The shortcomings of clinical practice guidelines

When Guideline-Concordant Standardized Care Results in Healthcare Disparities

AbstractClinical red blood cell transfusion guidelines have been widely adopted in clinical practice, resulting in standardized transfusion practices in hospitalized patients with anemia. Standardization of transfusion practice has been welcomed by clinicians and health systems as a mechanism for reducing unnecessary, harmful, and costly practice variation that results in healthcare disparities. However, overzealously applied guidelines can have deleterious consequences for individual patients, ultimately resulting in and/or exacerbating healthcare disparities, rather than resolving them. This article provides empirical examples of the adverse consequences from the well-meaning attempt to standardize transfusion practice based on clinical practice guidelines and discusses the ethical implications of standardized transfusion practice.

Cardiovascular Disease, Cancer and Multimorbidity Interactions: Clinical Implications

BACKGROUND

With the aging population, the frequency of cardiovascular disease (CVD), cancer and other morbid conditions are increasing dramatically. In addition, one disease may affect the other leading to a vicious cycle.

SUMMARY

With aging, the function of organs and systems of the human body decline including the autoimmune system resulting in a diminished response to various pathogens and a chronic inflammatory process; these changes, in addition to other risk factors, contributes to the development of multiple morbid conditions including CVD and cancer. Multimorbidity in the elderly has become the rule rather than the exception today. Further, this association between CVD and cancer, at least partially, is explained by both diseases sharing common risk factors and from accelerated vascular aging due to cancer and its associated therapies. Multiple studies have shown that the incidence of cancer is much higher in patients with CVD compared to the general population. These associations among CVD, cancer and their connection to systems of the human body provide an opportunity for novel therapies. Development of new drugs should be addressed to focus on multiple systems and not just only to one disease. Further, collecting information from registries and processing large amounts of data using artificial intelligence may assist the clinician when treating an individual patient in the future. Key messages: As the aging population increases, CVD, cancer and multimorbidity will continue to constitute a major health problem in the years to come. The physician who is taking care of such a patient, in addition to knowledge, requires clinical wisdom, clinical experience and common sense in order to apply the continuous evolving knowledge to the individual patient.

Fallacies in medical practice: Renin-angiotensin-aldosterone system inhibition and COVID-19 as a Paradigm

In emergency situations, such as during the coronavirus disease 2019 (COVID-19) pandemic, medical community looks for quick answers and guidance. Under these circumstances, experts instead of admitting ignorance, feel obliged to give an answer, often pressurized by political or other authorities, even when such an answer is unavailable. Under these circumstances, publications based on fallacious reasoning are virtually unavoidable. In the present review, we summarize examples underlying fallacious reasoning recommendations regarding treatment with Renin-Angiotensin-Aldosterone inhibitors (RAASi) in the COVID-19 context. Most scientific societies emphasize that RAASi use is safe and that these agents should not be discontinued, based mainly on the results of observational studies (OSs) and occasionally preprints, as relevant randomized controlled trials (RCTs) are currently lacking. However, over the past 4 decades, results from successful RCTs have repeatedly proved that practices based on OSs were wrong. Lack of RCTs results in uncertainty. In this setting, the physician's wisdom and knowledge related to pathophysiologic mechanisms and effect of pharmacologic agents become even more important as they may limit fallacies. Based on these principles, in diseases (e.g., mild, or moderate arterial hypertension, etc.) where equally effective alternative therapies to RAASi are available, these therapies should be applied, whereas in diseases (e.g., heart failure, diabetic kidney disease, etc.), where equally effective alternative therapy compared to RAASi is not available, RAASi should be used. Admittedly this strategy, like all the other recommendations, is not based on solid evidence but is intended to be individualized and follows the Hippocratic "Primum non nocere".

