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2013AHA心血管病风险评估指南

Stone and Peter W.F. Wilson

Jennifer Robinson, J. Sanford Schwartz, Susan T. Shero, Sidney C. Smith, Jr, Paul Sorlie, Neil J.Raymond Gibbons, Philip Greenland, Daniel T. Lackland, Daniel Levy, Christopher J. O'Donnell, David C. Goff, Jr, Donald M. Lloyd-Jones, Glen Bennett, Sean Coady, Ralph B. D'Agostino, Sr,Guidelines American College of Cardiology/American Heart Association Task Force on Practice 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk: A Report of the Print ISSN: 0009-7322. Online ISSN: 1524-4539

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2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk A Report of the American College of Cardiology/American Heart Association

Task Force on Practice Guidelines

Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation, American Society for Preventive Cardiology, American Society of Hypertension, Association of Black

Cardiologists, National Lipid Association, Preventive Cardiovascular Nurses Association, and WomenHeart: The National Coalition for Women with Heart Disease

EXPERT WORK GROUP MEMBERS

David C. Goff, Jr, MD, PhD, FACP, FAHA, Co-Chair

Donald M. Lloyd-Jones, MD, ScM, FACC, FAHA, Co-Chair

Glen Bennett, MPH* Christopher J. O’Donnell, MD,MPH*

Sean Coady, MS* Jennifer Robinson, MD, MPH, FAHA

Ralph B. D’Agostino, Sr, PhD, FAHA J. Sanford Schwartz, MD

Raymond Gibbons, MD, FACC, FAHA Susan T. Shero, MS, RN*

Philip Greenland, MD, FACC, FAHA Sidney C. Smith, Jr, MD, FACC, FAHA

Daniel T. Lackland, DrPH, FAHA Paul Sorlie, PhD*

Daniel Levy, MD* Neil J. Stone, MD, FACC, FAHA

Peter W.F. Wilson, MD, FAHA

Methodology Members

Harmon S. Jordan, ScD

Lev Nevo, MD

Janusz Wnek, PhD

ACCF/AHA TASK FORCE MEMBERS

Jeffrey L. Anderson, MD, FACC, FAHA, Chair

Jonathan L. Halperin, MD, FACC, FAHA, Chair-Elect

Nancy M. Albert, PhD, CCNS, CCRN, FAHA Judith S. Hochman, MD, FACC, FAHA

Biykem Bozkurt, MD, PhD, FACC, FAHA Richard J. Kovacs, MD, FACC, FAHA

Ralph G. Brindis, MD, MPH, MACC E. Magnus Ohman, MD, FACC

Lesley H. Curtis, PhD, FAHA Susan J. Pressler, PhD, RN, FAAN, FAHA

David DeMets, PhD Frank W. Sellke, MD, FACC, FAHA

Robert A. Guyton, MD, FACC Win-Kuang Shen, MD, FACC, FAHA

Subcommittee on Prevention Guidelines

Sidney C. Smith, Jr, MD, FACC, FAHA, Chair

Gordon F. Tomaselli, MD, FACC, FAHA, Co-Chair

*Ex-Officio Members.

This document was approved by the American College of Cardiology Board of Trustees and the American Heart Association Science Advisory and Coordinating Committee in November 2013.

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The American Heart Association requests that this document be cited as follows: Goff DC Jr, Lloyd-Jones DM, Bennett G,

Coady S, D’Agostino RB Sr, Gibbons R, Greenland P, Lackland DT, Levy D, O’Donnell CJ, Robinson J, Schwartz JS, Smith SC

Jr, Sorlie P, Shero ST, Stone NJ, Wilson PW. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;00:000–000.

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? 2013 The Expert Work Group Members. The Journal of the American College of Cardiology is published on behalf of the American College of Cardiology Foundation by Elsevier Inc.; Circulation is published on behalf of the American Heart Association, Inc., by Wolters Kluwer. This is an open access article under the terms of the Creative Commons Attribution Non-Commercial-NoDervis License, which permits use, distribution, and reproduction in any medium, provided that the Contribution is properly cited, the use is non-commercial, and no modifications or adaptations are made.

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DOI: 10.1161/01.cir.0000437741.48606.98

Table of Contents

Preamble and Transition to ACC/AHA Guidelines to Reduce Cardiovascular Risk (4)

1. Introduction (9)

1.1. Organization of the Work Group (9)

1.2. Document Review and Approval (9)

1.3. Charge to the Work Group (9)

1.4. Methodology and Evidence Review (9)

2. Risk Assessment: Recommendations (10)

3. Approach to Risk Assessment (11)

4. Development of New Pooled Cohort ASCVD Risk Equations (13)

4.1. Recommendations for Assessment of 10-Year Risk for a First Hard ASCVD Event (14)

5. Implications for Risk Assessment (15)

6. CQs and Systematic Evidence Review (18)

6.1. Critical Question 1 (18)

6.1.1. Summary of Systematic Reviews and Meta-Analyses for CQ1 (19)

6.1.2. Recommendations for CQ1: use of Newer Risk Markers After Quantitative Risk Assessment (20)

6.2. Critical Question 2 (21)

6.2.1. Summary of Evidence for CQ2 (21)

6.2.2. Recommendations for CQ2: Long-Term Risk Assessment (22)

7. Implementation Considerations for Risk Assessment (23)

8. Evidence Gaps and Future Research Needs (24)

9. Conclusions (24)

Appendix 1. Evidence Statements for CQ1 (26)

Appendix 2. Evidence Statements for CQ2 (32)

Appendix 3. Characteristics of Previously Published Risk Scores and Current Pooled Cohort Equations (34)

Appendix 4. Development and Steps for Implementation of the ASCVD Pooled Cohort Risk Equations (36)

Appendix 5. Author Relationships With Industry and Other Entities (Relevant) (41)

Appendix 6. ACC/AHA Expert Reviewer Relationships With Industry and Other Entities (45)

Appendix 7. Abbreviations (46)

References (47)

Preamble and Transition to ACC/AHA Guidelines to Reduce Cardiovascular Risk

The goals of the American College of Cardiology (ACC) and the American Heart Association (AHA) are to prevent cardiovascular (CV) diseases, improve the management of people who have these diseases through professional education and research, and develop guidelines, standards and policies that promote optimal patient care and CV health. Toward these objectives, the ACC and AHA have collaborated with the National Heart, Lung, and Blood Institute (NHLBI) and stakeholder and professional organizations to develop clinical practice guidelines for assessment of CV risk, lifestyle modifications to reduce CV risk, and management of blood cholesterol, overweight and obesity in adults.

In 2008, the NHLBI initiated these guidelines by sponsoring rigorous systematic evidence reviews for each topic by expert panels convened to develop critical questions (CQs), interpret the evidence and craft recommendations. In response to the 2011 report of the Institute of Medicine on the development of trustworthy clinical guidelines (1), the NHLBI Advisory Council (NHLBAC) recommended that the NHLBI focus specifically on reviewing the highest quality evidence and partner with other organizations to develop recommendations (2,3). Accordingly, in June 2013 the NHLBI initiated collaboration with the ACC and AHA to work with other organizations to complete and publish the 4 guidelines noted above and make them available to the widest possible constituency. Recognizing that the expert panels did not consider evidence beyond 2011 (except as specified in the methodology), the ACC, AHA, and collaborating societies plan to begin updating these guidelines starting in 2014.

