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Hospital-Based Medicine This publication is protected by copyright. No part of this publication may be reproduced, stored in a retrieval For the convenience ofsubscribers who provide care in system, or transmitted in any form or by any means, elec hospital settings, comprehensive hospital-focused content tronic or mechanical, including photocopy, without the aligned with the ABIM Focused Practice in Hospital Medicine express consent of the ACP. MKSAP 19 is for individual trlueprint is integrated throughout the syllabus, and self use only. Only one account per subscription will be per- assessment questions that are specific to the hospital setting mitted for the purpose of earning CME credits and MOC are specially designated with the blue hospitalist icon (E). points and for other authorized uses of MKSAP 19.

Hospital-Based Medicine This publication is protected by copyright. No part of this publication may be reproduced, stored in a retrieval For the convenience ofsubscribers who provide care in system, or transmitted in any form or by any means, elec hospital settings, comprehensive hospital-focused content tronic or mechanical, including photocopy, without the aligned with the ABIM Focused Practice in Hospital Medicine express consent of the ACP. MKSAP 19 is for individual trlueprint is integrated throughout the syllabus, and self use only. Only one account per subscription will be per- assessment questions that are specific to the hospital setting mitted for the purpose of earning CME credits and MOC are specially designated with the blue hospitalist icon (E). points and for other authorized uses of MKSAP 19. High Value Care Key Points Disclaimer Regarding Direct Purchases Key Points in the text that relate to High Value Care from Online Retailers concepts (that is, concepts that discuss balancing clinical CME and/or MOC for MKSAP 19 is available only to cus- benefit with costs and harms) are designated by the HVC tomers who purchase the program directly from ACP. icon [HVC]. ACP will not set up MKSAP CME/MOC accounts lor purchasers of MKSAP sold by unauthorized sellers (e.g., Educational Disclaimer Amazon, eBay), with whom ACP has no relationship. We do not honor third party sales. CME credits and MOC The editors and publisher of MKSAP 19 recognize that points cannot be awarded to those purchasers who have the development of new material offers many opportu- purchased the program from non authorized sellers. nities for error. Despite our best efforts, some errors may persist in print. Drug dosage schedules are, we believe, accurate and in accordance with current standards. Unauthorized Use of This Book Readers are advised, however, to ensure that the recom ls Against the Law mended dosages in MKSAP 19 concur with the informa Unauthorized reproduction of this publication is unlaw- tion provided in the product information material. This is ful. ACP prohibits reproduction of this publication or any especially important in cases of new, infrequently used, of its parts in any form either for individual use or for or highly toxic drugs. Application of the information in distribution. MKSAP 19 remains the professional responsibility of the practitioner. ACP will consider granting an individual permission to reproduce only limited portions of this publication for his The primary purpose of MKSAP 19 is educational. or her own exclusive use. Send requests in writing to Information presented, as well as publications, technol- MKSAP- Permissions, American College of Physicians, 190 N, ogies, products, and/or services discussed, is intended to Independence Mall West, Philadelphia, PA 19106 1572, or inform subscribers about the knowledge, techniques, and email your request to mksap-editors6acponline.org. experiences of the contributors. A diversity of professional opinion exists, and the views of the contributors are their MKSAP 19 ISBN: 978 1 938245 75 6 own and not those of the ACP. Inclusion of any material Cardiovascular Medicine ISBN : 978-1-938245 -84-8 in the program does not constitute endorsement or rec- Printed in the United States of America ommendation by the ACP. The ACP does not warrant the safety, reliability, accuracy, completeness, or usefulness of For order information in the U.S. or Canada, call and disclaims any and all liability for damages and claims 800 ACP 1915. In all other countries. call 215-351-2600 that may result from the use of information, publications, (Monday to Friday, 9 en 5 put ET). Fax inquiries to technologies, products, and/or services discussed in this 215 351 2799 or email to custserv@acponline.org. program.

