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Preparation of the patient for PCI

2023-06-05T01:24:27Z

Jair Basantes de la Calle:

__NOTOC__
{{PCI}}
{{CMG}} {{AE}} {{Anahita}}

==Overview==
There are several steps involved in preparing [[patients]] for [[PCI]], which include the use of [[medication|premedications]] and the use of a Heart Team approach. Attention should be given to possible [[Adverse effect (medicine)|adverse reactions]] to [[contrast]], possible [[anaphylactoid reaction]]s, use of [[statin]]s, [[bleeding]] risk in [[patients]], and the presence of on-site [[surgery|surgical]] backup services.

==Preparation of the Patient for PCI==
===Premedications===
#[[Aspirin]]
#[[Clopidogrel]]

== 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. GENERAL PROCEDURAL ISSUES FOR PCI (Please do not edit) ==

=== Radial and Femoral Approaches for PCI ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' In patients with ACS undergoing PCI, a radial approach is indicated in preference to a femoral approach to reduce the risk of death, vascular complications, or bleeding. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''2.''' In patients with SIHD undergoing PCI, the radial approach is recommended to reduce access site bleeding and vascular complications''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|}

=== <ref name="pmid35286170">{{cite journal| author=| title=Correction to: 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. | journal=Circulation | year= 2022 | volume= 145 | issue= 11 | pages= e771 | pmid=35286170 | doi=10.1161/CIR.0000000000001061 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=35286170 }}</ref> Choice of Stent Type ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' In patients undergoing PCI, DES should be used in preference to BMS to prevent restenosis, MI, or acute stent thrombosis ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|}
<ref name="pmid35286170" />

=== Use of Intravascular Imaging ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |" 1'''.''' In patients undergoing coronary stent implantation, IVUS can be useful for procedural guidance, particularly in cases of left main or complex coronary artery stenting, to reduce ischemic events. (Level of Evidence B-R)".
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki> 2. In patients undergoing coronary stent implantation, OCT is a reasonable alternative to IVUS for procedural guidance, except in the ostial left main disease.(Level of Evidence B-R)<nowiki>''</nowiki>
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| bgcolor="LemonChiffon" |<nowiki>''</nowiki>3. In patients with stent failure, IVUS or OCT is reasonable to determine the mechanism of stent failure.(Level of Evidence C-LD)<nowiki>''</nowiki>
|}
<ref name="pmid35286170" />

=== Thrombectomy ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightCoral" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit)
|-
| bgcolor="LightCoral" |"1'''.''' In patients with STEMI, routine aspiration thrombectomy before primary PCI is not useful. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:A]])'' <nowiki>"</nowiki>
|}

=== <ref name="pmid35286170" /> ===
=== Treatment of Calcified Lesions ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |" 1'''.''' In patients with fibrotic or heavily calcified lesions, plaque modification with rotational atherectomy can be useful to improve procedural success (Level of Evidence B-R)".
|}
<ref name="pmid35286170" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |" 2'''.''' In patients with fibrotic or heavily calcified lesions, plaque modification with orbital ather-ectomy, balloon atherotomy, laser angioplasty, or intracoronary lithotripsy may be considered to improve procedural success. (Level of Evidence B-NR)".
|}
<ref name="pmid35286170" />

=== Treatment of Saphenous Vein Graft (SVG) Disease (Previous CABG) ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |" 1'''.''' In select patients with previous CABG undergoing PCI of an SVG, the use of an embolic protection device, when technically feasible, is reasonable to decrease the risk of distal embolization (Level of Evidence B-R)".
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki> 2. In patients with previous CABG, if PCI of a diseased native coronary artery is feasible, then it is reasonable to choose PCI of the native coronary artery over PCI of the severely diseased SVG(Level of Evidence B-NR)<nowiki>''</nowiki>
|}
<ref name="pmid35286170" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightCoral" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit)
|-
| bgcolor="LightCoral" |"1'''.''' In patients with a chronic occlusion of an SVG, percutaneous revascularization of the SVG should not be performed ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:C-LD]])'' <nowiki>"</nowiki>
|}
<ref name="pmid35286170" />

=== Treatment of CTO ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |" 1'''.''' In patients with suitable anatomy who have refractory angina on medical therapy, after treatment of non-CTO lesions, the benefit of PCI of a CTO to improve symptoms is uncertain. (Level of Evidence B-R)".
|}
<ref name="pmid35286170" />

=== Treatment of Patients With Stent RestenosisRecommendations ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' In patients who develop clinical in-stent restenosis (ISR) for whom repeat PCI is planned, a DES should be used to improve outcomes if anatomic factors are appropriate and the patient is able to comply with DAPT ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|}
<ref name="pmid35286170" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |" 2. In patients with symptomatic recurrent diffuse ISR with an indication for revascularization, CABG can be useful over repeat PCI to reduce recurrent events. (Level of Evidence C-EO)".
|}
<ref name="pmid35286170" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |" 1'''.''' In patients who develop recurrent ISR, brachytherapy may be considered to improve symptoms. (Level of Evidence B-NR)".
|}

=== <ref name="pmid35286170" /> ===

=== Hemodynamic Support for Complex PCI ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |" 1'''.''' In selected high-risk patients, elective insertion of an appropriate hemodynamic support device as an adjunct to PCI may be reasonable to prevent hemodynamic compromise during PCI(Level of Evidence B-R)".
|}
<ref name="pmid35286170" />

==2011 and 2005 ACCF/AHA/SCAI Guidelines for Percutaneous Coronary Intervention (DO NOT EDIT)<ref name="pmid22070837">{{cite journal |author=Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH |title=2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: Executive Summary A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions |journal=[[Journal of the American College of Cardiology]] |volume=58 |issue=24 |pages=2550–83 |year=2011|month=December|pmid=22070837|doi=10.1016/j.jacc.2011.08.006|url=http://content.onlinejacc.org/cgi/reprint/58/24/2550.pdf|accessdate=2011-12-08|PDF}}</ref><ref name="pmid16490830">{{cite journal|author=Smith SC, Feldman TE, Hirshfeld JW, Jacobs AK, Kern MJ, King SB et al.| title=ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update 2001 Guidelines for Percutaneous Coronary Intervention). |journal=Circulation| year= 2006 | volume= 113 | issue= 7 | pages= e166-286 | pmid=16490830 | doi=10.1161/CIRCULATIONAHA.106.173220 |pmc=|url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16490830}}</ref>==
=== Heart Team Approach to Revascularization Decisions (DO NOT EDIT)<ref name="pmid22070837">{{cite journal |author=Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH |title=2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: Executive Summary A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions |journal=[[Journal of the American College of Cardiology]] |volume=58 |issue=24 |pages=2550–83 |year=2011|month=December|pmid=22070837|doi=10.1016/j.jacc.2011.08.006|url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(11)02875-0|accessdate=2011-12-08|url=http://content.onlinejacc.org/cgi/reprint/58/24/2550.pdf|PDF}}</ref>===
{|class="wikitable"
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| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|
<nowiki>"</nowiki>'''1.''' A Heart Team approach to [[revascularization]] is recommended in patients with [[PCI in the unprotected left main patient|unprotected left main]] or [[CAD|complex CAD]]. <ref name="pmid10859284">Feit F, Brooks MM, Sopko G, Keller NM, Rosen A, Krone R et al. (2000)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10859284 Long-term clinical outcome in the Bypass Angioplasty Revascularization Investigation Registry: comparison with the randomized trial. BARI Investigators.] ''Circulation''101 (24):2795-802. PMID: [http://pubmed.gov/1085928410859284]</ref><ref name="pmid9185632">King SB, Barnhart HX, Kosinski AS, Weintraub WS, Lembo NJ, Petersen JY et al. (1997) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9185632Angioplasty or surgery for multivessel coronary artery disease: comparison of eligible registry and randomized patients in the EAST trial and influence of treatment selection on outcomes. Emory Angioplasty versus Surgery Trial Investigators.]''Am J Cardiol'' 79 (11):1453-9. PMID:[http://pubmed.gov/9185632 9185632]</ref><ref name="pmid19228612">Serruys PW, Morice MC, Kappetein AP, Colombo A, Holmes DR, Mack MJ et al. (2009)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19228612 Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease.] ''N Engl J Med'' 360 (10):961-72.[http://dx.doi.org/10.1056/NEJMoa0804626 DOI:10.1056/NEJMoa0804626] PMID:[http://pubmed.gov/19228612 19228612]</ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
{|class="wikitable"
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| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|bgcolor="LemonChiffon"|
<nowiki>"</nowiki>'''1.''' Calculation of the Society of [[Thoracic]] [[Surgeon]]s and [[SYNTAX]] ([[SYNTAX|Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery]]) scores is reasonable in patients with [[PCI in the unprotected left main patient|unprotected left main]] and [[CAD|complex CAD]]. <ref name="pmid19228612">Serruys PW, Morice MC, Kappetein AP, Colombo A, Holmes DR, Mack MJ et al. (2009)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19228612 Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease.] ''N Engl J Med'' 360 (10):961-72.[http://dx.doi.org/10.1056/NEJMoa0804626 DOI:10.1056/NEJMoa0804626] PMID:[http://pubmed.gov/19228612 19228612]</ref><ref name="pmid21256999">Chakravarty T, Buch MH, Naik H, White AJ, Doctor N, Schapira J et al. (2011)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=21256999 Predictive accuracy of SYNTAX score for predicting long-term outcomes of unprotected left main coronary artery revascularization.] ''Am J Cardiol'' 107 (3):360-6.[http://dx.doi.org/10.1016/j.amjcard.2010.09.029 DOI:10.1016/j.amjcard.2010.09.029] PMID:[http://pubmed.gov/21256999 21256999]</ref><ref name="pmid11573040">Grover FL, Shroyer AL, Hammermeister K, Edwards FH, Ferguson TB, Dziuban SW et al. (2001)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11573040 A decade's experience with quality improvement in cardiac surgery using the Veterans Affairs and Society of Thoracic Surgeons national databases.]''Ann Surg'' 234 (4):464-72; discussion 472-4. PMID: [http://pubmed.gov/11573040 11573040]</ref><ref name="pmid20630454">Kim YH, Park DW, Kim WJ, Lee JY, Yun SC, Kang SJ et al. (2010)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=20630454 Validation of SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) score for prediction of outcomes after unprotected left main coronary revascularization.] ''JACC Cardiovasc Interv'' 3 (6):612-23.[http://dx.doi.org/10.1016/j.jcin.2010.04.004 DOI:10.1016/j.jcin.2010.04.004]PMID:[http://pubmed.gov/20630454 20630454]</ref><ref name="pmid20530001">Morice MC, Serruys PW, Kappetein AP, Feldman TE, Ståhle E, Colombo A et al. (2010)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=20530001 Outcomes in patients with de novo left main disease treated with either percutaneous coronary intervention using paclitaxel-eluting stents or coronary artery bypass graft treatment in the Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery (SYNTAX) trial.] ''Circulation'' 121 (24):2645-53.[http://dx.doi.org/10.1161/CIRCULATIONAHA.109.899211 DOI:10.1161/CIRCULATIONAHA.109.899211] PMID:[http://pubmed.gov/2053000120530001]</ref><ref name="pmid19559822">Shahian DM, O'Brien SM, Filardo G, Ferraris VA, Haan CK, Rich JB et al. (2009)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19559822 The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 1--coronary artery bypass grafting surgery.] ''Ann Thorac Surg'' 88 (1 Suppl):S2-22.[http://dx.doi.org/10.1016/j.athoracsur.2009.05.053DOI:10.1016/j.athoracsur.2009.05.053] PMID: [http://pubmed.gov/19559822 19559822]</ref><ref name="pmid20022608">Shahian DM, O'Brien SM, Normand SL, Peterson ED, Edwards FH (2010)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=20022608 Association of hospital coronary artery bypass volume with processes of care, mortality, morbidity, and the Society of Thoracic Surgeons composite quality score.] ''J Thorac Cardiovasc Surg'' 139 (2):273-82.[http://dx.doi.org/10.1016/j.jtcvs.2009.09.007 DOI:10.1016/j.jtcvs.2009.09.007] PMID:[http://pubmed.gov/2002260820022608]</ref><ref name="pmid17954059">Welke KF, Peterson ED, Vaughan-Sarrazin MS, O'Brien SM, Rosenthal GE, Shook GJ et al. (2007)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=17954059 Comparison of cardiac surgery volumes and mortality rates between the Society of Thoracic Surgeons and Medicare databases from 1993 through 2001.] ''Ann Thorac Surg'' 84 (5):1538-46. [http://dx.doi.org/10.1016/j.athoracsur.2007.06.022DOI:10.1016/j.athoracsur.2007.06.022] PMID: [http://pubmed.gov/1795405917954059]</ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
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===Contrast-Induced Acute Kidney Injury (DO NOT EDIT)<ref name="pmid22070837">{{cite journal |author=Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH |title=2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: Executive Summary A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions |journal=[[Journal of the American College of Cardiology]] |volume=58 |issue=24 |pages=2550–83 |year=2011|month=December|pmid=22070837|doi=10.1016/j.jacc.2011.08.006|url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(11)02875-0|accessdate=2011-12-08|url=http://content.onlinejacc.org/cgi/reprint/58/24/2550.pdf|PDF}}</ref>===

{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|
<nowiki>"</nowiki>'''1.''' Patients should be assessed for risk of [[Contrast induced nephropathy|contrast-induced acute kidney injury]] before PCI.<ref name="pmid15464318">{{cite journal |author=Mehran R, Aymong ED, Nikolsky E, Lasic Z, Iakovou I, Fahy M, Mintz GS, Lansky AJ, Moses JW, Stone GW, Leon MB, Dangas G |title=A simple risk score for prediction of contrast-induced nephropathy after percutaneous coronary intervention: development and initial validation |journal=[[Journal of the American College of Cardiology]] |volume=44 |issue=7 |pages=1393–9|year=2004 |month=October|pmid=15464318|doi=10.1016/j.jacc.2004.06.068|url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(04)01445-7|accessdate=2011-12-06}}</ref><ref name="pmid16461821">{{cite journal |author=Moscucci M, Rogers EK, Montoye C, Smith DE, Share D, O'Donnell M, Maxwell-Eward A, Meengs WL, De Franco AC, Patel K, McNamara R, McGinnity JG, Jani SM, Khanal S, Eagle KA |title=Association of a continuous quality improvement initiative with practice and outcome variations of contemporary percutaneous coronary interventions |journal=[[Circulation]] |volume=113 |issue=6|pages=814–22 |year=2006 |month=February|pmid=16461821 |doi=10.1161/CIRCULATIONAHA.105.541995|url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=16461821|accessdate=2011-12-06}}</ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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<nowiki>"</nowiki>'''2.''' Patients undergoing [[cardiac catheterization]] with [[Contrast induced nephropathy#Choice of contrast agent|contrast media]] should receive adequate preparatory [[Contrast induced nephropathy#Hydration with or without bicarbonate|hydration]].<ref name="pmid15267006">{{cite journal |author=Bader BD, Berger ED, Heede MB, Silberbaur I, Duda S, Risler T, Erley CM |title=What is the best hydration regimen to prevent contrast media-induced nephrotoxicity? |journal=[[Clinical Nephrology]] |volume=62 |issue=1 |pages=1–7 |year=2004|month=July |pmid=15267006 |doi= |url=|accessdate=2011-12-06}}</ref><ref name="pmid11822926">{{cite journal |author=Mueller C, Buerkle G, Buettner HJ, Petersen J, Perruchoud AP, Eriksson U, Marsch S, Roskamm H |title=Prevention of contrast media-associated nephropathy: randomized comparison of 2 hydration regimens in 1620 patients undergoing coronary angioplasty |journal=[[Archives of Internal Medicine]]|volume=162|issue=3 |pages=329–36 |year=2002 |month=February |pmid=11822926 |doi=|url=http://archinte.ama-assn.org/cgi/pmidlookup?view=long&pmid=11822926|accessdate=2011-12-06}}</ref><ref name="pmid7969280">{{cite journal |author=Solomon R, Werner C, Mann D, D'Elia J, Silva P |title=Effects of saline, mannitol, and furosemide to prevent acute decreases in renal function induced by radiocontrast agents|journal=[[The New England Journal of Medicine]] |volume=331 |issue=21 |pages=1416–20 |year=1994 |month=November|pmid=7969280|doi=10.1056/NEJM199411243312104 |url=http://dx.doi.org/10.1056/NEJM199411243312104|accessdate=2011-12-06}}</ref><ref name="pmid12411756">{{cite journal |author=Trivedi HS, Moore H, Nasr S, Aggarwal K, Agrawal A, Goel P, Hewett J |title=A randomized prospective trial to assess the role of saline hydration on the development of contrast nephrotoxicity |journal=[[Nephron. Clinical Practice]]|volume=93 |issue=1 |pages=C29–34 |year=2003 |month=January |pmid=12411756 |doi= |url=|accessdate=2011-12-06}}</ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
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<nowiki>"</nowiki>'''3.''' In patients with [[Chronic kidney disease|chronic kidney disease (CKD)]] ([[creatinine clearance]] ≤60 mL/min), the volume of [[Contrast induced nephropathy#Choice of contrast agent|contrast media]] should be minimized.<ref name="pmid19189906">{{cite journal|author=Marenzi G, Assanelli E, Campodonico J, Lauri G, Marana I, De Metrio M, Moltrasio M, Grazi M, Rubino M, Veglia F, Fabbiocchi F, Bartorelli AL |title=Contrast volume during primary percutaneous coronary intervention and subsequent contrast-induced nephropathy and mortality |journal=[[Annals of Internal Medicine]] |volume=150 |issue=3 |pages=170–7 |year=2009 |month=February |pmid=19189906 |doi=|url=|accessdate=2011-12-06}}</ref><ref name="pmid9375704">{{cite journal |author=McCullough PA, Wolyn R, Rocher LL, Levin RN, O'Neill WW|title=Acute renal failure after coronary intervention: incidence, risk factors, and relationship to mortality |journal=[[The American Journal of Medicine]]|volume=103 |issue=5 |pages=368–75 |year=1997 |month=November |pmid=9375704|doi=|url=http://linkinghub.elsevier.com/retrieve/pii/S0002-9343(97)00150-2|accessdate=2011-12-06}}</ref><ref name="pmid8589322">{{cite journal |author=Russo D, Minutolo R, Cianciaruso B, Memoli B, Conte G, De Nicola L |title=Early effects of contrast media on renal hemodynamics and tubular function in chronic renal failure |journal=[[Journal of the American Society of Nephrology : JASN]] |volume=6|issue=5 |pages=1451–8 |year=1995 |month=November|pmid=8589322 |doi= |url=http://jasn.asnjournals.org/cgi/pmidlookup?view=long&pmid=8589322|accessdate=2011-12-06}}</ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
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{| class="wikitable"
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| colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit)
|-
| bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' Administration of [[N-acetylcysteine|N-acetyl-L-cysteine]] is not useful for the prevention of [[contrast induced nephropathy|contrast-induced acute kidney injury]].<ref> Gonzales DA, Norsworthy KJ, Kern SJ, et al. A meta-analysis of N-acetylcysteine in contrast-induced nephrotoxicity: unsupervised clustering to resolve heterogeneity. BMC Med. 2007; 5: 32. Published online November 14, 2007. doi:10.1186/1741-7015-5-32</ref><ref>Ozcan EE, Guneri S, Akdeniz B, et al. Sodium bicarbonate, N-acetylcysteine, and saline for prevention of radiocontrast-induced nephropathy. A comparison of 3 regimens for protecting contrast-induced nephropathy in patients undergoing coronary procedures. A single-center prospective controlled trial. Am Heart J. 2007; 154: 539– 44.</ref> <ref>Thiele H, Hildebrand L, Schirdewahn C, et al. Impact of high-dose N-acetylcysteine versus placebo on contrast-induced nephropathy and myocardial reperfusion injury in unselected patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention: the LIPSIA-N-ACC (Prospective, Single-Blind, Placebo-Controlled, Randomized Leipzig Immediate PercutaneouS Coronary Intervention Acute Myocardial Infarction N-ACC) Trial. J Am Coll Cardiol. 2010; 55: 2201– 9.</ref><ref>Webb JG, Pate GE, Humphries KH, et al. A randomized controlled trial of intravenous N-acetylcysteine for the prevention of contrast-induced nephropathy after cardiac catheterization: lack of effect. Am Heart J. 2004; 148: 422–9.</ref><ref>ACT Investigators. Acetylcysteine for prevention of renal outcomes in patients undergoing coronary and peripheral vascular angiography: main results from the randomized Acetylcysteine for Contrast-Induced Nephropathy Trial (ACT). Circulation. 2011; 124: 1250–9.</ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|}

===Anaphylactoid Reactions (DO NOT EDIT)<ref name="pmid22070837">{{cite journal |author=Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH |title=2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: Executive Summary A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions |journal=[[Journal of the American College of Cardiology]]|volume=58 |issue=24 |pages=2550–83|year=2011|month=December|pmid=22070837|doi=10.1016/j.jacc.2011.08.006|url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(11)02875-0|accessdate=2011-12-08|url=http://content.onlinejacc.org/cgi/reprint/58/24/2550.pdf|PDF}}</ref>===

{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|
<nowiki>"</nowiki>'''1.''' Patients with prior evidence of an [[anaphylactoid reaction]] to [[contrast media]] should receive appropriate [[steroid]] and [[antihistamine]] [[prophylaxis]] before repeat [[contrast]] administration. <ref> Klein LW, Sheldon MW, Brinker J, et al. The use of radiographic contrast media during PCI: a focused review: a position statement of the Society of Cardiovascular Angiography and Interventions. Catheter Cardiovasc Interv. 2009; 74: 728– 46.</ref><ref>Levine GN, Kern MJ, Berger PB, et al. Management of patients undergoing percutaneous coronary revascularization. Ann Intern Med. 2003; 139: 123– 36.</ref><ref>Tramer MR, von Elm E, Loubeyre P, et al. Pharmacological prevention of serious anaphylactic reactions due to iodinated contrast media: systematic review. BMJ. 2006; 333: 675.</ref><ref>Greenberger PA, Patterson R, Tapio CM. Prophylaxis against repeated radiocontrast media reactions in 857 cases. Adverse experience with cimetidine and safety of beta-adrenergic antagonists. Arch Intern Med. 1985; 145: 2197– 200.</ref>''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
{|class="wikitable"
|-
|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit)
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' In patients with a prior history of [[allergic reaction]]s to shellfish or [[seafood]], [[anaphylactoid reaction|anaphylactoid]] [[prophylaxis]] for [[contrast]] reaction is not beneficial. <ref>Shehadi WH. Adverse reactions to intravascularly administered contrast media. A comprehensive study based on a prospective survey. Am J Roentgenol Radium Ther Nucl Med. 1975; 124: 145– 52.</ref><ref>Gill BV, Rice TR, Cartier A, et al. Identification of crab proteins that elicit IgE reactivity in snow crab-processing workers. J Allergy Clin Immunol. 2009; 124: 1055– 61.</ref><ref>Swoboda I, Bugajska-Schretter A, Verdino P, et al. Recombinant carp parvalbumin, the major cross-reactive fish allergen: a tool for diagnosis and therapy of fish allergy. J Immunol. 2002; 168: 4576– 84.</ref>''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}

===Statin Treatment (DO NOT EDIT)<ref name="pmid22070837">{{cite journal|author=Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH |title=2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: Executive Summary A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions |journal=[[Journal of the American College of Cardiology]]|volume=58 |issue=24 |pages=2550–83|year=2011|month=December|pmid=22070837|doi=10.1016/j.jacc.2011.08.006|url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(11)02875-0|accessdate=2011-12-08|url=http://content.onlinejacc.org/cgi/reprint/58/24/2550.pdf|PDF}}</ref>===