The joint ACC/AHA Task Force on Practice Guidelines (Task Force) appointed a subcommittee to shepherd this transition, communicate the rationale and expectations to the writing panels and partnering organizations and expeditiously publish the documents. The ACC/AHA and partner organizations recruited a limited number of expert reviewers for fiduciary examination of content, recognizing that each document had undergone extensive peer review by representatives of the NHLBAC, key Federal agencies and scientific experts. Each writing panel responded to comments from these reviewers. Clarifications were incorporated where appropriate, but there were no substantive changes as the bulk of the content was undisputed.

Although the Task Force led the final development of these prevention guidelines, they differ from other ACC/AHA guidelines. First, as opposed to an extensive compendium of clinical information, these documents are significantly more limited in scope and focus on selected CQs in each topic, based on the highest quality evidence available. Recommendations were derived from randomized trials, meta-analyses, and observational studies evaluated for quality, and were not formulated when sufficient evidence was not available. Second, the text accompanying each recommendation is succinct, summarizing the evidence for each question. The Full Panel Reports include more detailed information

about the evidence statements that serves as the basis for recommendations. Third, the format of the recommendations differs from other ACC/AHA guidelines. Each recommendation has been mapped from the NHLBI grading format to the ACC/AHA Class of Recommendation/Level of Evidence (COR/LOE) construct (Table 1) and is expressed in both formats. Because of the inherent differences in grading systems and the clinical questions driving the recommendations, alignment between the NHLBI and ACC/AHA formats is in some cases imperfect. Explanations of these variations are noted in the recommendation tables, where applicable.

Table 1. Applying Classification of Recommendation and Level of

Evidence

A recommendation with Level of Evidence

B or

C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Even when

randomized trials are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.

*Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as sex, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use.

?For comparative effectiveness recommendations (Class I and IIa; Level of Evidence A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated.

In consultation with NHLBI, the policies adopted by the writing panels to manage relationships of authors with industry and other entities (RWI) are outlined in the methods section of each panel report. These policies were in effect when this effort began in 2008 and throughout the writing process and voting on recommendations, until the process was transferred to ACC/AHA in 2013. In the interest of transparency, the ACC/AHA requested that panel authors resubmit RWI disclosures as of July 2013. Relationships relevant to this guideline are disclosed in Appendix 5. None of the ACC/AHA expert reviewers had relevant RWI (Appendix 6).

Systematic evidence reports and accompanying summary tables were developed by the expert panels and NHLBI. The guideline was reviewed by the ACC/AHA Task Force and approved by the ACC Board of Trustees, the AHA Science Advisory and Coordinating Committee, and the governing bodies of partnering organizations. In addition, ACC/AHA sought endorsement by other stakeholders, including professional organizations. It is the hope of the writing panels, stakeholders, professional organizations, NHLBI, and the Task Force that the guidelines will garner the widest possible readership for the benefit of patients, providers and the public health.

Guidelines attempt to define practices that meet the needs of patients in most circumstances and are not a replacement for clinical judgment. The ultimate decision about care of a particular patient must be made by the healthcare provider and patient in light of the circumstances presented by that patient. As a result, situations might arise in which deviations from these guidelines may be appropriate. These considerations notwithstanding, in caring for most patients, c linicians can employ the recommendations confidently to reduce the risks of atherosclerotic cardiovascular disease (ASCVD) events.

See Tables 2 and 3 for an explanation of the NHLBI recommendation grading methodology.

Table 2. NHLBI Grading the Strength of Recommendations

Grade Strength of Recommendation*

A Strong recommendation

There is high certainty based on evidence that the net benefit? is substantial.

B Moderate recommendation

There is moderate certainty based on evidence that the net benefit is moderate to substantial, or there is high certainty that the net benefit is moderate.

C Weak recommendation

There is at least moderate certainty based on evidence that there is a small net benefit.

D Recommendation against

There is at least moderate certainty based on evidence that it has no net benefit or that risks/harms outweigh benefits.

E Expert opinion (“There is insufficient evidence or evidence is unclear or conflicting, but this is what the Work Group recommends.”)

Net benefit is unclear. Balance of benefits and harms cannot be determined because of no evidence, insufficient evidence, unclear evidence, or conflicting evidence, but the Work Group thought it was important to provide clinical guidance and make a recommendation. Further research is recommended in this area.

N No recommendation for or against (“There is insufficient evidence or evidence is unclear or conflicting.”)

Net benefit is unclear. Balance of benefits and harms cannot be determined because of no evidence, insufficient evidence, unclear evidence, or conflicting evidence, and the Work Group thought no recommendation should be made. Further research is recommended in this area.

*In most cases, the strength of the recommendation should be closely aligned with the quality of the evidence; however, under some circumstances, there may be valid reasons for making recommendations that are not closely aligned with the quality of the evidence (e.g., strong recommendation when the evidence quality is moderate, like smoking cessation to reduce CVD risk or ordering an ECG as part of the initial diagnostic work-up for a patient presenting with possible MI). Those situations should be limited and the rationale explained clearly by the Work Group.

?Net benefit is defined as benefits minus risks/harms of the service/intervention.

CVD indicates cardiovascular risk; ECG, electrocardiography; MI, myocardial infarction; and NHLBI, National Heart, Lung, and Blood Institute.

Table 3. Quality Rating the Strength of Evidence

Type of Evidence Quality Rating* ?Well-designed, well-executed? RCTs that adequately represent populations to

which the results are applied and directly assess effects on health outcomes.

?MAs of such studies.

Highly certain about the estimate of effect. Further research is unlikely to change

our confidence in the estimate of effect.

High

?RCTs with minor limitations? affecting confidence in, or applicability of, the

results.

?Well-designed, well-executed nonrandomized controlled studies§ and well-

designed, well-executed observational studies║.

?MAs of such studies.

Moderately certain about the estimate of effect. Further research may have an

impact on our confidence in the estimate of effect and may change the estimate.

Moderate

?RCTs with major limitations.

Low ?Nonrandomized controlled studies and observational studies with major

limitations affecting confidence in, or applicability of, the results.

?Uncontrolled clinical observations without an appropriate comparison group

(e.g., case series, case reports).

?Physiological studies in humans.

?MAs of such studies.

Low certainty about the estimate of effect. Further research is likely to have an

impact on our confidence in the estimate of effect and is likely to change the

estimate.

*In some cases, other evidence, such as large all-or-none case series (e.g., jumping from airplanes or tall structures), can represent high or moderate quality evidence. In such cases, the rationale for the evidence rating exception should be explained by the Work Group and clearly justified.

?Well-designed, well-executed refers to studies that directly address the question, use adequate randomization, blinding, allocation concealment, are adequately powered, use ITT analyses, and have high follow-up rates.

?Limitations include concerns with the design and execution of a study that result in decreased confidence in the true estimate of the effect. Examples of such limitations include, but are not limited to: inadequate randomization, lack of blinding of study participants or outcome assessors, inadequate power, outcomes of interest are not prespecified or the primary outcomes, low follow-up rates, or findings based on subgroup analyses. Whether the limitations are considered minor or major is based on the number and severity of flaws in design or execution. Rules for determining whether the limitations are considered minor or major and how they will affect rating of the individual studies will be developed collaboratively with the methodology team.