High Value Care Key Points Disclaimer Regarding Direct Purchases Key Points in the text that relate to High Value Care from Online Retailers concepts (that is, concepts that discuss balancing clinical CME and/or MOC for MKSAP 19 is available only to cus- benefit with costs and harms) are designated by the HVC tomers who purchase the program directly from ACP. icon [HVC]. ACP will not set up MKSAP CME/MOC accounts lor purchasers of MKSAP sold by unauthorized sellers (e.g., Educational Disclaimer Amazon, eBay), with whom ACP has no relationship. We do not honor third party sales. CME credits and MOC The editors and publisher of MKSAP 19 recognize that points cannot be awarded to those purchasers who have the development of new material offers many opportu- purchased the program from non authorized sellers. nities for error. Despite our best efforts, some errors may persist in print. Drug dosage schedules are, we believe, accurate and in accordance with current standards. Unauthorized Use of This Book Readers are advised, however, to ensure that the recom ls Against the Law mended dosages in MKSAP 19 concur with the informa Unauthorized reproduction of this publication is unlaw- tion provided in the product information material. This is ful. ACP prohibits reproduction of this publication or any especially important in cases of new, infrequently used, of its parts in any form either for individual use or for or highly toxic drugs. Application of the information in distribution. MKSAP 19 remains the professional responsibility of the practitioner. ACP will consider granting an individual permission to reproduce only limited portions of this publication for his The primary purpose of MKSAP 19 is educational. or her own exclusive use. Send requests in writing to Information presented, as well as publications, technol- MKSAP- Permissions, American College of Physicians, 190 N, ogies, products, and/or services discussed, is intended to Independence Mall West, Philadelphia, PA 19106 1572, or inform subscribers about the knowledge, techniques, and email your request to mksap-editors6acponline.org. experiences of the contributors. A diversity of professional opinion exists, and the views of the contributors are their MKSAP 19 ISBN: 978 1 938245 75 6 own and not those of the ACP. Inclusion of any material Cardiovascular Medicine ISBN : 978-1-938245 -84-8 in the program does not constitute endorsement or rec- Printed in the United States of America ommendation by the ACP. The ACP does not warrant the safety, reliability, accuracy, completeness, or usefulness of For order information in the U.S. or Canada, call and disclaims any and all liability for damages and claims 800 ACP 1915. In all other countries. call 215-351-2600 that may result from the use of information, publications, (Monday to Friday, 9 en 5 put ET). Fax inquiries to technologies, products, and/or services discussed in this 215 351 2799 or email to custserv@acponline.org. program. Errata and Revisions Publisher's lnformation Errata and Revisions lor MKSAP 19 will be available Copyright c. 2022 American College of Physicians. AII through MKSAP 19 Digital at mksapl9.acponline.org as rights reserved. new information becomes known to the editors.

Errata and Revisions Publisher's lnformation Errata and Revisions lor MKSAP 19 will be available Copyright c. 2022 American College of Physicians. AII through MKSAP 19 Digital at mksapl9.acponline.org as rights reserved. new information becomes known to the editors. vlt

i i I L i Table of Contents t L t t t Epidemiology and Risk Factors Patients Older Than 75 Years . . 28 t Overview 7 Women 29 t Risk Factors for Cardiovascular Disease 1 Patients With Diabetes Mellitus 29 T f Lifestyle 1 I Dyslipidemia I Heart Failure t Hypertension 1 Pathophysiologz of Heart Failure . . . .30

L i Table of Contents t L t t t Epidemiology and Risk Factors Patients Older Than 75 Years . . 28 t Overview 7 Women 29 t Risk Factors for Cardiovascular Disease 1 Patients With Diabetes Mellitus 29 T f Lifestyle 1 I Dyslipidemia I Heart Failure t Hypertension 1 Pathophysiologz of Heart Failure . . . .30 I Diabetes Mellitus 2 Screening ..........30 \ Obesiry and Metabolic Syndrome . 2 Diagnosis and Evaluation of Heart Failure . . . . 30 t Inherited Fhctors 2 Clinical Evaluation .....30 Ethnicity. Diagnosis ......31 i Calculating Cardiovascular Risk . . . . . . 2 Evaluationforlschemia ........31 2 L Specific Risk Groups. D Classification ..........32 I Women 3 Management .......32 t Chronic Kidney Disease c Heart Failure With Reduced Ejection Fraction . . . .32 i I Systemic lnflammation and HIV. . 3 Heart Failure With Preserved Ejection Fraction . . . 37 t AcuteDecompensatedHeartFailure .....38 t Diagnostic Testing in Grdiology AdvancedRefractoryHeartFailure ......40 L Clinical History and Physical Examination . . . c SpecificPopulations ....47 I SpecificCardiomyopathies.. I Diagnostic Testing for Atherosclerotic ........4l t CoronaryArteryDisease . . . . . TakotsuboCardiomyopathy... ......... 4l \ 3 AcuteMyocarditis.... I Cardiac Stress Testing 3 .........41 I Visualization of the Coronary Anatomy . . B GiantCellMyocarditis. .........42 i I CoronaryArtery Calcium Scoring. . . . . . . 9 Sarcoidosis .....42 I Risks of Diagnostic Testing for Coronary Tachycardia-Mediated Cardiomyopathy. . . . . . . . . 42 5 ArteryDisease..... .9 t Diagnostic Testing for Structural Heart Disease 10 Arrhythmias i Diagnostic Testing for Cardiac Arrhythmias . . 10 Introduction. 43 \ Approach to the Patient With Bradycardia. . . . . . . 43 ...... I

