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Intracerebral hemorrhage (ICH) is a subtype of stroke that results from spontaneous nontraumatic bleeding into the parenchyma of the brain. ICH accounts for 10% to 15% of all strokes and carries a disproportionately high risk of early death and long-term disability.1 Evidence for optimal treatment of ICH has lagged beh... |
5 Performance measures are being increasingly used for quality improvement, exter- nal reporting, regulatory oversight by hospital and program accreditation groups, and possibly pay-for-performance pro- Performance measures differ from guidelines in that most rigorous guidelines describe a desirable treatment or pro- c... |
Rigorous performance measures often take the strongest high- est-level guidelines and provide a method for directly measur- ing and reporting them with the goal of improving healthcare In addition to being evidence-based, they need to be developed with attention to feasibility and whether they are actionable and clearl... |
Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest. This performance measure report was approved by the American Heart Association Science Advisory and Coordinatin... |
A link to the Copyright Permissions Request Form appears on the right side of the page. AHA/ASA Performance Measures development that has been used for other AHA cardiovas- cular performance measure sets.11,12 These ICH performance measures represent the next AHA/ASA stroke-specific mea- sure set and were developed wit... |
Specific guideline rec- ommendations selected were then converted into performance measures by specifying eligible patients through specific inclu- sion and exclusion criteria and the measure numerator and denominator that would allow quantitative reporting of aggre- gate data. Previously existing performance measures ... |
Writing group members were required to disclose in writing all financial relationships with industry relevant to this topic according to standard AHA reporting policies. Definition of ICH ICH was defined as spontaneous bleeding into the paren- chyma of the brain not caused by trauma. There are multiple different causes... |
Table 1 includes a list of International Classification of Diseases, 10th Revision, Table 1. ICD-10-CM Principal Diagnosis Codes for Eligible Patients With an ICH Diagnosis I61.0 Nontraumatic ICH in hemisphere, subcortical I61.1 Nontraumatic ICH in hemisphere, cortical I61.2 Nontraumatic ICH in hemisphere, unspecified ... |
As with acute ischemic stroke, it is recognized that there are multiple dimensions of care for ICH, including the prehospital setting, the emergency depart- ment, rehabilitation, and outpatient care directed at primary and secondary prevention. Most other stroke-related performance measures (such as those from TJC,13 A... |
In addition, it would be most desirable for performance measures to be directly linked to patient-specific outcomes as opposed to processes of care.17 Outcomes can be intermediate- term or acute outcomes (eg, development of pneumonia during the inpatient setting) or long-term outcomes (eg, functional out- come at 6 mon... |
2 AHA/ASA Guidelines for Adult Stroke Rehabilitation and Recovery were also reviewed.18 In addition, other documents of existing performance measures or quality metrics were reviewed to assess whether there were current performance measures developed for ischemic stroke or ICH that should be considered for inclusion an... |
Selection and Development of Performance Measures The process for the selection and development of these ICH performance measures used an approach from the AHA/ASA Stroke Performance Oversight Committee similar to that used for the 2014 AHA/ASA ischemic stroke performance mea- Only Class I (high consensus for benefit) ... |
Each writing group member participated in the development of at least 2 draft performance measures. Subsequent teleconferences were held in which each of these drafts was reviewed by the writ- ing group with input designed to improve the measurement set specifications before voting by the writing group. During these te... |
When deemed appropriate, these changes were made before the development of this final manuscript describing the ICH performance measures. Peer review of this manuscript was then conducted by reviewers selected by the AHA. After peer review and appropriate revi- sions, these ICH performance measures were approved by the... |