{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|bgcolor="LemonChiffon"|
<nowiki>"</nowiki>'''1.''' Administration of a high-[[dose]] [[statin]] is reasonable before PCI to reduce the risk of peri-procedural [[myocardial infarction]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]] for[[statin]]-naïve patients)'' <ref name="pmid15474697">{{cite journal |author=Briguori C, Colombo A, Airoldi F, Violante A, Focaccio A, Balestrieri P, Paolo Elia P, Golia B, Lepore S, Riviezzo G, Scarpato P, Librera M, Bonizzoni E, Ricciardelli B |title=Statin administration before percutaneous coronary intervention: impact on periprocedural myocardial infarction |journal=[[European Heart Journal]] |volume=25|issue=20 |pages=1822–8|year=2004|month=October |pmid=15474697|doi=10.1016/j.ehj.2004.07.017|url=http://eurheartj.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=15474697|accessdate=2011-12-06}}</ref><ref name="pmid19664895">{{cite journal |author=Briguori C, Visconti G, Focaccio A, Golia B, Chieffo A, Castelli A, Mussardo M, Montorfano M, Ricciardelli B, Colombo A|title=Novel approaches for preventing or limiting events (Naples) II trial: impact of a single high loading dose of atorvastatin on periprocedural myocardial infarction |journal=[[Journal of the American College of Cardiology]] |volume=54 |issue=23 |pages=2157–63 |year=2009|month=December|pmid=19664895|doi=10.1016/j.jacc.2009.07.005|url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(09)02248-7|accessdate=2011-12-06}}</ref><ref name="pmid15277322">{{cite journal |author=Pasceri V, Patti G, Nusca A, Pristipino C, Richichi G, Di Sciascio G |title=Randomized trial of atorvastatin for reduction of myocardial damage during coronary intervention: results from the ARMYDA (Atorvastatin for Reduction of MYocardial Damage during Angioplasty) study |journal=[[Circulation]] |volume=110|issue=6 |pages=674–8 |year=2004|month=August|pmid=15277322|doi=10.1161/01.CIR.0000137828.06205.87 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=15277322|accessdate=2011-12-06}}</ref><ref name="pmid17394957">{{cite journal|author=Patti G, Pasceri V, Colonna G, Miglionico M, Fischetti D, Sardella G, Montinaro A, Di Sciascio G |title=Atorvastatin pretreatment improves outcomes in patients with acute coronary syndromes undergoing early percutaneous coronary intervention: results of the ARMYDA-ACS randomized trial |journal=[[Journal of the American College of Cardiology]] |volume=49 |issue=12 |pages=1272–8|year=2007 |month=March|pmid=17394957|doi=10.1016/j.jacc.2007.02.025|url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(07)00661-4|accessdate=2011-12-06}}</ref><ref name="pmid18706705">{{cite journal |author=Yun KH, Jeong MH, Oh SK, Rhee SJ, Park EM, Lee EM, Yoo NJ, Kim NH, Ahn YK, Jeong JW |title=The beneficial effect of high loading dose of rosuvastatin before percutaneous coronary intervention in patients with acute coronary syndrome|journal=[[International Journal of Cardiology]] |volume=137 |issue=3|pages=246–51 |year=2009 |month=November|pmid=18706705|doi=10.1016/j.ijcard.2008.06.055|url=http://linkinghub.elsevier.com/retrieve/pii/S0167-5273(08)00853-X|accessdate=2011-12-06}}</ref><ref name="pmid20384433">{{cite journal |author=Zhang F, Dong L, Ge J|title=Effect of statins pretreatment on periprocedural myocardial infarction in patients undergoing percutaneous coronary intervention: a meta-analysis |journal=[[Annals of Medicine]] |volume=42|issue=3|pages=171–7|year=2010 |month=April|pmid=20384433|doi=10.3109/07853890903463976|url=http://informahealthcare.com/doi/abs/10.3109/07853890903463976|accessdate=2011-12-06}}</ref><ref name="pmid20825761">{{cite journal |author=Winchester DE, Wen X, Xie L, Bavry AA |title=Evidence of pre-procedural statin therapy a meta-analysis of randomized trials |journal=[[Journal of the American College of Cardiology]] |volume=56 |issue=14|pages=1099–109|year=2010|month=September|pmid=20825761|doi=10.1016/j.jacc.2010.04.023|url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(10)01920-0|accessdate=2011-12-06}}</ref>;''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]] for those on chronic statin therapy)'' <ref name="pmid19643320">{{cite journal |author=Di Sciascio G, Patti G, Pasceri V, Gaspardone A, Colonna G, Montinaro A |title=Efficacy of atorvastatin reload in patients on chronic statin therapy undergoing percutaneous coronary intervention: results of the ARMYDA-RECAPTURE (Atorvastatin for Reduction of Myocardial Damage During Angioplasty) Randomized Trial |journal=[[Journal of the American College of Cardiology]] |volume=54 |issue=6 |pages=558–65 |year=2009|month=August|pmid=19643320|doi=10.1016/j.jacc.2009.05.028|url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(09)01858-0|accessdate=2011-12-06}}</ref><nowiki>"</nowiki>
|}

===Bleeding Risk (DO NOT EDIT)<ref name="pmid22070837">{{cite journal|author=Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH |title=2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: Executive Summary A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions |journal=[[Journal of the American College of Cardiology]]|volume=58 |issue=24 |pages=2550–83 |year=2011|month=December|pmid=22070837|doi=10.1016/j.jacc.2011.08.006|url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(11)02875-0|accessdate=2011-12-08|url=http://content.onlinejacc.org/cgi/reprint/58/24/2550.pdf|PDF}}</ref>===

{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|
<nowiki>"</nowiki>'''1.''' All patients should be evaluated for risk of [[bleeding]] before PCI. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}

=== PCI in Hospitals Without On-Site Surgical Backup (DO NOT EDIT)<ref name="pmid22070837">{{cite journal |author=Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH |title=2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: Executive Summary A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions |journal=[[Journal of the American College of Cardiology]] |volume=58 |issue=24|pages=2550–83|year=2011|month=December|pmid=22070837|doi=10.1016/j.jacc.2011.08.006|url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(11)02875-0|accessdate=2011-12-08|url=http://content.onlinejacc.org/cgi/reprint/58/24/2550.pdf|PDF}}</ref>===
{|class="wikitable"
|-
|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm)
|-
|bgcolor="LightCoral"|
<nowiki>"</nowiki>'''1.''' Primary or [[elective]] PCI should not be performed in hospitals without on-site [[cardiac surgery]] capabilities without a proven plan for rapid transport to a [[cardiac surgery]] operating room in a nearby hospital or without appropriate [[hemodynamic]] support capability for transfer. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|bgcolor="LemonChiffon"|
<nowiki>"</nowiki>'''1.''' Primary PCI is reasonable in hospitals without on-site [[cardiac surgery]], provided that appropriate planning for program development has been accomplished.<ref name="pmid11960536">{{cite journal |author=Aversano T, Aversano LT, Passamani E, Knatterud GL, Terrin ML, Williams DO, Forman SA |title=Thrombolytic therapy vs primary percutaneous coronary intervention for myocardial infarction in patients presenting to hospitals without on-site cardiac surgery: a randomized controlled trial |journal=[[JAMA : the Journal of the American Medical Association]] |volume=287|issue=15 |pages=1943–51 |year=2002 |month=April |pmid=11960536 |doi=|url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=11960536|accessdate=2011-12-06}}</ref><ref name="pmid17278155">{{cite journal |author=Dehmer GJ, Blankenship J, Wharton TP, Seth A, Morrison DA, Dimario C, Muller D, Kellett M, Uretsky BF |title=The current status and future direction of percutaneous coronary intervention without on-site surgical backup: an expert consensus document from the Society for Cardiovascular Angiography and Interventions|journal=[[Catheterization and Cardiovascular Interventions : Official Journal of the Society for Cardiac Angiography & Interventions]] |volume=69 |issue=4 |pages=471–8 |year=2007 |month=March|pmid=17278155 |doi=10.1002/ccd.21097 |url=http://dx.doi.org/10.1002/ccd.21097|accessdate=2011-12-06}}</ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|bgcolor="LemonChiffon"|
<nowiki>"</nowiki>'''1.''' [[Elective]] PCI might be considered in hospitals without on-site [[cardiac surgery]], provided that appropriate planning for program development has been accomplished and rigorous clinical and [[angiographic]] criteria are used for proper patient selection.<ref name="pmid17278155">{{cite journal|author=Dehmer GJ, Blankenship J, Wharton TP, Seth A, Morrison DA, Dimario C, Muller D, Kellett M, Uretsky BF |title=The current status and future direction of percutaneous coronary intervention without on-site surgical backup: an expert consensus document from the Society for Cardiovascular Angiography and Interventions |journal=[[Catheterization and Cardiovascular Interventions : Official Journal of the Society for Cardiac Angiography & Interventions]] |volume=69 |issue=4 |pages=471–8|year=2007 |month=March |pmid=17278155 |doi=10.1002/ccd.21097|url=http://dx.doi.org/10.1002/ccd.21097 |accessdate=2011-12-06}}</ref><ref name="pmid17070152">{{cite journal |author=Melberg T, Nilsen DW, Larsen AI, Barvik S, Bonarjee V, Kuiper KK, Nordrehaug JE |title=Nonemergent coronary angioplasty without on-site surgical backup: a randomized study evaluating outcomes in low-risk patients |journal=[[American Heart Journal]]|volume=152 |issue=5 |pages=888–95 |year=2006 |month=November |pmid=17070152|doi=10.1016/j.ahj.2006.06.026|url=http://linkinghub.elsevier.com/retrieve/pii/S0002-8703(06)00622-3|accessdate=2011-12-06}}</ref><ref name="pmid19918168">{{cite journal |author=Singh PP, Singh M, Bedi US, Adigopula S, Singh S, Kodumuri V, Molnar J, Ahmed A, Arora R, Khosla S |title=Outcomes of nonemergent percutaneous coronary intervention with and without on-site surgical backup: a meta-analysis |journal=[[American Journal of Therapeutics]] |volume=18 |issue=2 |pages=e22–8|year=2011 |pmid=19918168 |doi=10.1097/MJT.0b013e3181bc0f5a|url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=1075-2765&volume=18&issue=2&spage=e22 |accessdate=2011-12-06}}</ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}

===Role of Onsite Cardiac Surgical Back-Up (DO NOT EDIT)<ref name="pmid16490830">{{cite journal| author=Smith SC, Feldman TE, Hirshfeld JW, Jacobs AK, Kern MJ, King SB et al.| title=ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update 2001 Guidelines for Percutaneous Coronary Intervention). |journal=Circulation | year= 2006 | volume= 113 | issue= 7 | pages= e166-286 | pmid=16490830|doi=10.1161/CIRCULATIONAHA.106.173220 | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16490830 }}</ref>===

{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' [[Elective]] PCI should be performed by operators with acceptable annual volume (at least 75 procedures per year) at high-volume centers (more than 400 procedures annually) that provide immediately available onsite emergency [[cardiac surgery|cardiac surgical]] services. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Primary PCI for patients with [[STEMI]] should be performed in facilities with onsite [[cardiac surgery]].''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}

{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]
|-
| bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' [[Elective]] PCI should not be performed at institutions that do not provide onsite [[cardiac surgery]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
==ACA 2021 Revascularization Guideline==
===Thrombectomy===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit)<ref name="pmid34895950">{{cite journal| author=Writing Committee Members. Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM | display-authors=etal| title=2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. | journal=J Am Coll Cardiol | year= 2022 | volume= 79 | issue= 2 | pages= e21-e129 | pmid=34895950 | doi=10.1016/j.jacc.2021.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34895950 }} </ref>
|-
| bgcolor="LightCoral"|Routine aspiration [[thrombectomy]] is not useful before primary [[PCI]] in [[patients]] with [[ST elevation myocardial infarction]].
|}
*Routine [[thrombectomy|rheolytic thrombectomy]] did not show any benefit based on trials done on [[patients]] with [[ST elevation myocardial infarction]] undergoing [[PCI|primary PCI]] even in the presence of [[thrombotic]] occlusion.<ref name="pmid16843170">{{cite journal| author=Ali A, Cox D, Dib N, Brodie B, Berman D, Gupta N | display-authors=etal| title=Rheolytic thrombectomy with percutaneous coronary intervention for infarct size reduction in acute myocardial infarction: 30-day results from a multicenter randomized study. | journal=J Am Coll Cardiol | year= 2006 | volume= 48 | issue= 2 | pages= 244-52 | pmid=16843170 | doi=10.1016/j.jacc.2006.03.044 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16843170 }} </ref><ref name="pmid20691553">{{cite journal| author=Migliorini A, Stabile A, Rodriguez AE, Gandolfo C, Rodriguez Granillo AM, Valenti R | display-authors=etal| title=Comparison of AngioJet rheolytic thrombectomy before direct infarct artery stenting with direct stenting alone in patients with acute myocardial infarction. The JETSTENT trial. | journal=J Am Coll Cardiol | year= 2010 | volume= 56 | issue= 16 | pages= 1298-306 | pmid=20691553 | doi=10.1016/j.jacc.2010.06.011 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20691553 }} </ref><ref name="pmid23991656">{{cite journal| author=Fröbert O, Lagerqvist B, Olivecrona GK, Omerovic E, Gudnason T, Maeng M | display-authors=etal| title=Thrombus aspiration during ST-segment elevation myocardial infarction. | journal=N Engl J Med | year= 2013 | volume= 369 | issue= 17 | pages= 1587-97 | pmid=23991656 | doi=10.1056/NEJMoa1308789 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23991656 }} </ref><ref name="pmid25853743">{{cite journal| author=Jolly SS, Cairns JA, Yusuf S, Meeks B, Pogue J, Rokoss MJ | display-authors=etal| title=Randomized trial of primary PCI with or without routine manual thrombectomy. | journal=N Engl J Med | year= 2015 | volume= 372 | issue= 15 | pages= 1389-98 | pmid=25853743 | doi=10.1056/NEJMoa1415098 | pmc=4995102 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25853743 }} [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=26075779 Review in: Ann Intern Med. 2015 Jun 16;162(12):JC2] </ref><ref name="pmid26474811">{{cite journal| author=Jolly SS, Cairns JA, Yusuf S, Rokoss MJ, Gao P, Meeks B | display-authors=etal| title=Outcomes after thrombus aspiration for ST elevation myocardial infarction: 1-year follow-up of the prospective randomised TOTAL trial. | journal=Lancet | year= 2016 | volume= 387 | issue= 10014 | pages= 127-35 | pmid=26474811 | doi=10.1016/S0140-6736(15)00448-1 | pmc=5007127 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26474811 }} </ref><ref name="pmid25176395">{{cite journal| author=Lagerqvist B, Fröbert O, Olivecrona GK, Gudnason T, Maeng M, Alström P | display-authors=etal| title=Outcomes 1 year after thrombus aspiration for myocardial infarction. | journal=N Engl J Med | year= 2014 | volume= 371 | issue= 12 | pages= 1111-20 | pmid=25176395 | doi=10.1056/NEJMoa1405707 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25176395 }} </ref>

==References==

{{reflist|2}}
[[Category:Cardiology]]
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High triglyceride causes

2023-04-30T23:58:53Z

Jair Basantes de la Calle:

__NOTOC__
{{Hyperlipoproteinemia}}
{{CMG}}; {{AE}} [[Priyamvada Singh|Priyamvada Singh, M.B.B.S.]] [mailto:psingh13579@gmail.com]; {{Ochuko}}

==Overview==
[[Hypertriglyceridemia]] can occur due to various causes, including genetics, familial, metabolic and drugs.

==Causes==
===Life Threatening Causes===
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Hypertriglyceridemia does not have life threatening causes.

===Common Causes===
*[[Diabetes mellitus]]
*[[Obesity]]

===Causes by Organ System===

{|style="width:80%; height:100px" border="1"
|style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" |'''Cardiovascular'''
|style="height:100px"; style="width:75%" border="1" bgcolor="Beige" | [[Alström syndrome]], [[apolipoprotein E|apoprotein E deficiency]], [[high chylomicron|chylomicron levels raised (plasma)]], [[familial chylomicronemia]], [[familial combined hyperlipidemia]], [[familial hypertriglyceridemia]], [[hyperlipoproteinemia type V|hyperlipoproteinemia, familial type 5]], [[IDL|intermediate density lipoprotein levels raised (plasma or serum)]], [[metabolic syndrome]], [[reaven syndrome|Reaven syndrome X]]
|-
|bgcolor="LightSteelBlue"| '''Chemical/Poisoning'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Dental'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Dermatologic'''
|bgcolor="Beige"| [[Systemic lupus erythematosus]]
|-
|-bgcolor="LightSteelBlue"
| '''Drug Side Effect'''
|bgcolor="Beige"| [[Abiraterone]], [[Amprenavir]], [[atazanavir|atazanavir sulfate]], [[atypical antipsychotics]], [[bendrofluazide]], [[beta-blockers]], [[bexarotene]], [[chlorthalidone]], [[clomiphene]], [[colesevelam|colesevelam hydrochloride]], [[colestyramine]], [[combined oral contraceptive pill]], [[desvenlafaxine]], [[diuretics]], [[Drospirenone and Ethinyl estradiol]], [[Efavirenz]], [[estrogen replacement therapy]], [[febuxostat]], [[fosamprenavir]], [[glucocorticoids]], [[hydrochlorothiazide]], [[interferon alpha]], [[Interferon alfa-2b ]], [[Indinavir]], [[Interferon gamma]], [[linagliptin]], [[lopinavir]], [[Medroxyprogesterone]], [[mirtazapine]], [[non-nucleoside reverse transcriptase inhibitors]], [[Norethindrone acetate and Ethinyl estradiol]], [[Norgestimate and Ethinyl estradiol]], [[Norgestrel and Ethinyl estradiol]], [[olanzapine]], [[isotretinoin|oral isotretinoin]], [[Pegaspargase]], [[Pegylated interferon alfa-2b]], [[propofol]], [[protease inhibitors]], [[raloxifene]], [[ritonavir]], [[Ruxolitinib]],[[saquinavir]], [[Siltuximab]], [[tamoxifen]], [[tazarotene]], [[temsirolimus]], [[tipranavir]], [[tocilizumab]], [[Tretinoin]]
|-
|-bgcolor="LightSteelBlue"
| '''Ear Nose Throat'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Endocrine'''
|bgcolor="Beige"| [[Cushing's syndrome]], [[diabetes mellitus]], [[hypothyroidism]], [[insulin resistance]], [[metabolic syndrome]], [[polycystic ovary syndrome]], [[reaven syndrome|Reaven syndrome X]]
|-
|-bgcolor="LightSteelBlue"
| '''Environmental'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Gastroenterologic'''
|bgcolor="Beige"|[[Acute pancreatitis]], [[Alagille syndrome]], [[carnitine palmitoyltransferase 1 deficiency]], [[cholesteryl ester storage disease]], [[glycogen storage disease|glycogen storage disease type 1]], [[glycogenosis type 1a]], [[liver cirrhosis]], [[non-alcoholic fatty liver disease]]
|-
|-bgcolor="LightSteelBlue"
| '''Genetic'''
|bgcolor="Beige"| [[Alagille syndrome]], [[Alström syndrome]], [[apolipoprotein E|apoprotein E deficiency]], [[carnitine palmitoyltransferase 1 deficiency]], [[cholesteryl ester storage disease]], [[congenital generalized lipodystrophy|congenital generalized lipodystrophy type 1]], [[apolipoprotein C2|deficiency of apolipoprotein C2 ]], [[familial chylomicronemia]], [[familial combined hyperlipidemia]], [[familial histiocytic reticulosis]], [[familial hypertriglyceridemia]], [[fish eye disease]], [[glycogen storage disease|glycogen storage disease type 1]], [[glycogenosis type 1a]], [[hyperlipoproteinemia type V|hyperlipoproteinemia, familial type 5]], [[lecithin cholesterol acyltransferase deficiency]], [[metabolic syndrome]], [[Niemann-Pick disease|Niemann-Pick disease type B]], [[reaven syndrome|Reaven syndrome X]], [[sphingomyelinase deficiency]], [[Tangier disease]]
|-
|-bgcolor="LightSteelBlue"
| '''Hematologic'''
|bgcolor="Beige"| [[Familial histiocytic reticulosis]]
|-
|-bgcolor="LightSteelBlue"
| '''Iatrogenic'''
|bgcolor="Beige"| [[Parenteral nutrition]]
|-
|-bgcolor="LightSteelBlue"
| '''Infectious Disease'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Musculoskeletal/Orthopedic'''
|bgcolor="Beige"| [[Systemic lupus erythematosus]]
|-
|-bgcolor="LightSteelBlue"
| '''Neurologic'''
|bgcolor="Beige"| [[Niemann-Pick disease|Niemann-Pick disease type B]], [[sphingomyelinase deficiency]]
|-
|-bgcolor="LightSteelBlue"
| '''Nutritional/Metabolic'''
|bgcolor="Beige"| [[Alcohol]], [[apolipoprotein E|apoprotein E deficiency]], [[high chylomicron|chylomicron levels raised (plasma)]], [[apolipoprotein C2|deficiency of apolipoprotein C2]], [[familial chylomicronemia]], [[familial combined hyperlipidemia]], [[familial hypertriglyceridemia]], [[glycogen storage disease|glycogen storage disease type 1]], [[glycogenosis type 1a]], [[carbohydrate|high carbohydrate or high glycemic index]], [[hyperlipoproteinemia type V|hyperlipoproteinemia, familial type 5]], [[IDL|intermediate density lipoprotein levels raised (plasma or serum)]], [[lipodystrophy]], [[lipoprotein lipase deficiency]], [[metabolic syndrome]], [[obesity]], [[reaven syndrome|Reaven syndrome X]], [[Tangier disease]], [[VLDL|very low density lipoprotein levels raised (plasma or serum)]], [[vitamin E deficiency|vitamin E deficiency, familial isolated]]
|-
|-bgcolor="LightSteelBlue"
| '''Obstetric/Gynecologic'''
|bgcolor="Beige"| [[Polycystic ovary syndrome]], [[pregnancy]]
|-
|-bgcolor="LightSteelBlue"
| '''Oncologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Ophthalmologic'''
|bgcolor="Beige"| [[Diabetes mellitus]], [[Lecithin cholesterol acyltransferase deficiency]]
|-
|-bgcolor="LightSteelBlue"
| '''Overdose/Toxicity'''
|bgcolor="Beige"| [[Alcohol]]
|-
|-bgcolor="LightSteelBlue"
| '''Psychiatric'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Pulmonary'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Renal/Electrolyte'''
|bgcolor="Beige"| [[Chronic kidney disease]], [[chronic renal insufficiency]], [[diabetes mellitus]], [[nephrotic syndrome]], [[systemic lupus erythematosus]]
|-
|-bgcolor="LightSteelBlue"
| '''Rheumatology/Immunology/Allergy'''
|bgcolor="Beige"| [[Macrophage activation syndrome]], [[metabolic syndrome]], [[paraproteinemias]], [[reaven syndrome|Reaven syndrome X]], [[systemic lupus erythematosus]]
|-
|-bgcolor="LightSteelBlue"
| '''Sexual'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Trauma'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Urologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Miscellaneous'''
|bgcolor="Beige"| [[Alcohol]]
|-
|}