I Diabetes Mellitus 2 Screening ..........30 \ Obesiry and Metabolic Syndrome . 2 Diagnosis and Evaluation of Heart Failure . . . . 30 t Inherited Fhctors 2 Clinical Evaluation .....30 Ethnicity. Diagnosis ......31 i Calculating Cardiovascular Risk . . . . . . 2 Evaluationforlschemia ........31 2 L Specific Risk Groups. D Classification ..........32 I Women 3 Management .......32 t Chronic Kidney Disease c Heart Failure With Reduced Ejection Fraction . . . .32 i I Systemic lnflammation and HIV. . 3 Heart Failure With Preserved Ejection Fraction . . . 37 t AcuteDecompensatedHeartFailure .....38 t Diagnostic Testing in Grdiology AdvancedRefractoryHeartFailure ......40 L Clinical History and Physical Examination . . . c SpecificPopulations ....47 I SpecificCardiomyopathies.. I Diagnostic Testing for Atherosclerotic ........4l t CoronaryArteryDisease . . . . . TakotsuboCardiomyopathy... ......... 4l \ 3 AcuteMyocarditis.... I Cardiac Stress Testing 3 .........41 I Visualization of the Coronary Anatomy . . B GiantCellMyocarditis. .........42 i I CoronaryArtery Calcium Scoring. . . . . . . 9 Sarcoidosis .....42 I Risks of Diagnostic Testing for Coronary Tachycardia-Mediated Cardiomyopathy. . . . . . . . . 42 5 ArteryDisease..... .9 t Diagnostic Testing for Structural Heart Disease 10 Arrhythmias i Diagnostic Testing for Cardiac Arrhythmias . . 10 Introduction. 43 \ Approach to the Patient With Bradycardia. . . . . . . 43 ...... I CoronaryArtery Disease Clinical PresentationandEvaluation . 43 Stable Angina Pectoris 13 SinusBradycardia... 43 L Diagnosis and Evaluation. . . . . 13 Atrioventricular Block 43 I General Approach to Treatment of Stable Treatment. 45 Angina Pectoris t4 Approach to the Patient With Tachycardia. . . . . . . 45 Coronary Revascularization. . . t6 Clinical PresentationandEvaluation ...... . 45 Acute Coronary Syndromes 17 Antiarrhythmic Drugs 46 General Considerations. . . . . . t7 SinusTachycardia... 48 ST Elevation Myocardial I nfarction 1B Supraventricular Tachycardias. . . . 49 Non-ST Elevation Acute Coronary Syndromes n9 Clinical Presentation. 49 Medical Therapy for Acute Coronary Syndromes 24 Atrioventricular Nodal Reentrant Tachycardia 49 Acute Coronary Syndromes Not Associated Atrioventricular Reciprocating Tachycardia. . 49 With Obstructive Coronary Artery Disease . . . 27 Premature Atrial Contractions and Care After an Acute Coronary Syndrome . . . . . 28 AtrialTachycardia... 50 Management of Coronary Artery Disease Atrial Fibrillation. . . 50 in Specific Populations. 28 Clinical Presentation. 51 Patients With Asymptomatic Vascular Disease 28 Acute Management . .51