Physical Therapy Management of Nontraumatic Shoulder Problems Lacks High-Quality Clinical Practice Guidelines: A Systematic Review With Quality Assessment Using the AGREE II Checklist

OBJECTIVES

To appraise the quality of clinical practice guidelines (CPGs) for physical therapy management of nontraumatic shoulder pain disorders.

DESIGN

Systematic review of CPGs.

LITERATURE SEARCH

Two reviewers independently conducted a search of 7 databases and 7 gray literature sources.

STUDY SELECTION CRITERIA

We included systematically developed CPGs for physical therapy management of nontraumatic musculoskeletal conditions of the shoulder in adults that were available in full text in the English language. We excluded CPGs for physical therapy management of surgically treated shoulder pain disorders.

DATA SYNTHESIS

Three reviewers independently rated the quality of included CPGs using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. Data were compiled into tables that displayed AGREE II domain scores for each CPG and mean item scores across the CPGs.

RESULTS

We included 9 CPGs. Five CPGs focused on rotator cuff disorders, 2 focused on frozen shoulder, and 2 covered a range of soft tissue shoulder diagnoses. Three CPGs were judged as high quality (all were 5 or more years old) and 6 were judged as low quality. The quality domains in which CPGs were rated highest were "scope and purpose" (all CPGs scored greater than 50% and 4 scored greater than 80%) and "clarity of presentation" (all CPGs scored greater than 50% and 7 scored greater than 80%). The domains in which CPGs were rated most poorly were "applicability" (6 CPGs scored 40% or less) and "editorial independence" (4 CPGs scored less than 40%).

CONCLUSION

There were no high-quality, contemporary CPGs to guide physical therapy management of nontraumatic shoulder pain. J Orthop Sports Phys Ther 2021;51(2):63-71. Epub 25 Dec 2020. doi:10.2519/jospt.2021.9397.

Updating the Evidence: Suctioning Practices of Physiotherapists in Ontario

Purpose: The purpose of this article is to describe current tracheal suctioning practices of physiotherapists in the province of Ontario and to determine what factors influence these practices. Method: A cross-sectional online survey was conducted. An online survey link and quick response code were mailed to Ontario physiotherapists who were actively providing patient care and were authorized to perform tracheal suctioning as identified by the College of Physiotherapists of Ontario. Results: Ninety physiotherapists participated in the survey (23% response rate). Most (66%) suctioned in an intensive care setting, and many (41%) reported frequently using a closed endotracheal suctioning system. Hyperoxygenation was frequently performed before suctioning by 48% of participants, and only 18% frequently hyperoxygenated after suctioning. Most participants reported infrequently performing saline instillation (52%) and infrequently hyperinflating before suctioning (79%). Clean gloves were reported as the personal protective equipment most frequently worn across all suctioning approaches, and goggles and sterile gloves were least often worn while suctioning. Previous suctioning experience had the most influence on suctioning practices, and limited access to equipment had the least influence. Conclusions: Some of the tracheal suctioning practices of physiotherapists in Ontario vary from evidence-based clinical guidelines.

Transcatheter Mitral Valve Repair in Patients with Heart Failure: A Meta-Analysis

BACKGROUND

Severe secondary mitral regurgitation (MR) is associated with poor prognosis in heart failure patients with left ventricular systolic dysfunction. Few observational and randomized controlled studies demonstrated the efficacy of transcatheter mitral valve repair in heart failure patients with significant MR. A meta-analysis of published studies was performed to evaluate the role of transcatheter mitral valve repair using the MitraClip device in heart failure patients with significant secondary MR.

METHODS

A literature search was performed using PubMed, Cochran CENTRAL, and Embase databases using the search terms "percutaneous mitral valve repair" or "transcatheter mitral valve repair" and "heart failure." Studies that compared medical therapy plus transcatheter mitral valve repair using MitraClip to medical therapy alone in heart failure patients with significant secondary MR were included for pooled analysis. A random-effects model with the Mantel-Haenszel method was used to analyze the data.