§Nonrandomized controlled studies refer to intervention studies where assignment to intervention and comparison groups is not random (e.g., quasi-experimental study design)

║Observational studies include prospective and retrospective cohort, case-control, and cross sectional studies.

ITT indicates intention-to-treat; MA, meta-analysis; and RCT, randomized controlled trial.

1. Introduction

1.1. Organization of the Work Group

The Risk Assessment Work Group (Work Group) was composed of 11 members and 5 ex-officio members, including internists, cardiologists, endocrinologists, and experts in CV epidemiology, biostatistics, healthcare management and economics, and guideline development.

1.2. Document Review and Approval

A formal peer review process, which included 12 expert reviewers and representatives of Federal agencies, was initially completed under the auspices of the NHLBI. This document was also reviewed by 3 expert reviewers nominated by the ACC and the AHA when the management of the guideline transitioned to the ACC/AHA. The ACC and AHA Reviewers’ RWI information is published in this document (6).

This document was approved for publication by the governing bodies of the ACC and AHA and endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation, American Society for Preventive Cardiology, American Society of Hypertension, Association of Black Cardiologists, National Lipid Association, Preventive Cardiovascular Nurses Association, and WomenHeart: The National Coalition for Women with Heart Disease.

1.3. Charge to the Work Group

The Work Group was 1 of 3 work groups appointed by the NHLBI to develop its own recommendations and provide cross-cutting input to 3 Expert Panels for updating guidelines on blood cholesterol, blood pressure (BP), and overweight/obesity.

The Work Group was asked to examine the scientific evidence on risk assessment for initial ASCVD events, and to develop an approach for risk assessment that could be used in practice and used or adapted by the risk factor panels (cholesterol, hypertension, and obesity) in their guidelines and algorithms. Specifically, the Work Group was charged with 2 tasks:

1.To develop or recommend an approach to quantitative risk assessment that could be used to guide

care; and

2.To pose and address a small number of questions judged to be critical to refining and adopting

risk assessment in clinical practice using systematic review methodology.

1.4. Methodology and Evidence Review

This guideline is based on the Full Work Group Report which is provided as a supplement to the guideline. The Full Work Group Report contains background and additional material related to content, methodology, evidence synthesis, rationale, and references and is supported by the NHLBI Systematic Evidence Review which can be found at

(https://www.wendangku.net/doc/922667596.html,/guidelines/cvd_adult/risk_assessment/). These documents also describe the process for the development of novel, comprehensive multivariable risk equations for the prediction of 10-year risk for development of ASCVD in nonHispanic African-American and nonHispanic White men and women from 40 to 79 years of age. These equations were developed from several long-standing population-based cohort studies funded by the NHLBI. Ten-year risk was defined as the risk of

developing a first ASCVD event, defined as nonfatal myocardial infarction or coronary heart disease (CHD) death, or fatal or nonfatal stroke, over a 10-year period among people free from ASCVD at the beginning of the period.

In addition, through evaluation of evidence developed through systematic reviews of the literature, the Work Group addressed the following 2 CQs:

CQ1: “What is the evidence regarding reclassification or contribution to risk assessment when high-sensitivity C-reactive protein (hs-CRP), apolipoprotein B (ApoB), glomerular filtration rate (GFR), microalbuminuria, family history, cardiorespiratory fitness, ankle-brachial index (ABI), carotid intima-media thickness (CIMT), or coronary artery calcium (CAC) score are

considered in addition to the variables that are in the traditional risk scores?”

CQ2: “Are models constructed to assess the long-term (≥15 years or lifetime) risk for a first

cardiovascular disease (CVD) event in adults effective in assessing variation in long-term risk

among adults at low and/or intermediate short-term risk, whether analyzed separately or

combined?”

The evidence and recommendations in the guideline focus on the large proportion of the adult population without clinical signs or symptoms of ASCVD, who merit evaluation for the primary

prevention of ASCVD. They do not apply to those with clinically-manifest ASCVD, who require

secondary prevention approaches, or to highly-selected patient subgroups, such as those with symptoms suggestive of CVD who require diagnostic strategies rather than risk assessment. Furthermore, these recommendations were not developed for use in specific subgroups of asymptomatic individuals at

unusually high risk, such as those with genetically determined extreme values of traditional risk factors

(e.g., patients with familial hypercholesterolemia).

2. Risk Assessment: Recommendations

Table 4. Summary of Recommendations for Risk Assessment

Recommendations NHLBI Grade

NHLBI

Evidence

Statements

ACC/AHA

COR

ACC/AHA

LOE

1.The race- and sex-specific Pooled Cohort

Equations* to predict 10-year risk for a first

hard ASCVD event should be used in

nonHispanic African Americans and

nonHispanic Whites, 40 to 79 years of age.

B (Moderate) N/A I B (4-8)

A downloadable spreadsheet enabling estimation of 10-year and lifetime risk for ASCVD and a web-based

calculator are available at https://www.wendangku.net/doc/922667596.html,/cvriskcalculator and https://www.wendangku.net/doc/922667596.html,/science-

and-quality/practice-guidelines-and-quality-standards/2013-prevention-guideline-tools.aspx.

*Derived from the ARIC study (8), CHS (5), CARDIA study (23), Framingham original and offspring cohorts (4,6).

?Based on new evidence reviewed during ACC/AHA update of evidence.

?Age, sex, total and HDL–cholesterol, systolic BP, use of antihypertensive therapy, diabetes, and current smoking.

ABI indicates ankle-brachial index; ACC, American College of Cardiology; AHA, American Heart Association;

ApoB, Apolipoprotein B; ASCVD, atherosclerotic cardiovascular disease; BP, blood pressure; CAC, coronary artery

calcium;; CKD, chronic kidney disease; CIMT, carotid intima-media thickness; COR, Class of Recommendation;

CQ, critical question, ES, evidence statement; HDL–C, high-density lipoprotein cholesterol; hs-CRP, high-

sensitivity C-reactive protein; LOE, Level of Evidence; and NHLBI, National Heart, Lung, and Blood Institute.

3. Approach to Risk Assessment

In addressing its charge, the Work Group recognized the need for a risk assessment approach that was

based on the types of data that primary care providers could easily collect and that could be implemented

in routine clinical practice. After deliberation, the Work Group endorsed the existing and widely

employed paradigm of matching the intensity of preventive efforts with the individual’s absolute risk

(24,25). The Work Group acknowledges that none of the risk assessment tools or novel risk markers

examined in the present document have been formally evaluated in randomized controlled trials of

2. Use of the sex-specific Pooled Cohort

Equations for nonHispanic Whites may be

considered when estimating risk in patients

from populations other than African

Americans and nonHispanic Whites.

E (Expert Opinion) Appendix 2 CQ2/ES1 IIb C 3. If, after quantitative risk assessment, a risk-

based treatment decision is uncertain,

assessment of 1 or more of the following—

family history, hs-CRP, CAC score, or

ABI—may be considered to inform

treatment decision making.