CoronaryArtery Disease Clinical PresentationandEvaluation . 43 Stable Angina Pectoris 13 SinusBradycardia... 43 L Diagnosis and Evaluation. . . . . 13 Atrioventricular Block 43 I General Approach to Treatment of Stable Treatment. 45 Angina Pectoris t4 Approach to the Patient With Tachycardia. . . . . . . 45 Coronary Revascularization. . . t6 Clinical PresentationandEvaluation ...... . 45 Acute Coronary Syndromes 17 Antiarrhythmic Drugs 46 General Considerations. . . . . . t7 SinusTachycardia... 48 ST Elevation Myocardial I nfarction 1B Supraventricular Tachycardias. . . . 49 Non-ST Elevation Acute Coronary Syndromes n9 Clinical Presentation. 49 Medical Therapy for Acute Coronary Syndromes 24 Atrioventricular Nodal Reentrant Tachycardia 49 Acute Coronary Syndromes Not Associated Atrioventricular Reciprocating Tachycardia. . 49 With Obstructive Coronary Artery Disease . . . 27 Premature Atrial Contractions and Care After an Acute Coronary Syndrome . . . . . 28 AtrialTachycardia... 50 Management of Coronary Artery Disease Atrial Fibrillation. . . 50 in Specific Populations. 28 Clinical Presentation. 51 Patients With Asymptomatic Vascular Disease 28 Acute Management . .51 lx

: l i Long TermManagement .......52 1 Pericardial Effusion and Cardiac Tamponade B6 .' Management in Patients With Heart Failure . . . . .54 Pericardial Effusion. 86 t SubclinicalAtrialFibrillation... ........ 54 Cardiac Tamponade 87 I AtrialFlutter .......55 Constrictive Pericard itis 88 VentricularArrhythmias ....55 Clinical Presentation and Evaluation . . . BB _t l PrematureVentricularContractions ..... 55 Management 90 I VentricularTachycardia ........56 Inherited Syndromes Characterized by Adult Congenital Heart Disease : SuddenCardiacDeath. .....57 Introduction. .......90 I SuddenCardiacArrest. .....59 PatentForamenOvale. ......91 EpidemiolograndRiskFactors .........59 AtrialSeptalDefect. ........91 I

l PrematureVentricularContractions ..... 55 Management 90 I VentricularTachycardia ........56 Inherited Syndromes Characterized by Adult Congenital Heart Disease : SuddenCardiacDeath. .....57 Introduction. .......90 I SuddenCardiacArrest. .....59 PatentForamenOvale. ......91 EpidemiolograndRiskFactors .........59 AtrialSeptalDefect. ........91 I AcuteManagement. ....59 PathophysiologzandGenetics .......... 91 : Device Therapy for Prevention ofSudden Death. . . 61 Clinical Presentation. ..........92 DiagnosticEvaluation ..........92 a Valvular Heart Disease Treatment. .....92 General Principles. 67 Follow up After Atrial Septal Delect Closure . . . . .92 \ Aortic Stenosis. . . . . 63 VentricularSeptal Defect ....94 Clinical Presentation and Evaluation 63 Pathophysiolory .... ..........91 : Management 66 Clinical Presentation. ..........94 Aortic Regurgitation . 67 DiagnosticEvaluation ..........94 i Clinical Presentation and Evaluation 67 Treatment. .....94 t

Management 66 Clinical Presentation. ..........94 Aortic Regurgitation . 67 DiagnosticEvaluation ..........94 i Clinical Presentation and Evaluation 67 Treatment. .....94 t 67 Follow up After Ventricular Septal Defect Closure. . . 94 Management Bicuspid Aorlic Valve Disease 68 PatentDuctusArteriosus ....95 MitralStenosis..... 68 Pathophysiolory .... ..........95 Clinical Presentation and Evaluation 68 Clinical Presentation. ..........95 Management 70 DiagnosticEvaluation ..........95 Mitral Regurgitation . 70 Treatment. .....95 Clinical Presentation and Evaluation 70 PulmonaryStenosis ........95 Management 77 Pathophysiolory .... ..........95 Tricuspid Valve Disease 72 Clinical Presentation. ... ...... .95 Prosthetic Valves . DiagnosticEvaluation ..........95 Infective Endocarditis. 74 Treatment. .....95 Diagnosis and Management. . . . . . . 74 Follow-up After Pulmonary Stenosis Repair . . . . .96 Prophylaxis 75 AorticCoarctation.. ........96 Pathophysiolory .... ..........96 Myocardial Disease ClinicalPresentation. ..........96 DiagnosticEvaluation ..........96 HypertrophicCardiomyopathy . . . . . . .. 77 .