===Causes in Alphabetical Order===
{{col-begin|width=80%}}
{{col-break|width=33%}}
*[[Acute pancreatitis]]
*[[Alagille syndrome]]
*[[Alcohol]]<ref name="pmid19355858">{{cite journal| author=Kolovou GD, Anagnostopoulou KK, Kostakou PM, Bilianou H, Mikhailidis DP| title=Primary and secondary hypertriglyceridaemia. | journal=Curr Drug Targets | year= 2009 | volume= 10 | issue= 4 | pages= 336-43 | pmid=19355858 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19355858 }} </ref>
*[[Alström syndrome]]
*[[Amprenavir]]
*[[apolipoprotein E|Apoprotein E deficiency]]
*[[atazanavir|Atazanavir sulfate]]
*[[Atypical antipsychotics]]
*[[Bendrofluazide]]
*[[Beta-blockers]] <ref name="pmid19355858">{{cite journal| author=Kolovou GD, Anagnostopoulou KK, Kostakou PM, Bilianou H, Mikhailidis DP| title=Primary and secondary hypertriglyceridaemia. | journal=Curr Drug Targets | year= 2009 | volume= 10 | issue= 4 | pages= 336-43 | pmid=19355858 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19355858 }} </ref>
*[[Bexarotene]]
*[[Carnitine palmitoyltransferase 1 deficiency]]
*[[Chlorthalidone]]<ref name="pmid19355858">{{cite journal| author=Kolovou GD, Anagnostopoulou KK, Kostakou PM, Bilianou H, Mikhailidis DP| title=Primary and secondary hypertriglyceridaemia. | journal=Curr Drug Targets | year= 2009 | volume= 10 | issue= 4 | pages= 336-43 | pmid=19355858 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19355858 }} </ref>
*[[Cholesteryl ester storage disease]]
*[[Chronic kidney disease]] <ref name="pmid19355858">{{cite journal| author=Kolovou GD, Anagnostopoulou KK, Kostakou PM, Bilianou H, Mikhailidis DP| title=Primary and secondary hypertriglyceridaemia. | journal=Curr Drug Targets | year= 2009 | volume= 10 | issue= 4 | pages= 336-43 | pmid=19355858 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19355858 }} </ref>
*[[Chronic renal insufficiency]]
*[[high chylomicron|Chylomicron levels raised (plasma)]]
*[[Clomiphene]]
*[[colesevelam|Colesevelam hydrochloride]]
*[[Colestyramine]]
*[[Combined oral contraceptive pill]]
*[[congenital generalized lipodystrophy|Congenital generalized lipodystrophy type 1]]
*[[Cushing's syndrome]]
*[[apolipoprotein C2|Deficiency of apolipoprotein C2 ]]
*[[Desvenlafaxine]]
*[[Diabetes mellitus]]<ref name="pmid19355858">{{cite journal| author=Kolovou GD, Anagnostopoulou KK, Kostakou PM, Bilianou H, Mikhailidis DP| title=Primary and secondary hypertriglyceridaemia. | journal=Curr Drug Targets | year= 2009 | volume= 10 | issue= 4 | pages= 336-43 | pmid=19355858 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19355858 }} </ref>
{{col-break|width=33%}}
*[[Diuretics]]
*[[Efavirenz]]
*[[Estrogen replacement therapy]]
*[[Familial chylomicronemia]]<ref name="pmid19355858">{{cite journal| author=Kolovou GD, Anagnostopoulou KK, Kostakou PM, Bilianou H, Mikhailidis DP| title=Primary and secondary hypertriglyceridaemia. | journal=Curr Drug Targets | year= 2009 | volume= 10 | issue= 4 | pages= 336-43 | pmid=19355858 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19355858 }} </ref>
*[[Familial combined hyperlipidemia]]<ref name="pmid19355858">{{cite journal| author=Kolovou GD, Anagnostopoulou KK, Kostakou PM, Bilianou H, Mikhailidis DP| title=Primary and secondary hypertriglyceridaemia. | journal=Curr Drug Targets | year= 2009 | volume= 10 | issue= 4 | pages= 336-43 | pmid=19355858 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19355858 }} </ref>
*[[Familial histiocytic reticulosis]]
*[[Familial hypertriglyceridemia]]<ref name="pmid19355858">{{cite journal| author=Kolovou GD, Anagnostopoulou KK, Kostakou PM, Bilianou H, Mikhailidis DP| title=Primary and secondary hypertriglyceridaemia. | journal=Curr Drug Targets | year= 2009 | volume= 10 | issue= 4 | pages= 336-43 | pmid=19355858 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19355858 }} </ref>
*[[Fish eye disease]] <ref name="pmid19355858">{{cite journal| author=Kolovou GD, Anagnostopoulou KK, Kostakou PM, Bilianou H, Mikhailidis DP| title=Primary and secondary hypertriglyceridaemia. | journal=Curr Drug Targets | year= 2009 | volume= 10 | issue= 4 | pages= 336-43 | pmid=19355858 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19355858 }} </ref>
*[[Fosamprenavir]]
*[[Glucocorticoids]]
*[[glycogen storage disease|Glycogen storage disease type 1]]
*[[Glycogenosis type 1a]]
*[[carbohydrate|High carbohydrate or high glycemic index]]
*[[Hydrochlorothiazide]]
*[[hyperlipoproteinemia type V|Hyperlipoproteinemia, familial type 5]]<ref name="pmid1078394">{{cite journal| author=Fallat RW, Glueck CJ| title=Familial and acquired type V hyperlipoproteinemia. | journal=Atherosclerosis | year= 1976 | volume= 23 | issue= 1 | pages= 41-62 | pmid=1078394 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1078394 }} </ref>
*[[Hypothyroidism]] <ref name="pmid19355858">{{cite journal| author=Kolovou GD, Anagnostopoulou KK, Kostakou PM, Bilianou H, Mikhailidis DP| title=Primary and secondary hypertriglyceridaemia. | journal=Curr Drug Targets | year= 2009 | volume= 10 | issue= 4 | pages= 336-43 | pmid=19355858 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19355858 }} </ref>
*[[Indinavir]]
*[[Insulin resistance]]
*[[Interferon alpha]]
*[[Interferon gamma]]
*[[IDL|Intermediate density lipoprotein levels raised (plasma or serum)]]
*[[Lecithin cholesterol acyltransferase deficiency]]
*[[Linagliptin]]
*[[Lipodystrophy]]
*[[Lipoprotein lipase deficiency]]
*[[Liver cirrhosis]]
*[[Lopinavir]]
*[[Macrophage activation syndrome]]
*[[Medroxyprogesterone]]
*[[Metabolic syndrome]] <ref name="pmid19355858">{{cite journal| author=Kolovou GD, Anagnostopoulou KK, Kostakou PM, Bilianou H, Mikhailidis DP| title=Primary and secondary hypertriglyceridaemia. | journal=Curr Drug Targets | year= 2009 | volume= 10 | issue= 4 | pages= 336-43 | pmid=19355858 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19355858 }} </ref>
{{col-break|width=33%}}
*[[Mirtazapine]]
*[[Nephrotic syndrome]]<ref name="pmid19355858">{{cite journal| author=Kolovou GD, Anagnostopoulou KK, Kostakou PM, Bilianou H, Mikhailidis DP| title=Primary and secondary hypertriglyceridaemia. | journal=Curr Drug Targets | year= 2009 | volume= 10 | issue= 4 | pages= 336-43 | pmid=19355858 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19355858 }} </ref>
*[[Niemann-Pick disease|Niemann-Pick disease type B]]
*[[Non-alcoholic fatty liver disease]]
*[[Non-nucleoside reverse transcriptase inhibitors]]
*[[Norgestrel and Ethinyl estradiol]]
*[[Obesity]]<ref name="pmid19355858">{{cite journal| author=Kolovou GD, Anagnostopoulou KK, Kostakou PM, Bilianou H, Mikhailidis DP| title=Primary and secondary hypertriglyceridaemia. | journal=Curr Drug Targets | year= 2009 | volume= 10 | issue= 4 | pages= 336-43 | pmid=19355858 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19355858 }} </ref>
*[[Olanzapine]]
*[[isotretinoin|Oral isotretinoin]]
*[[Paraproteinemias]]
*[[Parenteral nutrition]]
*[[Pegaspargase]]
*[[Polycystic ovary syndrome]]
*[[Pregnancy]]
*[[Propofol]]
*[[Protease inhibitors]]
*[[reaven syndrome|Reaven syndrome X]]
*[[Ritonavir]]
*[[Saquinavir]]
*[[Siltuximab]]
*[[Sphingomyelinase deficiency]]
*[[Systemic lupus erythematosus]]
*[[Tamoxifen]]
*[[Tangier disease]] <ref name="pmid19355858">{{cite journal| author=Kolovou GD, Anagnostopoulou KK, Kostakou PM, Bilianou H, Mikhailidis DP| title=Primary and secondary hypertriglyceridaemia. | journal=Curr Drug Targets | year= 2009 | volume= 10 | issue= 4 | pages= 336-43 | pmid=19355858 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19355858 }} </ref>
*[[Temsirolimus]]
*[[Tipranavir]]
*[[Tocilizumab]]
*[[Tretinoin]]
*[[VLDL|Very low density lipoprotein levels raised (plasma or serum)]]
*[[vitamin E deficiency|Vitamin E deficiency, familial isolated]]
{{col-end}}
Diagnosis

== 2018 AHA ACC Guideline on the Management of Blood Cholesterol. Hypertriglyceridemia Recommendations ==
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' In adults 20 years of age or older with moderate hypertriglyceridemia (fasting or nonfasting triglycerides 175 to 499 mg/dL [2.0 to 5.6 mmol/L]), clinicians should address and treat lifestyle factors (obesity and metabolic syndrome), secondary factors (diabetes mellitus, chronic liver or kidney disease and/or nephrotic syndrome, hypothyroidism), and medications that increase triglycerides''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])'' <nowiki>"</nowiki>
|}
<ref name="pmid304233912">{{cite journal| author=Grundy SM, Stone NJ, Bailey AL, Beam C, Birtcher KK, Blumenthal RS | display-authors=etal| title=2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. | journal=J Am Coll Cardiol | year= 2019 | volume= 73 | issue= 24 | pages= 3168-3209 | pmid=30423391 | doi=10.1016/j.jacc.2018.11.002 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30423391 }}</ref>
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |" 2'''.''' In adults 40 to 75 years of age with moderate or severe hypertriglyceridemia and ASCVD risk of 7.5% or higher, it is reasonable to reevaluate ASCVD risk after lifestyle and secondary factors are addressed and to consider a persistently elevated triglyceride level as a factor favoring initiation or intensification of statin therapy (Level of Evidence B-R)".
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki> 3. In adults 40 to 75 years of age with severe hypertriglyceridemia (fasting triglycerides ≥500 mg/dL [≥5.6 mmol/L]) and ASCVD risk of 7.5% or higher, it is reasonable to address reversible causes of high triglyceride and to initiate statin therapy (Level of Evidence B-R)<nowiki>''</nowiki>
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki>4. In adults with severe hypertriglyceridemia (fasting triglycerides ≥500 mg/dL [≥5.7 mmol/L]), and especially fasting triglycerides ≥1000 mg/dL (11.3 mmol/L)), it is reasonable to identify and address other causes of hypertriglyceridemia), and if triglycerides are persistently elevated or increasing, to further reduce triglycerides by the implementation of a very low-fat diet, avoidance of refined carbohydrates and alcohol, consumption of omega-3 fatty acids, and, if necessary to prevent acute pancreatitis, fibrate therapy (Level of Evidence B- NR)<nowiki>''</nowiki>
|}
<ref name="pmid304233912" />

==References==
{{Reflist|2}}

{{Lipopedia}}

[[fr:Hypertriglycéridémie]]
[[pt:Hipertrigliceridemia]]

[[Category:Endocrinology]]
[[Category:Cardiology]]
[[Category:Dermatology]]

{{WH}}
{{WS}}

Congestive heart failure clinical assessment

2023-04-30T23:57:02Z

Jair Basantes de la Calle:

__NOTOC__
{| class="infobox" style="float:right;"
|-
| [[File:Siren.gif|30px|link= Heart failure resident survival guide]]|| || 
| [[Heart failure resident survival guide|'''Resident''' '''Survival''' '''Guide''']]
|}

{{Congestive heart failure}}
{{CMG}}; {{AE}} [[User:Edzelco|Edzel Lorraine Co, D.M.D., M.D.]] [Mailto:efco@alum.up.edu.ph].

==Overview==
[[Clinical assessment]] of a [[patient]] based on a thorough [[history taking]] and [[physical examination]] is still the cornerstone in diagnosing [[heart failure]]. Based on the gathered data, [[patients]] can be assessed if he has an underlying [[heart]] condition which necessitates a disease-specific [[therapy]] such as [[amyloid heart disease]], a [[cardiomyopathy]], or a developing [[decompensated heart failure]]. It is important to investigate for presence of [[heart]] [[congestion]] so as to treat it the at the earliest stage to avoid deterioration in the [[quality of life]] and [[prognosis]].

==Diagnostic algorithm for [[heart failure]]==

{{familytree/start}}
{{familytree | | | | | | | | | A01 | | | | | |A01=Suspected [[heart failure]]
*[[Risk factors]]
*[[Symptoms]] and/or [[signs]]
*Abnormal [[ECG]]}}
{{familytree | | | | | | | | | |!| | | | | | | | }}
{{familytree | | | | | | | | | A01 | | | | | |A01= [[NT-proBNP]] ≥ 125 pg/mL or [[BNP]] ≥ 35 pg/mL
or if [[HF]] strongly suspected
or if [[NT-proBNP]]/[[BNP]] unavailable }}
{{familytree | | | | | | | | | |!| | | | | | | | }}
{{familytree | | | | | | | | | A01 | | | | | |A01=[[Echocardiography]]}}
{{familytree | | | | | | | | | |!| | | | | | | | }}
{{familytree | | | | | | | | | A01 | | | | | |A01=Abnormal findings}}
{{familytree | | | | | | | |,|-|^|-|.| | | | | | }}
{{familytree | | | | S|-| C1 | | C2 | | | |C2=Yes|C1= NO|S= [[Hear failure]] unlikely, other dignosis shoulb be considered }}
{{familytree | | | | | | | | | | | |!| | | | | | | | }}
{{familytree | | | | | | | | | | | B01 | | | | | |B01=[[Heart failure]] confirmed based on [[LVEF]]}}
{{familytree | | | | |,|-|-|-|-|-|-|+|-|-|-|-|-|-|.| }}
{{familytree | | | C01 | | | | | C02 | | | | | C03 |C01=[[LVEF]]≤ 40%|C02=[[LVEF]]=41-49%|C03=[[LVEF]]≥50%}}
{{familytree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline
|-
|}<ref name="pmid34447992">{{cite journal |vauthors=McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Francesco Piepoli M, Price S, Rosano GMC, Ruschitzka F, Kathrine Skibelund A |title=2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure |journal=Eur Heart J |volume=42 |issue=36 |pages=3599–3726 |date=September 2021 |pmid=34447992 |doi=10.1093/eurheartj/ehab368 |url=}}</ref>

=== '''Diagnostic of HF and EF-Based Classification.''' ===
[[File:Diagnostic Algorithm for HF and EF-Based Classification.png|thumb|'''Diagnostic Algorithm for HF and EF-Based Classification''']]
<ref name="pmid35363500" /> <ref name="pmid35830183" />

===Criteria for definition of advanced [[heart failure]]===
1. Severe and persistent symptoms of [[heart failure]] [[NYHA]] class III-IV 
2. Severe [[cardiac]] dysfunction is defined by at least one of the following: 
* [[LVEF]] <_30%
* Isolated [[RV]] failure ([[ARVC]])
* Non-operable severe [[valve]] abnormalities
* Non-operable severe [[congenital]] abnormalities
* Persistently high (or increasing) [[BNP]] or [[NT-proBNP]] values and severe [[LV diastolic dysfunction]] or structural abnormalities 
3. Episodes of [[pulmonary]] or [[systemic congestion]] requiring high-dose i.v. [[diuretics]] (or [[diuretic]] combinations) or episodes of low [[output]] requiring [[inotropes]] or [[vasoactive]] drugs or [[malignant arrhythmias]] causing >1 unplanned visit or hospitalization in the last 12 months 
4. Severe impairment of [[exercise capacity]] with inability to [[exercise]] or low 6MWT distance (<300 m) or [[pVO2]] <12 mL/kg/min or <50% predicted value, estimated to be of [[cardiac]] origin<ref name="pmid34447992">{{cite journal |vauthors=McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Francesco Piepoli M, Price S, Rosano GMC, Ruschitzka F, Kathrine Skibelund A |title=2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure |journal=Eur Heart J |volume=42 |issue=36 |pages=3599–3726 |date=September 2021 |pmid=34447992 |doi=10.1093/eurheartj/ehab368 |url=}}</ref>

==Clinical Assessment==
===Framingham Criteria===
==== Major Criteria ====
* [[Paroxysmal nocturnal dyspnea]]
* [[Jugular vein|Jugular vein distention]]
* [[Rales]]
* [[cardiomegaly|Radiographic cardiomegaly]]
* [[pulmonary edema|Acute pulmonary edema]]
* [[Third heart sound]] ([[S3]])
* [[Central venous pressure]] > 16 cm H2O
* [[Circulation time]] ≥ 25 sec
* [[Hepatojugular reflux]]
* [[Pulmonary edema]]
* [[Anasarca|Visceral congestion]]
* [[Cardiomegaly]] at [[autopsy]]
* [[Weight loss]] ≥ 4.5 kg in 5 days in response to treatment of heart failure

==== Minor Criteria ====
* [[ankle edema|Bilateral ankle edema]]
* [[cough|Nocturnal cough]]
* [[Dyspnea|Dyspnea on ordinary exertion]]
* [[Hepatomegaly]]
* [[Pleural effusion]]
* [[vital capacity|30% decrease in baseline vital capacity]]
* [[Tachycardia]]

===Boston Criteria of Congestive Heart Failure===
====Category I: History====
*[[dyspnea|Rest dyspnea]] 4 points
*[[Orthopnea]] 4 points
*[[Paroxysmal nocturnal dyspnea]] 3 points
*[[Dyspnea]] on walking on level ground 2 points
*[[Dyspnea]] on climbing 1 point

====Category II: Physical Examination====
*[[Heart rate|Heart rate abnormality]] (1 point if 91 to 110 bpm; if >110 bpm, 2 points)
*[[Jugular venous pressure|Jugular venous pressure elevation]] (2 points if >6 cm H2O; 3 points if >6 cm H2O and [[hepatomegaly]] or [[edema]])
*[[rales|Lung crackles]] (1 point if basilar; 2 points if more than basilar)
*[[Wheezing]] 3 points
*[[S3|Third heart sound]] 3 points

====HFpEF====
The [H2FPEF https://www.mdcalc.com/calc/10105/h2fpef-score-for-heart-failure-with-preserved-ejection-fraction] can help diagnose<ref name="pmid35830183">{{cite journal| author=Reddy YNV, Kaye DM, Handoko ML, van de Bovenkamp AA, Tedford RJ, Keck C | display-authors=etal| title=Diagnosis of Heart Failure With Preserved Ejection Fraction Among Patients With Unexplained Dyspnea. | journal=JAMA Cardiol | year= 2022 | volume= 7 | issue= 9 | pages= 891-899 | pmid=35830183 | doi=10.1001/jamacardio.2022.1916 | pmc=9280610 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=35830183 }} </ref>.

====Category III: Chest Radiography====
*[[pulmonary edema|Alveolar pulmonary edema]] 4 points
*[[pulmonary edema|Interstitial pulmonary edema]] 3 points
*[[pleural effusion|Bilateral pleural effusion]] 3 points
*Cardiothoracic ratio >0.50 (posteroanterior projection) 3 points
*Upper zone flow redistribution 2 points

No more than 4 points are allowed from each of three categories; hence the composite score (the sum of the subtotal from each category) has a possible maximum of 12 points.

The diagnosis of heart failure is classified as "definite" at a score of 8 to 12 points, "possible" at a score of 5 to 7 points, and "unlikely" at a score of 4 points or less.

== 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT) <ref name="pmid35363500">{{cite journal| author=Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM | display-authors=etal| title=2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. | journal=Circulation | year= 2022 | volume= 145 | issue= 18 | pages= e876-e894 | pmid=35363500 | doi=10.1161/CIR.0000000000001062 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=35363500 }} </ref> ==

===INITIAL AND SERIAL EVALUATION (DO NOT EDIT) <ref name="pmid35363500">{{cite journal| author=Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM | display-authors=etal| title=2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. | journal=Circulation | year= 2022 | volume= 145 | issue= 18 | pages= e876-e894 | pmid=35363500 | doi=10.1161/CIR.0000000000001062 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=35363500 }} </ref> ===

====[[Clinical Assessment]]: [[History]] and [[Physical Examination]] (DO NOT EDIT) <ref name="pmid35363500">{{cite journal| author=Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM | display-authors=etal| title=2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. | journal=Circulation | year= 2022 | volume= 145 | issue= 18 | pages= e876-e894 | pmid=35363500 | doi=10.1161/CIR.0000000000001062 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=35363500 }} </ref> ====

{|class="wikitable" style="width:80%"
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' In [[patients]] with [[HF]], [[vital sign]]s and evidence of [[clinical]] [[congestion]] should be assessed at each encounter to guide overall [[management]], including adjustment of [[diuretics]] and other [[medications]].<ref name="pmid23293303">{{cite journal| author=Ambrosy AP, Pang PS, Khan S, Konstam MA, Fonarow GC, Traver B | display-authors=etal| title=Clinical course and predictive value of congestion during hospitalization in patients admitted for worsening signs and symptoms of heart failure with reduced ejection fraction: findings from the EVEREST trial. | journal=Eur Heart J | year= 2013 | volume= 34 | issue= 11 | pages= 835-43 | pmid=23293303 | doi=10.1093/eurheartj/ehs444 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23293303 }} </ref><ref name="pmid31510768">{{cite journal| author=Selvaraj S, Claggett B, Pozzi A, McMurray JJV, Jhund PS, Packer M | display-authors=etal| title=Prognostic Implications of Congestion on Physical Examination Among Contemporary Patients With Heart Failure and Reduced Ejection Fraction: PARADIGM-HF. | journal=Circulation | year= 2019 | volume= 140 | issue= 17 | pages= 1369-1379 | pmid=31510768 | doi=10.1161/CIRCULATIONAHA.119.039920 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31510768 }} </ref><ref name="pmid31220936">{{cite journal| author=Selvaraj S, Claggett B, Shah SJ, Anand IS, Rouleau JL, Desai AS | display-authors=etal| title=Utility of the Cardiovascular Physical Examination and Impact of Spironolactone in Heart Failure With Preserved Ejection Fraction. | journal=Circ Heart Fail | year= 2019 | volume= 12 | issue= 7 | pages= e006125 | pmid=31220936 | doi=10.1161/CIRCHEARTFAILURE.119.006125 | pmc=6686863 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31220936 }} </ref><ref name="pmid24622114">{{cite journal| author=Caldentey G, Khairy P, Roy D, Leduc H, Talajic M, Racine N | display-authors=etal| title=Prognostic value of the physical examination in patients with heart failure and atrial fibrillation: insights from the AF-CHF trial (atrial fibrillation and chronic heart failure). | journal=JACC Heart Fail | year= 2014 | volume= 2 | issue= 1 | pages= 15-23 | pmid=24622114 | doi=10.1016/j.jchf.2013.10.004 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24622114 }} </ref><ref name="pmid31051151">{{cite journal| author=Simonavičius J, Sanders van-Wijk S, Rickenbacher P, Maeder MT, Pfister O, Kaufmann BA | display-authors=etal| title=Prognostic Significance of Longitudinal Clinical Congestion Pattern in Chronic Heart Failure: Insights From TIME-CHF Trial. | journal=Am J Med | year= 2019 | volume= 132 | issue= 9 | pages= e679-e692 | pmid=31051151 | doi=10.1016/j.amjmed.2019.04.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31051151 }} </ref><ref name="pmid30172362">{{cite journal| author=Fudim M, Parikh KS, Dunning A, DeVore AD, Mentz RJ, Schulte PJ | display-authors=etal| title=Relation of Volume Overload to Clinical Outcomes in Acute Heart Failure (From ASCEND-HF). | journal=Am J Cardiol | year= 2018 | volume= 122 | issue= 9 | pages= 1506-1512 | pmid=30172362 | doi=10.1016/j.amjcard.2018.07.023 | pmc=6924269 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30172362 }} </ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])'' <nowiki>"</nowiki>