RESULTS

Four studies, 2 randomized controlled and 2 nonrandomized studies met the criteria for analysis. Pooled analysis included a total of 1,421 patients, of which 746 patients underwent transcatheter mitral valve repair and 675 patients received medical therapy alone. When compared to medical therapy, transcatheter mitral valve repair significantly decreased all-cause mortality (OR 0.58, 95% CI 0.37-0.91; p = 0.02). A trend toward significant reduction in rehospitalizations (OR 0.35, 95% CI 0.12-1.00; p = 0.05) was also observed. Periprocedural complications ranged from 7.5 to 12.6%.

CONCLUSION

Evidence from pooled analysis suggests that transcatheter mitral valve repair using MitraClip on top of medical therapy, in appropriately selected symptomatic heart failure patients with significant secondary MR, provides survival benefit and may decrease hospitalizations when compared with guideline-directed medical therapy alone.

Methodological components and quality of evidence summaries: a scoping review protocol

OBJECTIVE

The objective of this review is to identify and map the available evidence related to evidence summary methodologies and indicators of quality.

INTRODUCTION

It can be challenging for clinicians and policy makers to keep up-to-date with current evidence and best practice. An evidence summary is a way to provide health care decision makers with the most recent, highest quality evidence available on a particular topic in an easily digestible format to facilitate evidence-based clinical decisions. However, objectively evaluating the methodological quality of these types of evidence reviews is challenging.

INCLUSION CRITERIA

Articles, papers, books, dissertations, reports and websites will be included if they evaluate, or describe the development or appraisal of, an evidence summary methodology.

METHODS

A three-step search strategy will be used to find both published and unpublished literature. The following databases will be searched: US National Library of Medicine Database (PubMed) Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, ProQuest Dissertations and Theses, and Embase. The gray literature search will include relevant government and university websites, the Health Evidence Network website, the World Health Organization (WHO) Health Evidence Network website, the McMaster Health Systems Evidence website, and relevant websites included in the Canadian Agency for Drugs and Technologies in Health (CADTH) Grey Matters Handbook. Sources published in English will be considered, with no date limitation.

[Evidence-Based Information Which Could Influence Arterial Hypertension Treatment Approach after Publication of SPRINT Trial Results]

The article discusses results of secondary analysis of the data obtained in the SPRINT study and published in recent years. Unresolved issues in the tactics of managing patients with arterial hypertension are discussed. One of such issues is choosing an optimum level of blood pressure (BP) for a subgroup of patients with certain characteristics, including elderly and senile patients, patients with chronic kidney disease, and patients with arterial hypertension who continue smoking. The article discusses calculation of a threshold of risk for complications of cardiovascular diseases, at which a maximum advantage of intensified regimens of antihypertensive therapy could be achieved. In addition, the article addresses approaches to selection of antihypertensive drugs in the current conditions. The authors discussed the role of candesartan in the treatment of arterial hypertension, a sartan most studied in a broad range of patients. The issue of a rapid increase in BP without a damage to target organs is addressed; evidence for the role of captopril in such clinical situation is provided.

Nonprescription drugs recommended in guidelines for common pain conditions

Evidence-based pain guidelines allow recommendation of nonprescription analgesics to patients, facilitating self-care. We researched clinical practice guidelines for common conditions on websites of pain associations, societies, health institutions and organizations, PubMed, ProQuest, Embase, Google Scholar until April 2019. We wanted to determine whether there is a consensus between guidelines. From 114 identified guidelines, migraine (27) and osteoarthritis (26) have been published most around the world, while dysmenorrhea (14) is mainly discussed in developing countries. Specific recommendations to pregnant women, children and older people predominantly come from the UK and USA. We found that acetaminophen and oral nonsteroidal anti-inflammatory drugs (NSAIDs) represent first-line management across all pain conditions in adults and children. In osteoarthritis, topical NSAIDs should be considered before oral NSAIDs. This knowledge might persuade patients that using these drugs first could enable fast and effective pain relief.