67 Follow up After Ventricular Septal Defect Closure. . . 94 Management Bicuspid Aorlic Valve Disease 68 PatentDuctusArteriosus ....95 MitralStenosis..... 68 Pathophysiolory .... ..........95 Clinical Presentation and Evaluation 68 Clinical Presentation. ..........95 Management 70 DiagnosticEvaluation ..........95 Mitral Regurgitation . 70 Treatment. .....95 Clinical Presentation and Evaluation 70 PulmonaryStenosis ........95 Management 77 Pathophysiolory .... ..........95 Tricuspid Valve Disease 72 Clinical Presentation. ... ...... .95 Prosthetic Valves . DiagnosticEvaluation ..........95 Infective Endocarditis. 74 Treatment. .....95 Diagnosis and Management. . . . . . . 74 Follow-up After Pulmonary Stenosis Repair . . . . .96 Prophylaxis 75 AorticCoarctation.. ........96 Pathophysiolory .... ..........96 Myocardial Disease ClinicalPresentation. ..........96 DiagnosticEvaluation ..........96 HypertrophicCardiomyopathy . . . . . . .. 77 . Treatment. .....96 Clinical Presentation. 77 Follow-up After Aortic Coarctation Repair. . . . . . . 97 Evaluation 77 TetraloryofFallot ..........97 RiskStratification... 78 Diagnostic Evaluation After Repair of Management 79 Tetralogrof Fallot ......98 Cardiac Amyloidosis 81 Treatment of Tetralogz of Fallot Residua . . . . . . . . 98 Restrictive Cardiomyopathy. . . . 82 Adults With Cyanotic Congenital Heart Disease . . . . . . 98 Clinical Presentation and Evaluation 82 ..........98 GeneralManagement Management 82 EisenmengerSyndrome ........98 Cardiac Tumors 83

Treatment. .....96 Clinical Presentation. 77 Follow-up After Aortic Coarctation Repair. . . . . . . 97 Evaluation 77 TetraloryofFallot ..........97 RiskStratification... 78 Diagnostic Evaluation After Repair of Management 79 Tetralogrof Fallot ......98 Cardiac Amyloidosis 81 Treatment of Tetralogz of Fallot Residua . . . . . . . . 98 Restrictive Cardiomyopathy. . . . 82 Adults With Cyanotic Congenital Heart Disease . . . . . . 98 Clinical Presentation and Evaluation 82 ..........98 GeneralManagement Management 82 EisenmengerSyndrome ........98 Cardiac Tumors 83 Diseases of the Aorta Pericardial Disease lntroduction. 99 Acute Pericarditis . . .84 Thoracic Aortic Aneurysm. . . . . 99 Clinical Presentation and Evaluation ,84 Screening and Surveillance 99 Management .86 Treatment. 101 x

Abdominal Aortic Aneurysm. . . . 101 Gdiovascular Disease in Gncer Survivorc Screening and Surveillance . . . 101 Cardiotoxicity of Radiation Therapy to the Thorax . . . .111 Treatment. 101 CardiotoxicityofChemotherapy.... ........112 AorticAtheroma... to2 Acute Aortic Syndromes. 702 Pregnancy and Cardiovascular Disease Pathophysiolory .... 702 Cardiovascular Changes During Pregnancy. . . . . 714 Diagnosis and Evaluation. . . . . 103 Treatment. Prepregnancy Evaluation [4 to4 Management of Cardiovascular Disease Role of Genetic Testing and Family Screening 106 During Pregnancy. 115 Peripartum Cardiomyopathy. . . 115 Peripheral Artery Disease Other Cardiovascular Disorders . . . tt6 Epidemiologr and Screening 106 Cardiovascular Medication Use Clinical Presentation. 106 During Pregnancy. 7t6 Evaluation to7 Anticoagulation Therapy During Pregnancy 176 History and Physical Examination ro7 Diagnostic Testing 108 Bibliography 118 Medical Therapy 109 Cardiovascular Risk Reduction . . . 109 Symptom Relief . . 110 Self-Assessment Test. 723 Interventional Therapy . 110 Acute Limb Ischemia , 111 lndex 279 xt