The writing group agreed that it is appropriate to exclude admissions with length of stay >120 days, as is done in the NQF-endorsed ICH measures, to avoid double counting patients when generating quarterly reports. ICH may be identified by discharge International Classification of Diseases codes (as required by TJC), p... |
Three are identical to measures in the AHA/ASA ischemic stroke performance measure set. The Discussion provides additional comments on the measures, including the limitations of some of the current measures, opportunities for improvement, and rec- ommendations for implementation and field testing. Appendix Table A1 pro... |
Regardless of how the data are collected, the reliability of data abstraction methods used in performance measure assessment should be validated by inde- pendent review of a subset of cases consisting of manual chart review (in the case of electronically derived performance data) or independent abstracter review (in th... |
The purpose of these performance measures is to improve the quality of care for patients with ICH by providing hospitals, stroke teams, and regulatory bodies with a way to directly measure and potentially benchmark this quality of care. The writing group, through its internal discussions and deliberations, understands ... |
This is why significant effort was made to harmonize these performance measures with other existing measures, espe- cially when these earlier measures had been endorsed by the NQF. When the writing group felt that an existing performance measure was not optimal, the relevant performance measure was made according to wr... |
Performance Measure NQF Endorsed CDC PCNASR/AHA GWTG-Stroke TJC CMS HIQRP AHA Ischemic Stroke Performance Measure New Measure 1 Baseline severity score 2 Coagulopathy reversal o 3 Venous thromboembolism prophylaxis o o o o o 4 Admission unit 5 Dysphagia screen: assessment o o 6 Dysphagia screen: management o o 7 Long-t... |
The recommendation for a baseline severity score in all patients with acute ICH was new in the 2015 AHA/ASA ICH guidelines and was considered as a metric for Comprehensive Stroke Centers in the 2011 AHA/ASA recommendations. Numerous baseline severity scores for ICH exist,22 24 with the general goal of their use being t... |
This approach was largely affirmed by others during the public comment period. Components of the ICH score and 1 straight- forward method of calculating ICH hematoma volume can be found in work by Hemphill et al22 and Kothari et al.25 The performance measure for reversal of coagulopathy follows from the 2015 AHA/ASA IC... |
However, the writing group felt that the absence of any time frame for administra- tion did not appropriately reflect quality because treatment with prothrombin complex concentrates or fresh-frozen plasma at a time point outside the hyperacute period was not the intended approach and meeting the metric by treat- ing ma... |
The 2015 ICH guidelines did not include a Class I recommen- dation for reversal of newer anticoagulant agents such as dabi- gatran, rivaroxaban, or apixaban. Thus, the writing group felt that a specific performance measure should not be developed at this time. However, this is an important issue for future guideline an... |
However, these are also issues that generally apply to all stroke patients, Hemphill et al Performance Measures for ICH e249 and this factored significantly into the writing group s delib- erations on whether to draft entirely independent and unique performance measures on these topics for ICH or to consider whether th... |
These new measures deserve pilot testing to assess feasibility and reliability. The new measures relate to hospital admission unit, long-term blood pressure management, and corticosteroid use for intracranial pressure management. It is recognized that for ICH specifi- cally, improved outcomes are seen in patients who a... |
Hypertension is the most common cause of ICH, and the 2015 AHA/ASA ICH guidelines contain a new prevention- focused recommendation for the initiation of blood pressure control immediately after ICH onset.1,2 The related new perfor- mance measure does not apply to specific targets or agents for acute blood pressure cont... |
The new AHA definition of hyperten- sion as a blood pressure >130/80 mmHg was incorporated as the target for initiation of treatment.34 Corticosteroids are not recommended for treating elevated intracranial pressure or cerebral edema in patients with ICH.2 There is limited information on the extent to which this still ... |
In addition, the writing group recognizes that there are many issues that might be desirable in performance mea- sures but do not currently meet the high evidence standards (Class I or III recommendations) required for consideration. Quality assessment and performance measure implementation in stroke are still at an ea... |