Management of rectal cancer in Canada: an evidence-based comparison of clinical practice guidelines

Background

Rectal cancer requires a multidisciplinary and multimodality treatment approach. Clinical practice guidelines (CPGs) provide a framework for delivering consistent, evidence-based health care. We compared provincial/territorial CPGs across Canada to identify areas of variability and evaluate their quality.

Methods

We retrieved CPGs from Canadian organizations responsible for cancer care oversight and evaluated their quality and developmental methodology using the AGREE-II instrument. Recommendations for diagnostic and staging investigations, treatment by stage, and post-treatment surveillance of stage I–III rectal cancers were abstracted and compared.

Results

We identified 7 sets of CPGs for analysis, varying in content, presentation, quality, and year last updated. Differences were noted in locoregional staging: 4 recommended magnetic resonance imaging over endorectal ultrasonography, 2 recommended either modality, and 3 specified scenarios for one over the other. Recommendations also varied for use of staging computed tomography of the chest versus chest radiography and for surgical management and indications for transanal excision. Recommendations for neoadjuvant therapy in stage II/III disease also differed: 3 guidelines recommended long-course chemoradiation over short-course radiation therapy alone, while 3 others recommended short-course radiation in specific clinical scenarios. Adjuvant chemotherapy for stage II/III disease was uniformly recommended, with variable protocols. The use of proctosigmoidoscopy and interval/duration of endoscopic post-treatment surveillance varied among guidelines.

Conclusion

Canadian CPGs vary in their recommendations for staging, treatment, and surveillance of rectal cancer. Some of these differences reflect areas with limited definitive evidence. Consistent guidelines with uniform implementation across provinces/territories may lead to more equitable care to patients.

Healthcare professionals' experiences of providing individualized nutritional care for Older People in hospital and home care: a qualitative study

Background

Recent studies indicate inadequate nutritional care practices in healthcare institutions and identify several barriers to perform individualized nutritional care to older persons. Organisation of care can become rigid and standardised, thus failing to be respectful of and responsive to each person’s needs and preferences. There is limited research exploring health professionals’ views on how structure of care allows them to individualize nutritional care to older persons. In this study we aim to explore how healthcare professionals’ experience providing individualised nutritional care within the organisational frames of acute geriatric hospital care and home care.

Methods

Semi-structured interviews with 23 healthcare professionals from hospital acute geriatric care and home care. Interviews were analyzed using thematic analysis.

Results

Two main themes and six sub-themes emerged from the material. Theme 1: ‘Meeting patients with complex nutritional problems’ with the sub-themes: ‘It is much more complex than just not eating’ and ‘seeing nutrition as a part of the whole’. Theme 2: ‘The structure of the nutritional care’, with the sub-themes: ‘Nutritional routines: Much ado, but for what?’, ‘lack of time to individualize nutritional care’, ‘lack of interdisciplinary collaboration in nutritional care’ and ‘meeting challenging situations with limited resources in home care’.

Conclusions

The healthcare professionals described having a high focus on and priority of nutritional care when caring for older persons. They did however find it challenging to practice individualized nutritional care due to the complexity of the patients’ nutritional problems and constraints in the way nutritional care was organised. By describing the challenges the healthcare professionals face when trying to individualize the nutritional care, this study may provide important knowledge to health professionals and policy makers on how to decrease the gap between older patients’ preferences for care and nutritional care practice.

