heart failure (NYHA

class 3 or 4) or evidence of severe left ventricular dysfunction

• Patients with mechanical valves• Hypertrophic obstructive

cardiomyopathy (HOCM)• Patients with diabetes with poor

functional capacity

• Poor functional capacity(less than four METs)

• Past Hx of AF or well-controlled AF > one year

• NYHA class 1 or 2 CHF • Mild AS, valve area > 1.5 cm2

• Rare ventricular ectopic activity with normal LV function

• Patients on anticoagulationtherapy

• Stable pacemaker patient• Prior history of SVT • Compensated valvular disease,

except AS (see above for AS)• Controlled hypertension• Myocardial infarction > six months

➢ Referral to cardiologist isappropriate for preoperative evaluation.

➢ Perioperative follow-up asmutually agreed upon by primarycare physician, surgeon andcardiologist.

➢ Referral to cardiologist isappropriate for preoperative evaluation.

➢ Cardiology referral at physician’s discretion.


PREOPERATIVE EVALUATION(For patients whose surgery requires or may require general or spinal anesthesia.)



Hypertensive Emergencies

Refractory or Severe Hypertension

Possible Secondary Causes ofHypertension

Evidence of End Organ Damage

• Malignant HTN, as evidenced by:- Papilledema- CHF- Neurologic signs or symptoms- Rapidly deteriorating renal

function - Acute cardiac ischemia

• Failure to reach targets onconventional therapy for six to twelve months (see Pertinent Clinical Targets, page iv).

• Severe hypertensionBP > 220/120 mm Hg

• Creatinine ≥ 2.0 mg/dL, or≥ 2+ dipstick proteinuria

• Unexplained hypokalemia• Hyperadrenergic signs and

symptoms (diaphoresis, tremor, palpitations, paroxysms ofhypertension)

• Signs and symptoms of Cushing’s syndrome (central obesity, easy bruiseability, proximal muscle weakness, striae)

• Age < 30 years • Sudden elevation of BP in

previously stable patient• Abdominal bruit• BP differential in arms or legs

• Heart: ECG, CXR orechocardiogram suggesting ischemic heart disease, or evidenceof LV abnormality such as LBBB or LVH

• Kidney: Proteinuria, azotemia• Eye: Retinopathy• Cerebrovascular disease• Peripheral vascular disease

➢ Immediate referral to physician with expertise in themanagement of hypertension.

➢ Refer to physician with expertise in the management ofhypertension until goals met.

➢ Consider referral to physician with expertise in themanagement of hypertension.

➢ Indication for more extensive work-up for secondary causes of hypertension, and/or referral to physician with expertise in the management of hypertension, forevaluating potential secondary causes.

➢ Indication for more intensive therapy or referral to appropriatespecialist.


HYPERTENSION


LIPIDS AND METABOLIC SYNDROME


Refractory Dyslipidemia

Metabolic Syndrome (This syndromehas been associated with high riskfor future development of CAD)

Patient with at least three of thefollowing:

• Fasting triglycerides > 150 mg/dL • HDL < 40 mg/dL in male, < 50

mg/dL in female• Increased waist circumference > 40

inches in male, > 35 inches in female

• Hypertension with BP > 130/85

• FBS > 110 mg/dL

• Failure to meet NCEP (ATP III) goals in 12 months (or 6 months in patients with recent CV event) (see Pertinent Clinical Targets, page iv).

• Failure to meet NCEP (ATP III) goals after 12 months

• High-risk patients using ATP III risk assessment, and/or other risk stratification or screening for the presence of CAD

➢ Refer to physician with expertise in the treatment of lipiddisorders.

➢ Consider referral to physician with expertise in the treatmentof this disorder.

➢ Consider referral to cardiologist.




Heart Failure (decreased or pre-served systolic function)

• Decompensated as evidenced by:

➢ Need for parenteral IV asoactive drugs

➢ ≥ Two ER visits or hospitaladmissions for heart failurein six months

➢ Current admission toICU/CCU for heart failure

➢ Systolic blood pressure < 90➢ Worsening renal function ➢ Significant arrhythmias➢ Manifestations of myocardial

ischemia➢ Syncope or near syncope➢ Refractory to medical therapy➢ Worsening LV function

• Stable ➢ Non-adherent or non-compliant

• EF by imaging < 30%

• Newly diagnosed heart failure

➢ Refer to cardiologist or heart failure specialist/program.

➢ Consider referral to heart failure specialist/program, healtheducator, case manager, behaviorchange specialist or cardiologist.