|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' In [[patients]] with [[symptomatic]] [[HF]], [[clinical factors]] indicating the presence of [[advanced HF]] should be sought via the [[history and physical examination]]. <ref name="pmid12672310">{{cite journal| author=Anker SD, Negassa A, Coats AJ, Afzal R, Poole-Wilson PA, Cohn JN | display-authors=etal| title=Prognostic importance of weight loss in chronic heart failure and the effect of treatment with angiotensin-converting-enzyme inhibitors: an observational study. | journal=Lancet | year= 2003 | volume= 361 | issue= 9363 | pages= 1077-83 | pmid=12672310 | doi=10.1016/S0140-6736(03)12892-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12672310 }} </ref><ref name="pmid16765130">{{cite journal| author=Eshaghian S, Horwich TB, Fonarow GC| title=Relation of loop diuretic dose to mortality in advanced heart failure. | journal=Am J Cardiol | year= 2006 | volume= 97 | issue= 12 | pages= 1759-64 | pmid=16765130 | doi=10.1016/j.amjcard.2005.12.072 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16765130 }} </ref><ref name="pmid19808355">{{cite journal| author=Gorodeski EZ, Chu EC, Reese JR, Shishehbor MH, Hsich E, Starling RC| title=Prognosis on chronic dobutamine or milrinone infusions for stage D heart failure. | journal=Circ Heart Fail | year= 2009 | volume= 2 | issue= 4 | pages= 320-4 | pmid=19808355 | doi=10.1161/CIRCHEARTFAILURE.108.839076 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19808355 }} </ref><ref name="pmid12798577">{{cite journal| author=Kittleson M, Hurwitz S, Shah MR, Nohria A, Lewis E, Givertz M | display-authors=etal| title=Development of circulatory-renal limitations to angiotensin-converting enzyme inhibitors identifies patients with severe heart failure and early mortality. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 11 | pages= 2029-35 | pmid=12798577 | doi=10.1016/s0735-1097(03)00417-0 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12798577 }} </ref><ref name="pmid18768944">{{cite journal| author=Poole JE, Johnson GW, Hellkamp AS, Anderson J, Callans DJ, Raitt MH | display-authors=etal| title=Prognostic importance of defibrillator shocks in patients with heart failure. | journal=N Engl J Med | year= 2008 | volume= 359 | issue= 10 | pages= 1009-17 | pmid=18768944 | doi=10.1056/NEJMoa071098 | pmc=2922510 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18768944 }} </ref><ref name="pmid17643574">{{cite journal| author=Setoguchi S, Stevenson LW, Schneeweiss S| title=Repeated hospitalizations predict mortality in the community population with heart failure. | journal=Am Heart J | year= 2007 | volume= 154 | issue= 2 | pages= 260-6 | pmid=17643574 | doi=10.1016/j.ahj.2007.01.041 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17643574 }} </ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])'' <nowiki>"</nowiki>

|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' In [[patients]] with [[cardiomyopathy]], a 3-generation [[family history]] should be obtained or updated when assessing the cause of the [[cardiomyopathy]] to identify possible [[inherited disease]]. <ref name="pmid32624524">{{cite journal| author=Marume K, Noguchi T, Tateishi E, Morita Y, Miura H, Nishimura K | display-authors=etal| title=Prognosis and Clinical Characteristics of Dilated Cardiomyopathy With Family History via Pedigree Analysis. | journal=Circ J | year= 2020 | volume= 84 | issue= 8 | pages= 1284-1293 | pmid=32624524 | doi=10.1253/circj.CJ-19-1176 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32624524 }} </ref><ref name="pmid26925241">{{cite journal| author=Waddell-Smith KE, Donoghue T, Oates S, Graham A, Crawford J, Stiles MK | display-authors=etal| title=Inpatient detection of cardiac-inherited disease: the impact of improving family history taking. | journal=Open Heart | year= 2016 | volume= 3 | issue= 1 | pages= e000329 | pmid=26925241 | doi=10.1136/openhrt-2015-000329 | pmc=4762189 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26925241 }} </ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])'' <nowiki>"</nowiki>

|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' In [[patients]] presenting with [[HF]], a thorough [[history and physical examination]] should direct [[diagnostic strategies]] to uncover specific causes that may warrant [[disease-specific management]]. <ref name="pmid28329248">{{cite journal| author=González-López E, Gagliardi C, Dominguez F, Quarta CC, de Haro-Del Moral FJ, Milandri A | display-authors=etal| title=Clinical characteristics of wild-type transthyretin cardiac amyloidosis: disproving myths. | journal=Eur Heart J | year= 2017 | volume= 38 | issue= 24 | pages= 1895-1904 | pmid=28329248 | doi=10.1093/eurheartj/ehx043 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28329248 }} </ref><ref name="pmid26498944">{{cite journal| author=Lousada I, Comenzo RL, Landau H, Guthrie S, Merlini G| title=Light Chain Amyloidosis: Patient Experience Survey from the Amyloidosis Research Consortium. | journal=Adv Ther | year= 2015 | volume= 32 | issue= 10 | pages= 920-8 | pmid=26498944 | doi=10.1007/s12325-015-0250-0 | pmc=4635176 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26498944 }} </ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])'' <nowiki>"</nowiki>

|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' In [[patients]] presenting with [[HF]], a thorough [[history and physical examination]] should be obtained and performed to identify [[cardiac]] and [[noncardiac]] [[disorders]], [[lifestyle]] and [[behavioral]] factors, and [[social determinants of health]] that might cause or accelerate the development or progression of [[HF]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO])'' <nowiki>"</nowiki>

|}

====Initial [[Laboratory]] and [[Electrocardiographic]] Testing (DO NOT EDIT) <ref name="pmid35363500">{{cite journal| author=Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM | display-authors=etal| title=2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. | journal=Circulation | year= 2022 | volume= 145 | issue= 18 | pages= e876-e894 | pmid=35363500 | doi=10.1161/CIR.0000000000001062 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=35363500 }} </ref> ====

{|class="wikitable" style="width:80%"
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' For [[patients]] presenting with [[HF]], the specific cause of [[HF]] should be explored using additional laboratory testing for appropriate [[management]]. <ref name="pmid: 25948538">{{cite journal| author=Cardinale D, Colombo A, Bacchiani G, Tedeschi I, Meroni CA, Veglia F | display-authors=etal| title=Early detection of anthracycline cardiotoxicity and improvement with heart failure therapy. | journal=Circulation | year= 2015 | volume= 131 | issue= 22 | pages= 1981-8 | pmid=: 25948538 | doi=10.1161/CIRCULATIONAHA.114.013777 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25948538 }} </ref><ref name="pmid15148277">{{cite journal| author=Cardinale D, Sandri MT, Colombo A, Colombo N, Boeri M, Lamantia G | display-authors=etal| title=Prognostic value of troponin I in cardiac risk stratification of cancer patients undergoing high-dose chemotherapy. | journal=Circulation | year= 2004 | volume= 109 | issue= 22 | pages= 2749-54 | pmid=15148277 | doi=10.1161/01.CIR.0000130926.51766.CC | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15148277 }} </ref><ref name="pmid29019612">{{cite journal| author=Castaño A, Narotsky DL, Hamid N, Khalique OK, Morgenstern R, DeLuca A | display-authors=etal| title=Unveiling transthyretin cardiac amyloidosis and its predictors among elderly patients with severe aortic stenosis undergoing transcatheter aortic valve replacement. | journal=Eur Heart J | year= 2017 | volume= 38 | issue= 38 | pages= 2879-2887 | pmid=29019612 | doi=10.1093/eurheartj/ehx350 | pmc=5837725 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29019612 }} </ref><ref name="pmid27386769">{{cite journal| author=Maurer MS, Hanna M, Grogan M, Dispenzieri A, Witteles R, Drachman B | display-authors=etal| title=Genotype and Phenotype of Transthyretin Cardiac Amyloidosis: THAOS (Transthyretin Amyloid Outcome Survey). | journal=J Am Coll Cardiol | year= 2016 | volume= 68 | issue= 2 | pages= 161-72 | pmid=27386769 | doi=10.1016/j.jacc.2016.03.596 | pmc=4940135 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27386769 }} </ref><ref name="pmid27143678">{{cite journal| author=Gillmore JD, Maurer MS, Falk RH, Merlini G, Damy T, Dispenzieri A | display-authors=etal| title=Nonbiopsy Diagnosis of Cardiac Transthyretin Amyloidosis. | journal=Circulation | year= 2016 | volume= 133 | issue= 24 | pages= 2404-12 | pmid=27143678 | doi=10.1161/CIRCULATIONAHA.116.021612 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27143678 }} </ref><ref name="pmid28494620">{{cite journal| author=Brown EE, Lee YZJ, Halushka MK, Steenbergen C, Johnson NM, Almansa J | display-authors=etal| title=Genetic testing improves identification of transthyretin amyloid (ATTR) subtype in cardiac amyloidosis. | journal=Amyloid | year= 2017 | volume= 24 | issue= 2 | pages= 92-95 | pmid=28494620 | doi=10.1080/13506129.2017.1324418 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28494620 }} </ref><ref name="pmid29482029">{{cite journal| author=Crawford TC, Okada DR, Magruder JT, Fraser C, Patel N, Houston BA | display-authors=etal| title=A Contemporary Analysis of Heart Transplantation and Bridge-to-Transplant Mechanical Circulatory Support Outcomes in Cardiac Sarcoidosis. | journal=J Card Fail | year= 2018 | volume= 24 | issue= 6 | pages= 384-391 | pmid=29482029 | doi=10.1016/j.cardfail.2018.02.009 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29482029 }} </ref><ref name="pmid19864165">{{cite journal| author=Wu RS, Gupta S, Brown RN, Yancy CW, Wald JW, Kaiser P | display-authors=etal| title=Clinical outcomes after cardiac transplantation in muscular dystrophy patients. | journal=J Heart Lung Transplant | year= 2010 | volume= 29 | issue= 4 | pages= 432-8 | pmid=19864165 | doi=10.1016/j.healun.2009.08.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19864165 }} </ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])'' <nowiki>"</nowiki>

|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' For [[patients]] who are diagnosed with [[HF]], laboratory evaluation should include [[complete blood count]], [[urinalysis]], [[serum electrolytes]], [[blood urea nitrogen]], [[serum creatinine]], [[glucose]], [[lipid profile]], [[liver function tests]], [[iron studies]], and [[thyroid-stimulating hormone]] to optimize [[management]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO]])'' <nowiki>"</nowiki>

|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' For all [[patients]] presenting with [[HF]], a [[12-lead ECG]] should be performed at the initial encounter to optimize [[management]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO]])'' <nowiki>"</nowiki>

|}

===Use of [[Biomarkers]] for [[Prevention]], Initial [[Diagnosis]], and [[Risk Stratification]] (DO NOT EDIT) <ref name="pmid35363500">{{cite journal| author=Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM | display-authors=etal| title=2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. | journal=Circulation | year= 2022 | volume= 145 | issue= 18 | pages= e876-e894 | pmid=35363500 | doi=10.1161/CIR.0000000000001062 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=35363500 }} </ref> ===

{|class="wikitable" style="width:80%"
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' In [[patients]] presenting with [[dyspnea]], measurement of [[B-type natriuretic peptide]] ([[BNP]]) or [[N-terminal prohormone of B-type natriuretic peptide]] ([[NT-proBNP]]) is useful to support a [[diagnosis]] or exclusion of [[HF]]. <ref name="pmid11401111">{{cite journal| author=Richards AM, Doughty R, Nicholls MG, MacMahon S, Sharpe N, Murphy J | display-authors=etal| title=Plasma N-terminal pro-brain natriuretic peptide and adrenomedullin: prognostic utility and prediction of benefit from carvedilol in chronic ischemic left ventricular dysfunction. Australia-New Zealand Heart Failure Group. | journal=J Am Coll Cardiol | year= 2001 | volume= 37 | issue= 7 | pages= 1781-7 | pmid=11401111 | doi=10.1016/s0735-1097(01)01269-4 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11401111 }} </ref><ref name="pmid14662703">{{cite journal| author=Tang WH, Girod JP, Lee MJ, Starling RC, Young JB, Van Lente F | display-authors=etal| title=Plasma B-type natriuretic peptide levels in ambulatory patients with established chronic symptomatic systolic heart failure. | journal=Circulation | year= 2003 | volume= 108 | issue= 24 | pages= 2964-6 | pmid=14662703 | doi=10.1161/01.CIR.0000106903.98196.B6 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14662703 }} </ref><ref name="pmid15921792">{{cite journal| author=Zaphiriou A, Robb S, Murray-Thomas T, Mendez G, Fox K, McDonagh T | display-authors=etal| title=The diagnostic accuracy of plasma BNP and NTproBNP in patients referred from primary care with suspected heart failure: results of the UK natriuretic peptide study. | journal=Eur J Heart Fail | year= 2005 | volume= 7 | issue= 4 | pages= 537-41 | pmid=15921792 | doi=10.1016/j.ejheart.2005.01.022 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15921792 }} </ref><ref name="pmid22564550">{{cite journal| author=Son CS, Kim YN, Kim HS, Park HS, Kim MS| title=Decision-making model for early diagnosis of congestive heart failure using rough set and decision tree approaches. | journal=J Biomed Inform | year= 2012 | volume= 45 | issue= 5 | pages= 999-1008 | pmid=22564550 | doi=10.1016/j.jbi.2012.04.013 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22564550 }} </ref><ref name="pmid22104551">{{cite journal| author=Kelder JC, Cramer MJ, van Wijngaarden J, van Tooren R, Mosterd A, Moons KG | display-authors=etal| title=The diagnostic value of physical examination and additional testing in primary care patients with suspected heart failure. | journal=Circulation | year= 2011 | volume= 124 | issue= 25 | pages= 2865-73 | pmid=22104551 | doi=10.1161/CIRCULATIONAHA.111.019216 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22104551 }} </ref><ref name="pmid24969534">{{cite journal| author=Booth RA, Hill SA, Don-Wauchope A, Santaguida PL, Oremus M, McKelvie R | display-authors=etal| title=Performance of BNP and NT-proBNP for diagnosis of heart failure in primary care patients: a systematic review. | journal=Heart Fail Rev | year= 2014 | volume= 19 | issue= 4 | pages= 439-51 | pmid=24969534 | doi=10.1007/s10741-014-9445-8 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24969534 }} </ref><ref name="pmid11216950">{{cite journal| author=Dao Q, Krishnaswamy P, Kazanegra R, Harrison A, Amirnovin R, Lenert L | display-authors=etal| title=Utility of B-type natriuretic peptide in the diagnosis of congestive heart failure in an urgent-care setting. | journal=J Am Coll Cardiol | year= 2001 | volume= 37 | issue= 2 | pages= 379-85 | pmid=11216950 | doi=10.1016/s0735-1097(00)01156-6 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11216950 }} </ref><ref name="pmid7905953">{{cite journal| author=Davis M, Espiner E, Richards G, Billings J, Town I, Neill A | display-authors=etal| title=Plasma brain natriuretic peptide in assessment of acute dyspnoea. | journal=Lancet | year= 1994 | volume= 343 | issue= 8895 | pages= 440-4 | pmid=7905953 | doi=10.1016/s0140-6736(94)92690-5 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7905953 }} </ref><ref name="pmid12124404">{{cite journal| author=Maisel AS, Krishnaswamy P, Nowak RM, McCord J, Hollander JE, Duc P | display-authors=etal| title=Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. | journal=N Engl J Med | year= 2002 | volume= 347 | issue= 3 | pages= 161-7 | pmid=12124404 | doi=10.1056/NEJMoa020233 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12124404 }} [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=12401145 Review in: J Fam Pract. 2002 Oct;51(10):816] [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=12511135 Review in: ACP J Club. 2003 Jan-Feb;138(1):23] </ref><ref name="pmid18243855">{{cite journal| author=Januzzi JL, Chen-Tournoux AA, Moe G| title=Amino-terminal pro-B-type natriuretic peptide testing for the diagnosis or exclusion of heart failure in patients with acute symptoms. | journal=Am J Cardiol | year= 2008 | volume= 101 | issue= 3A | pages= 29-38 | pmid=18243855 | doi=10.1016/j.amjcard.2007.11.017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18243855 }} </ref><ref name="pmid25052418">{{cite journal| author=Santaguida PL, Don-Wauchope AC, Ali U, Oremus M, Brown JA, Bustamam A | display-authors=etal| title=Incremental value of natriuretic peptide measurement in acute decompensated heart failure (ADHF): a systematic review. | journal=Heart Fail Rev | year= 2014 | volume= 19 | issue= 4 | pages= 507-19 | pmid=25052418 | doi=10.1007/s10741-014-9444-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25052418 }} </ref><ref name="pmid24957908">{{cite journal| author=Hill SA, Booth RA, Santaguida PL, Don-Wauchope A, Brown JA, Oremus M | display-authors=etal| title=Use of BNP and NT-proBNP for the diagnosis of heart failure in the emergency department: a systematic review of the evidence. | journal=Heart Fail Rev | year= 2014 | volume= 19 | issue= 4 | pages= 421-38 | pmid=24957908 | doi=10.1007/s10741-014-9447-6 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24957908 }} </ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki>

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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.'''In [[patients]] with chronic [[HF]], measurements of [[BNP]] or [[NT-proBNP]] levels are recommended for [[risk stratification]]. <ref name="pmid25052418">{{cite journal| author=Santaguida PL, Don-Wauchope AC, Ali U, Oremus M, Brown JA, Bustamam A | display-authors=etal| title=Incremental value of natriuretic peptide measurement in acute decompensated heart failure (ADHF): a systematic review. | journal=Heart Fail Rev | year= 2014 | volume= 19 | issue= 4 | pages= 507-19 | pmid=25052418 | doi=10.1007/s10741-014-9444-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25052418 }} </ref><ref name="pmid16979009">{{cite journal| author=van Kimmenade RR, Januzzi JL, Ellinor PT, Sharma UC, Bakker JA, Low AF | display-authors=etal| title=Utility of amino-terminal pro-brain natriuretic peptide, galectin-3, and apelin for the evaluation of patients with acute heart failure. | journal=J Am Coll Cardiol | year= 2006 | volume= 48 | issue= 6 | pages= 1217-24 | pmid=16979009 | doi=10.1016/j.jacc.2006.03.061 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16979009 }} </ref><ref name="pmid15451800">{{cite journal| author=Bettencourt P, Azevedo A, Pimenta J, Friões F, Ferreira S, Ferreira A| title=N-terminal-pro-brain natriuretic peptide predicts outcome after hospital discharge in heart failure patients. | journal=Circulation | year= 2004 | volume= 110 | issue= 15 | pages= 2168-74 | pmid=15451800 | doi=10.1161/01.CIR.0000144310.04433.BE | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15451800 }} </ref><ref name="pmid11216951">{{cite journal| author=Cheng V, Kazanagra R, Garcia A, Lenert L, Krishnaswamy P, Gardetto N | display-authors=etal| title=A rapid bedside test for B-type peptide predicts treatment outcomes in patients admitted for decompensated heart failure: a pilot study. | journal=J Am Coll Cardiol | year= 2001 | volume= 37 | issue= 2 | pages= 386-91 | pmid=11216951 | doi=10.1016/s0735-1097(00)01157-8 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11216951 }} </ref><ref name="pmid17498579">{{cite journal| author=Fonarow GC, Peacock WF, Phillips CO, Givertz MM, Lopatin M, ADHERE Scientific Advisory Committee and Investigators| title=Admission B-type natriuretic peptide levels and in-hospital mortality in acute decompensated heart failure. | journal=J Am Coll Cardiol | year= 2007 | volume= 49 | issue= 19 | pages= 1943-50 | pmid=17498579 | doi=10.1016/j.jacc.2007.02.037 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17498579 }} </ref><ref name="pmid14975475">{{cite journal| author=Logeart D, Thabut G, Jourdain P, Chavelas C, Beyne P, Beauvais F | display-authors=etal| title=Predischarge B-type natriuretic peptide assay for identifying patients at high risk of re-admission after decompensated heart failure. | journal=J Am Coll Cardiol | year= 2004 | volume= 43 | issue= 4 | pages= 635-41 | pmid=14975475 | doi=10.1016/j.jacc.2003.09.044 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14975475 }} </ref><ref name="pmid15364340">{{cite journal| author=Maisel A, Hollander JE, Guss D, McCullough P, Nowak R, Green G | display-authors=etal| title=Primary results of the Rapid Emergency Department Heart Failure Outpatient Trial (REDHOT). A multicenter study of B-type natriuretic peptide levels, emergency department decision making, and outcomes in patients presenting with shortness of breath. | journal=J Am Coll Cardiol | year= 2004 | volume= 44 | issue= 6 | pages= 1328-33 | pmid=15364340 | doi=10.1016/j.jacc.2004.06.015 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15364340 }} </ref><ref name="pmid19157603">{{cite journal| author=Zairis MN, Tsiaousis GZ, Georgilas AT, Makrygiannis SS, Adamopoulou EN, Handanis SM | display-authors=etal| title=Multimarker strategy for the prediction of 31 days cardiac death in patients with acutely decompensated chronic heart failure. | journal=Int J Cardiol | year= 2010 | volume= 141 | issue= 3 | pages= 284-90 | pmid=19157603 | doi=10.1016/j.ijcard.2008.12.017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19157603 }} </ref><ref name="pmid19398076">{{cite journal| author=Dhaliwal AS, Deswal A, Pritchett A, Aguilar D, Kar B, Souchek J | display-authors=etal| title=Reduction in BNP levels with treatment of decompensated heart failure and future clinical events. | journal=J Card Fail | year= 2009 | volume= 15 | issue= 4 | pages= 293-9 | pmid=19398076 | doi=10.1016/j.cardfail.2008.11.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19398076 }} </ref><ref name="pmid20185037">{{cite journal| author=O'Connor CM, Hasselblad V, Mehta RH, Tasissa G, Califf RM, Fiuzat M | display-authors=etal| title=Triage after hospitalization with advanced heart failure: the ESCAPE (Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness) risk model and discharge score. | journal=J Am Coll Cardiol | year= 2010 | volume= 55 | issue= 9 | pages= 872-8 | pmid=20185037 | doi=10.1016/j.jacc.2009.08.083 | pmc=3835158 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20185037 }} </ref><ref name="pmid12921811">{{cite journal| author=O'Brien RJ, Squire IB, Demme B, Davies JE, Ng LL| title=Pre-discharge, but not admission, levels of NT-proBNP predict adverse prognosis following acute LVF. | journal=Eur J Heart Fail | year= 2003 | volume= 5 | issue= 4 | pages= 499-506 | pmid=12921811 | doi=10.1016/s1388-9842(03)00098-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12921811 }} </ref><ref name="pmid19539144">{{cite journal| author=Cohen-Solal A, Logeart D, Huang B, Cai D, Nieminen MS, Mebazaa A| title=Lowered B-type natriuretic peptide in response to levosimendan or dobutamine treatment is associated with improved survival in patients with severe acutely decompensated heart failure. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 25 | pages= 2343-8 | pmid=19539144 | doi=10.1016/j.jacc.2009.02.058 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19539144 }} </ref><ref name="pmid24179162">{{cite journal| author=Salah K, Kok WE, Eurlings LW, Bettencourt P, Pimenta JM, Metra M | display-authors=etal| title=A novel discharge risk model for patients hospitalised for acute decompensated heart failure incorporating N-terminal pro-B-type natriuretic peptide levels: a European coLlaboration on Acute decompeNsated Heart Failure: ELAN-HF Score. | journal=Heart | year= 2014 | volume= 100 | issue= 2 | pages= 115-25 | pmid=24179162 | doi=10.1136/heartjnl-2013-303632 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24179162 }} </ref><ref name="pmid24922626">{{cite journal| author=Flint KM, Allen LA, Pham M, Heidenreich PA| title=B-type natriuretic peptide predicts 30-day readmission for heart failure but not readmission for other causes. | journal=J Am Heart Assoc | year= 2014 | volume= 3 | issue= 3 | pages= e000806 | pmid=24922626 | doi=10.1161/JAHA.114.000806 | pmc=4309072 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24922626 }} </ref><ref name="pmid21743005">{{cite journal| author=Kociol RD, Horton JR, Fonarow GC, Reyes EM, Shaw LK, O'Connor CM | display-authors=etal| title=Admission, discharge, or change in B-type natriuretic peptide and long-term outcomes: data from Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) linked to Medicare claims. | journal=Circ Heart Fail | year= 2011 | volume= 4 | issue= 5 | pages= 628-36 | pmid=21743005 | doi=10.1161/CIRCHEARTFAILURE.111.962290 | pmc=3465672 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21743005 }} </ref><ref name="pmid23250981">{{cite journal| author=Kociol RD, McNulty SE, Hernandez AF, Lee KL, Redfield MM, Tracy RP | display-authors=etal| title=Markers of decongestion, dyspnea relief, and clinical outcomes among patients hospitalized with acute heart failure. | journal=Circ Heart Fail | year= 2013 | volume= 6 | issue= 2 | pages= 240-5 | pmid=23250981 | doi=10.1161/CIRCHEARTFAILURE.112.969246 | pmc=3865520 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23250981 }} </ref><ref name="pmid18545069">{{cite journal| author=Verdiani V, Ognibene A, Rutili MS, Lombardo C, Bacci F, Terreni A | display-authors=etal| title=NT-ProBNP reduction percentage during hospital stay predicts long-term mortality and readmission in heart failure patients. | journal=J Cardiovasc Med (Hagerstown) | year= 2008 | volume= 9 | issue= 7 | pages= 694-9 | pmid=18545069 | doi=10.2459/JCM.0b013e3282f447ae | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18545069 }} </ref><ref name="pmid15948093">{{cite journal| author=Bayés-Genís A, Lopez L, Zapico E, Cotes C, Santaló M, Ordonez-Llanos J | display-authors=etal| title=NT-ProBNP reduction percentage during admission for acutely decompensated heart failure predicts long-term cardiovascular mortality. | journal=J Card Fail | year= 2005 | volume= 11 | issue= 5 Suppl | pages= S3-8 | pmid=15948093 | doi=10.1016/j.cardfail.2005.04.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15948093 }} </ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki>