Denominator Included patients: All patients with ICH Excluded patients: <18 y of age Patients who arrive at hospital >48 h after last known well time Length of stay >120 d Clear documentation for comfort care/palliative care measures established before hospital arrival Period of Assessment First 6 h after hospital arri... |
Method of Reporting Per patient: documentation of whether a severity score was measured and a total score was recorded as part of the initial evaluation on arrival at the hospital Per patient population: percentage of patients in whom a severity score was measured and a total score was recorded as part of the initial e... |
Hemphill et al Performance Measures for ICH e251 Appendix. Continued 2. Coagulopathy Reversal: Percentage of patients with ICH and an INR >1.4 resulting from warfarin treatment who receive therapy to replace vitamin K dependent clotting factors within 90 min of ED presentation and who also receive intravenous vitamin K... |
Vitamin K is needed to ensure that coagulopathy does not return after the effect of initial reversal has passed. Source for Recommendations From the 2015 AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage Patients with ICH whose INR is elevated because of vitamin K antagonist should have thei... |
A specific time for the vitamin K administration is not delineated. Recombinant factor VIIa is not recommended by the AHA/ASA ICH guidelines and is not acceptable. Appendix. Continued 3. Venous Thromboembolism Prophylaxis: Percentage of patients with ICH who receive lower limb pneumatic compression on hospital day 0 or... |
Graduated compression stockings are not beneficial to reduce DVT or improve outcome (Class III; Level of Evidence A). Method of Reporting Per patient: documentation of whether patient received pneumatic compression on hospital day 0 or 1 Per patient population: percentage of patients receiving pneumatic compression on ... |
Hemphill et al Performance Measures for ICH e253 Appendix. Continued 4. Admission Unit: Percentage of patients with ICH who are admitted to an intensive care unit or dedicated stroke unit with physician and nursing neuroscience acute care expertise Numerator Patients admitted to an intensive care unit or dedicated stro... |
Source for Recommendation From the 2015 AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage Initial monitoring and management of patients with ICH should take place in an intensive care unit or dedicated stroke unit with physician and nursing neuroscience acute care expertise (Class I; Level o... |
AHA indicates American Heart Association; ASA, American Stroke Association; ED, emergency department; ICH, intracerebral hemorrhage; and TJC, The Joint Commission. Appendix. Continued 5. Dysphagia Screening Within 24 h: Percentage of patients 18 y of age with a diagnosis of ICH for whom there is documentation that a dy... |
Several studies have demonstrated a reduction in pneumonia after institutional implementation of dysphagia screening protocols but without randomized control groups. Several swallow screening methods have been published in the literature, each with benefits and limitations, without sufficient evidence to recommend a si... |
Hemphill et al Performance Measures for ICH e255 Appendix. Continued 6. Passed Dysphagia Screen Before First Oral Intake of Fluids, Nutrition, or Medications: Percentage of patients 18 y of age with a diagnosis of ICH who were documented to have passed the most recent dysphagia screen before oral intake Numerator Inclu... |
Several swallow screening methods have been published in the literature, each with benefits and limitations, without sufficient evidence to recommend a single consensus method. Source for Recommendation From the 2015 AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage A formal screening proced... |
AHA indicates American Heart Association; AMA, American Medical Association; ASA, American Stroke Association; CDC, Centers for Disease Control and Prevention; GWTG Stroke, Get With The Guidelines Stroke; ICH, intracerebral hemorrhage; NQF, National Quality Forum; PCNASP, Paul Coverdell National Acute Stroke program; a... |
The methods for dysphagia assessment and recommendations should be based on an institutional protocol and may include some combination of a structured bedside swallowing screen administered by nursing staff, bedside swallow evaluation by a speech-language pathologist, videofluoroscopic swallow evaluation, fiberoptic en... |