➢ Consider referral to cardiologist with mutually agreed uponfollow-up between specialist and referring physician.


HEART FAILURE


ARRHYTHMIAS OR SYNCOPE(Excluding PACs, PVCs)


Atrial Fibrillation or Flutter(paroxysmal or persistent)

Other Supraventricular Tachycardias

AV block

• Signs and/or symptoms of CHF• Symptomatic hypotension• Worsening angina• Uncontrolled ventricular response

rate including with exertion• Embolic phenomena• Symptomatic bradycardia or

pauses in excess of three seconds• New onset atrial fibrillation• Consideration of cardioversion or

Class I or Class III antiarrhythmicdrug therapy*

• Intolerance of or unresponsivenessto standard therapy

• Worsening left ventricular function• Syncope or other CNS symptoms• Evidence of significant valvular

heart disease

(Signs and symptoms as describedabove for atrial fibrillation)• Recurrent sustained SVT (> 30

seconds duration)

• Wolff-Parkinson-White syndrome or other ventricular pre-excitation on ECG

• Recurrent or persistent atrialflutter

• 3rd-degree AV block • 2nd-degree AV block Mobitz II • 2nd-degree AV block Mobitz I

(Wenckebach) symptomatic

• 2nd-degree AV block Mobitz I (Wenckebach) asymptomatic

• Marked 1st-degree AV block

➢ Refer to cardiologist forevaluation, with follow-up as determined by cardiologist in concert with primary care physician.


➢ Refer to cardiologist or cardiac electrophysiologist for evaluation,with follow-up as determined by cardiac specialist in concert with primary care physician.


➢ Consider referral to acardiologist.





Implanted Cardiac Devices

Abnormality on ECG or ambulatoryECG monitor

Syncope or Near-Syncope

Other Bradyarrhythmias

Nonsustained VentricularTachycardia (< 30 seconds induration)

• Wolff-Parkinson-White orventricular pre-excitation syndrome

• Prolonged QT syndrome• Tachy-brady syndrome

• Bifascicular block• New onset LBBB

• Abnormal ECG or cardiovascular evaluation

• Unexplained after initial evaluation

• Symptomaticor

• Heart rate < 45

• > three beats with structural heartdisease

• Symptomatic

• Asymptomatic with no structural heart disease

➢ Periodic review by cardiologist orcardiac electrophysiologist.

➢ Refer to cardiologist or cardiac electrophysiologist for evaluation,with follow-up as determined by cardiologist in concert with primary care physician.






➢ Consider referral to cardiologist for evaluation, with follow-up as determined by cardiologist in concert with primary care physician




Sustained Ventricular Tachycardia, Ventricular Fibrillation or Out-of-Hospital Cardiac Arrest(> 30 seconds duration or requiringemergency therapy before 30 seconds duration)

Other • Patients receiving antiarrhythmic drugs (Class I and Class III)*

• Frequent or symptomatic PVCs

➢ Immediate referral to cardiologist or cardiac electrophysiologist for evaluation, with follow-up as determined by cardiac specialist in concert with primary carephysician.

➢ Consider referral to cardiologist for evaluation, with follow-up as determined by cardiologist in concert with primary care physician.


*Antiarrhythmic Agents by ClassClass I Class III

Quinidine IA AmiodaroneProcainamide IA BretyliumDisopyramide IA SotalolLidocaine IB IbutilideMexiletine IB DofetilideTocainide IB AzimilidePhenytoin IBFlecainide ICPropafenone ICEncainide IC

Moricizine IC

Reference: Crawford, Michael H. and DiMarco, John P., Ed. Cardiology, Mosby, 2001; chapter 4, 2.



VALVULAR HEART DISEASE


Known or suspected valvular heartdisease or prior valvular surgery

• New or recurrent arrhythmias• Syncope• Angina• Neurologic presentations• Significant change in murmur• Unexplained fever or suspected

endocarditis• Signs or symptoms of heart failure• Signs or symptoms of embolic

phenomenon (e.g., Amaurosis Fugax)

• Significant change inechocardiogram

• Change in baseline ECG• Decreasing cardiovascular

functional capacity• Unexplained murmur despite

recent echocardiogram

➢ Referral to cardiologist for earlierthan scheduled reevaluation, with follow-up as recommended by cardiologist.

➢ For all patients withhemodynamically important VHD or prior valvular heartsurgery, a longitudinalmanagement plan should be developed by the cardiologist.