Cardiovascular Medicine 5 High Value Care Recommendations I I L The American College of Physicians, in collaboration with a safe and effective stratery in patients with heart failure t multiple other organizations, is engaged in a worldwide with reduced ejection fraction (see Item 1). I initiative to promote the practice of High Value Care (HVC). o Current guidelines recommend against routine surveil- t The goals of the HVC initiative are to improve health care lance echocardiography in patients with chronic heart t outcomes by providing care ofproven benefit and reduc failure in the absence of a change in clinical status or ing costs by avoiding unnecessary and even harmful inter- planned intervention. t ventions. The initiative comprises several programs that r Serial B-Wpe natriuretic peptide measurements should not I integrate the important concept of health care value (bal be used to guide care of patients with chronic heart failure. L ancing clinical benefit with costs and harms) for a given o Routine invasive pulmonary artery catheterization for I t intervention into a broad range of educational materials hemodynamic monitoring is not recommended in patients I to address the needs oftrainees, practicing physicians, with decompensated heart failure. t and patients. . Two key elements are associated with a successful transi- \ I

Cardiovascular Medicine 5 High Value Care Recommendations I I L The American College of Physicians, in collaboration with a safe and effective stratery in patients with heart failure t multiple other organizations, is engaged in a worldwide with reduced ejection fraction (see Item 1). I initiative to promote the practice of High Value Care (HVC). o Current guidelines recommend against routine surveil- t The goals of the HVC initiative are to improve health care lance echocardiography in patients with chronic heart t outcomes by providing care ofproven benefit and reduc failure in the absence of a change in clinical status or ing costs by avoiding unnecessary and even harmful inter- planned intervention. t ventions. The initiative comprises several programs that r Serial B-Wpe natriuretic peptide measurements should not I integrate the important concept of health care value (bal be used to guide care of patients with chronic heart failure. L ancing clinical benefit with costs and harms) for a given o Routine invasive pulmonary artery catheterization for I t intervention into a broad range of educational materials hemodynamic monitoring is not recommended in patients I to address the needs oftrainees, practicing physicians, with decompensated heart failure. t and patients. . Two key elements are associated with a successful transi- \ I F{VC content has been integrated into MKSAP 19 in sev- tion to home following hospitalization for heart failure: a tI follow-up phone call within 2 to 3 days of discharge and eral important ways. MKSAP 19 includes HVC identified an office visit within 7 to 14 days of hospital discharge i key points in the text, HVC focused multiple-choice ques t tions, and, in MKSAP Digital, an HVC custom quiz. From (see ltem 52). . [n patients with atrial fibrillation, rivaroxaban is nonin I the text and questions, we have generated the following ferior to warfarin in the prevention of stroke or systemic list of HVC recommendations that meet the definition t embolism and is associated with less intracranial and below of high value care and bring us closer to our goal I fatal bleeding (see Item 11). of improving patient outcomes while conserving finite o Premature ventricular contractions (PVCs) without high- resources. i risk features (syncope, family history of premature sud- : High Value Care Recommendation: A recommendation to den cardiac death, structural heart disease) are managed L choose diagnostic and management strategies for patients with reassurance; treatment is reserved for bothersome in specific clinical situations that balance clinical benefit symptoms or frequent PVCs. with cost and harms with the goal of improving patient o Device pocket infection is a clinical diagnosis; aspiration I outcomes. of a cardiac implantable device pocket should never be performed for diagnostic purposes (see ltem 64). : Below are the High Value Care Recommendations for the . In patients with valvular heart disease who are at high Cardiovascular Medicine section of MKSAP 19. risk for infective endocarditis, antibiotic prophylaxis is o Cardiac stress testing is not routinely recommended in not recommended for nondental procedures, such as asymptomatic patients with diabetes mellitus to detect transesophageal echocardiography, esophagogastroduo - subclinical coronary artery disease. denoscopy, colonoscopy, or cystoscopy, in the absence of o With few exceptions, fasting and nonfasting total cho- active infection (see Item 108). t lesterol and HDL cholesterol levels have fairly similar . In patients with suspected infective endocarditis (lE), prognostic value and association with cardiovascular transthoracic echocardiography (TTE) is recommended outcomes (see Item 19). as the initial imaging study in most clinical situations; r No study has demonstrated the benefit of intensifying in all patients with known or suspected IE and nondi- lipid management, such as with the initiation of ezeti- agnostic TTE results, or if complications have developed L mibe, when LDL cholesterol level is lower than 70 mgldL or are clinically suspected or if intracardiac device leads \ (t.Bt mmol/L) (see Item 21). are present, transesophageal echocardiography is recom o There is no role for dual antiplatelet therapy with aspirin mended (see Item 18). 1 and clopidogrel in patients with chronic stable angina in . Genetic testing is not indicated in first-degree relatives the absence ofrevascularization (see Item 41). of patients with hypertrophic cardiomyopathy unless a . For patients with new-onset heart failure, directly initiat- pathogenic genetic variant is identified in the index patient. ing valsartan-sacubitril rather than a pretreatment period r No treatment or follow-up is needed in asymptomatic with an ACE inhibitor or angiotensin receptor blocker, is patients with a patent foramen ovale.