Refining diagnosis and management of chronic venous disease: Outcomes of a modified Delphi consensus process

Chronic venous disease (CVD) is a common condition with major health consequences that is associated with poor long-term prognosis, significant socioeconomic impact, disabling symptoms and reduced quality of life. To provide practical guidance for diagnosis and management of CVD, a Delphi panel of 5 experts in steering committee and 28 angiologists/vascular surgeons met with the major aim of providing a supplement for established national and international guidelines. A total of 24 statements were voted upon in two rounds, of which consensus was reached on 22 statements, indicating a high level of overall agreement. Consensus was reached on 7 of 8 statements relative to diagnosis (CEAP classification, diagnostic tools, QoL assessment, diagnostic imaging) and on 15 of 16 statements on management (conservative treatments, compressive therapy, pharmacological therapy, surgical treatment). The results of the consensus reached are discussed herein from which it is clear that diagnostic and management approaches utilising personalised therapies tailored to the individual patient should be favoured. While it is clear that additional studies are needed on many aspects of diagnosis and management of CVD, the present Delphi survey provides some key recommendations for clinicians treating CVD that may be useful in daily practice.

Guidelines for Medical Nutrition Therapy in Gestational Diabetes Mellitus: Systematic Review and Critical Appraisal

BACKGROUND

Medical nutrition therapy is the cornerstone of gestational diabetes mellitus treatment. However, guidelines often present contradictory guidance to health care practitioners.

OBJECTIVE

To systematically review and critically appraise medical nutrition therapy guidelines for treating patients with gestational diabetes mellitus.

DESIGN

We searched Medline, the Cochrane Library, Guidelines International Network, and Google Scholar to retrieve clinical practice guidelines (CPGs) for medical nutrition therapy in gestational diabetes mellitus from professional or governmental organizations, published in English, between January 1, 2007, and November 24, 2018. CPGs were reviewed and appraised using the Appraisal of Guidelines, Research, and Evaluation II instrument.

RESULTS

Of 1,286 retrieved articles, 21 CPGs fulfilled the inclusion criteria. CPGs of the Academy of Nutrition and Dietetics, Diabetes Canada, and Malaysia Health Technology Assessment Section received the greatest overall scores and the highest scores concerning rigor of recommendations development. Many CPGs failed to involve multidisciplinary teams in their development, including patients, and often, dietitians. Applicability of the recommendations was low, lacking facilitators and tools to enhance implementation. Many CPGs demonstrated low editorial independence by failing to disclose funding and competing interests. More medical nutrition therapy recommendations were incorporated in the Academy of Nutrition and Dietetics and Malaysia Health Technology Assessment Section CPGs. The Malaysia Health Technology Assessment Section, Diabetes Canada, Academy of Nutrition and Dietetics, and Endocrine Society guidelines were recommended by the review panel herein without modifications. Overall, the CPGs suggested the consumption of adequate protein and the selection of foods with low glycemic index, divided into three main meals and two to four snacks. Weight gain recommendations were mostly based on the Institute of Medicine body mass index thresholds.

CONCLUSIONS

With few exceptions, the main developmental limitations of the appraised CPGs involved low rigor of recommendations development, lack of multidisciplinary stakeholder involvement, low applicability, and inadequate editorial independence. This indicates a need for developing more clear, unbiased, practical, and evidence-based CPGs.

Clinical-pathological correlations of BAV and the attendant thoracic aortopathies. Part 1: Pluridisciplinary perspective on their hemodynamics and morphomechanics

Clinical BAV manifestations pertain to faulty aortic valve (AOV) function, the associated aortopathy, and other complications such as endocarditis, thrombosis and thromboembolism. BAV arises during valvulogenesis when 2 of the 3 leaflets/cusps of the AOV are fused together. Ensuing asymmetric BAV morphologies alter downstream ejection jet flow-trajectories. Based on BAV morphologies, ejection-flows exhibit different wall-impingement and scouring patterns in the proximal aorta, with excessive hydrodynamic wall-shear that correlates closely with mural vascular smooth muscle cell and extracellular matrix disruptions, revealing hemodynamic participation in the pathogenesis of BAV-associated aortopathies. Since the embryologic regions implicated in both BAV and aortopathies derive from neural crest cells and second heart field cells, there may exist a common multifactorial/polygenic embryological basis linking the abnormalities. The use of Electronic Health Records - encompassing integrated NGS variant panels and phenotypic data - in clinical studies could speed-up comprehensive understanding of multifactorial genetic-phenotypic and environmental factor interactions. This Survey represents the first in a 2-article pluridisciplinary work. Taken in toto, the series covers hemodynamic/morphomechanical and environmental (milieu intérieur) aspects in Part 1, and molecular, genetic and associated epigenetic aspects in Part 2. Together, Parts 1-2 should serve as a reference-milestone and driver for further pluridisciplinary research and its urgent translations in the clinical setting.