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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' In [[patients]] [[hospitalized]] for [[HF]], measurement of [[BNP]] or [[NT-proBNP]] levels at admission is recommended to establish [[prognosis]]. <ref name="pmid25052418">{{cite journal| author=Santaguida PL, Don-Wauchope AC, Ali U, Oremus M, Brown JA, Bustamam A | display-authors=etal| title=Incremental value of natriuretic peptide measurement in acute decompensated heart failure (ADHF): a systematic review. | journal=Heart Fail Rev | year= 2014 | volume= 19 | issue= 4 | pages= 507-19 | pmid=25052418 | doi=10.1007/s10741-014-9444-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25052418 }} </ref><ref name="pmid16979009">{{cite journal| author=van Kimmenade RR, Januzzi JL, Ellinor PT, Sharma UC, Bakker JA, Low AF | display-authors=etal| title=Utility of amino-terminal pro-brain natriuretic peptide, galectin-3, and apelin for the evaluation of patients with acute heart failure. | journal=J Am Coll Cardiol | year= 2006 | volume= 48 | issue= 6 | pages= 1217-24 | pmid=16979009 | doi=10.1016/j.jacc.2006.03.061 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16979009 }} </ref><ref name="pmid15451800">{{cite journal| author=Bettencourt P, Azevedo A, Pimenta J, Friões F, Ferreira S, Ferreira A| title=N-terminal-pro-brain natriuretic peptide predicts outcome after hospital discharge in heart failure patients. | journal=Circulation | year= 2004 | volume= 110 | issue= 15 | pages= 2168-74 | pmid=15451800 | doi=10.1161/01.CIR.0000144310.04433.BE | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15451800 }} </ref><ref name="pmid11216951">{{cite journal| author=Cheng V, Kazanagra R, Garcia A, Lenert L, Krishnaswamy P, Gardetto N | display-authors=etal| title=A rapid bedside test for B-type peptide predicts treatment outcomes in patients admitted for decompensated heart failure: a pilot study. | journal=J Am Coll Cardiol | year= 2001 | volume= 37 | issue= 2 | pages= 386-91 | pmid=11216951 | doi=10.1016/s0735-1097(00)01157-8 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11216951 }} </ref><ref name="pmid17498579">{{cite journal| author=Fonarow GC, Peacock WF, Phillips CO, Givertz MM, Lopatin M, ADHERE Scientific Advisory Committee and Investigators| title=Admission B-type natriuretic peptide levels and in-hospital mortality in acute decompensated heart failure. | journal=J Am Coll Cardiol | year= 2007 | volume= 49 | issue= 19 | pages= 1943-50 | pmid=17498579 | doi=10.1016/j.jacc.2007.02.037 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17498579 }} </ref><ref name="pmid14975475">{{cite journal| author=Logeart D, Thabut G, Jourdain P, Chavelas C, Beyne P, Beauvais F | display-authors=etal| title=Predischarge B-type natriuretic peptide assay for identifying patients at high risk of re-admission after decompensated heart failure. | journal=J Am Coll Cardiol | year= 2004 | volume= 43 | issue= 4 | pages= 635-41 | pmid=14975475 | doi=10.1016/j.jacc.2003.09.044 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14975475 }} </ref><ref name="pmid15364340">{{cite journal| author=Maisel A, Hollander JE, Guss D, McCullough P, Nowak R, Green G | display-authors=etal| title=Primary results of the Rapid Emergency Department Heart Failure Outpatient Trial (REDHOT). A multicenter study of B-type natriuretic peptide levels, emergency department decision making, and outcomes in patients presenting with shortness of breath. | journal=J Am Coll Cardiol | year= 2004 | volume= 44 | issue= 6 | pages= 1328-33 | pmid=15364340 | doi=10.1016/j.jacc.2004.06.015 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15364340 }} </ref><ref name="pmid19157603">{{cite journal| author=Zairis MN, Tsiaousis GZ, Georgilas AT, Makrygiannis SS, Adamopoulou EN, Handanis SM | display-authors=etal| title=Multimarker strategy for the prediction of 31 days cardiac death in patients with acutely decompensated chronic heart failure. | journal=Int J Cardiol | year= 2010 | volume= 141 | issue= 3 | pages= 284-90 | pmid=19157603 | doi=10.1016/j.ijcard.2008.12.017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19157603 }} </ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki>

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|colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4.''' In [[patients]] at risk of developing [[HF]], [[BNP]] or [[NT-proBNP]]-based screening followed by [[team-based care]], including a [[cardiovascular]] specialist, can be useful to prevent the development of [[LV dysfunction]] or new-onset [[HF]]. <ref name="pmid23810874">{{cite journal| author=Huelsmann M, Neuhold S, Resl M, Strunk G, Brath H, Francesconi C | display-authors=etal| title=PONTIAC (NT-proBNP selected prevention of cardiac events in a population of diabetic patients without a history of cardiac disease): a prospective randomized controlled trial. | journal=J Am Coll Cardiol | year= 2013 | volume= 62 | issue= 15 | pages= 1365-72 | pmid=23810874 | doi=10.1016/j.jacc.2013.05.069 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23810874 }} </ref><ref name="pmid23821090">{{cite journal| author=Ledwidge M, Gallagher J, Conlon C, Tallon E, O'Connell E, Dawkins I | display-authors=etal| title=Natriuretic peptide-based screening and collaborative care for heart failure: the STOP-HF randomized trial. | journal=JAMA | year= 2013 | volume= 310 | issue= 1 | pages= 66-74 | pmid=23821090 | doi=10.1001/jama.2013.7588 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23821090 }} [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=24368334 Review in: Evid Based Med. 2014 Jun;19(3):107] </ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])'' <nowiki>"</nowiki>

|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''5.'''In [[patients]] [[hospitalized]] for [[HF]], a predischarge [[BNP]] or [[NT-proBNP]] level can be useful to inform the trajectory of the [[patient]] and establish a postdischarge [[prognosis]]. <ref name="pmid15451800">{{cite journal| author=Bettencourt P, Azevedo A, Pimenta J, Friões F, Ferreira S, Ferreira A| title=N-terminal-pro-brain natriuretic peptide predicts outcome after hospital discharge in heart failure patients. | journal=Circulation | year= 2004 | volume= 110 | issue= 15 | pages= 2168-74 | pmid=15451800 | doi=10.1161/01.CIR.0000144310.04433.BE | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15451800 }} </ref><ref name="pmid14975475">{{cite journal| author=Logeart D, Thabut G, Jourdain P, Chavelas C, Beyne P, Beauvais F | display-authors=etal| title=Predischarge B-type natriuretic peptide assay for identifying patients at high risk of re-admission after decompensated heart failure. | journal=J Am Coll Cardiol | year= 2004 | volume= 43 | issue= 4 | pages= 635-41 | pmid=14975475 | doi=10.1016/j.jacc.2003.09.044 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14975475 }} </ref><ref name="pmid19398076">{{cite journal| author=Dhaliwal AS, Deswal A, Pritchett A, Aguilar D, Kar B, Souchek J | display-authors=etal| title=Reduction in BNP levels with treatment of decompensated heart failure and future clinical events. | journal=J Card Fail | year= 2009 | volume= 15 | issue= 4 | pages= 293-9 | pmid=19398076 | doi=10.1016/j.cardfail.2008.11.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19398076 }} </ref><ref name="pmid20185037">{{cite journal| author=O'Connor CM, Hasselblad V, Mehta RH, Tasissa G, Califf RM, Fiuzat M | display-authors=etal| title=Triage after hospitalization with advanced heart failure: the ESCAPE (Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness) risk model and discharge score. | journal=J Am Coll Cardiol | year= 2010 | volume= 55 | issue= 9 | pages= 872-8 | pmid=20185037 | doi=10.1016/j.jacc.2009.08.083 | pmc=3835158 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20185037 }} </ref><ref name="pmid12921811">{{cite journal| author=O'Brien RJ, Squire IB, Demme B, Davies JE, Ng LL| title=Pre-discharge, but not admission, levels of NT-proBNP predict adverse prognosis following acute LVF. | journal=Eur J Heart Fail | year= 2003 | volume= 5 | issue= 4 | pages= 499-506 | pmid=12921811 | doi=10.1016/s1388-9842(03)00098-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12921811 }} </ref><ref name="pmid19539144">{{cite journal| author=Cohen-Solal A, Logeart D, Huang B, Cai D, Nieminen MS, Mebazaa A| title=Lowered B-type natriuretic peptide in response to levosimendan or dobutamine treatment is associated with improved survival in patients with severe acutely decompensated heart failure. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 25 | pages= 2343-8 | pmid=19539144 | doi=10.1016/j.jacc.2009.02.058 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19539144 }} </ref><ref name="pmid24179162">{{cite journal| author=Salah K, Kok WE, Eurlings LW, Bettencourt P, Pimenta JM, Metra M | display-authors=etal| title=A novel discharge risk model for patients hospitalised for acute decompensated heart failure incorporating N-terminal pro-B-type natriuretic peptide levels: a European coLlaboration on Acute decompeNsated Heart Failure: ELAN-HF Score. | journal=Heart | year= 2014 | volume= 100 | issue= 2 | pages= 115-25 | pmid=24179162 | doi=10.1136/heartjnl-2013-303632 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24179162 }} </ref><ref name="pmid24922626">{{cite journal| author=Flint KM, Allen LA, Pham M, Heidenreich PA| title=B-type natriuretic peptide predicts 30-day readmission for heart failure but not readmission for other causes. | journal=J Am Heart Assoc | year= 2014 | volume= 3 | issue= 3 | pages= e000806 | pmid=24922626 | doi=10.1161/JAHA.114.000806 | pmc=4309072 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24922626 }} </ref><ref name="pmid21743005">{{cite journal| author=Kociol RD, Horton JR, Fonarow GC, Reyes EM, Shaw LK, O'Connor CM | display-authors=etal| title=Admission, discharge, or change in B-type natriuretic peptide and long-term outcomes: data from Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) linked to Medicare claims. | journal=Circ Heart Fail | year= 2011 | volume= 4 | issue= 5 | pages= 628-36 | pmid=21743005 | doi=10.1161/CIRCHEARTFAILURE.111.962290 | pmc=3465672 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21743005 }} </ref><ref name="pmid23250981">{{cite journal| author=Kociol RD, McNulty SE, Hernandez AF, Lee KL, Redfield MM, Tracy RP | display-authors=etal| title=Markers of decongestion, dyspnea relief, and clinical outcomes among patients hospitalized with acute heart failure. | journal=Circ Heart Fail | year= 2013 | volume= 6 | issue= 2 | pages= 240-5 | pmid=23250981 | doi=10.1161/CIRCHEARTFAILURE.112.969246 | pmc=3865520 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23250981 }} </ref><ref name="pmid18545069">{{cite journal| author=Verdiani V, Ognibene A, Rutili MS, Lombardo C, Bacci F, Terreni A | display-authors=etal| title=NT-ProBNP reduction percentage during hospital stay predicts long-term mortality and readmission in heart failure patients. | journal=J Cardiovasc Med (Hagerstown) | year= 2008 | volume= 9 | issue= 7 | pages= 694-9 | pmid=18545069 | doi=10.2459/JCM.0b013e3282f447ae | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18545069 }} </ref><ref name="pmid15948093">{{cite journal| author=Bayés-Genís A, Lopez L, Zapico E, Cotes C, Santaló M, Ordonez-Llanos J | display-authors=etal| title=NT-ProBNP reduction percentage during admission for acutely decompensated heart failure predicts long-term cardiovascular mortality. | journal=J Card Fail | year= 2005 | volume= 11 | issue= 5 Suppl | pages= S3-8 | pmid=15948093 | doi=10.1016/j.cardfail.2005.04.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15948093 }} </ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])'' <nowiki>"</nowiki>

|}

===Genetic Evaluation and Testing 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT) <ref name="pmid35363500">{{cite journal| author=Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM | display-authors=etal| title=2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. | journal=Circulation | year= 2022 | volume= 145 | issue= 18 | pages= e876-e894 | pmid=35363500 | doi=10.1161/CIR.0000000000001062 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=35363500 }} </ref> ===

{|class="wikitable" style="width:80%"
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]

|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' In first-degree relatives of selected [[patients]] with [[genetic]] or [[inherited]] [[cardiomyopathies]], [[genetic screening]] and counseling are recommended to detect [[cardiac disease]] and prompt consideration of [[treatments]] to decrease [[HF]] progression and sudden [[death]]. <ref name="pmid32624524">{{cite journal| author=Marume K, Noguchi T, Tateishi E, Morita Y, Miura H, Nishimura K | display-authors=etal| title=Prognosis and Clinical Characteristics of Dilated Cardiomyopathy With Family History via Pedigree Analysis. | journal=Circ J | year= 2020 | volume= 84 | issue= 8 | pages= 1284-1293 | pmid=32624524 | doi=10.1253/circj.CJ-19-1176 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32624524 }} </ref><ref name="pmid26925241">{{cite journal| author=Waddell-Smith KE, Donoghue T, Oates S, Graham A, Crawford J, Stiles MK | display-authors=etal| title=Inpatient detection of cardiac-inherited disease: the impact of improving family history taking. | journal=Open Heart | year= 2016 | volume= 3 | issue= 1 | pages= e000329 | pmid=26925241 | doi=10.1136/openhrt-2015-000329 | pmc=4762189 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26925241 }} </ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])'' <nowiki>"</nowiki>
|}

{|class="wikitable" style="width:80%"
|-
|colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' In select [[patients]] with [[nonischemic cardiomyopathy]], referral for [[genetic counseling]] and testing is reasonable to identify conditions that could guide [[treatment]] for [[patients]] and [[family]] members.<ref name="pmid24503780">{{cite journal| author=Pugh TJ, Kelly MA, Gowrisankar S, Hynes E, Seidman MA, Baxter SM | display-authors=etal| title=The landscape of genetic variation in dilated cardiomyopathy as surveyed by clinical DNA sequencing. | journal=Genet Med | year= 2014 | volume= 16 | issue= 8 | pages= 601-8 | pmid=24503780 | doi=10.1038/gim.2013.204 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24503780 }} </ref><ref name="pmid25163546">{{cite journal| author=Haas J, Frese KS, Peil B, Kloos W, Keller A, Nietsch R | display-authors=etal| title=Atlas of the clinical genetics of human dilated cardiomyopathy. | journal=Eur Heart J | year= 2015 | volume= 36 | issue= 18 | pages= 1123-35a | pmid=25163546 | doi=10.1093/eurheartj/ehu301 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25163546 }} </ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])'' <nowiki>"</nowiki>
|}

===Evaluation With Cardiac Imaging 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT) <ref name="pmid35363500">{{cite journal| author=Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM | display-authors=etal| title=2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. | journal=Circulation | year= 2022 | volume= 145 | issue= 18 | pages= e876-e894 | pmid=35363500 | doi=10.1161/CIR.0000000000001062 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=35363500 }} </ref> ===

{|class="wikitable" style="width:80%"
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]

|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' In [[patients]] with suspected or new-onset [[HF]], or those presenting with acute decompensated [[HF]], a [[chest]] [[X-ray]] should be performed to assess [[heart]] size and [[pulmonary congestion]] and to detect alternative [[cardiac]], [[pulmonary]], and other [[diseases]] that may cause or contribute to the [[patient]]'s [[symptoms]]. <ref name="pmid8945695">{{cite journal| author=Badgett RG, Mulrow CD, Otto PM, Ramírez G| title=How well can the chest radiograph diagnose left ventricular dysfunction? | journal=J Gen Intern Med | year= 1996 | volume= 11 | issue= 10 | pages= 625-34 | pmid=8945695 | doi=10.1007/BF02599031 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8945695 }} </ref><ref name="pmid15006584">{{cite journal| author=Knudsen CW, Omland T, Clopton P, Westheim A, Abraham WT, Storrow AB | display-authors=etal| title=Diagnostic value of B-Type natriuretic peptide and chest radiographic findings in patients with acute dyspnea. | journal=Am J Med | year= 2004 | volume= 116 | issue= 6 | pages= 363-8 | pmid=15006584 | doi=10.1016/j.amjmed.2003.10.028 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15006584 }} [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=15341468 Review in: ACP J Club. 2004 Sep-Oct;141(2):48] </ref>''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])'' <nowiki>"</nowiki>

|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' In [[patients]] with suspected or newly diagnosed [[HF]], [[transthoracic echocardiography]] ([[TTE]]) should be performed during initial evaluation to assess [[cardiac]] structure and function. <ref name="pmid18848689">{{cite journal| author=Tribouilloy C, Rusinaru D, Mahjoub H, Goissen T, Lévy F, Peltier M| title=Impact of echocardiography in patients hospitalized for heart failure: a prospective observational study. | journal=Arch Cardiovasc Dis | year= 2008 | volume= 101 | issue= 7-8 | pages= 465-73 | pmid=18848689 | doi=10.1016/j.acvd.2008.06.012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18848689 }} </ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])'' <nowiki>"</nowiki>

|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' In [[patients]] with [[HF]] who have had a significant [[clinical]] change, or who have received GDMT and are being considered for invasive procedures or device [[therapy]], repeat measurement of [[EF]], degree of structural remodeling, and [[valvular]] function are useful to inform [[therapeutic]] interventions.<ref name="pmid: 9120160">{{cite journal| author=Doughty RN, Whalley GA, Gamble G, MacMahon S, Sharpe N| title=Left ventricular remodeling with carvedilol in patients with congestive heart failure due to ischemic heart disease. Australia-New Zealand Heart Failure Research Collaborative Group. | journal=J Am Coll Cardiol | year= 1997 | volume= 29 | issue= 5 | pages= 1060-6 | pmid=: 9120160 | doi=10.1016/s0735-1097(97)00012-0 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9120160 }} </ref><ref name="pmid28096098">{{cite journal| author=Duncker D, König T, Hohmann S, Bauersachs J, Veltmann C| title=Avoiding Untimely Implantable Cardioverter/Defibrillator Implantation by Intensified Heart Failure Therapy Optimization Supported by the Wearable Cardioverter/Defibrillator-The PROLONG Study. | journal=J Am Heart Assoc | year= 2017 | volume= 6 | issue= 1 | pages= | pmid=28096098 | doi=10.1161/JAHA.116.004512 | pmc=5523634 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28096098 }} </ref><ref name="pmid31475295">{{cite journal| author=Januzzi JL, Prescott MF, Butler J, Felker GM, Maisel AS, McCague K | display-authors=etal| title=Association of Change in N-Terminal Pro-B-Type Natriuretic Peptide Following Initiation of Sacubitril-Valsartan Treatment With Cardiac Structure and Function in Patients With Heart Failure With Reduced Ejection Fraction. | journal=JAMA | year= 2019 | volume= 322 | issue= 11 | pages= 1085-1095 | pmid=31475295 | doi=10.1001/jama.2019.12821 | pmc=6724151 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31475295 }} </ref><ref name="pmid11255520">{{cite journal| author=Solomon SD, Glynn RJ, Greaves S, Ajani U, Rouleau JL, Menapace F | display-authors=etal| title=Recovery of ventricular function after myocardial infarction in the reperfusion era: the healing and early afterload reducing therapy study. | journal=Ann Intern Med | year= 2001 | volume= 134 | issue= 6 | pages= 451-8 | pmid=11255520 | doi=10.7326/0003-4819-134-6-200103200-00009 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11255520 }} </ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])'' <nowiki>"</nowiki>

|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' In [[patients]] for whom [[echocardiography]] is inadequate, alternative [[imaging]] (eg, [[cardiac magnetic resonance]] [CMR], [[cardiac computed tomography]] [CT], [[radionuclide imaging]]) is recommended for assessment of [[LVEF]].<ref name="pmid10952828">{{cite journal| author=Bellenger NG, Burgess MI, Ray SG, Lahiri A, Coats AJ, Cleland JG | display-authors=etal| title=Comparison of left ventricular ejection fraction and volumes in heart failure by echocardiography, radionuclide ventriculography and cardiovascular magnetic resonance; are they interchangeable? | journal=Eur Heart J | year= 2000 | volume= 21 | issue= 16 | pages= 1387-96 | pmid=10952828 | doi=10.1053/euhj.2000.2011 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10952828 }} </ref><ref name="pmid12088775">{{cite journal| author=Grothues F, Smith GC, Moon JC, Bellenger NG, Collins P, Klein HU | display-authors=etal| title=Comparison of interstudy reproducibility of cardiovascular magnetic resonance with two-dimensional echocardiography in normal subjects and in patients with heart failure or left ventricular hypertrophy. | journal=Am J Cardiol | year= 2002 | volume= 90 | issue= 1 | pages= 29-34 | pmid=12088775 | doi=10.1016/s0002-9149(02)02381-0 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12088775 }} </ref><ref name="pmid2861314">{{cite journal| author=Longmore DB, Klipstein RH, Underwood SR, Firmin DN, Hounsfield GN, Watanabe M | display-authors=etal| title=Dimensional accuracy of magnetic resonance in studies of the heart. | journal=Lancet | year= 1985 | volume= 1 | issue= 8442 | pages= 1360-2 | pmid=2861314 | doi=10.1016/s0140-6736(85)91786-6 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2861314 }} </ref><ref name="pmid30630640">{{cite journal| author=Doherty JU, Kort S, Mehran R, Schoenhagen P, Soman P, Dehmer GJ | display-authors=etal| title=ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS 2019 Appropriate Use Criteria for Multimodality Imaging in the Assessment of Cardiac Structure and Function in Nonvalvular Heart Disease: A Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and the Society of Thoracic Surgeons. | journal=J Am Coll Cardiol | year= 2019 | volume= 73 | issue= 4 | pages= 488-516 | pmid=30630640 | doi=10.1016/j.jacc.2018.10.038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30630640 }} </ref><ref name="pmid8623737">{{cite journal| author=van Royen N, Jaffe CC, Krumholz HM, Johnson KM, Lynch PJ, Natale D | display-authors=etal| title=Comparison and reproducibility of visual echocardiographic and quantitative radionuclide left ventricular ejection fractions. | journal=Am J Cardiol | year= 1996 | volume= 77 | issue= 10 | pages= 843-50 | pmid=8623737 | doi=10.1016/s0002-9149(97)89179-5 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8623737 }} </ref><ref name="pmid31134368">{{cite journal| author=Fu H, Wang X, Diao K, Huang S, Liu H, Gao Y | display-authors=etal| title=CT compared to MRI for functional evaluation of the right ventricle: a systematic review and meta-analysis. | journal=Eur Radiol | year= 2019 | volume= 29 | issue= 12 | pages= 6816-6828 | pmid=31134368 | doi=10.1007/s00330-019-06228-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31134368 }} </ref><ref name="pmid27510625">{{cite journal| author=Kaniewska M, Schuetz GM, Willun S, Schlattmann P, Dewey M| title=Noninvasive evaluation of global and regional left ventricular function using computed tomography and magnetic resonance imaging: a meta-analysis. | journal=Eur Radiol | year= 2017 | volume= 27 | issue= 4 | pages= 1640-1659 | pmid=27510625 | doi=10.1007/s00330-016-4513-1 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27510625 }} </ref><ref name="pmid21831552">{{cite journal| author=Takx RA, Moscariello A, Schoepf UJ, Barraza JM, Nance JW, Bastarrika G | display-authors=etal| title=Quantification of left and right ventricular function and myocardial mass: comparison of low-radiation dose 2nd generation dual-source CT and cardiac MRI. | journal=Eur J Radiol | year= 2012 | volume= 81 | issue= 4 | pages= e598-604 | pmid=21831552 | doi=10.1016/j.ejrad.2011.07.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21831552 }} </ref>''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])'' <nowiki>"</nowiki>