Lesions (operated or unoperated)such as:• Tetralogy of Fallot• Transposition of great vessels• Right ventricular dysplasia• Ostium primum ASD (cushion

defect)• Eisenmenger syndrome• Secundum ASD• Ventricular septal defect without

Eisenmenger physiology• Coarctation, PDA, etc.

• Asymptomatic

• Symptomatic➢ Atrial and/or ventricular

arrhythmias➢ Syncope➢ Hypertension (S/P coarct

repair)➢ Heart failure➢ Angina➢ Cyanosis➢ Respiratory insufficiency

➢ Initial evaluation by adult or pediatric cardiologist, with follow-up as determined by cardiologist.Consider referral to sub-specialistwith special training/experience in congenital heart disease.

➢ Refer to cardiologist for earlier than scheduled reevaluation.


CONGENITAL HEART DISEASE(In the adult patient > 18 years of age)



Pregnant, Contemplating Pregnancy,or Women of Childbearing Potential

• Significant valvular disease• Uncontrolled hypertension • Chronic anticoagulation for

cardiovascular indication• Congenital heart disease• LV dysfunction or prior history

of peripartum cardiomyopathy• Known coronary disease• Pulmonary hypertension• Marfan’s Syndrome• Hypertrophic obstructive

cardiomyopathy• Significant arrhythmias• Cardiomyopathy

➢ Should be referred to cardiologistor other appropriate specialist for evaluation and ongoing care.

Patients with a need for chroniccardiovascular pharmacotherapy mayneed referral to specialist if primary

physician is unfamiliar withteratogenicity of these drug classes.


PREGNANT OR CONTEMPLATING PREGNANCY


OTHER


Conditions including but notlimited to:

• Hypertrophic cardiomyopathy• Pericardial diseases• Marfan’s Syndrome• Cardiac tumors• Aortic dissection

• Discovery ➢ Refer to cardiologist.



Appendix


Auerbach, Andrew D., M.D., MPH, et al. "Patient Characteristics Associated with Care by a Cardiologist Among Adults Hospitalized with Severe Congestive Heart Failure." Journal of the American College of Cardiology, Vol. 36, No. 7, December 2000, 2119-2125.

Beller, George A., M.D., FACC. "President’s Page: Geographic Variations in Delivery of Cardiovascular Care: An Issue of Great Importance to Cardiovascular Specialists." Journal of the American College of Cardiology, Vol. 36, No. 2, August 2000, 652-655.

Borowsky, Steven J., M.D., MPH, et al. "Effect of Physician Specialty on Use of Necessary Coronary Angiography." Journalof the American College of Cardiology, Vol. 26, No. 6, November 1995, 1484-1491.

Casale, Paul N., M.D., FACC, et al. "Patients Treated by Cardiologists Have a Lower In-Hospital Mortality for Acute Myocardial Infarction." Journal of the American College of Cardiology, Vol. 32, No. 4, October 1998, 885-889.

Fye, W. Bruce, M.D., FACC, et al. "Task Force 4: Referral Guidelines and the Collaborative Care of Patients With Cardiovascular Disease." Journal of the American College of Cardiology, May 1997, 1162-1169.

Go, Alan S., M.D., et al. "A Systematic Review of the Effects of Physician Specialty on the Treatment of Coronary Disease and Heart Failure in the United States." The American Journal of Medicine, Vol. 108, February 15, 2000, pp. 216-226.

Hill, Joseph A., M.D., PhD, and Richard E. Kerber, M.D. "Current Perspective: Quo Vadis? How Should We Train Cardiologists at the Turn of the Century?" Circulation, Vol. 102, August 22, 2000, pp. 932-936.

Jollis, James G., M.D., et al. "Outcome of Acute Myocardial Infarction According to the Specialty of the Admitting Physician." The New England Journal of Medicine, Vol. 335, No. 25, December 19, 1996, pp. 1880-1887.

Ladenson, Paul W., M.D. "Cardiology." The Consultation Guide. Ed. Tim Hiscock. Baltimore, MD: Lippincott Williams & Wilkins, 1999, pp. 31-102.

Schreiber, Theodore L., M.D., FACC, et al. "Cardiologist Versus Internist Management of Patients with Unstable Angina: Treatment Patterns and Outcomes." Journal of the American College of Cardiology, Vol. 26, No. 3, September 1995, 577-582.

Stein, Richard A., M.D., et al. "AHA Science Advisory: Safety and Utility of Exercise Testing in Emergency Room Chest Pain Centers." Circulation, Vol. 102, September 19, 2000, pp. 1463-1467.