E (Expert Opinion) Appendix 1 IIb? B (9-17) 4. The contribution to risk assessment for a

first ASCVD event using ApoB, CKD,

albuminuria, or cardiorespiratory fitness is

uncertain at present.

N (No Recommendation For or Against) Appendix 1 N/A N/A 5. CIMT is not recommended for routine

measurement in clinical practice for risk

assessment for a first ASCVD event.

N (No Recommendation For or Against) Appendix 1 III: No Benefit? B (12,16,18) 6. It is reasonable to assess traditional ASCVD

risk factors? every 4 to 6 years in adults 20 to

79 years of age who are free from ASCVD

and to estimate 10-year ASCVD risk every 4

to 6 years in adults 40 to 79 years of age

without ASCVD.

B (Moderate) Appendix 2 CQ2/ES7 IIa B (19,20) 7. Assessing 30-year or lifetime ASCVD risk

based on traditional risk factors? may be

considered in adults 20 to 59 years of age

without ASCVD and who are not at high

short-term risk. C (Weak) Appendix 2 CQ2/ES2, CQ2/ES3, CQ2/ES4, CQ2/ES5,

CQ2/ES6

IIb C (20-22)

screening strategies with clinical events as outcomes. Nevertheless, this approach balances an understanding of an individual’s absolute risk for CVD and potential treatment benefits against the potential absolute risks for harm from therapy. Using this framework, treatment can be targeted to those most likely to benefit without undue risk for harm, in the context of a “risk discussion.” A risk discussion could include the assessment of the patient’s risk for ASCVD, and potential benefits, negative aspects, risks, and patient preferences regarding initiation of relevant preventive therapies.

By its nature, such an approach requires a platform for reliable quantitative estimation of absolute risk based upon data from representative population samples. It is important to note that risk estimation is based on group averages that are then applied to individual patients in practice. This process is admittedly imperfect; no one has 10% or 20% of a heart attack during a 10-year period. Individuals with the same estimated risk will either have or not have the event of interest, and only those patients who are destined to have an event can have their event prevented by therapy. The criticism of the risk estimation approach to treatment-decision making also applies to the alternative, and much less efficient approach, of checking the patient’s characteristics against numerous and complex inclusion and exclusion criteria for a potentially large number of pertinent trials. Only a small fraction of trial participants have events, and only a fraction of these events are prevented by therapy. Using either approach, the clinician must apply the average results obtained from groups of patients to the individual patient in practice.

Given the modification and adoption of the Framingham 10-year risk score for CHD risk assessment by the “Third Report of the National Cholesterol Education Program Expert Panel on Diagnosis, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)”

(25), and the uptake of this algorithm by practice sites across the United States, the Work Group began by discussing the value of retaining this algorithm. In collaboration with other NHLBI panels, the Work Group decided not to use this algorithm in its 2013 recommendations, because of its derivation in an exclusively White sample population and the limited scope of the outcome (in determining CHD alone). Rather, the Work Group derived risk equations from community-based cohorts that are broadly representative of the U.S. population of Whites and African Americans, and focused on estimation of first hard ASCVD events (defined as first occurrence of nonfatal myocardial infarction or CHD death, or fatal or nonfatal stroke) as the outcome of interest because it was deemed to be of greater relevance to both patients and providers. The focus on hard ASCVD, rather than CHD alone, is also consistent with evidence reviewed in a statement from the AHA/American Stroke Association calling for the inclusion of ischemic stroke in the outcome of interest for CVD risk assessment (26).

Numerous multivariable risk scores/equations have been derived and published (Appendix 3, and for more details, the Full Work Group Report Supplement). As part of its deliberations, the Work Group considered previously published risk scores with validation in NHLBI cohort data as 1 possible approach.

However, a number of persistent concerns with existing risk equations were identified including nonrepresentative or historically dated populations, limited ethnic diversity, narrowly defined endpoints, endpoints influenced by provider preferences (e.g., revascularizations), and endpoints with poor reliability (e.g., angina and heart failure [HF]). Given the inherent limitations of existing scores, the Work Group judged that a new risk score was needed to address some of the deficiencies of existing scores, such as utilizing a population sample that approaches, to the degree possible, the ideal sample for algorithm development and closely represents the U.S. population.

Data are sparse regarding usage and impact of absolute risk scores in clinical practice in primary prevention settings (27). Two systematic reviews, based on few studies, support the conclusion that risk assessment, combined with counseling, is associated with favorable but modest changes in patient knowledge and intention to change, and with provider prescribing behavior and risk factor control (28,29). No data are available on hard event outcomes. The Work Group specifically calls for research in this area (Section 8).

The Work Group notes that the “2009 ACCF/AHA Performance Measures for the Primary Prevention of CVD” specifically recommended use of global CVD risk estimation in clinical practice (30). Likewise, the U.S. Preventive Services Task Force recommendations for aspirin (31), NHLBI Adult Treatment Panel III recommendations (25), and European (32) and Canadian (33,34) guidelines for primary prevention of CVD, among others, have all recommended the use of absolute risk assessment for decision making about the intensity of lifestyle and pharmacological preventive interventions. Risk scores have been implemented in practice through paper scoring sheets, and increasingly through websites and downloadable applications. The electronic medical record can be adapted to estimate absolute risks automatically using patient data and published equations, and it is anticipated that risk estimation using this technology will become a mainstream application of the current and future risk algorithms.

4. Development of New Pooled Cohort ASCVD Risk Equations

Having made the decision to develop new equations to estimate the 10-year risk for developing a first ASCVD event, the Work Group used the best available data from community-based cohorts of adults, with adjudicated endpoints for CHD death, nonfatal myocardial infarction, and fatal or nonfatal stroke. Cohorts that included African-American or White participants with at least 12 years of follow-up were included. Data from other race/ethnic groups were insufficient, precluding their inclusion in the final analyses. The final pooled cohorts included participants from several large, racially and geographically diverse, modern NHLBI-sponsored cohort studies, including the ARIC (Atherosclerosis Risk in Communities) study (8), Cardiovascular Health Study (5), and the CARDIA (Coronary Artery Risk Development in Young Adults) study (7), combined with applicable data from the Framingham Original and Offspring Study cohorts (4,6).

The Work Group used state-of-the-art statistical methods to derive and internally validate the Pooled Cohort Equations, which provide sex-and race-specific estimates of the 10-year risk for ASCVD for African-American and White men and women 40 to 79 years of age. The variables that statistically merit inclusion in the risk assessment equations are age, total and HDL-cholesterol, systolic BP (including treated or untreated status), diabetes, and current smoking status.

An expanded description of the derivation and validation of the Pooled Cohort Equations, as well as the means for implementing them in clinical practice, are provided in Appendix 4. Additional details are provided in the Full Report of the Work Group. A specific clinical vignette is also provided as an example in Appendix 4. In the clinical vignette, the 10-year risk is calculated for a patient 55 years of age who is a nonsmoker without diabetes, and with total cholesterol 213 mg/dL, HDL–cholesterol 50 mg/dL, and untreated systolic BP 120 mm Hg. Using these values in the Pooled Cohort Equations, the predicted 10-year ASCVD risks are 2.1% for White women, 3.0% for African-American women, 5.3% for White men, and 6.1% for African-American men.

