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Applying Standards of Care to Conditions: Ischemic Heart Disease Next, let’s take a brief look at stable Ischemic Heart Disease with guidelines produced by the American College of Cardiology/American Heart Association Task Force on practice guidelines and four professional societies.
The guidelines currently include specific recommendations that address the following issues: patient education, management of proven risk factors (dyslipidemia, hypertension, diabetes, physical activity body weight, and smoking), risk factor reduction strategies of unproven benefit, medical therapy to prevent myocardial infarction and death and to relieve symptoms, alternative therapy, revascularization to improve survival and symptoms, and patient follow-up.
An example of a specific guideline is emergency room care for ischemic heart disease, which includes the following: 1. Get a brief history and physical including an assessment of the patient’s risk factors for heart disease, 2. Get an interpretation of an electrocardiogram (EKG or ECG), 3. Establish IV access, 4. Administer oxygen, 5. Give aspirin, and 6. Examine laboratory values including assessment of serum levels of biochemical markers for cardiac muscle death. From there, based on a risk assessment, the administration of nitroglycerine, beta blockers, fibrinolytics, thrombolytics, or heparin should be given as needed.
It should be noted that the standard of care for evaluating patients with possible coronary artery disease is changing rapidly. Several times per year there is new research in respected medical journals that describes changes in the evaluation and treatment of ischemic heart disease patients. For now, the initial approach for all patients as outlined in the standards of care is to be focused on eliminating unhealthy behaviors, such as smoking, and effectively promoting lifestyle changes that reduce cardiovascular risk, such as increasing weight loss, physical activity, and adopting a healthy diet. Also included is an evidence-based set of pharmacologic interventions aimed at reducing the risk for future events.
Applying Standards of Care to Conditions: Chronic PainChronic pain management is broken into many sections depending on where the pain is (lower back, migraine, or one of several other categories), what caused it (surgery, injury, disease), method of treatment (opioids, non-opioids, surgical, non-drug, or other method), or just the need to determine the severity of the pain. Let’s take a look at the standards of care for cancer-related pain.
The major outcomes considered were: Pain intensity/relief Quality of life Side effects of pharmacologic agents Recommendations include the use of the following with strong support: Methadone Extended- and sustained-release opioids Transdermal fentanyl Buprenorphine Oxycodone and naloxone Tramadol and tapentadol Anesthetics Bone-modifying agents Gabapentin combinations Non-steroidal anti-inflammatory drugs
As well as the following that carry a less strong recommendation, but are still deemed likely to be effective: Early opioid use Abiraterone Antidepressants Duloxetine Cannabis/cannabinoids Radiopharmaceuticals
For refractory pain, intraspinal analgesia was recommended, with Ketamine deemed useful, when balanced with the harm it may cause. |