|}

{|class="wikitable" style="width:80%"
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|colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]

|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''5.''' In [[patients]] with [[HF]] or [[cardiomyopathy]], CMR can be useful for [[diagnosis]] or [[management]]. <ref name="pmid11913479">{{cite journal| author=Anderson LJ, Holden S, Davis B, Prescott E, Charrier CC, Bunce NH | display-authors=etal| title=Cardiovascular T2-star (T2*) magnetic resonance for the early diagnosis of myocardial iron overload. | journal=Eur Heart J | year= 2001 | volume= 22 | issue= 23 | pages= 2171-9 | pmid=11913479 | doi=10.1053/euhj.2001.2822 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11913479 }} </ref><ref name="pmid19682818">{{cite journal| author=Bruder O, Schneider S, Nothnagel D, Dill T, Hombach V, Schulz-Menger J | display-authors=etal| title=EuroCMR (European Cardiovascular Magnetic Resonance) registry: results of the German pilot phase. | journal=J Am Coll Cardiol | year= 2009 | volume= 54 | issue= 15 | pages= 1457-66 | pmid=19682818 | doi=10.1016/j.jacc.2009.07.003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19682818 }} </ref><ref name="pmid23331632">{{cite journal| author=Bruder O, Wagner A, Lombardi M, Schwitter J, van Rossum A, Pilz G | display-authors=etal| title=European Cardiovascular Magnetic Resonance (EuroCMR) registry--multi national results from 57 centers in 15 countries. | journal=J Cardiovasc Magn Reson | year= 2013 | volume= 15 | issue= | pages= 9 | pmid=23331632 | doi=10.1186/1532-429X-15-9 | pmc=3564740 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23331632 }} </ref><ref name="pmid23498672">{{cite journal| author=Karamitsos TD, Piechnik SK, Banypersad SM, Fontana M, Ntusi NB, Ferreira VM | display-authors=etal| title=Noncontrast T1 mapping for the diagnosis of cardiac amyloidosis. | journal=JACC Cardiovasc Imaging | year= 2013 | volume= 6 | issue= 4 | pages= 488-97 | pmid=23498672 | doi=10.1016/j.jcmg.2012.11.013 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23498672 }} </ref><ref name="pmid28728692">{{cite journal| author=Martinez-Naharro A, Treibel TA, Abdel-Gadir A, Bulluck H, Zumbo G, Knight DS | display-authors=etal| title=Magnetic Resonance in Transthyretin Cardiac Amyloidosis. | journal=J Am Coll Cardiol | year= 2017 | volume= 70 | issue= 4 | pages= 466-477 | pmid=28728692 | doi=10.1016/j.jacc.2017.05.053 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28728692 }} </ref><ref name="pmid23498674">{{cite journal| author=Puntmann VO, Voigt T, Chen Z, Mayr M, Karim R, Rhode K | display-authors=etal| title=Native T1 mapping in differentiation of normal myocardium from diffuse disease in hypertrophic and dilated cardiomyopathy. | journal=JACC Cardiovasc Imaging | year= 2013 | volume= 6 | issue= 4 | pages= 475-84 | pmid=23498674 | doi=10.1016/j.jcmg.2012.08.019 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23498674 }} </ref><ref name="pmid25104503">{{cite journal| author=Sado DM, Maestrini V, Piechnik SK, Banypersad SM, White SK, Flett AS | display-authors=etal| title=Noncontrast myocardial T1 mapping using cardiovascular magnetic resonance for iron overload. | journal=J Magn Reson Imaging | year= 2015 | volume= 41 | issue= 6 | pages= 1505-11 | pmid=25104503 | doi=10.1002/jmri.24727 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25104503 }} </ref><ref name="pmid23564562">{{cite journal| author=Sado DM, White SK, Piechnik SK, Banypersad SM, Treibel T, Captur G | display-authors=etal| title=Identification and assessment of Anderson-Fabry disease by cardiovascular magnetic resonance noncontrast myocardial T1 mapping. | journal=Circ Cardiovasc Imaging | year= 2013 | volume= 6 | issue= 3 | pages= 392-8 | pmid=23564562 | doi=10.1161/CIRCIMAGING.112.000070 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23564562 }} </ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B-NR]])'' <nowiki>"</nowiki>

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| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''6.''' In [[patients]] with [[HF]], an evaluation for possible [[ischemic heart disease]] can be useful to identify the cause and guide [[management]]. <ref name="pmid16098295">{{cite journal| author=Elhendy A, Sozzi F, van Domburg RT, Bax JJ, Schinkel AF, Roelandt JR | display-authors=etal| title=Effect of myocardial ischemia during dobutamine stress echocardiography on cardiac mortality in patients with heart failure secondary to ischemic cardiomyopathy. | journal=Am J Cardiol | year= 2005 | volume= 96 | issue= 4 | pages= 469-73 | pmid=16098295 | doi=10.1016/j.amjcard.2005.04.004 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16098295 }} </ref><ref name="pmid15077089">{{cite journal| author=Miller WL, Hodge DO, Tointon SK, Rodeheffer RJ, Nelson SM, Gibbons RJ| title=Relationship of myocardial perfusion imaging findings to outcome of patients with heart failure and suspected ischemic heart disease. | journal=Am Heart J | year= 2004 | volume= 147 | issue= 4 | pages= 714-20 | pmid=15077089 | doi=10.1016/j.ahj.2003.10.045 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15077089 }} </ref><ref name="pmid32588042">{{cite journal| author=Chow BJW, Coyle D, Hossain A, Laine M, Hanninen H, Ukkonen H | display-authors=etal| title=Computed tomography coronary angiography for patients with heart failure (CTA-HF): a randomized controlled trial (IMAGE-HF 1C). | journal=Eur Heart J Cardiovasc Imaging | year= 2021 | volume= 22 | issue= 9 | pages= 1083-1090 | pmid=32588042 | doi=10.1093/ehjci/jeaa109 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32588042 }} </ref><ref name="pmid28798192">{{cite journal| author=Ferreira JP, Rossignol P, Demissei B, Sharma A, Girerd N, Anker SD | display-authors=etal| title=Coronary angiography in worsening heart failure: determinants, findings and prognostic implications. | journal=Heart | year= 2018 | volume= 104 | issue= 7 | pages= 606-613 | pmid=28798192 | doi=10.1136/heartjnl-2017-311750 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28798192 }} </ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B-NR]])'' <nowiki>"</nowiki>

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{|class="wikitable" style="width:80%"
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|colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]

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| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''7.''' In [[patients]] with [[HF]] and [[coronary artery disease]] ([[CAD]]) who are candidates for [[coronary revascularization]], noninvasive [[stress imaging]] ([[stress echocardiography]], [[single-photon emission CT]] [SPECT], CMR, or [[positron emission tomography]] [PET] may be considered for detection of [[myocardial ischemia]] to help guide [[coronary revascularization]]. <ref name="pmid11923039">{{cite journal| author=Allman KC, Shaw LJ, Hachamovitch R, Udelson JE| title=Myocardial viability testing and impact of revascularization on prognosis in patients with coronary artery disease and left ventricular dysfunction: a meta-analysis. | journal=J Am Coll Cardiol | year= 2002 | volume= 39 | issue= 7 | pages= 1151-8 | pmid=11923039 | doi=10.1016/s0735-1097(02)01726-6 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11923039 }} </ref><ref name="pmid19761983">{{cite journal| author=D'Egidio G, Nichol G, Williams KA, Guo A, Garrard L, deKemp R | display-authors=etal| title=Increasing benefit from revascularization is associated with increasing amounts of myocardial hibernation: a substudy of the PARR-2 trial. | journal=JACC Cardiovasc Imaging | year= 2009 | volume= 2 | issue= 9 | pages= 1060-8 | pmid=19761983 | doi=10.1016/j.jcmg.2009.02.017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19761983 }} </ref><ref name="pmid23595888">{{cite journal| author=Ling LF, Marwick TH, Flores DR, Jaber WA, Brunken RC, Cerqueira MD | display-authors=etal| title=Identification of therapeutic benefit from revascularization in patients with left ventricular systolic dysfunction: inducible ischemia versus hibernating myocardium. | journal=Circ Cardiovasc Imaging | year= 2013 | volume= 6 | issue= 3 | pages= 363-72 | pmid=23595888 | doi=10.1161/CIRCIMAGING.112.000138 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23595888 }} </ref><ref name="pmid25617608">{{cite journal| author=Orlandini A, Castellana N, Pascual A, Botto F, Cecilia Bahit M, Chacon C | display-authors=etal| title=Myocardial viability for decision-making concerning revascularization in patients with left ventricular dysfunction and coronary artery disease: a meta-analysis of non-randomized and randomized studies. | journal=Int J Cardiol | year= 2015 | volume= 182 | issue= | pages= 494-9 | pmid=25617608 | doi=10.1016/j.ijcard.2015.01.025 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25617608 }} </ref><ref name="pmid16198841">{{cite journal| author=Desideri A, Cortigiani L, Christen AI, Coscarelli S, Gregori D, Zanco P | display-authors=etal| title=The extent of perfusion-F18-fluorodeoxyglucose positron emission tomography mismatch determines mortality in medically treated patients with chronic ischemic left ventricular dysfunction. | journal=J Am Coll Cardiol | year= 2005 | volume= 46 | issue= 7 | pages= 1264-9 | pmid=16198841 | doi=10.1016/j.jacc.2005.06.057 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16198841 }} </ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B-NR]])'' <nowiki>"</nowiki>

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{|class="wikitable" style="width:80%"
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|colspan="1" style="text-align:center; background:LightCoral"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit)

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| bgcolor="LightCoral"|<nowiki>"</nowiki>'''8.''' In [[patients]] with [[HF]] in the absence of 1) [[clinical status]] change, 2) [[treatment]] interventions that might have had a significant effect on [[cardiac function]], or 3) candidacy for [[invasive procedures]] or [[device therapy]], routine repeat assessment of [[LV function]] is not indicated. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:C-EO]])'' <nowiki>"</nowiki>

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===Invasive Evaluation 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT) <ref name="pmid35363500">{{cite journal| author=Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM | display-authors=etal| title=2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. | journal=Circulation | year= 2022 | volume= 145 | issue= 18 | pages= e876-e894 | pmid=35363500 | doi=10.1161/CIR.0000000000001062 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=35363500 }} </ref> ===

{|class="wikitable" style="width:80%"
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|colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]

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| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' In [[patients]] with [[HF]], [[endomyocardial]] [[biopsy]] may be useful when a specific [[diagnosis]] is suspected that would influence [[therapy]]. <ref name="pmid17959655">{{cite journal| author=Cooper LT, Baughman KL, Feldman AM, Frustaci A, Jessup M, Kuhl U | display-authors=etal| title=The role of endomyocardial biopsy in the management of cardiovascular disease: a scientific statement from the American Heart Association, the American College of Cardiology, and the European Society of Cardiology. | journal=Circulation | year= 2007 | volume= 116 | issue= 19 | pages= 2216-33 | pmid=17959655 | doi=10.1161/CIRCULATIONAHA.107.186093 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17959655 }} </ref><ref name="pmid30145929">{{cite journal| author=Maurer MS, Schwartz JH, Gundapaneni B, Elliott PM, Merlini G, Waddington-Cruz M | display-authors=etal| title=Tafamidis Treatment for Patients with Transthyretin Amyloid Cardiomyopathy. | journal=N Engl J Med | year= 2018 | volume= 379 | issue= 11 | pages= 1007-1016 | pmid=30145929 | doi=10.1056/NEJMoa1805689 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30145929 }} </ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B-NR]])'' <nowiki>"</nowiki>

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| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' In selected [[patients]] with [[HF]] with persistent or worsening [[symptoms]], [[signs]], [[diagnostic]] parameters, and in whom [[hemodynamics]] are uncertain, invasive [[hemodynamic]] monitoring can be useful to guide [[management]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:C-EO]])'' <nowiki>"</nowiki>

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{|class="wikitable" style="width:80%"
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|colspan="1" style="text-align:center; background:LightCoral"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit)

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| bgcolor="LightCoral"|<nowiki>"</nowiki>'''3.''' In [[patients]] with [[HF]], routine use of invasive [[hemodynamic]] monitoring is not recommended. <ref name="pmid16204662">{{cite journal| author=Binanay C, Califf RM, Hasselblad V, O'Connor CM, Shah MR, Sopko G | display-authors=etal| title=Evaluation study of congestive heart failure and pulmonary artery catheterization effectiveness: the ESCAPE trial. | journal=JAMA | year= 2005 | volume= 294 | issue= 13 | pages= 1625-33 | pmid=16204662 | doi=10.1001/jama.294.13.1625 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16204662 }} </ref><ref name="pmid16204666">{{cite journal| author=Shah MR, Hasselblad V, Stevenson LW, Binanay C, O'Connor CM, Sopko G | display-authors=etal| title=Impact of the pulmonary artery catheter in critically ill patients: meta-analysis of randomized clinical trials. | journal=JAMA | year= 2005 | volume= 294 | issue= 13 | pages= 1664-70 | pmid=16204666 | doi=10.1001/jama.294.13.1664 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16204666 }} [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=16646614 Review in: ACP J Club. 2006 May-Jun;144(3):70] </ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B-R]])'' <nowiki>"</nowiki>
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{|class="wikitable" style="width:80%"
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|colspan="1" style="text-align:center; background:LightCoral"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm)

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| bgcolor="LightCoral"|<nowiki>"</nowiki>'''2.''' For [[patients]] undergoing routine evaluation of [[HF]], [[endomyocardial]] [[biopsy]] should not be performed because of the [[risk]] of [[complications]]. <ref name="pmid1729344">{{cite journal| author=Deckers JW, Hare JM, Baughman KL| title=Complications of transvenous right ventricular endomyocardial biopsy in adult patients with cardiomyopathy: a seven-year survey of 546 consecutive diagnostic procedures in a tertiary referral center. | journal=J Am Coll Cardiol | year= 1992 | volume= 19 | issue= 1 | pages= 43-7 | pmid=1729344 | doi=10.1016/0735-1097(92)90049-s | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1729344 }} </ref><ref name="pmid20868954">{{cite journal| author=Veress G, Bruce CJ, Kutzke K, Andreen K, Click RL, Scott CG | display-authors=etal| title=Acute thrombus formation as a complication of right ventricular biopsy. | journal=J Am Soc Echocardiogr | year= 2010 | volume= 23 | issue= 10 | pages= 1039-44 | pmid=20868954 | doi=10.1016/j.echo.2010.07.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20868954 }} </ref>''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:C-LD]])'' <nowiki>"</nowiki>

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===Wearables and Remote Monitoring (Including Telemonitoring and Device Monitoring) 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT) <ref name="pmid35363500">{{cite journal| author=Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM | display-authors=etal| title=2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. | journal=Circulation | year= 2022 | volume= 145 | issue= 18 | pages= e876-e894 | pmid=35363500 | doi=10.1161/CIR.0000000000001062 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=35363500 }} </ref> ===

{|class="wikitable" style="width:80%"
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|colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]

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| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' In selected [[adult]] [[patients]] with [[NYHA class III]] [[HF]] and [[history]] of a [[HF]] [[hospitalization]] in the past year or elevated [[natriuretic peptide]] levels, on maximally tolerated stable doses of GDMT with optimal device therapy, the usefulness of wireless monitoring of [[PA]] [[pressure]] by an implanted [[hemodynamic]] monitor to reduce the risk of subsequent [[HF]] [[hospitalization]] is uncertain. <ref name="pmid21315441">{{cite journal| author=Abraham WT, Adamson PB, Bourge RC, Aaron MF, Costanzo MR, Stevenson LW | display-authors=etal| title=Wireless pulmonary artery haemodynamic monitoring in chronic heart failure: a randomised controlled trial. | journal=Lancet | year= 2011 | volume= 377 | issue= 9766 | pages= 658-66 | pmid=21315441 | doi=10.1016/S0140-6736(11)60101-3 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21315441 }} </ref><ref name="pmid25286913">{{cite journal| author=Adamson PB, Abraham WT, Bourge RC, Costanzo MR, Hasan A, Yadav C | display-authors=etal| title=Wireless pulmonary artery pressure monitoring guides management to reduce decompensation in heart failure with preserved ejection fraction. | journal=Circ Heart Fail | year= 2014 | volume= 7 | issue= 6 | pages= 935-44 | pmid=25286913 | doi=10.1161/CIRCHEARTFAILURE.113.001229 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25286913 }} </ref><ref name="pmid28982501">{{cite journal| author=Givertz MM, Stevenson LW, Costanzo MR, Bourge RC, Bauman JG, Ginn G | display-authors=etal| title=Pulmonary Artery Pressure-Guided Management of Patients With Heart Failure and Reduced Ejection Fraction. | journal=J Am Coll Cardiol | year= 2017 | volume= 70 | issue= 15 | pages= 1875-1886 | pmid=28982501 | doi=10.1016/j.jacc.2017.08.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28982501 }} </ref><ref name="pmid34461042">{{cite journal| author=Lindenfeld J, Zile MR, Desai AS, Bhatt K, Ducharme A, Horstmanshof D | display-authors=etal| title=Haemodynamic-guided management of heart failure (GUIDE-HF): a randomised controlled trial. | journal=Lancet | year= 2021 | volume= 398 | issue= 10304 | pages= 991-1001 | pmid=34461042 | doi=10.1016/S0140-6736(21)01754-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34461042 }} </ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B-R]])'' <nowiki>"</nowiki>

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{|class="wikitable" style="width:80%"
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|colspan="1" style="text-align:center; background:White"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Value Statement: Uncertain Value]]

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| bgcolor="White"|<nowiki>"</nowiki>'''2.''' In [[patients]] with [[NYHA class III]] [[HF]] with a [[HF]] [[hospitalization]] within the previous year, wireless monitoring of the [[PA]] [[pressure]] by an implanted [[hemodynamic]] monitor provides uncertain value. <ref name="pmid34461042">{{cite journal| author=Lindenfeld J, Zile MR, Desai AS, Bhatt K, Ducharme A, Horstmanshof D | display-authors=etal| title=Haemodynamic-guided management of heart failure (GUIDE-HF): a randomised controlled trial. | journal=Lancet | year= 2021 | volume= 398 | issue= 10304 | pages= 991-1001 | pmid=34461042 | doi=10.1016/S0140-6736(21)01754-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34461042 }} </ref><ref name="pmid27647784">{{cite journal| author=Martinson M, Bharmi R, Dalal N, Abraham WT, Adamson PB| title=Pulmonary artery pressure-guided heart failure management: US cost-effectiveness analyses using the results of the CHAMPION clinical trial. | journal=Eur J Heart Fail | year= 2017 | volume= 19 | issue= 5 | pages= 652-660 | pmid=27647784 | doi=10.1002/ejhf.642 | pmc=5434920 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27647784 }} </ref><ref name="pmid26874380">{{cite journal| author=Sandhu AT, Goldhaber-Fiebert JD, Owens DK, Turakhia MP, Kaiser DW, Heidenreich PA| title=Cost-Effectiveness of Implantable Pulmonary Artery Pressure Monitoring in Chronic Heart Failure. | journal=JACC Heart Fail | year= 2016 | volume= 4 | issue= 5 | pages= 368-75 | pmid=26874380 | doi=10.1016/j.jchf.2015.12.015 | pmc=4851610 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26874380 }} </ref><ref name="pmid28272808">{{cite journal| author=Schmier JK, Ong KL, Fonarow GC| title=Cost-Effectiveness of Remote Cardiac Monitoring With the CardioMEMS Heart Failure System. | journal=Clin Cardiol | year= 2017 | volume= 40 | issue= 7 | pages= 430-436 | pmid=28272808 | doi=10.1002/clc.22696 | pmc=6490396 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28272808 }} </ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B-NR]])'' <nowiki>"</nowiki>

|}

===Exercise and Functional Capacity Testing 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT) <ref name="pmid35363500">{{cite journal| author=Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM | display-authors=etal| title=2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. | journal=Circulation | year= 2022 | volume= 145 | issue= 18 | pages= e876-e894 | pmid=35363500 | doi=10.1161/CIR.0000000000001062 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=35363500 }} </ref> ===

{|class="wikitable" style="width:80%"
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|colspan="1" style="text-align:center; background:LightGreen"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]

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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' In [[patients]] with [[HF]], assessment and documentation of [[NYHA]] functional classification are recommended to determine eligibility for [[treatments]]. <ref name="pmid16442912">{{cite journal| author=Ahmed A, Aronow WS, Fleg JL| title=Higher New York Heart Association classes and increased mortality and hospitalization in patients with heart failure and preserved left ventricular function. | journal=Am Heart J | year= 2006 | volume= 151 | issue= 2 | pages= 444-50 | pmid=16442912 | doi=10.1016/j.ahj.2005.03.066 | pmc=2771182 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16442912 }} </ref><ref name="pmid12445535">{{cite journal| author=Muntwyler J, Abetel G, Gruner C, Follath F| title=One-year mortality among unselected outpatients with heart failure. | journal=Eur Heart J | year= 2002 | volume= 23 | issue= 23 | pages= 1861-6 | pmid=12445535 | doi=10.1053/euhj.2002.3282 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12445535 }} </ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])'' <nowiki>"</nowiki>

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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' In selected [[ambulatory]] [[patients]] with [[HF]], [[cardiopulmonary exercise testing]] ([[CPET]]) is recommended to determine appropriateness of advanced [[treatments]] (eg, LVAD, [[heart transplant]]). <ref name="pmid26067685">{{cite journal| author=Brawner CA, Shafiq A, Aldred HA, Ehrman JK, Leifer ES, Selektor Y | display-authors=etal| title=Comprehensive analysis of cardiopulmonary exercise testing and mortality in patients with systolic heart failure: the Henry Ford Hospital cardiopulmonary exercise testing (FIT-CPX) project. | journal=J Card Fail | year= 2015 | volume= 21 | issue= 9 | pages= 710-8 | pmid=26067685 | doi=10.1016/j.cardfail.2015.06.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26067685 }} </ref><ref name="pmid21450614">{{cite journal| author=Corrà U, Giordano A, Mezzani A, Gnemmi M, Pistono M, Caruso R | display-authors=etal| title=Cardiopulmonary exercise testing and prognosis in heart failure due to systolic left ventricular dysfunction: a validation study of the European Society of Cardiology Guidelines and Recommendations (2008) and further developments. | journal=Eur J Prev Cardiol | year= 2012 | volume= 19 | issue= 1 | pages= 32-40 | pmid=21450614 | doi=10.1177/1741826710393994 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21450614 }} </ref><ref name="pmid23352391">{{cite journal| author=Feldman D, Pamboukian SV, Teuteberg JJ, Birks E, Lietz K, Moore SA | display-authors=etal| title=The 2013 International Society for Heart and Lung Transplantation Guidelines for mechanical circulatory support: executive summary. | journal=J Heart Lung Transplant | year= 2013 | volume= 32 | issue= 2 | pages= 157-87 | pmid=23352391 | doi=10.1016/j.healun.2012.09.013 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23352391 }} </ref><ref name="pmid1999029">{{cite journal| author=Mancini DM, Eisen H, Kussmaul W, Mull R, Edmunds LH, Wilson JR| title=Value of peak exercise oxygen consumption for optimal timing of cardiac transplantation in ambulatory patients with heart failure. | journal=Circulation | year= 1991 | volume= 83 | issue= 3 | pages= 778-86 | pmid=1999029 | doi=10.1161/01.cir.83.3.778 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1999029 }} </ref><ref name="pmid26776864">{{cite journal| author=Mehra MR, Canter CE, Hannan MM, Semigran MJ, Uber PA, Baran DA | display-authors=etal| title=The 2016 International Society for Heart Lung Transplantation listing criteria for heart transplantation: A 10-year update. | journal=J Heart Lung Transplant | year= 2016 | volume= 35 | issue= 1 | pages= 1-23 | pmid=26776864 | doi=10.1016/j.healun.2015.10.023 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26776864 }} </ref>''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])'' <nowiki>"</nowiki>
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{|class="wikitable" style="width:80%"
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|colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]