Numerous other potential risk markers were considered for inclusion in the Pooled Cohort Equations, but for many there was no additional utility demonstrated upon their inclusion; for others, data were insufficient at the present time to determine their additional value. The equations were also assessed in external validation studies using data from other available cohorts. Other than the Framingham CHD risk score (and its derivative ATP-III risk assessment profile) and the European SCORE (System for Cardiac Operative Risk Evaluation) algorithm for CVD death, these equations have been subjected to more rigorous validation than other currently available equations, and they are the only risk assessment equations that include significant numbers of African Americans and focus on estimation of 10-year risk for the clinically relevant endpoint of ASCVD. The Work Group specifically calls for further research to develop similar equations applicable to other ethnic groups, to validate the utility of the Pooled Cohort Equations in diverse primary prevention settings, and to assess the potential benefit of novel risk markers when added to these equations, so that the equations may be modified or expanded over time as new data become available.

4.1. Recommendations for Assessment of 10-Year Risk for a First Hard ASCVD Event

Recommendation 1.

The race- and sex-specific Pooled Cohort Equations to predict 10-year risk for a first hard ASCVD* event should be used in nonHispanic African Americans and nonHispanic Whites, 40 to 79 years of age. (Grade B, Moderate); ACC/AHA COR I, LOE B

Recommendation 2.

Use of the sex-specific Pooled Cohort Equations for nonHispanic Whites may be considered when estimating risk in patients from populations other than African Americans and nonHispanic Whites. (Grade E, Expert Opinion); ACC/AHA COR IIb, LOE C

A downloadable spreadsheet enabling estimation of 10-year and lifetime risk for ASCVD and a web-based calculator are available at https://www.wendangku.net/doc/922667596.html,/cvriskcalculator and https://www.wendangku.net/doc/922667596.html,/science-and-quality/practice-guidelines-and-quality-standards/2013-prevention-guideline-tools.aspx.

*Ten-year risk was defined as the risk of developing a first ASCVD event, defined as nonfatal myocardial infarction or CHD death, or fatal or nonfatal stroke, over a 10-year period among people free from ASCVD at the beginning of the period.

5.Implications for Risk Assessment

A range of estimated 10-year risk for a first hard ASCVD event is illustrated in the Full Work Group Report Supplement (Tables 8-11), across a broad range of risk factor burdens for selected combinations of the risk factors in sex-race groups (African-American and White women and men).The estimated risks are specific to defined combinations of the risk factors, and demonstrate how they vary over a broad spectrum of potential profiles. Risk factor levels that are more adverse than those shown in these tables should always be associated with a higher estimated risk. For example, if a given risk factor combination indicates an estimated 10-year risk for hard ASCVD of 8%, but a patient has a higher level of systolic BP or total cholesterol, or a lower level of high-density lipoprotein cholesterol, than shown for that cell, then the estimated risk would be ≥8%. Because the estimated probabilities can become unstable when approaching the limits of the sample data, the risk probabilities are truncated at 1% and 30%. The proportion of the U.S. adult population, 40 to 79 years of age, in selected strata of estimated 10-year risk for hard ASCVD events, are shown overall and by sex and race in Table 5. When compared with nonHispanic Whites, estimated 10-year risk for ASCVD is generally lower in Hispanic-American and Asian-American populations and higher in American-Indian populations (35,36); hence, the lack of ethnic-specific risk algorithms are an important gap in our efforts to understand and prevent ASCVD in these populations. While the development of algorithms specific to these race/ethnic groups is encouraged, in the interim, providers may consider using the equations for nonHispanic Whites for these patients. When doing so, it is important to remember that the estimated risks may be over-estimates, especially for Hispanic- and Asian-Americans.

6. CQs and Systematic Evidence Review

6.1. Critical Question 1

“What is the evidence regarding reclassification or contribution to risk assessment when hs-CRP, ApoB, GFR, microalbuminuria, family history, cardiorespiratory fitness, ABI, CAC, or CIMT are considered in addition to the variables that are in the traditional risk scores?”

The concept of matching the intensity of risk factor management to the estimated risk for CVD has been well established since the 27th Bethesda Conference in 1996 (24). As a consequence, widespread attention has focused on the accuracy and reliability of risk assessment. Claims that a minority of the risk for CVD can be explained by the major traditional risk factors, or that most patients presenting with CHD have no elevated traditional risk factors, have been disproven (37,38). Nonetheless, the desire to improve existing quantitative risk estimation tools has helped to stimulate and maintain interest in the search for new risk markers for CVD which might further enhance risk assessment.

CQ1 was developed to address whether newer risk markers have been identified that actually improve risk assessment enough to warrant routine measurement in clinical practice. This question applies to risk assessment in the general population, that is, the typical asymptomatic adult in routine clinical practice. This question does not address other highly selected patient subgroups, such as those with symptoms suggestive of CVD.

CQ1 was addressed using 2 independent approaches. First, in the process of developing the Pooled Cohort Equations, the additional risk markers listed in CQ1 were tested for inclusion in the model if they were available in the databases and could be evaluated on the basis of at least 10 years of follow up. A review of meta-analyses and systematic reviews published before September 19, 2013 was conducted in 2 stages. In the first stage, meta-analyses and systematic reviews published before April 2011 were identified and reviewed. In a second stage, conducted to update the evidence base before publication, additional meta-analyses and systematic reviews published before September 19, 2013 were identified and reviewed using the same criteria applied in the first stage. The reliance on published meta-analyses to evaluate novel biomarkers is a conservative approach that helps avoid the influence of positive publication bias that can occur early in the evaluation of a novel association and assures that we relied on a mature body of evidence(39).

Members of the Work Group proposed an initial list of novel risk markers for inclusion in CQ1 which was then prioritized during several rounds of discussion. In selecting the final list, the Work Group gave priority to factors that have engendered substantial discussion in the scientific community and that could be reasonably considered as potentially feasible for widespread population use by primary care providers in routine clinical settings in the United States. These deliberations considered availability, cost,

assay reliability, and risks of the test or downstream testing. The final list of new risk markers to be evaluated included several blood and urine biomarkers (hs-CRP, ApoB, creatinine [or estimated GFR], and microalbuminuria), several measures of subclinical cardiovascular disease (CAC, CIMT, and ABI), family history, and cardiorespiratory fitness. Other novel potential screening tools may be the subject of future guideline updates. When considering the utility of incorporating these new risk factors into routine risk assessment, guidance published by Hlatky et al(40) was considered. Special attention was given to the additional value these markers contributed to risk assessment in terms of discrimination, calibration, reclassification, and cost-effectiveness, in the context of any potential harm.

6.1.1. Summary of Systematic Reviews and Meta-Analyses for CQ1

Thirteen systematic review articles or meta-analyses met the inclusion/exclusion criteria (9-18,41-43). Publication dates ranged from 2008 to 2013. The Work Group reviewed the 13 systematic reviews and meta-analyses and created a table to list their key findings (Appendix 1). None of these markers has been evaluated as a screening test in randomized controlled trials with clinical events as outcomes. On the basis of current evidence, it is the opinion of the Work Group that assessments of family history of premature CVD, and measurement of hs-CRP, CAC, and ABI show some promise for clinical utility among the novel risk markers, based on limited data. Table 6 provides expert opinion regarding thresholds of these measures that may be considered for clinical decision making.