Therapeutic Options for Neuroendocrine Tumors: A Systematic Review and Network Meta-analysis

IMPORTANCE

Multiple therapies are currently available for patients with neuroendocrine tumors (NETs), yet many therapies have not been compared head-to-head within randomized clinical trials (RCTs).

OBJECTIVE

To assess the relative safety and efficacy of therapies for NETs.

DATA SOURCES

PubMed, Embase, the Cochrane Central Register of Controlled Trials, trial registries, meeting abstracts, and reference lists from January 1, 1947, to March 2, 2018, were searched. Key search terms included neuroendocrine tumors, gastrointestinal neoplasms, therapy, and randomized controlled trial.

STUDY SELECTION

Randomized clinical trials comparing 2 or more therapies in patients with NETs (primarily gastrointestinal and pancreatic) were evaluated. Thirty RCTs met the selection criteria.

DATA EXTRACTION AND SYNTHESIS

Pairs of independent reviewers screened studies, extracted data, and assessed the risk of bias. A network meta-analysis with a frequentist approach was used to compare the efficacy of therapies; the Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline was used.

MAIN OUTCOMES AND MEASURES

Disease control, progression-free survival, overall survival, adverse events, and quality of life.

RESULTS

The systematic review identified 30 relevant RCTs comprising 3895 patients (48.4% women) assigned to 22 different therapies for NETs. These therapies showed a broad range of risk for serious and nonserious adverse events. The network meta-analyses included 16 RCTs with predominantly a low risk of bias; nevertheless, precision-of-treatment estimates and estimated heterogeneity were limited. The network meta-analysis found 7 therapies for pancreatic NETs: everolimus (hazard ratio [HR], 0.35 [95% CI, 0.28-0.45]), everolimus plus somatostatin analogue (HR, 0.35 [95% CI, 0.25-0.51]), everolimus plus bevacizumab plus somatostatin analogue (HR, 0.44 [95% CI, 0.26-0.75]), interferon (HR, 0.37 [95% CI, 0.16-0.83]), interferon plus somatostatin analogue (HR, 0.31 [95% CI, 0.13-0.71]), somatostatin analogue (HR, 0.46 [95% CI, 0.33-0.66]), and sunitinib (HR, 0.42 [95% CI, 0.26-0.67]), and 5 therapies for gastrointestinal NETs: bevacizumab plus somatostatin analogue (HR, 0.22 [95% CI, 0.05-0.99]), everolimus plus somatostatin analogue (HR, 0.31 [95% CI, 0.11-0.90]), interferon plus somatostatin analogue (HR, 0.27 [95% CI, 0.07-0.96]), Lu 177-dotatate plus somatostatin analogue (HR, 0.08 [95% CI, 0.03-0.26], and somatostatin analogues (HR, 0.40 [95% CI, 0.21-0.78]) with higher efficacy than placebo and suggests an overall superiority of combination therapies.

CONCLUSIONS AND RELEVANCE

The findings from this study suggest that a range of efficient therapies with different safety profiles is available for patients with NETs.