Warnes, Carole A., M.D., FACC, et al. "Task Force 1: The Changing Profile of Congenital Heart Disease in Adult Life." Journal of the American College of Cardiology, Vol. 37, No. 5, April 2001, 1161-1175.

Zipes, Douglas, M.D., FACC. "President’s Page: Forging Change in Health Care Policy – The Principle Is the Thing." Journal of the American College of Cardiology, Vol. 38, No. 1, July 2001, 270-271.

ibliographyBSpecialty Referral Guidelines for Cardiovascular Evaluation and Management


ACC - American College of CardiologyACE - Angiotensin converting enzyme AF - Atrial fibrillationAHA - American Heart AssociationAS - Aortic stenosisASD - Atrial septal defectATP - Adult Treatment PanelCCS - Canadian Classification SystemCHF - Congestive heart failureCNS - Central nervous systemCVD - Cardiovascular diseaseCXR - Chest X RayECG - ElectrocardiogramEF - Ejection fractionER - Emergency roomFBS - Fasting blood sugarGAP - Guidelines Applied in PracticeHDL - High-density lipoproteinHOCM - Hypertrophic obstructive cardiomyopathyHTN - HypertensionLBBB - Left bundle branch blockLDL - Low-density lipoproteinLVEF - Left ventricular ejection fractionLVH - Left ventricular hypertrophyMETs - Metabolic equivalent tasksMI - Myocardial infarctionNCEP - National Cholesterol Educational ProgramNYHA - New York Heart AssociationPDA - Patent ductus arteriosusPTCA - Percutaneous transluminal coronary angioplastyS/P - Status postSVT - Supraventricular tachycardiaVHD - Valvular heart disease

bbreviationsASpecialty Referral Guidelines for Cardiovascular Evaluation and Management


This section has been provided as a summary of the pertinent blood pressure, cholesterol and diabetes clinical targets for a personwith cardiovascular disease.

Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure – The Sixth Report

• Evidence-based and consensus support for the treatment of hypertension• Encourages lifestyle modification to prevent hypertension and as additional therapy for all with hypertension

Blood Pressure Goal• < 140/90 mm Hg and lower if tolerated• < 130/80 mm Hg for patients with diabetes (ADA/NKF goal) • < 125/75 mm Hg for patients with renal failure/proteinuria

If BP Elevated Over Goal, then• Lifestyle modifications• Pharmacology

•• For most patients, start with a low dose of a long-acting once-daily drug and titratedose based on agent, need and response

•• Low-dose combination therapy as appropriate

National Cholesterol Education Program – Expert Panel on Detection, Evaluation and Treatment of High BloodCholesterol in Adults – Adult Treatment Panel (ATP) III

• Evidence-based support for the treatment of patients with coronary heart disease• Focuses on primary prevention in patients with multiple risk factors for coronary heart disease

For patients with known atherosclerosis or diabetes, treatment decisions based on LDL or non-HDL cholesterol• LDL < 100 mg/dL• If Triglycerides > 200 mg/dL after LDL goal is reached, set secondary goal for non-HDL cholesterol

(total cholesterol – HDL ) 30 mg/dL higher than LDL goal.Note: Normal serum triglyceride is <150 mg/dl and low HDL cholesterol is <40 mg/dl

Common appropriate interventions• LDL > 130mg/dL

•• Intensive lifestyle therapies•• Maximum control of other factors•• Consider starting LDL-lowering drugs simultaneously with lifestyle therapies

• LDL 100-129 mg dL•• LDL lowering by lifestyle and/or drug therapies•• Treatment of metabolic syndrome•• Drug therapy for other lipid risk factors

elected Clinical TargetsSSpecialty Referral Guidelines for Cardiovascular Evaluation and Management



American Diabetes Association: Clinical Practice Recommendations 2001

Criteria for the diagnosis of diabetes*• FPG >126mg/dL• 2-h PG >200mg/dL• Symptoms of diabetes and casual plasma glucose concentration >200mg/dL

* A diagnosis of diabetes must be confirmed, on a subsequent day, by measurement of FPG, 2-h PG, or randomplasma glucose (if symptoms are present).

Glycemic Control Goals for People with Diabetes

• Whole Blood Values•• Average preprandial glucose (mg/dL) 80-120•• Average Bedtime Glucose (mg/dL) 100-140

• Plasma Values•• Average preprandial glucose (mg/dL) 90-130•• Average bedtime glucose (mg/dL) 110-150

From: Diabetes Care, vol. 25, suppl. 1, January 2002.