Measures to control BP should begin immediately after ICH onset (Class I, Level of Evidence A). Method of Reporting Per patient: documentation of an oral or transdermal antihypertensive medication prescribed at the time of hospital discharge or a documented BP of <130/80 mmHg at the time of hospital discharge Per patie... |
Comprehensive stroke units that include rehabilitation services demonstrate improved outcomes compared with other models of stroke unit care, and most studies of rehabilitation in stroke have included patients with ICH and ischemic stroke. Source for Recommendations From the 2015 AHA/ASA Guidelines for the Management o... |
Analogous Measures Endorsed by Other Organizations Identical measures endorsed or used by NQF (Nos. 0244 and 0441), TJC (STK-10), AHA Ischemic Stroke Performance Measure 9, AHA GWTG-Stroke, and CDC PCNASP AHA indicates American Heart Association; ASA, American Stroke Association; CDC, Centers for Disease Control and Pr... |
A prior randomized clinical trial in ICH found increased complications and no outcome benefit. This has also been found in traumatic brain and spinal cord injury, and corticosteroids are not recommended in these conditions. Source for Recommendation From the 2015 AHA/ASA Guidelines for the Management of Spontaneous Int... |
Analogous Measures Endorsed by Other Organizations None AHA indicates American Heart Association; ASA, American Stroke Association; COPD, chronic obstructive pulmonary disease; ED, emergency department; and ICH, intracerebral hemorrhage. Hemphill et al Performance Measures for ICH e259 Disclosures Writing Group Disclos... |
A relationship is considered to be significant if (a) the person receives $10000 or more during any 12-month period, or 5% or more of the person s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $10000 or more of the fair market value of the entity. A relationship is ... |
Spontaneous intracerebral hemorrhage. N Engl J Med. 2001;344:1450 1460. doi: 10.1056/NEJM200105103441907. 2. Hemphill JC 3rd, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M, Fung GL, Goldstein JN, Macdonald RL, Mitchell PH, Scott PA, Selim MH, Woo D; on behalf of the American Heart Association Stroke Council... |
Nothacker M, Stokes T, Shaw B, Lindsay P, Sipil R, Follmann M, Kopp I; Guidelines International Network (G-I-N) Performance Measures Working Group. Reporting standards for guideline-based performance measures. Implement Sci. 2016;11:6. doi: 10.1186/s13012-015-0369-z. 9. K tter T, Blozik E, Scherer M. Methods for the gu... |
Characteristics, perfor- mance measures, and in-hospital outcomes of the first one million stroke and transient ischemic attack admissions in Get With The Guidelines Stroke. Circ Cardiovasc Qual Outcomes. 2010;3:291 302. doi: 10.1161/CIRCOUTCOMES.109.921858. 15. George MG, Tong X, McGruder H, Yoon P, Rosamond W, Winqui... |
Leifer D, Bravata DM, Connors JJ 3rd, Hinchey JA, Jauch EC, Johnston SC, Latchaw R, Likosky W, Ogilvy C, QureshiAI, Summers D, Sung GY, Williams LS, Zorowitz R; on behalf of the American Heart Association Special Writing Group of the Stroke Council; Atherosclerotic Peripheral Vascular Disease Working Group; Council on ... |
Kothari RU, Brott T, Broderick JP, BarsanWG, Sauerbeck LR, Zuccarello M, Khoury J. The ABCs of measuring intracerebral hemorrhage vol- umes. Stroke. 1996;27:1304 1305. doi: 10.1161/01.STR.27.8.1304. 26. Kuramatsu JB, Gerner ST, Schellinger PD, Glahn J, Endres M, Sobesky J, Flechsenhar J, Neugebauer H, J ttler E, Grau A... |
Steiner T, Poli S, Griebe M, H sing J, Hajda J, Freiberger A, Bendszus M, B sel J, Christensen H, Dohmen C, Hennerici M, Kollmer J, Hemphill et al Performance Measures for ICH e261 Stetefeld H, Wartenberg KE, Weimar C, Hacke W, Veltkamp R. Fresh frozen plasma versus prothrombin complex concentrate in patients with intr... |
Smith WS, Weingart S. Emergency neurological life support (ENLS): what to do in the first hour of a neurological emergency. Neurocrit Care. 2012;17(suppl 1):S1 S3. doi: 10.1007/s12028-012-9741-x. 34. Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison Himmelfarb C, DePalma SM, Gidding S, Jamerson KA, Jon... |
Prevention of Infective Endocarditis Guidelines From the American Heart Association A Guideline From the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and... |
The writing group reviewed input from national and international experts on infective endocarditis. The recommendations in this document reflect analyses of relevant literature regarding procedure-related bacteremia and infective endocarditis, in vitro susceptibility data of the most common microorganisms that cause in... |