Towards an individualized management strategy for patients with chronic venous disease: Results of a Delphi consensus

Objective To obtain consensus on management criteria for symptomatic patients with chronic venous disease (CVD; C2-C6) and superficial venous reflux. Method We used a Delphi method by means of 36 statements sent by email to experts in the field of phlebology across the world over the course of three rounds. The statements addressed criteria for different venous treatments in patients with different characteristics (e.g. extensive comorbidities, morbid obesity and peripheral arterial disease). If at least 70% of the ratings for a specific statement were between 6 and 9 (agreement) or between 1 and 3 (disagreement), experts' consensus was reached. Results Twenty-five experts were invited to participate, of whom 24 accepted and completed all three rounds. Consensus was reached in 25/32 statements (78%). However, several statements addressing UGFS, single phlebectomies, patients with extensive comorbidities and morbid obesity remained equivocal. Conclusion Considerable consensus was reached within a group of experts but also some gaps in available research were highlighted.

The endlessness evolution of medicine, continuous increase in life expectancy and constant role of the physician

In this review, the endlessness evolution of medical science and medical technology, and its effects on disease metamorphosis and increased life expectancy are discussed. In certain instances, the past will be compared with the present and predictions for the future will be outlined. Further, the constant role of the physician in maintaining the health of human beings is emphasized in this endlessness evolution.

Conceptual Foundations of Systems Biology Explaining Complex Cardiac Diseases

Systems biology is an important concept that connects molecular biology and genomics with computing science, mathematics and engineering. An endeavor is made in this paper to associate basic conceptual ideas of systems biology with clinical medicine. Complex cardiac diseases are clinical phenotypes generated by integration of genetic, molecular and environmental factors. Basic concepts of systems biology like network construction, modular thinking, biological constraints (downward biological direction) and emergence (upward biological direction) could be applied to clinical medicine. Especially, in the field of cardiology, these concepts can be used to explain complex clinical cardiac phenotypes like chronic heart failure and coronary artery disease. Cardiac diseases are biological complex entities which like other biological phenomena can be explained by a systems biology approach. The above powerful biological tools of systems biology can explain robustness growth and stability during disease process from modulation to phenotype. The purpose of the present review paper is to implement systems biology strategy and incorporate some conceptual issues raised by this approach into the clinical field of complex cardiac diseases. Cardiac disease process and progression can be addressed by the holistic realistic approach of systems biology in order to define in better terms earlier diagnosis and more effective therapy.

Coronary Atherosclerosis: Pathophysiologic Basis for Diagnosis and Management

Coronary atherosclerosis is a long lasting and continuously evolving disease with multiple clinical manifestations ranging from asymptomatic to stable angina, acute coronary syndrome (ACS), heart failure (HF) and sudden cardiac death (SCD). Genetic and environmental factors contribute to the development and progression of coronary atherosclerosis. In this review, current knowledge related to the diagnosis and management of coronary atherosclerosis based on pathophysiologic mechanisms will be discussed. In addition to providing state-of-the-art concepts related to coronary atherosclerosis, special consideration will be given on how to apply data from epidemiologic studies and randomized clinical trials to the individual patient. The greatest challenge for the clinician in the twenty-first century is not in absorbing the fast accumulating new knowledge, but rather in applying this knowledge to the individual patient.

Heart Rate, Life Expectancy and the Cardiovascular System: Therapeutic Considerations

It has long been known that life span is inversely related to resting heart rate in most organisms. This association between heart rate and survival has been attributed to the metabolic rate, which is greater in smaller animals and is directly associated with heart rate. Studies have shown that heart rate is related to survival in apparently healthy individuals and in patients with different underlying cardiovascular diseases. A decrease in heart rate due to therapeutic interventions may result in an increase in survival. However, there are many factors regulating heart rate, and it is quite plausible that these may independently affect life expectancy. Nonetheless, a fast heart rate itself affects the cardiovascular system in multiple ways (it increases ventricular work, myocardial oxygen consumption, endothelial stress, aortic/arterial stiffness, decreases myocardial oxygen supply, other) which, in turn, may affect survival. In this brief review, the effects of heart rate on the heart, arterial system and survival will be discussed.