21


This document, Specialty Referral Guidelines for Cardiovascular Evaluation and Management, represents a work in progress.While this version of the Guidelines reflects the input of over 100 physicians and other health care professionals represent-ing literally thousands of years of clinical experience, their ultimate effectiveness can only be enhanced through thereceipt of additional input or feedback from practicing physicians based on their actual use of the Guidelines.

Please help us help you in this important effort by taking the time to share your experiences with us.

Thank you,American Healthways

Please return this form by fax to:

American Healthways • Specialty Referral Guidelines Council • 3841 Green Hills Village Drive, Suite 300Nashville, TN 37215 • Fax: 615.665.7697

hysician Input/Feedback RequestP

Name:

Address:

City: State: Zip:

Phone: Fax:

E-mail:

❑ Primary Physican ❑ Specialist / Type:

Specific Recommendations:

Goal of the Recommendations:


PHYSICIAN INPUT/FEEDBACK FORM

22


This document, Specialty Referral Guidelines for Cardiovascular Evaluation and Management, represents a work in progress.We anticipate issuing updated versions on the basis of additional physician input and feedback, changes in medicalpractice and changes in standards of care for this population.

If you are a physician, other provider or health plan whose organization is using the Guidelines, please complete thisRequest Form and fax it back to us so that we may advise you of updates to the Guidelines as they become available.

Thank you.

American Healthways

Please return this form by fax to:

American Healthways • Specialty Referral Guidelines Council • 3841 Green Hills Village Drive, Suite 300Nashville, TN 37215 • Fax: 615.665.7697

egistration and Version Update RequestR

Name:

Title:

Organization Name:

Address:

City: State: Zip:

Phone: Fax:

E-mail:


VERSION UPDATE REQUEST FORM


Index


AAbdominal bruit 6ACE inhibitors iAcute coronary syndrome 2,3Angina 2,3,5,9,12,13Anti-coagulation therapy 5Aortic stenosis 5,19Atherosclerosis 20Atrial fibrillation 5,9,19Atrial flutter 9AV block 9

BBeta-blockers iBlood pressure 8,20Bradycardia 9Bradyarrhythmias 10

CCardiovascular disease i,ii,4,

19,20Chest pain 3Cholesterol 20Coarctation, PDA 13Congestive heart failure i,2,5,19Coronary calcium score 4Creatinine 6

DDiabetes 5,20,21Dipstick proteinuria 6Dyslipidemia 7

EECG 4,6,9,10,12,19Eisenmenger syndrome 13

FFBS (fasting blood sugar) 7,19

GGuidelines Applied in Practice

(GAP) i,19

HHDL 7,19,20Heart failure 8,12,13,Hyperadrenergic 6Hypertension 5,6,7,13,14,19,20Hypertrophic obstructive

cardiomyopathy (HOCM) 5,14,19

Hypokalemia 6

IImplanted defibrillator 5Ischemia 2,3,6,8

LLBBB (left bundle branch

block) 6,10,19LDL 19,20LVEF (left ventricular ejection

fraction) 2,19LVH (left ventricular

hypertrophy) 6,19

MMalignant HTN 6Malignant hypertension 5Marfan’s Syndrome 14,15Mechanical valves 5Metabolic syndrome 7,20Mobitz I 9Mobitz II 9Myocardial infarction (MI)

i,2,3,5,18,19 Myocardial ischemia 3,8

NNCEP (National Cholesterol

Education Program) 7,19NYHA (New York Heart

Association) 5,19

OOstium primum ASD 13

PPacemaker 5Papilledema 6Peripartum cardiomyopathy 14Pregnancy 14Primary physician ii,14Proteinuria 6,20PTCA/stent 2Pulmonary hypertension 14

RReferral i,iiRenal function 6,8

SSecundum ASD 13Stress test 4Supraventricular tachycardia.

9,19Syncope 5,8,9,10,11,12,13

TTetralogy of Fallot 13Transposition of great vessels 13Triglycerides 7,20

UUnstable angina 2,3

VValvular heart disease 9,12,19Ventricular arrhythmia 13Ventricular dysplasia 13Ventricular ectopic activity 5Ventricular fibrillation 11Ventricular septal defect 13Ventricular tachycardia 9,11,19

WWPW (Wolff-Parkinson-White

Syndrome) 9,10

ndexISpecialty Referral Guidelines for Cardiovascular Evaluation and Management

3841 Green Hills Village DriveNashville, TN 372151-800-327-3822


specialty referral guidelines for cardiovascular...

Documents