To make photocopies for personal or educational use, call the Copyright Clearance Center, 978-750-8400. Expert peer review of AHA Scientific Statements and Guidelines is conducted at the AHA National Center. For more on AHA statements and guidelines development, visit http://www.americanheart.org/presenter.jhtml?identi... |
These changes are intended to define more clearly when infective endocarditis prophylaxis is or is not recommended and to provide more uniform and consistent global recommendations. (Circulation. 2007;116:1736-1754.) Key Words: AHA Scientific Statements cardiovascular diseases endocarditis prevention antibiotic prophyl... |
Classification of Recommendations: Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is beneficial, useful, and effective. Class II: Conditions for which there is conflicting evi- dence and/or a divergence of opinion about the usefulness/ efficacy of a procedur... |
In 1955, the first AHA document on this subject was published in Circulation.6 Table 1 shows a summary of the documents published from 1955 to 1997.1,6 13 The 1960 document called atten- tion to the possible emergence of penicillin-resistant oral microflora as a result of prolonged therapy for prevention of IE, and ped... |
The 1984 recom- mendations attempted to simplify prophylactic regimens by providing clear lists of procedures for which prophy- laxis was and was not recommended and reduced postpro- cedure prophylaxis for dental, GI, and GU tract procedures to only 1 oral or parenteral dose.12 In 1990, a more complete list of cardiac ... |
The rationale for prophylaxis was based largely on expert opinion and what seemed to be a rational and prudent attempt to prevent a life-threatening infection. On the basis of the ACC and AHA Task Force on Practice Guide- lines evidence-based grading system for ranking recommen- dations, the recommendations in the AHA ... |
The Committee believes that of these 5 underlying principles, the first 4 are valid and have not changed during the past 30 years. Numerous publications have questioned the validity of the fifth principle and suggested revision of the guidelines, primarily for reasons as shown in Table 2. Another reason that led the Co... |
For 2 days after, 200 000 to 250 000 U by mouth 4 times per day. 1960 (8) Step I: prophylaxis 2 days before surgery with procaine penicillin 600 000 U IM on each day Step II: day of surgery: procaine penicillin 600 000 U IM supplemented by crystalline penicillin 600 000 U IM 1 hour before surgical procedure Step III: f... |
of patients and providers, would be reasonable and prudent, and would represent the conclusions of published studies and the collective wisdom of many experts on IE and relevant national and international societies. Potential Consequences of Substantive Changes in Recommendations Substantive changes in recommendations ... |
Patients with underlying cardiac conditions that carry a lifetime risk of acquisition of IE, such as mitral valve prolapse (MVP), had a sense of reassurance and comfort that antibiotics administered in association with a dental proce- dure were effective and usually safe to prevent IE. Healthcare providers, especially ... |
A placebo-controlled, multicenter, randomized, double-blinded study to evaluate the efficacy of IE prophylaxis in patients who undergo a dental, GI, or GU tract procedure has not been done. Such a study would require a large number of patients per treatment group and standardization of the specific invasive procedures ... |
Invasion of the blood- stream with a microbial species that has the pathogenic potential to colonize this site can then result in IE. Transient Bacteremia Mucosal surfaces are populated by a dense endogenous microflora. Trauma to a mucosal surface, particularly the Table 2. Primary Reasons for Revision of the IE Prophy... |
Bacterial Adherence The ability of various microbial species to adhere to specific sites determines the anatomic localization of infection caused by these microorganisms. Mediators of bacterial adherence serve as virulence factors in the pathogenesis of IE. Numer- ous bacterial surface components present in streptococc... |
Within this secluded focus, the buried microorganisms multiply as rap- idly as bacteria in broth cultures to reach maximal microbial densities of 108 colony-forming units per gram of vegetation within a short time on the left side of the heart, apparently uninhibited by host defenses in left-sided lesions. Right-sided ... |