The Work Group notes that the review by Peters et al. (16) provides evidence to support the contention that assessing CAC is likely to be the most useful of the current approaches to improving risk assessment among individuals found to be at intermediate risk after formal risk assessment. Furthermore, the Work Group recognizes that the “2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults” made recommendations regarding CAC testing (44). However, the Work Group notes that the outcomes in the studies reviewed by Peters et al. (16) and by Greenland et al. (44) were CHD outcomes, not hard ASCVD events that included stroke; hence, uncertainty remains regarding the contribution of assessing CAC to estimating 10-year risk of first hard ASCVD events after formal risk assessment using the new Pooled Cohort Equations. Furthermore, issues of cost and radiation exposure related to measuring CAC were discussed resulting in some uncertainty regarding potential risks of more widespread screening, which resulted in a decision in the current guideline to make assessment of CAC a Class IIb recommendation among individuals for whom a risk-based treatment decision is uncertain after formal risk estimation. The Work Group notes that this Class IIb recommendation is consistent with the recommendations in the 2010 ACCF/AHA guideline (44) for patients with a 10-year CHD risk of <10%, as well as for many other patients, because of the lower risk threshold (7.5% 10-year risk for a first hard ASCVD event) adopted by the “2013 ACC/AHA guideline on the treatment of blood cholesterol to

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表1缺血性心血管病（ICVD） 10年发病危险度评估表（男）第一步：评分年齡（:岁）得分 35-39 0 40-44 1 45-49 2 50-54 3 55-59 4 收:缩压（mmHg）得分 <1 20 -2 120- 0 130 - 1 140- 2 160- 5 >180 8 总胆固fi?(iinnol/L) 得分 <5.20 0 N5.20 1 体重盾数(kg/m2) 得分 <240 24?1 >2S 2 第二步鲁求和吸烟得分否0 是2糖尿病得分否0 是 1 年龄平均危险杀低危晞 35?39 L.0 0.3 40-14 1.4 0.4 45-49 1.9 0.5 50-54 2.60.7 55?59 3.6 1.0 10年ICVD绝対危险参考标准总分 10 年ICVD 危险(％) W J 03 0 0.5 1 0.6 2 0.8 3 1.1 4 1.5 5 f) 2.1 2.9 7 3.9 8 5.4 9 7.3 10 9.7 11 12.8 12 16.8 13 21.7 14 27.7 15 35.3 16 443 >17 N52.6 第三步：绝疋危险

无糖尿満 BM>28 BMK24 (TCM5. 20mol/L) 不吸烟吸烟 SBP mmHg (TC<5. 20mol/L) 不吸烟吸烟 180 ? 160?179 140?159 130?139 120?129 <120 180? 160?丄79 140?159 130?139 120?129 <120 180? 160?179 140?159 130?139 120?129 <120 69 ? gg S ? 69 ? S S ? 9 6 守?g 寸寸 T § 6 m ? 69 ? s S ?09 寸年於（岁）中危僦极低危很局施高危绝对危险底 >40 20?10- 5?<5 (%)

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心内科前十大疾病诊疗常规遵义市红花岗区人民医院

目录一、高血压病二、心绞痛三、急性心肌梗死四、急性心力衰竭五、慢性心力衰竭六、心源性休克七、阵发性室上速八、心房颤动九、瓣膜性心脏病十、心肌病

一、高血压诊疗常规高脂血症，糖尿病，糖耐量异常，心血管病家族史，肥胖，纤维蛋白原升高，靶器官损害伴随的临床情况。 3、症状、体征：大多数起病缓慢，一般缺乏临床表现。常见症状有头晕、头痛、颈项板紧、疲劳、心悸等，呈轻度持续性；在紧张或劳累后加重，不一定与血压水平有关，多数可自行缓解。也可以出现视力模糊、鼻出血等较重症状。约五分之一患者无症状，仅在测量血压时或发生心、脑、肾等并发症时才发现。体检时听诊可有主动脉瓣区第二心音亢进、收缩期杂音或收缩早期喀喇音，少数患者在颈部或腹部可听到血管杂音。脑部表现：短暂性脑缺血发作、高血压脑病、脑出血、脑血栓形成。心脏表现：高血压性心脏病、合并冠心病。肾脏表现：肾功减退早期可表现为夜尿、多尿、蛋白尿、管型和红细胞尿，晚期可出现氮质血症和尿毒症。眼底改变：视网膜动脉痉挛、变细；视网膜动脉狭窄、动静脉交叉压迫；眼底出血或棉絮状渗出；视乳头水肿。 4、入院常规检查：血常规、尿常规、血糖、血脂、肾功能、电解质和心电图。

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mmol/L （70 mg/dl ）以下。（3）缺血性卒中或TIA 患者发病后均应接受空腹血糖、HbA1c 监测，无明确糖尿病病史的患者在急性期后应常规接受口服葡萄糖耐量试验来筛查糖代谢异常和糖尿病。对糖尿病或糖尿病前期患者进行生活方式和（或）药物干预能减少缺血性卒中或TIA 事件，推荐HbA1c 治疗目标（二）口服抗血小板药物在非心原性缺血性卒中/TIA 二级预防中的应用推荐意见如下：（1）对非心原性栓塞性缺血性卒中或TIA 患者，建议予口服抗血小板药物而非抗凝药物预防卒中复发及其他心血管事件的发生。（2）阿司匹林（50~325 mg/d）或氯吡格雷（75 mg）单药治疗均可作为首选抗血小板药物；阿司匹林单药抗血小板治疗的最佳剂量为75~150 mg/d。阿司匹林（25 mg）+缓释型双嘧达莫（200 mg）2次/d 或西洛他唑（100 mg）2 次，均可作为阿司匹林和氯吡格雷的替代治疗药物。（3）发病24 h 内，具有卒中高复发风险（ABCD2评分》4分）的急性非心原性TIA或轻型缺血性卒中患者（NIHSS评分W 3分），应尽早给予阿司匹林联合氯吡格雷治疗21 d,应严密观察出血风险，此后可单用阿司匹林或氯吡格雷作为缺血性卒中长期二级预防一线用药。（4）发病30 d 内伴有症状性颅内动脉严重狭窄（狭窄率70%~99% ）的缺血性卒中或TIA 患者，应尽早给予阿司匹林联合氯吡格雷治疗90 d。此后阿司匹林或氯吡格雷单用均作为长期二级预防一线用药。（5）伴有主动脉弓动脉粥样硬化斑块证据的缺血性卒中或

