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-2014-080 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.