Okell and Elliott23 in 1935 reported that 11% of patients with poor oral hygiene had positive blood cultures with viridans group streptococci and that 61% of patients had viridans group streptococcal bacteremia with dental extraction. As a result of these early studies and subsequent studies, during the past 50 years, ... |
Few data exist on the risk of or prevention of IE associated with a GI or GU tract procedure. Accordingly, the Committee undertook a critical analysis of published data in the context of the historical rationale for recommending antibiotic prophylaxis for IE before a dental procedure. The following factors were conside... |
There has been a disproportionate focus on the frequency of bacteremia associated with dental procedures rather than on the species of bacteria recovered from blood cultures. Studies suggest that more than 700 species of bacteria, including aerobic and anaerobic Gram-positive and Gram- negative microorganisms, may be i... |
There are no published data that demonstrate that a greater magnitude of bacteremia, compared with a lower magnitude, is more likely to cause IE in humans. The magnitude of bacteremia resulting from a dental procedure is relatively low ( 104 colony-forming units of bacteria per milliliter), similar to that resulting fr... |
Given the preponderance of published data, there may not be a clinically significant difference in the frequency, nature, magnitude, and duration of bacteremia associated with a dental procedure compared with that resulting from routine daily activities. Accordingly, it is inconsistent to recommend prophylaxis of IE fo... |
* However, numerous other dental procedures have been re- ported to be associated with risks of bacteremia that are similar to that resulting from tooth extraction. A precise determination of the relative risk of bacteremia that results from a specific dental procedure in patients with or without dental disease is prob... |
Accordingly, it is not clear which dental procedures are more or less likely to cause a transient bacteremia or result in a greater magnitude of bacteremia than that which results from routine daily activities such as chewing food, tooth brushing, or flossing. In patients with underlying cardiac conditions, lifelong an... |
Hall et al78 reported that neither penicillin V nor amoxicillin therapy was effective in reducing the frequency of bacteremia compared with untreated control subjects. In patients who underwent a dental extraction, penicillin or ampicillin therapy compared with placebo diminished the percentage of viridans group strept... |
On the basis of these data, it is unlikely that topical antiseptics are effective to significantly reduce the frequency, magnitude, and duration of bacteremia associated with a dental procedure. Cumulative Risk Over Time of Bacteremias From Routine Daily Activities Compared With the Bacteremia From a Dental Procedure G... |
Nevertheless, even if the esti- mates of bacteremia from routine daily activities are off by a factor of 1000, it is likely that the frequency and cumulative duration of exposure to bacteremia from routine daily events over 1 year are much higher than those that result from dental procedures. Results of Clinical Studie... |
Furthermore, in a number of cases, the incubation period between the dental procedure and the onset of symptoms of IE was van der Meer and colleagues85 published a study of dental procedures in the Netherlands and the efficacy of antibiotic prophylaxis to prevent IE in patients with native or prosthetic cardiac valves.... |
The authors concluded that dental treatment was not a risk factor for IE even in patients with valvular heart disease and that few cases of IE could be prevented with prophylaxis even if it were 100% effective. These studies are in agreement with a recently published French study of the estimated risk of IE in adults w... |
Furthermore, there are numerous poorly documented case reports that implicate dental proce- dures associated with the development of IE, but these reports did not prove a direct causal relationship. Even in the event of a close temporal relationship between a dental procedure and IE, it is not possible to determine wit... |
These and other factors have led to a heightened awareness among patients and healthcare providers of the possible association between dental procedures and IE, which likely has led to substantial overreporting of cases attributable to dental procedures. Although the absolute risk for IE from a dental procedure is impo... |