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Advances in Clinical Medicine临床医学进展, 2015, 5(3), 177-182 Published Online September 2015 in Hans. https://www.wendangku.net/doc/922667596.html,/journal/acm https://www.wendangku.net/doc/922667596.html,/10.12677/acm.2015.53028 Survey of the Risk Assessment of Cardiovascular Disease Xueping Li, Yanhong Xie, Zhaoxia Xu*, Yiqin Wang Shanghai University of Traditional Chinese Medicine, Shanghai Email: *1403759578@https://www.wendangku.net/doc/922667596.html, Received: Aug. 8th, 2015; accepted: Aug. 28th, 2015; published: Sept. 9th, 2015 Copyright ? 2015 by authors and Hans Publishers Inc. This work is licensed under the Creative Commons Attribution International License (CC BY). https://www.wendangku.net/doc/922667596.html,/licenses/by/4.0/ Abstract Cardiovascular diseases become the biggest burden of disease worldwide because of its high inci-dence and mortality. By collecting a large number of related literatures and comparing the present commonly used cardiovascular disease risk assessment tools such as Framingham risk assessment, the United States cholesterol program adult treatment group report (NCEP ATP III), Systematic Coronary Risk Evaluation in Europe, the British QRISK cardiovascular risk algorithm, Reynolds Risk Score and so on, we find that CVD risk assessment models are continuously im-proved with more risk factor being found and also there are different degrees of limitations. As the effective and comprehensive risk assessment of CVD, which takes conventional risk factors and ge-netic factors into consideration, is not available in China, we thus put forward the new research thinking that combines traditional Chinese medical method, information from TCM Four diagnostic methods, with CVD risk assessment to study the risk assessment of disease in our country. Keywords Cardiovascular Disease, Risk Factor, Risk Assessment, Information from TCM Four Diagnostic Methods 心血管疾病风险评估研究的概况李雪平，谢艳虹，许朝霞*，王忆勤上海中医药大学基础医学院，上海 Email: *1403759578@https://www.wendangku.net/doc/922667596.html, *通讯作者。

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心血管内科诊疗常规考试题库

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Ｂ、血脂异常Ｃ、年龄 D、吸烟 E、血压正确答案是:A 第６题主动脉-冠状动脉旁路移植术的适应症不包括 A、左冠状动脉主干病变狭窄>50% B、有轻度室性心律失常伴左主干或3支病变Ｃ、稳定型心绞痛对内科药物治疗反应不佳，影响工作和生活 D、冠状动脉3支病变伴左心室射血分数<5０% E、左前降支和回旋支近端狭窄≥70% 正确答案是：B 第７题主动脉瓣狭窄的晚期，可见 A、收缩压升高,脉压正常Ｂ、收缩压和脉压均升高 C、脉压升高,收缩压正常 D、收缩压和脉压均下降 E、收缩压和舒张压均下降正确答案是：D

心血管疾病风险评估表

表1缺血性心血管病（ICVE＞）10年发病危险度评估表（男）

旳?09 60 ?9” 卄?" 6￡?9￡ 69 ?gq 旳?0￡幵?0P 6￡?9￡ ve V LO O A 呼旳? OS ， 6f?? 卯 69?$￡旳?0￡ 6B ?济幵?OV 6￡?並 a (、一\loidoz -g 入 0片)畏径聂淡 G CVIOSOe -g v u l ) 2 V 6FH ?02G Z ?鱼 6g-?0￡ 6 卜I ?091 S T O N l v 旨?0269-?m 6ZT ?09T ?020Z V 6 2?目 62 ?691?0龙 6卜一? 09 一 MHUIUI

Ris MO DIABETES Non-smoker Smoker 5 6 7 8 140/95 140/85 iao/io5 TO DIABETES Non-smoker Smoker 45678 4567S 180/105 6huje 3 」 nssa 」 dps 8 120/75 160/95 "0/85 120/75 1AOZ105 13/9S 140/ftS 120/75 AOE 60 180/105 16^/95 140/85 120/7S 6HWE a 」 nssa 」 d poo_8 160/105 160/95 ■40/45 120/75 180/105 13/9S 140/85 120/75 Total Cholesterol：HDL ratio Total Cholesterol ：HDL ratio

Risk level men ZO DIABETES Non-smoker a 5 6 a Smoker A 5 6 Z 8 DIABETES Zon-smoker 4 5 6 7 S Smoker 4 5 6 Z 8 lao/ios 1W>/9S Mo/as 120/75 AOE 70 ltO/105 140/95 149/" 120/75 SHIUE a 」 ns 笆d poo U0/10S IW)/95 60 140/A5 120/75 IW>/95 AGE 50 140/65 120/75 UO/105 1frO/? 140/M 1?OZ10S 140/95 140/85 110/75 130/105 IS0Z105 140/95 140/85 120/75 E E ajns 笆 d poo 120/75 1*0/105 140/8$ 110/75 4 5 6 7 8 Total Cholesterol:HDL ratio

心血管内科诊疗常规课件

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●应提供行为指导、小组治疗、药物治疗或综合多种有效疗法。 ●对于预设戒断日者（即患者需在某一特定日期前戒烟），可选用尼古丁替代疗法（NRT）、伐尼克兰或安非他酮进行戒断治疗。 ●患有心肺疾病或与其共同生活者，应该意识到主动吸烟及被动吸烟（二手烟）的风险。 ●对于孕期及分娩后女性的戒烟具体建议，详见NICE公共健康指南26。 ●应强调孕期戒烟的重要性，NICE应在指南强调。（2）饮食应根据以下原则提供专业支持，以制定心血管风险最低的食谱： ●饱和脂肪的摄入量应低于总脂肪摄入量的10％（最好是瘦肉和低脂乳制品） ●以多不饱和脂肪替代饱和脂肪 ●每日摄入五份蔬果 ●每周至少摄入两份鱼类（最好是油性） ●考虑定期食用全谷类和坚果 ●保持盐的摄入量低于每日6克 ●男性酒精摄入量每周应低于21单位，女性应低于14单位 ●避免/减少摄入：

2013AHA心血管病风险评估指南

Stone and Peter W.F. Wilson Jennifer Robinson, J. Sanford Schwartz, Susan T. Shero, Sidney C. Smith, Jr, Paul Sorlie, Neil J.Raymond Gibbons, Philip Greenland, Daniel T. Lackland, Daniel Levy, Christopher J. O'Donnell, David C. Goff, Jr, Donald M. Lloyd-Jones, Glen Bennett, Sean Coady, Ralph B. D'Agostino, Sr,Guidelines American College of Cardiology/American Heart Association Task Force on Practice 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk: A Report of the Print ISSN: 0009-7322. Online ISSN: 1524-4539 Copyright ? 2013 American Heart Association, Inc. All rights reserved.is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231Circulation published online November 12, 2013;Circulation. https://www.wendangku.net/doc/922667596.html,/content/early/2013/11/11/01.cir.0000437741.48606.98.citation World Wide Web at: The online version of this article, along with updated information and services, is located on the https://www.wendangku.net/doc/922667596.html,/content/suppl/2013/11/07/01.cir.0000437741.48606.98.DC1.html Data Supplement (unedited) at: https://www.wendangku.net/doc/922667596.html,//subscriptions/is online at: Circulation Information about subscribing to Subscriptions: https://www.wendangku.net/doc/922667596.html,/reprints Information about reprints can be found online at: Reprints: document. Permissions and Rights Question and Answer available in the Permissions in the middle column of the Web page under Services. Further information about this process is Once the online version of the published article for which permission is being requested is located, click Request can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office.Circulation Requests for permissions to reproduce figures, tables, or portions of articles originally published in Permissions:

稳定型缺血性心脏病诊治疗指南(中文版译文)