F{VC content has been integrated into MKSAP 19 in sev- tion to home following hospitalization for heart failure: a tI follow-up phone call within 2 to 3 days of discharge and eral important ways. MKSAP 19 includes HVC identified an office visit within 7 to 14 days of hospital discharge i key points in the text, HVC focused multiple-choice ques t tions, and, in MKSAP Digital, an HVC custom quiz. From (see ltem 52). . [n patients with atrial fibrillation, rivaroxaban is nonin I the text and questions, we have generated the following ferior to warfarin in the prevention of stroke or systemic list of HVC recommendations that meet the definition t embolism and is associated with less intracranial and below of high value care and bring us closer to our goal I fatal bleeding (see Item 11). of improving patient outcomes while conserving finite o Premature ventricular contractions (PVCs) without high- resources. i risk features (syncope, family history of premature sud- : High Value Care Recommendation: A recommendation to den cardiac death, structural heart disease) are managed L choose diagnostic and management strategies for patients with reassurance; treatment is reserved for bothersome in specific clinical situations that balance clinical benefit symptoms or frequent PVCs. with cost and harms with the goal of improving patient o Device pocket infection is a clinical diagnosis; aspiration I outcomes. of a cardiac implantable device pocket should never be performed for diagnostic purposes (see ltem 64). : Below are the High Value Care Recommendations for the . In patients with valvular heart disease who are at high Cardiovascular Medicine section of MKSAP 19. risk for infective endocarditis, antibiotic prophylaxis is o Cardiac stress testing is not routinely recommended in not recommended for nondental procedures, such as asymptomatic patients with diabetes mellitus to detect transesophageal echocardiography, esophagogastroduo - subclinical coronary artery disease. denoscopy, colonoscopy, or cystoscopy, in the absence of o With few exceptions, fasting and nonfasting total cho- active infection (see Item 108). t lesterol and HDL cholesterol levels have fairly similar . In patients with suspected infective endocarditis (lE), prognostic value and association with cardiovascular transthoracic echocardiography (TTE) is recommended outcomes (see Item 19). as the initial imaging study in most clinical situations; r No study has demonstrated the benefit of intensifying in all patients with known or suspected IE and nondi- lipid management, such as with the initiation of ezeti- agnostic TTE results, or if complications have developed L mibe, when LDL cholesterol level is lower than 70 mgldL or are clinically suspected or if intracardiac device leads \ (t.Bt mmol/L) (see Item 21). are present, transesophageal echocardiography is recom o There is no role for dual antiplatelet therapy with aspirin mended (see Item 18). 1 and clopidogrel in patients with chronic stable angina in . Genetic testing is not indicated in first-degree relatives the absence ofrevascularization (see Item 41). of patients with hypertrophic cardiomyopathy unless a . For patients with new-onset heart failure, directly initiat- pathogenic genetic variant is identified in the index patient. ing valsartan-sacubitril rather than a pretreatment period r No treatment or follow-up is needed in asymptomatic with an ACE inhibitor or angiotensin receptor blocker, is patients with a patent foramen ovale. xltl

. In patients with peripheral artery disease and intermit- monotherapy in patients with peripheral artery disease tent claudication, supervised exercise training is the most (see Item 3). ! ,| effective treatment for improving maximal walking dis- o Neither pentoxifflline nor chelation therapy with ethy- i tance and pain-free walking distance (see Item 86). lenediaminetetraacetic acid has any benefit for the l . There is no evidence to support the use ofdual antiplate- treatment of symptomatic peripheral artery disease Il let therapy with aspirin and clopidogrel over antiplatelet (see Item 86). , 1 'l xtv