Risk of Adverse Reactions and Cost-Effectiveness of Prophylactic Therapy Nonfatal adverse reactions, such as rash, diarrhea, and GI upset, occur commonly with the use of antimicrobials; however, only single-dose therapy is recommended for dental prophylaxis, and these common adverse reactions are usually not severe and... |
The Committee believes that a single dose of amoxicillin or ampicillin is safe and is the preferred prophy- lactic agent for individuals who do not have a history of type I hypersensitivity reaction to a penicillin, such as anaphy- laxis, urticaria, or angioedema. Fatal anaphylaxis from a cephalosporin is estimated to ... |
There should be a shift in emphasis away from a focus on a dental procedure and antibiotic prophylaxis toward a greater emphasis on improved access to dental care and oral health in patients with underlying cardiac conditions associated with the highest risk of adverse out- come from IE and those conditions that predis... |
Underlying Conditions Over a Lifetime That Have the Highest Predisposition to the Acquisition of Endocarditis In Olmsted County, Minnesota, the incidence of IE in adults incidence has remained stable during the past 4 decades and is similar to that reported in other studies.100 103 Previously, RHD was the most common u... |
In a separate study, the risk of IE per 100 000 patient-years was 271 in patients with congenital aortic stenosis and 145 in patients with ventricular septal defect.105 In that same study, the risk of IE before closure of a ventricular septal defect was more than twice that after closure. Although these data provide us... |
On the basis of the data from Steckelberg and Wilson91 and others,2 it is clear that the underlying conditions discussed above represent a lifetime increased risk of acquisition of IE compared with individuals with no known underlying cardiac condition. Accordingly, when utilizing previous AHA guide- lines in the decis... |
Each of these comorbid conditions independently increases the risk of adverse outcome from IE, and they often occur in combina- tion, which further increases morbidity and mortality rates. Additionally, there may be long-term consequences of IE. Over time, the cardiac valve damaged by IE may undergo progressive functio... |
Patients with relapsing or recurrent IE are at greater risk of congestive heart failure and increased need for cardiac valve replacement surgery, and they have a higher mortality rate than patients with a first episode of native valve IE.118 124 Additionally, patients with multiple episodes of native or prosthetic valv... |
In most instances, treatment of patients who have infected prosthetic materials requires surgical removal in addition to medical therapy with associated high morbidity and mortality rates. Should IE Prophylaxis Be Recommended for Patients With the Highest Risk of Acquisition of IE or for Patients With the Highest Risk ... |
In patients with underlying cardiac conditions associated with the highest risk of adverse outcome from IE (Table 3), IE prophylaxis for dental proce- Table 3. Cardiac Conditions Associated With the Highest Risk of Adverse Outcome From Endocarditis for Which Prophylaxis With Dental Procedures Is Reasonable Prosthetic c... |
Additionally, the change in emphasis to restrict prophylaxis for only those patients with the highest risk of adverse outcome should reduce the uncertainties among patients and providers about who should receive prophylaxis. MVP is the most common underlying condition that predisposes to acquisition of IE in the Wester... |
In these circumstances, it is important to obtain blood cultures and other relevant tests before administration of antibiotics intended to prevent IE. Failure to do so may result in delay in diagnosis or treatment of a concomitant case of IE. Regimens for Dental Procedures Previous AHA guidelines on prophylaxis listed ... |
In this limited patient population, prophylactic antimicro- bial therapy should be directed against viridans group strep- tococci. During the past 2 decades, there has been a signifi- cant increase in the percentage of strains of viridans group streptococci resistant to antibiotics recommended in previous AHA guideline... |
In other studies, resistance of viridans group streptococci to penicillin ranged from 17% to 50%137 142 and resistance to ceftriaxone ranged from 22% to 42%.131,140 Ceftriaxone was 2 to 4 times more active in vitro than cefazolin.131,140 Similarly high rates of resistance were reported for macrolides, ranging from 22% ... |
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