2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS 美国SIHD诊治指南执行纲要中的推荐部分广西医科大学第五附院，柳州市人民医院心内科胡世红教授译自：JACC Vol. 60, No. 24, 2012 ：2564-603 1.8. 患者知情参与的至关重要性 Ⅰ类推荐 1.应当通过一个包括患者和提供者在内的共享决策过程，来做出诊断和治疗选择，对患者解释有关风险、获益和费用的信息（C）。 2.SIHD的诊断:推荐 2.1.胸痛患者的临床评估 Ⅰ类推荐 1.对胸痛患者在进行附加的检测前，应详细询问病史和全面体检以评估IHD的可能性（C）。 2.对表现为急性心绞痛的患者应分出稳定的与不稳定的；对不稳定的患者应进一步分为低危、中危或高危（C）。胸痛的临床表现： ·典型心绞痛(定义）1）胸骨后胸部不适，具有典型特征和持续时间，即2）由于用力或情绪紧张而激发，3）经休息或用硝酸甘

油可缓解； ·不典型心绞痛（可能）满足以上2项特征； ·非心源性胸痛没有或只满足1项典型心绞痛特征。 2.1.2.ECG 2.1.2.1.静息ECG风险评估 I类推荐 1.对不明显的、非心原性胸痛的患者，推荐做一份静息ECG（B）。 2.1. 3.对需要无创检测的疑似SIHD患者，初始诊断的负荷试验和先进的成像 2.1. 3.1.能运动的患者 I类推荐 1.对于有可判断的ECG、预测IHD可能性为中度且至少有适度的体能或没有致残合并症的患者，推荐行标准的运动ECG检测(A)。 2.对于ECG不能判断、预测IHD可能性为中度到高度且至少有适度的体能或没有致残合并症的患者，推荐行运动负荷核素MPI或UCG检查(B)。 IIa类推荐 1.对于需要检测预测梗阻性IHD可能性低的患者，标准的运动ECG可能是有用的，只要患者有一份可判断的ECG和至少有适度的体能或没有致残合并症(C)。 2.对于有一份可判断的ECG、预测梗阻性IHD的可能性为中度到高度、且至少有适度的体能或没有致残合并症的患者，行运动负荷核素MPI

智慧树知到《常见心血管病的诊治》章节测试答案

智慧树知到《常见心血管病的诊治》章节测试答案第一章 1、根据下列哪项可定心功能失代偿期？（） A.心率加快 B.心肌肥厚与心脏扩张 C.心排血量下降 D.有效血容量增加 E.心肌耗氧量增加答案: 有效血容量增加 2、体循环淤血的最可靠体征为（）。 A.平卧时颈静脉充盈 B.右肋弓下可触及肝脏 C.腹水 D.下肢浮肿 E.静脉压升高答案: 静脉压升高 3、左心衰竭时,最早出现的症状是（）。 A.夜间阵发性呼吸困难 B.心悸 C.端坐呼吸 D.咳嗽，咯血 E.劳力性呼吸困难

答案: 劳力性呼吸困难 4、洋地黄中毒最常见表现是（）。 A.心电图QT间期短 B.心电图ST—T段呈鱼钩样改变 C.窦性心动过缓 D.3度房室传导阻滞 E.出现室早二联律答案: 出现室早二联律 5、目前，比较肯定能降低慢性心力衰竭患者死亡率的药物为（）。 A.洋地黄 B.利尿剂 C.多巴酚丁胶 D.卡托普利 E.钙离子拮抗剂答案: 卡托普利 6、慢性左心功能不全常见的症状和体征不包括（）。 A.夜间阵发性呼吸困难 B.第三心音奔马律 C.双肺底湿性吵音 D.咳嗽 E.颈静脉怒张答案: 颈静脉怒张

7、单纯左心功能不全还会再现下列哪项表现？（） A.劳力性呼吸困难 B.咳嗽、咳痰 C.咳粉红色泡沫痰 D.下肢浮肿 E.疲乏、无力答案: 下肢浮肿 8、关于慢性心功能不全的代偿调节机制，下列哪项不正确？（） A.交感神经兴奋 B.水钠瀦留 C.心肌肥厚 D.心钠素释放 E.迷走神经兴奋答案: 迷走神经兴奋 9、下列哪项不是使用洋地黄的禁忌证（）？ A.预激综合征伴房颤或扑动 B.II度或高度AVB C.肥厚梗阻型心肌病而无心房颤动或明显心衰 D.单纯性重度二尖瓣狭窄伴窦性心律者 E.阵发性室上性心动过速答案: 阵发性室上性心动过速 10、下列哪项不是充血性心力衰竭的表现？（）

心内科常见疾病诊疗常规

一、高血压诊疗常规 1、定义：原发性高血压是以血压升高为主要临床表现的综合征，通常简称为高血压。高血压是多种心、脑血管疾病的重要病因和危险因素，影响重要脏器例如心、脑、肾的结构与功能，最终导致这些器官的功能衰竭，迄今是心脑血管病死亡的主要原因。我国采用国际上统一的血压分类和标准，高血压定义为收缩压≥140mmHg和（或）舒张压≥90mmHg且可除外继发性高血压。 2、高血压分级诊断：收缩压（mmHg）舒张压（mmHg） 1级高血压（轻度）140-15990-99 亚组：临界高血压140-14990-94 2级高血压（中度）160-179100-109 3级高血压（重度）≥180≥110 单纯收缩期高血压≥140＜90 临界收缩期高血压140~149＜90 3、高血压危险度的分层诊断：低危组：高血压1级，不伴有下列危险因素（见注），治疗以改善生活方式为主，如6个月后无效，再给药物治疗。中危组：高血压1级伴1-2个危险因素或高血压2级不伴或伴有不超过2个危险因素者。治疗除改善生活方式外，给予药物治疗。高危组：高血压1-2级伴至少3个危险因素者，必须药物治疗，或高血压3级病人，但无其他危险因素。极高危组：高血压3级或高血压1-2级伴靶器官损害及相关的临床疾病者（包括糖尿病），必须尽快给予强化治疗。注：心血管疾病危险因素包括：高血压水平（1~3级），男性，女性（大于55），吸烟，高脂血症，糖尿病，糖耐量异常，心血管病家族史，肥胖，纤维蛋白原升高，靶器官损害伴随的临床情况。 4、症状、体征：大多数起病缓慢，一般缺乏临床表现。常见症状有头晕、头痛、颈项板紧、疲劳、心悸等，呈轻度持续性；在紧张或劳累后加重，不一定与血压水平有关，多数可自行缓解。也可以出现视力模糊、鼻出血等较重症状。约五分之一患者无症状，仅在测量血压时或发生心、脑、肾等并发症时才发现。体检时听诊可有主动脉瓣区第二心音亢进、收缩期杂音或收缩早期喀喇音，少数患者在颈部或腹部可听到血管杂音。脑部表现：短暂性脑缺血发作、高血压脑病、脑出血、脑血栓形成。心脏表现：高血压性心脏病、合并冠心病。肾脏表现：肾功减退早期可表现为夜尿、多尿、蛋白尿、管型和红细胞尿，晚期可出现氮质血症和尿毒症。眼底改变：视网膜动脉痉挛、变细；视网膜动脉狭窄、动静脉交叉压迫；眼底出血或棉絮状渗出；视乳头水肿。

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2013AHA心血管病风险评估指南

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