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| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' In [[ambulatory]] [[patients]] with [[HF]], performing a [[CPET]] or 6-minute [[walk test]] is reasonable to assess [[functional capacity]]. <ref name="pmid26067685">{{cite journal| author=Brawner CA, Shafiq A, Aldred HA, Ehrman JK, Leifer ES, Selektor Y | display-authors=etal| title=Comprehensive analysis of cardiopulmonary exercise testing and mortality in patients with systolic heart failure: the Henry Ford Hospital cardiopulmonary exercise testing (FIT-CPX) project. | journal=J Card Fail | year= 2015 | volume= 21 | issue= 9 | pages= 710-8 | pmid=26067685 | doi=10.1016/j.cardfail.2015.06.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26067685 }} </ref><ref name="pmid21450614">{{cite journal| author=Corrà U, Giordano A, Mezzani A, Gnemmi M, Pistono M, Caruso R | display-authors=etal| title=Cardiopulmonary exercise testing and prognosis in heart failure due to systolic left ventricular dysfunction: a validation study of the European Society of Cardiology Guidelines and Recommendations (2008) and further developments. | journal=Eur J Prev Cardiol | year= 2012 | volume= 19 | issue= 1 | pages= 32-40 | pmid=21450614 | doi=10.1177/1741826710393994 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21450614 }} </ref><ref name="pmid19254672">{{cite journal| author=Alahdab MT, Mansour IN, Napan S, Stamos TD| title=Six minute walk test predicts long-term all-cause mortality and heart failure rehospitalization in African-American patients hospitalized with acute decompensated heart failure. | journal=J Card Fail | year= 2009 | volume= 15 | issue= 2 | pages= 130-5 | pmid=19254672 | doi=10.1016/j.cardfail.2008.10.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19254672 }} </ref><ref name="pmid8411500">{{cite journal| author=Bittner V, Weiner DH, Yusuf S, Rogers WJ, McIntyre KM, Bangdiwala SI | display-authors=etal| title=Prediction of mortality and morbidity with a 6-minute walk test in patients with left ventricular dysfunction. SOLVD Investigators. | journal=JAMA | year= 1993 | volume= 270 | issue= 14 | pages= 1702-7 | pmid=8411500 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8411500 }} </ref><ref name="pmid20887617">{{cite journal| author=Boxer R, Kleppinger A, Ahmad A, Annis K, Hager D, Kenny A| title=The 6-minute walk is associated with frailty and predicts mortality in older adults with heart failure. | journal=Congest Heart Fail | year= 2010 | volume= 16 | issue= 5 | pages= 208-13 | pmid=20887617 | doi=10.1111/j.1751-7133.2010.00151.x | pmc=3027222 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20887617 }} </ref><ref name="pmid23177293">{{cite journal| author=Forman DE, Fleg JL, Kitzman DW, Brawner CA, Swank AM, McKelvie RS | display-authors=etal| title=6-min walk test provides prognostic utility comparable to cardiopulmonary exercise testing in ambulatory outpatients with systolic heart failure. | journal=J Am Coll Cardiol | year= 2012 | volume= 60 | issue= 25 | pages= 2653-61 | pmid=23177293 | doi=10.1016/j.jacc.2012.08.1010 | pmc=3766897 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23177293 }} </ref><ref name="pmid32677748">{{cite journal| author=Grundtvig M, Eriksen-Volnes T, Ørn S, Slind EK, Gullestad L| title=6 min walk test is a strong independent predictor of death in outpatients with heart failure. | journal=ESC Heart Fail | year= 2020 | volume= 7 | issue= 5 | pages= 2904-2911 | pmid=32677748 | doi=10.1002/ehf2.12900 | pmc=7524091 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32677748 }} </ref><ref name="pmid26892413">{{cite journal| author=Keteyian SJ, Patel M, Kraus WE, Brawner CA, McConnell TR, Piña IL | display-authors=etal| title=Variables Measured During Cardiopulmonary Exercise Testing as Predictors of Mortality in Chronic Systolic Heart Failure. | journal=J Am Coll Cardiol | year= 2016 | volume= 67 | issue= 7 | pages= 780-9 | pmid=26892413 | doi=10.1016/j.jacc.2015.11.050 | pmc=4761107 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26892413 }} </ref><ref name="pmid28551310">{{cite journal| author=McCabe N, Butler J, Dunbar SB, Higgins M, Reilly C| title=Six-minute walk distance predicts 30-day readmission after acute heart failure hospitalization. | journal=Heart Lung | year= 2017 | volume= 46 | issue= 4 | pages= 287-292 | pmid=28551310 | doi=10.1016/j.hrtlng.2017.04.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28551310 }} </ref><ref name="pmid31369636">{{cite journal| author=Ramalho SHR, Cipriano Junior G, Vieira PJC, Nakano EY, Winkelmann ER, Callegaro CC | display-authors=etal| title=Inspiratory muscle strength and six-minute walking distance in heart failure: Prognostic utility in a 10 years follow up cohort study. | journal=PLoS One | year= 2019 | volume= 14 | issue= 8 | pages= e0220638 | pmid=31369636 | doi=10.1371/journal.pone.0220638 | pmc=6675323 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31369636 }} </ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])'' <nowiki>"</nowiki>

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| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4.''' In [[ambulatory]] [[patients]] with unexplained [[dyspnea]], [[CPET]] is reasonable to evaluate the cause of [[dyspnea]]. <ref name="pmid22336677">{{cite journal| author=Parshall MB, Schwartzstein RM, Adams L, Banzett RB, Manning HL, Bourbeau J | display-authors=etal| title=An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea. | journal=Am J Respir Crit Care Med | year= 2012 | volume= 185 | issue= 4 | pages= 435-52 | pmid=22336677 | doi=10.1164/rccm.201111-2042ST | pmc=5448624 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22336677 }} </ref><ref name="pmid29803552">{{cite journal| author=Reddy YNV, Olson TP, Obokata M, Melenovsky V, Borlaug BA| title=Hemodynamic Correlates and Diagnostic Role of Cardiopulmonary Exercise Testing in Heart Failure With Preserved Ejection Fraction. | journal=JACC Heart Fail | year= 2018 | volume= 6 | issue= 8 | pages= 665-675 | pmid=29803552 | doi=10.1016/j.jchf.2018.03.003 | pmc=6076329 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29803552 }} </ref>''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])'' <nowiki>"</nowiki>
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===Initial and Serial Evaluation: Clinical Assessment: HF Risk Scoring 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT) <ref name="pmid35363500">{{cite journal| author=Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM | display-authors=etal| title=2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. | journal=Circulation | year= 2022 | volume= 145 | issue= 18 | pages= e876-e894 | pmid=35363500 | doi=10.1161/CIR.0000000000001062 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=35363500 }} </ref> ===

{|class="wikitable" style="width:80%"
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|colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]

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| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' In [[ambulatory]] or [[hospitalized]] [[patients]] with [[HF]], validated multivariable risk scores can be useful to estimate subsequent risk of [[mortality]]. <ref name="pmid9193435">{{cite journal| author=Aaronson KD, Schwartz JS, Chen TM, Wong KL, Goin JE, Mancini DM| title=Development and prospective validation of a clinical index to predict survival in ambulatory patients referred for cardiac transplant evaluation. | journal=Circulation | year= 1997 | volume= 95 | issue= 12 | pages= 2660-7 | pmid=9193435 | doi=10.1161/01.cir.95.12.2660 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9193435 }} </ref><ref name="pmid16534009">{{cite journal| author=Levy WC, Mozaffarian D, Linker DT, Sutradhar SC, Anker SD, Cropp AB | display-authors=etal| title=The Seattle Heart Failure Model: prediction of survival in heart failure. | journal=Circulation | year= 2006 | volume= 113 | issue= 11 | pages= 1424-33 | pmid=16534009 | doi=10.1161/CIRCULATIONAHA.105.584102 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16534009 }} </ref><ref name="pmid23095984">{{cite journal| author=Pocock SJ, Ariti CA, McMurray JJ, Maggioni A, Køber L, Squire IB | display-authors=etal| title=Predicting survival in heart failure: a risk score based on 39 372 patients from 30 studies. | journal=Eur Heart J | year= 2013 | volume= 34 | issue= 19 | pages= 1404-13 | pmid=23095984 | doi=10.1093/eurheartj/ehs337 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23095984 }} </ref><ref name="pmid16219658">{{cite journal| author=Pocock SJ, Wang D, Pfeffer MA, Yusuf S, McMurray JJ, Swedberg KB | display-authors=etal| title=Predictors of mortality and morbidity in patients with chronic heart failure. | journal=Eur Heart J | year= 2006 | volume= 27 | issue= 1 | pages= 65-75 | pmid=16219658 | doi=10.1093/eurheartj/ehi555 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16219658 }} </ref><ref name="pmid19168876">{{cite journal| author=Wedel H, McMurray JJ, Lindberg M, Wikstrand J, Cleland JG, Cornel JH | display-authors=etal| title=Predictors of fatal and non-fatal outcomes in the Controlled Rosuvastatin Multinational Trial in Heart Failure (CORONA): incremental value of apolipoprotein A-1, high-sensitivity C-reactive peptide and N-terminal pro B-type natriuretic peptide. | journal=Eur J Heart Fail | year= 2009 | volume= 11 | issue= 3 | pages= 281-91 | pmid=19168876 | doi=10.1093/eurjhf/hfn046 | pmc=2645061 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19168876 }} </ref><ref name="pmid31995119">{{cite journal| author=Simpson J, Jhund PS, Lund LH, Padmanabhan S, Claggett BL, Shen L | display-authors=etal| title=Prognostic Models Derived in PARADIGM-HF and Validated in ATMOSPHERE and the Swedish Heart Failure Registry to Predict Mortality and Morbidity in Chronic Heart Failure. | journal=JAMA Cardiol | year= 2020 | volume= 5 | issue= 4 | pages= 432-441 | pmid=31995119 | doi=10.1001/jamacardio.2019.5850 | pmc=6990745 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31995119 }} </ref><ref name="pmid22114101">{{cite journal| author=O'Connor CM, Whellan DJ, Wojdyla D, Leifer E, Clare RM, Ellis SJ | display-authors=etal| title=Factors related to morbidity and mortality in patients with chronic heart failure with systolic dysfunction: the HF-ACTION predictive risk score model. | journal=Circ Heart Fail | year= 2012 | volume= 5 | issue= 1 | pages= 63-71 | pmid=22114101 | doi=10.1161/CIRCHEARTFAILURE.111.963462 | pmc=3692371 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22114101 }} </ref><ref name="pmid30919549">{{cite journal| author=O'Connor C, Fiuzat M, Mulder H, Coles A, Ahmad T, Ezekowitz JA | display-authors=etal| title=Clinical factors related to morbidity and mortality in high-risk heart failure patients: the GUIDE-IT predictive model and risk score. | journal=Eur J Heart Fail | year= 2019 | volume= 21 | issue= 6 | pages= 770-778 | pmid=30919549 | doi=10.1002/ejhf.1450 | pmc=6830509 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30919549 }} </ref><ref name="pmid21068341">{{cite journal| author=Komajda M, Carson PE, Hetzel S, McKelvie R, McMurray J, Ptaszynska A | display-authors=etal| title=Factors associated with outcome in heart failure with preserved ejection fraction: findings from the Irbesartan in Heart Failure with Preserved Ejection Fraction Study (I-PRESERVE). | journal=Circ Heart Fail | year= 2011 | volume= 4 | issue= 1 | pages= 27-35 | pmid=21068341 | doi=10.1161/CIRCHEARTFAILURE.109.932996 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21068341 }} </ref><ref name="pmid31606361">{{cite journal| author=Angraal S, Mortazavi BJ, Gupta A, Khera R, Ahmad T, Desai NR | display-authors=etal| title=Machine Learning Prediction of Mortality and Hospitalization in Heart Failure With Preserved Ejection Fraction. | journal=JACC Heart Fail | year= 2020 | volume= 8 | issue= 1 | pages= 12-21 | pmid=31606361 | doi=10.1016/j.jchf.2019.06.013 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31606361 }} </ref><ref name="pmid15687312">{{cite journal| author=Fonarow GC, Adams KF, Abraham WT, Yancy CW, Boscardin WJ, ADHERE Scientific Advisory Committee, Study Group, and Investigators| title=Risk stratification for in-hospital mortality in acutely decompensated heart failure: classification and regression tree analysis. | journal=JAMA | year= 2005 | volume= 293 | issue= 5 | pages= 572-80 | pmid=15687312 | doi=10.1001/jama.293.5.572 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15687312 }} [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=15989313 Review in: ACP J Club. 2005 Jul-Aug;143(1):25] </ref><ref name="pmid20123668">{{cite journal| author=Peterson PN, Rumsfeld JS, Liang L, Albert NM, Hernandez AF, Peterson ED | display-authors=etal| title=A validated risk score for in-hospital mortality in patients with heart failure from the American Heart Association get with the guidelines program. | journal=Circ Cardiovasc Qual Outcomes | year= 2010 | volume= 3 | issue= 1 | pages= 25-32 | pmid=20123668 | doi=10.1161/CIRCOUTCOMES.109.854877 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20123668 }} </ref><ref name="pmid14625335">{{cite journal| author=Lee DS, Austin PC, Rouleau JL, Liu PP, Naimark D, Tu JV| title=Predicting mortality among patients hospitalized for heart failure: derivation and validation of a clinical model. | journal=JAMA | year= 2003 | volume= 290 | issue= 19 | pages= 2581-7 | pmid=14625335 | doi=10.1001/jama.290.19.2581 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14625335 }} [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=15122843 Review in: ACP J Club. 2004 May-Jun;140(3):80] </ref><ref name="pmid20185037">{{cite journal| author=O'Connor CM, Hasselblad V, Mehta RH, Tasissa G, Califf RM, Fiuzat M | display-authors=etal| title=Triage after hospitalization with advanced heart failure: the ESCAPE (Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness) risk model and discharge score. | journal=J Am Coll Cardiol | year= 2010 | volume= 55 | issue= 9 | pages= 872-8 | pmid=20185037 | doi=10.1016/j.jacc.2009.08.083 | pmc=3835158 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20185037 }} </ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])'' <nowiki>"</nowiki>

|}

== Patients at risk for HF, Stage A. ==

=== Primary prevention recommendations for patients at risk for HF. 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT) ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]

|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' In patients with hypertension, blood pressure should be controlled in accordance with GDMT for hypertension to prevent symptomatic HF (Level of Evidence A).

|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''2.''' In patients with type 2 diabetes and either established CVD or at high cardiovascular risk, SGLT2i should be used to prevent hospitalization for HF (Level of Evidence A).

|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''3.''' In the general population, healthy lifestyle habits such as regular physical activity, maintaining normal weight, healthy dietary patterns, and avoiding smoking are helpful to reduce future risk of HF (Level of Evidence B-NR).

|}
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]

|-
| bgcolor="LemonChiffon" |<nowiki>"</nowiki>'''1.''' For patients at risk of developing HF, natriuretic peptide biomarker-based screening followed by team-based care, including a cardiovascular specialist optimizing GDMT, can be useful to prevent the development of LV dysfunction (systolic or diastolic) or new-onset HF ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]]).''
|-
| bgcolor="LemonChiffon" |<nowiki>"</nowiki>'''2.''' In the general population, validated multivariable risk scores can be useful to estimate subsequent risk of incident HF ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]]).''
|}<ref name="pmid35363500" />

== Stage B: Patients with PRE- HF ==

=== Management of patients in stage B. Preventing heart failure in pre-HF patients. 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT) ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]

|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' In patients with LVEF ≤40%, ACEi should be used to prevent symptomatic HF and reduce mortality ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki>

|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''2.''' In patients with a recent or remote history of MI or ACS, statins should be used to prevent symptomatic HF and adverse cardiovascular events. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki>

|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''3.''' In patients with a recent MI and LVEF ≤40% who are intolerant to ACEi, ARB should be used to prevent symptomatic HF and reduce mortality ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])'' <nowiki>"</nowiki>

|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''4.''' In patients with a recent or remote history of MI or acute coronary syndrome (ACS) and LVEF ≤40%, evidence-based beta blockers should be used to reduce mortality ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen" |"'''5.''' In patients who are at least 40 days post-MI with LVEF ≤30% and NYHA class I symptoms while obtaining GDMT and have a reasonable expectation of noteworthy survival for >1 year, an ICD is suggested for primary prevention of sudden cardiac death (SCD) to reduce total mortality ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen" |"'''6.''' In patients with LVEF ≤40%, beta blockers should be used to prevent symptomatic HF. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])'' <nowiki>"</nowiki>
|}

{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightCoral" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm)

|-
| bgcolor="LightCoral" |"1'''.''' In patients with LVEF <50%, thiazolidinediones should not be used because they raise the risk of HF, including hospitalizations''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightCoral" |"2'''.''' In patients with LVEF <50%, nondihydropyridine calcium channel blockers with negative inotropic effects may be harmful.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C- LD]])'' <nowiki>"</nowiki>
|}

<ref name="pmid35363500" />

== Stage C ==

=== Non-pharmacological Therapy ===

=== Self-Care Support in HF. 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT) ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]

|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' Patients with HF should receive care from multidisciplinary units to facilitate the performance of GDMT, address possible barriers to self-care, decrease the risk of succeeding rehospitalization for HF, and enhance survival (Level of Evidence A)<nowiki>"</nowiki>

|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''2.''' Patients with HF should receive specific education and support to facilitate HF self-care in a multidisciplinary manner (Level of Evidence B-R)".

|}
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]

|-
| bgcolor="LemonChiffon" |<nowiki>"</nowiki>'''1.''' In patients with HF, vaccinating against respiratory illnesses is reasonable to reduce mortality (Level of Evidence B-R)".
|-
| bgcolor="LemonChiffon" |<nowiki>"</nowiki>'''2.''' In adults with HF, screening for depression, social isolation, frailty, and low health literacy as risk factors for poor self-care is reasonable to improve management (Level of Evidence B-R)".
|}
<ref name="pmid35363500" />

=== Dietary Sodium Restriction in patients on Stage C. 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT) ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]

|-
| bgcolor="LemonChiffon" |<nowiki>"</nowiki>'''1.''' For patients with stage C HF, avoiding excessive sodium intake is reasonable to reduce congestive symptoms. (Level of Evidence C-LD)".
|}
<ref name="pmid35363500" />

The AHA currently advises cutting sodium intake to under 2300 mg per day to promote overall cardiovascular health, yet there are no studies that back up this amount of limitation. When combined with dietary counseling, the DASH diet can achieve salt restriction without sacrificing nutritional adequacy and may be linked to fewer hospitalizations for HF. Also, it is high in antioxidants and potassium. <ref name="pmid35363500" />

=== Activity, Exercise Prescription, and Cardiac Rehabilitation. 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT) ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]

|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' For patients with HF who are competent of participating, exercise training (or regular physical activity) is advised to enhance the functional status, exercise routine, and QOL (Level of Evidence A)<nowiki>"</nowiki>

|}
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]

|-
| bgcolor="LemonChiffon" |<nowiki>"</nowiki>'''1.''' In patients with HF, a cardiac rehabilitation program can be helpful to improve functional capacity, exercise tolerance, and health-related quality of life (Level of Evidence B-NR)".
|}
<ref name="pmid35363500" />

=== Diuretics and Decongestion Strategies in Patients With HF. 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT) ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]

|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' In patients with HF who have fluid retention, diuretics are recommended to relieve conges-tion, improve symptoms, and prevent worsening HF (Level of Evidence B -NR)<nowiki>"</nowiki>

|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''2.''' For patients with HF and congestive symptoms, the addition of a thiazide (eg, metolazone) to therapy with a loop diuretic should be dedicated for patients who do not react to moderate- or high-dose loop diuretics to minimize electrolyte anomalies (Level of Evidence B-NR)".

|}
<ref name="pmid35363500" />

The majority of HF patients utilize loop diuretics as their first diuretic choice. Patients with hypertension, HF, and modest fluid retention may be candidates for thiazide diuretics such as chlorthalidone or hydrochlorothiazide. In patients with persistent edema that does not respond to loop diuretics alone, metolazone or chlorothiazide may be given in addition to loop diuretics. Diuretics should never be administered alone; instead, they should be used in conjunction with other GDMT for HF to lower hospitalization rates and increase survival<ref name="pmid35363500" />.

== Pharmacological Treatment for HFrEF. 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT) ==
'''Renin-Angiotensin System Inhibition With ACEi or ARB or ARNi'''
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]

|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' In patients with HFrEF and NYHA class II to III symptoms, the use of ARNi is recommended to reduce morbidity and mortality ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki>

|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''2.''' In patients with previous or current symptoms of chronic HFrEF, the use of ACEi is beneficial to reduce morbidity and mortality when the use of ARNi is not feasible ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki>

|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''3.''' In patients with previous or current symptoms of chronic HFrEF who are intolerant to ACEi because of cough or angioedema and when the use of ARNi is not feasible, the use of ARB is recommended to reduce morbidity and mortality''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki>

|-
|Value Statement: High Value (A): "'''4'''. In patients with previous or current symptoms of chronic HFrEF, in whom ARNi is not feasible, treatment with an ACEi or ARB provides high economic value
|-
| bgcolor="LightGreen" |"'''5.''' In patients with chronic symptomatic HFrEF NYHA class II or III who tolerate an ACEi or ARB, replacement by an ARNi is recommended to further reduce morbidity and mortality''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])'' <nowiki>"</nowiki>
|-
|Value Statement: High Value (A): In patients with chronic symptomatic HFrEF, treatment with an ARNi instead of an ACEi provides high economic value.
|}

{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightCoral" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm)

|-
| bgcolor="LightCoral" |"1'''.''' ARNi should not be administered concomitantly with ACEi or within 36 hours of the last dose of an ACEi''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightCoral" |"2'''.''' ARNi should not be administered to patients with any history of angioedema.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C- LD]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightCoral" |"3'''.''' ACEi should not be administered to patients with any history of angioedema.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C- LD]])'' <nowiki>"</nowiki>
|}
<ref name="pmid35363500" />

=== Beta Blockers ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]

|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' In patients with HFrEF, with current or previous symptoms, use of 1 of the 3 beta blockers proven to reduce mortality (eg, bisoprolol, carvedilol, sustained-release metoprolol succinate) is recommended to reduce mortality and hospitalization (Level of Evidence A)<nowiki>"</nowiki>
|-
|Value Statement: High Value (A): In patients with HFrEF, with current or previous symptoms, beta-blocker therapy provides high economic value
|}
<ref name="pmid35363500" />

=== Mineralocorticoid Receptor Antagonists ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]

|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' In patients with HFrEF and NYHA class II to IV symptoms, an MRA (spironolactone or eplerenone) is recommended to reduce morbidity and mortality, if eGFR is >30 mL/min/1.73 m2 and serum potassium is <5.0 mEq/L. Careful monitoring of potassium, renal function, and diuretic dosing should be performed at initiation and closely monitored thereafter to minimize risk of hyperkalemia and renal insufficiency(Level of Evidence A)<nowiki>"</nowiki>
|-
|Value Statement: High Value (A): In patients with HFrEF and NYHA class II to IV symptoms, MRA therapy provides high economic value.
|}
<ref name="pmid35363500" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightCoral" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm)

|-
| bgcolor="LightCoral" |"1'''.''' ARNi should not be administered concomi-tantly with ACEi or within 36 hours of the last dose of an ACEi''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])'' <nowiki>"</nowiki>
|}
<ref name="pmid35363500" />

=== Sodium-Glucose Cotransporter 2 Inhibitors ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]

|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' In patients with symptomatic chronic HFrEF, SGLT2i are advised to decrease hospitalization for HF and cardiovascular mortality, irrespective of the existence of type 2 diabetes(Level of Evidence A)<nowiki>"</nowiki>
|-
|Value Statement: High Value (A): In patients with symptomatic chronic HFrEF, SGLT2i medicine supplies medium economic value
|}
<ref name="pmid35363500" />

=== Hydralazine and Isosorbide Dinitrate ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]

|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' In patients with HFrEF and NYHA class II to IV symptoms, an MRA (spironolactone or eplerenone) is recommended to reduce morbidity and mortality, if eGFR is >30 mL/min/1.73 m2 and serum potassium is <5.0 mEq/L. Careful monitoring of potassium, renal function, and diuretic dosing should be performed at initiation and closely monitored thereafter to minimize risk of hyperkalemia and renal insufficiency(Level of Evidence A)<nowiki>"</nowiki>
|-
|Value Statement: High Value (B-NR): For patients self-identified as African American with NYHA class III to IV HFrEF who are receiving optimal medical therapy with ACEi or ARB, beta-blockers, and MRA, the combination of hydralazine and isosorbide dinitrate provides high economic value
|}
<ref name="pmid35363500" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]

|-
| bgcolor="LemonChiffon" |<nowiki>"</nowiki>'''1.''' In patients with existing or prior symptomatic HFrEF who cannot be given first-line agents, such as ARNi, ACEi, or ARB, because of drug intolerance or renal insufficiency, a mixture of hydralazine and isosorbide dinitrate might be considered to reduce morbidity and mortality (Level of Evidence C-LD)".
|}
<ref name="pmid35363500" />

=== Other drugs to consider ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]

|-
| bgcolor="LemonChiffon" |<nowiki>"</nowiki>'''1.''' In patients with HF class II to IV symptoms, omega-3 polyunsaturated fatty acid (PUFA) supplementation may be suitable to use as adjunctive therapy to decrease mortality and cardiovascular hospitalization (Level of Evidence B-R)".
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki>'''2'''. In patients with HF who experience hyperkalemia (serum potassium level ≥5.5 mEq/L) while taking a renin-angiotensin-aldosterone system inhibitor (RAASi), the effectiveness of potassium binders (patiromer, sodium zirconium cyclosilicate) to improve outcomes by facilitating the continuation of RAASi therapy is uncertain (Level of Evidence B-R)"
|}
<ref name="pmid35363500" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightCoral" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit)

|-
| bgcolor="LightCoral" |"1'''.''' In patients with chronic HFrEF without a precise indication (eg, venous thromboembolism [VTE], AF, a prior thromboembolic event, or a cardioembolic source), anticoagulation is not suggested''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])'' <nowiki>"</nowiki>
|}
<ref name="pmid35363500" />

=== Drugs of Unproven Value or That May Worsen HF ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightCoral" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit)

|-
| bgcolor="LightCoral" |"1'''.''' In patients with HFrEF, dihydropyridine calcium channel-blocking drugs are not recommended therapy for HF''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightCoral" |"2'''.''' In patients with HFrEF, vitamins, nutritional supplements, and hormonal therapy are not guided other than to rectify specific deficiencies ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])'' <nowiki>"</nowiki>
|}
<ref name="pmid35363500" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightCoral" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm)

|-
| bgcolor="LightCoral" |"3'''.''' In patients with HFrEF, nondihydropyridine calcium channel-blocking drugs are not recommended''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightCoral" |"4'''.''' In patients with HFrEF, class IC antiarrhythmic medications and dronedarone may increase the risk of mortality .''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightCoral" |"5'''.'''In patients with HFrEF, thiazolidinediones increase the risk of worsening HF symptoms and hospitalization .''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C- A]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightCoral" |"6. In patients with type 2 diabetes and high cardiovascular risk, the dipeptidyl pepti-dase-4 (DPP-4) inhibitors saxagliptin and alogliptin increase the risk of HF hospitaliza-tion and should be avoided in patients with H F (''[[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]]'')<nowiki>''</nowiki>
|-
| bgcolor="LightCoral" |"7.In patients with HFrEF, NSAIDs worsen HF symptoms and should be avoided or withdrawn whenever possible (''[[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]]'')<nowiki>''</nowiki>
|}
<ref name="pmid35363500" />

=== '''Guideline directed medical therapy: Sequencing and Uptitration''' ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]

|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' In patients with HFrEF, titration of guideline-directed medication dosing to reach target doses demonstrated to be efficacious in RCTs is required, to diminish cardiovascular mortality and HF hospitalizations, unless not sufficiently accepted Level of Evidence A)<nowiki>"</nowiki>
|}
<ref name="pmid35363500" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]

|-
| bgcolor="LemonChiffon" |" 2'''.''' In patients with HFrEF, titration, and optimization of guideline-directed medications as frequently as every 1 to 2 weeks relying on the patient’s symptoms, vital signs, and laboratory results can be helpful to optimize management (Level of Evidence C-LD)".
|}

== <ref name="pmid35363500" /> ==

== Additional Medical Therapies. 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT) ==

=== Management of Stage C: Ivabradine ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]

|-
| bgcolor="LemonChiffon" |" '''1.''' For patients with symptomatic (NYHA class II to III) stable chronic HFrEF (LVEF ≤35%) who are obtaining GDMT, including a beta blocker at the maximum accepted dose, and who are in sinus rhythm with a heart rate of ≥70 bpm at rest, ivabradine can be advantageous to decrease HF hospitalizations and cardiovascular death(Level of Evidence B-R)".
|}

=== <ref name="pmid35363500" /> ===

=== Management of Stage C: Digoxin ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]

|-
| bgcolor="LemonChiffon" |" '''1.''' In patients with symptomatic HFrEF despite GDMT (or who are unable to tolerate GDMT), digoxin might be considered to decrease hospitalizations for HF (Level of Evidence B-R)".
|}

=== <ref name="pmid35363500" /> ===

=== Management of Stage C: Soluble Guanylyl Cyclase Stimulators ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]

|-
| bgcolor="LemonChiffon" |" '''1.''' In selected high-risk patients with HFrEF and recent worsening of HF already on GDMT, an oral soluble guanylate cyclase stimulator (vericiguat) may be considered to reduce HF hospitalization and cardiovascular death(Level of Evidence B-R)".
|}
<ref name="pmid35363500" />

=== Device and Interventional Therapies for HFrEF ===

=== ICDs and CRTs ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]

|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' In patients with nonischemic DCM or ischemic heart disease at least 40 days post-MI with LVEF ≤35% and NYHA class II or III symptoms on chronic GDMT, who keep a reasonable expectation of noteworthy survival for >1 year, ICD therapy is guided for primary prevention of SCD to decrease total mortality ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki>
|-
|"2. Value Statement: High Value (A): A transvenous ICD delivers high financial value in the primary prevention of SCD particularly when the patient’s risk of death provoked by ventricular arrhythmia is deemed high and the risk of non arrhythmic death (either cardiac or noncardiac) is deemed low founded on the patient’s burden of comorbidities and functional status
|-
| bgcolor="LightGreen" |"3'''.''' In patients at least 40 days post-MI with LVEF ≤30% and NYHA class I symptoms while obtaining GDMT, who maintain a reasonable expectation of noteworthy survival for >1 year, ICD therapy is guided for primary prevention of SCD to reduce total mortality ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])'' <nowiki>"</nowiki>

|-
| bgcolor="LightGreen" |"4'''.''' For patients who have LVEF ≤35%, sinus rhythm, left bundle branch block (LBBB) with a QRS duration ≥150 ms, and NYHA class II, III, or ambulatory IV symptoms on GDMT, CRT is demonstrated to decrease total mortality, decrease hospitalizations, and enhance symptoms and QOL''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])'' <nowiki>"</nowiki>

|-
|5. Value Statement: High Value (B-NR): "'''4'''. In patients with previous or current symptoms of chronic HFrEF, in whom ARNi is not feasible, treatment with an ACEi or ARB provides high economic value
|}
<ref name="pmid35363500" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]

|-
| bgcolor="LemonChiffon" |" 6'''. ''' For patients who have LVEF ≤35%, sinus rhythm, a non-LBBB pattern with a QRS duration ≥150 ms, and NYHA class II, III, or ambulatory class IV symptoms on GDMT, CRT can be useful to reduce total mortality, reduce hospitalizations, and improve symptoms and QOL (Level of Evidence B-R)".
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki> 7. In patients with high-degree or complete heart block and LVEF of 36% to 50%, CRT is reasonable to reduce total mortality, reduce hospitalizations, and improve symptoms and QOL (Level of Evidence B-R)<nowiki>''</nowiki>
|-
| bgcolor="LemonChiffon" | <nowiki>''</nowiki>8. For patients who have LVEF ≤35%, sinus rhythm, LBBB with a QRS duration of 120 to 149 ms, and NYHA class II, III, or ambulatory IV symptoms on GDMT, CRT can be useful to reduce total mortality, reduce hospitalizations, and improve symptoms and QOL (Level of Evidence B- NR)<nowiki>''</nowiki>
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki>9. In patients with AF and LVEF ≤35% on GDMT, CRT can be useful to reduce total mortality, improve symptoms and QOL, and increase LVEF, if: a) the patient requires ventricular pacing or otherwise meets CRT criteria and b) atrioventricular nodal ablation or pharmacologic rate control will allow near 100% ventricular pacing with CRT. (Level of Evidence B- NR)<nowiki>''</nowiki>
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki> 10. For patients on GDMT who have LVEF ≤35% and are undergoing placement of a new or replacement device implantation with anticipated requirement for significant (>40%) ventricular pacing, CRT can be useful to reduce total mortality, reduce hospitalizations and improve symptoms and QOL (Level of Evidence B- NR)<nowiki>''</nowiki>
|-
| bgcolor="LemonChiffon" |11. <nowiki>''</nowiki>In patients with genetic arrhythmogenic cardiomyopathy with high-risk features of sudden death, with EF ≤45%, implantation of ICD is reasonable to decrease sudden death (Level of evidence B- NR)<nowiki>''</nowiki>
|}
<ref name="pmid35363500" />

{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]

|-
| bgcolor="LemonChiffon" |"12'''.''' For patients who have LVEF ≤35%, sinus rhythm, a non-LBBB pattern with QRS duration of 120 to 149 ms, and NYHA class III or ambulatory class IV on GDMT, CRT may be considered to reduce total mortality, reduce hospitalizations, and improve symptoms and QOL ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B-NR]])'' <nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki>13. For patients who have LVEF ≤30%, ischemic cause of HF, sinus rhythm, LBBB with a QRS duration ≥150 ms, and NYHA class I symptoms on GDMT, CRT may be considered to reduce hospitalizations and improve symptoms and QOL (''[[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B-NR]]'')<nowiki>''</nowiki>
|}
<ref name="pmid35363500" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightCoral" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit)

|-
| bgcolor="LightCoral" |"14'''.''' In patients with QRS duration <120 ms, CRT is not recommended''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightCoral" |"15'''.''' For patients with NYHA class I or II symptoms and non-LBBB pattern with QRS duration <150 ms, CRT is not recommended.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightCoral" |"16'''.''' For patients whose comorbidities or frailty limit survival with a good functional capacity to <1 year, ICD and cardiac resynchronization therapy with defibrillation (CRT-D) are not indicated.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C- LD]])'' <nowiki>"</nowiki>
|}<ref name="pmid35363500" />

=== Revascularization for CAD ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]

|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' In selected patients with HF, reduced EF (EF ≤35%), and suitable coronary anatomy, surgical revascularization plus GDMT is worthwhile to improve symptoms, cardiovascular hospitalizations, and long-term all-cause mortality''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])'' <nowiki>"</nowiki>
|}
<ref name="pmid35363500" />

=== Valvular Heart Diseases ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]

|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' In patients with HF, VHD should be managed in a multidisciplinary manner in accordance with clinical practice guidelines for VHD to prevent worsening of HF and adverse clinical outcomes ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>''</nowiki>2. In patients with chronic severe secondary MR and HFrEF, optimization of GDMT is recommended before any intervention for secondary MR related to LV dysfunction ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])'' <nowiki>"</nowiki>
|}
<ref name="pmid35363500" />

== HF With Mildly Reduced Ejection Fraction. 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT) ==
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]

|-
| bgcolor="LemonChiffon" |" 1'''. '''In patients with HFmrEF, SGLT2i can be beneficial in decreasing HF hospitalizations and cardiovascular (Level of Evidence B-R)".
|}
<ref name="pmid35363500" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]

|-
| bgcolor="LemonChiffon" |"2'''.''' Among patients with current or previous symptomatic HFmrEF (LVEF, 41%–49%), use of evidence-based beta blockers for HFrEF, ARNi, ACEi, or ARB, and MRAs may be considered to reduce the risk of HF hospitalization and cardiovascular mortality, particularly among patients with LVEF on the lower end of this spectrum ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B-NR]])'' <nowiki>"</nowiki>
|}
<ref name="pmid35363500" />

== HF With Improved Ejection Fraction. 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT) ==
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]

|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' In patients with HFimpEF after treatment, GDMT should be continued to prevent relapse of HF and LV dysfunction, even in patients who may become asymptomatic.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])'' <nowiki>"</nowiki>
|}
<ref name="pmid35363500" />

== HF With Preserved Ejection Fraction. 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT) ==
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]

|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' Patients with HFpEF and hypertension should have medication titrated to attain blood pressure targets in accordance with published clinical practice guidelines to prevent morbidity''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])'' <nowiki>"</nowiki>
|}
<ref name="pmid35363500" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]

|-
| bgcolor="LemonChiffon" |" 2'''.''' In patients with HFpEF, SGLT2i can be beneficial in decreasing HF hospitalizations and cardiovascular mortality (Level of Evidence B-R)".
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki> 3. In patients with HFpEF, management of AF can be useful to improve symptoms (Level of Evidence C-EO)<nowiki>''</nowiki>
|}
<ref name="pmid35363500" />

{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]

|-
| bgcolor="LemonChiffon" |" 4'''. ''' I selected patients with HFpEF, MRAs may be considered to decrease hospitalizations, par-icularly among patients with LVEF on the lower end of this spectrrum Level of Evidence B-R)".
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki> 5. n selected patients with HFpEF, the use of ARB may be considered to decrease hospital-zations, particularly among patients with LVEF on the lower end of this spectru(m Level of Evidence B-R)<nowiki>''</nowiki>
|-
| bgcolor="LemonChiffon" | <nowiki>''</nowiki>6. In selected patients with HFpEF, ARNi may be considered to decrease hospitalizations, particularly among patients with LVEF on the lower end of this spectrum (Level of Evidence B- NR)<nowiki>''</nowiki>
|}
<ref name="pmid35363500" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightCoral" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit)

|-
| bgcolor="LightCoral" |"7'''.''' In patients with HFpEF, routine use of nitrates or phosphodiesterase-5 inhibitors to increase activity or QOL is ineffective ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])'' <nowiki>"</nowiki>
|}
<ref name="pmid35363500" />

=== Treatment for Heart Failure with Preserved Ejection Failure (LVEF ≥50%) <ref name="pmid35363500" /> ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]

|-
| bgcolor="LightGreen" |Diuretics as needed
|}
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]

|-
| bgcolor="LemonChiffon" |Sodium-glucose cotransporter-2 inhibitor.
|}
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]

|-
| bgcolor="LemonChiffon" |Aangiotensin receptor-neprilysin inhibitor
|-
| bgcolor="LemonChiffon" |Mineralocorticoid receptor antagonist
|-
| bgcolor="LemonChiffon" |Angiotensin receptor blocker
|}

== Cardiac Amyloidosis. 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT) ==

=== Diagnosis ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]

|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' Patients for whom there is a clinical suspicion for cardiac amyloidosis should have screening for serum and urine monoclonal light chains with serum and urine immunofixation electrophoresis and serum free light chains''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])'' <nowiki>"</nowiki>

|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''2.''' In patients with high clinical suspicion for cardiac amyloidosis, without evidence of serum or urine monoclonal light chains, bone scintigraphy should be performed to confirm the presence of transthyretin cardiac amyloidosis ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])'' <nowiki>"</nowiki>

|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''3.''' In patients for whom a diagnosis of transthyretin cardiac amyloidosis is made, genetic testing with TTR gene sequencing is recommended to differentiate hereditary variant from wild-type transthyretin cardiac amyloidosis''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])'' <nowiki>"</nowiki>
|}
<ref name="pmid35363500" />

''Clinical suspicion for cardiac amyloidosis: LV wall thickness ≥14 mm in conjunction with fatigue, dyspnea, or edema, especially in the context of discordance between wall thickness on echocardiogram and QRS voltage on an ECG, and in the context of aortic stenosis, HFpEF, carpal tunnel syndrome, spinal stenosis, and autonomic or sensory polyneuropathy <ref name="pmid35363500" />''

=== Treatment ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]

|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' In select patients with wild-type or variant transthyretin cardiac amyloidosis and NYHA class I to III HF symptoms, transthyretin tetramer stabilizer therapy (tafamidis) is indicated to reduce cardiovascular morbidity and mortality''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])'' <nowiki>"</nowiki>
|-
|"2. Value Statement: High Value (B- NR): At 2020 list prices, tafamidis provides low economic value (>$180 000 per QALY gained) in patients with HF with wild-type or variant transthyretin cardiac amyloidosis
|}
<ref name="pmid35363500" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]

|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki>3. In patients with cardiac amyloidosis and AF, anticoagulation is reasonable to reduce the risk of stroke regardless of the CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke or transient ischemic attack, vascular disease, age 65 to 74 years, sex category (''[[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]]'')<nowiki>''</nowiki>
|}
<ref name="pmid35363500" />

=== Source ===
*[https://www.ahajournals.org/doi/epub/10.1161/CIR.0000000000001063.full.pdf 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines]<ref name="pmid35363499">{{cite journal |vauthors=Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW |title=2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=145 |issue=18 |pages=e895–e1032 |date=May 2022 |pmid=35363499 |doi=10.1161/CIR.0000000000001063 |url=}} </ref>

==References==
{{Reflist|2}}
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{{WikiDoc Sources}}

[[Category:Cardiology]]
[[Category:Disease]]
[[Category:Emergency medicine]]
[[Category:Intensive care medicine]]
[[Category:Medicine]]
[[Category:Up-To-Date]]
[[Category:Up-To-Date cardiology]]

Bleeding overview

2023-03-02T13:40:33Z

Jair Basantes de la Calle: /* Overview */

__NOTOC__
{{Bleeding}}
{{CMG}}

==Overview==
'''Bleeding''' is the loss of [[blood]] from the circulatory system.<ref>{{cite web|url=http://www.healthline.com/adamcontent/bleeding|title=Bleeding Health Article|publisher=Healthline|accessdate=2007-06-18}}</ref> Bleeding can occur internally, where blood leaks from [[blood vessel]]s inside the body or externally, either through a natural opening such as the [[vagina]], [[mouth]] or [[rectum]], or through a break in the [[skin]].
The complete loss of blood is referred to as [[exsanguination]],<ref>{{cite web|url=http://dictionary.reference.com/browse/exsanguination|title=Dictionary Definitions of Exsanguination|publisher=Reference.com|accessdate=2007-06-18}}</ref> and [[desanguination]] is a massive blood loss. Loss of 10-15% of total blood volume can be endured without clinical [[sequela]]e in a healthy person, and [[blood donation]] typically takes 8-10% of the donor's blood volume.<ref>{{cite web|url=http://www.blood.co.uk/pages/b36faint.html|title=Blood Donation Information|publisher=UK National Blood Service|accessdate=2007-06-18}}</ref>

==Definition of Multivessel Disease==
For AEGIS-II inclusion criteria #5, multivessel disease criteria can be met by findings on the cardiac catheterization for the index MI, a prior cardiac catheterization, or both:
*Index MI cardiac catheterization: 50% or greater stenosis of the left main or at least 2 coronary artery territories (LAD, LCX, RCA) (prior to any interventions performed)
*Prior cardiac catheterization: 50% or greater stenosis of left main or at least 2 coronary artery territories (LAD, LCx, RCA) (prior to any interventions performed)
*Both: Index MI cardiac catheterization with 1 vessel with 50% or greater stenosis (prior to any interventions performed) AND prior PCI of at least 1 vessel different from index MI vessel
*Prior multivessel CABG
Multivessel disease requires a 50% or greater stenosis in at least 2 of the 3 major epicardial artery territories (LAD, LCx, RCA) or the left main vessel. Branch vessel disease may qualify as part of the territory of that branch vessel (for example, a diagonal vessel is considered part of the LAD territory). For the purpose of this study, the ramus is considered part of the Left Circumflex artery territory. If a branch vessel is used as a qualifying vessel, that branch should be of large enough size to potentially undergo revascularization if clinically indicated, e.g. >2mm vessel size.
==References==
{{reflist|2}}
{{WH}}
{{WS}}

[[Category:Medical emergencies]]
[[Category:Blood]]
[[Category:Hematology]]

Bleeding causes

2023-03-02T13:39:26Z

Jair Basantes de la Calle: /* MVD Tool */

__NOTOC__
{{Bleeding}}
{{CMG}}}

==Overview==

==Definition of Multivessel Disease==

For AEGIS-II inclusion criteria #5, multivessel disease criteria can be met by findings on the cardiac catheterization for the index MI, a prior cardiac catheterization, or both:
* Index MI cardiac catheterization: 50% or greater stenosis of the left main or at least 2 coronary artery territories (LAD, LCX, RCA) (prior to any interventions performed)
* Prior cardiac catheterization: 50% or greater stenosis of left main or at least 2 coronary artery territories (LAD, LCx, RCA) (prior to any interventions performed)
* Both: Index MI cardiac catheterization with 1 vessel with 50% or greater stenosis (prior to any interventions performed) AND prior PCI of at least 1 vessel different from index MI vessel
* Prior multivessel CABG

Multivessel disease requires a 50% or greater stenosis in at least 2 of the 3 major epicardial artery territories (LAD, LCx, RCA) or the left main vessel. Branch vessel disease may qualify as part of the territory of that branch vessel (for example, a diagonal vessel is considered part of the LAD territory). For the purpose of this study, the ramus is considered part of the Left Circumflex artery territory. If a branch vessel is used as a qualifying vessel, that branch should be of large enough size to potentially undergo revascularization if clinically indicated, e.g. >2mm vessel size.

==Causes==
*[[Hematemesis]] - vomiting fresh blood
*[[Hemoptysis]] - coughing up blood from the lungs
*[[Hematochezia]] - rectal blood
*[[Hematuria]] - blood in the urine from urinary bleeding
*[[Intracranial hemorrhage]] - bleeding in the skull.
*[[Cerebral hemorrhage]] - a type of intracranial hemorrhage, bleeding within the brain tissue itself.
*[[Intracerebral hemorrhage]] - bleeding in the brain caused by the rupture of a blood vessel within the head. See also [[hemorrhagic stroke]].
*[[Subarachnoid hemorrhage]] (SAH) implies the presence of blood within the [[subarachnoid space]] from some pathologic process. The common medical use of the term SAH refers to the nontraumatic types of hemorrhages, usually from rupture of a berry aneurysm or [[arteriovenous malformation]](AVM). The scope of this article is limited to these nontraumatic hemorrhages.
*[[Pulmonary hemorrhage]]
*[[Vaginal bleeding]]
*[[Postpartum hemorrhage]]
*[[Breakthrough bleeding]]
*[[Ovarian]] bleeding. This is a potentially catastrophic and not so rare complication among lean patients with [[polycystic ovary syndrome]] undergoing [[transvaginal oocyte retrieval]].<ref name=Liberty>{{cite journal |author=Liberty G, Hyman JH, Eldar-Geva T, Latinsky B, Gal M, Margalioth EJ |title=Ovarian hemorrhage after transvaginal ultrasonographically guided oocyte aspiration: a potentially catastrophic and not so rare complication among lean patients with polycystic ovary syndrome |journal=Fertil. Steril. |volume= 93|issue= 3|pages= 874–879|year=2008 |month=December |pmid=19064264 |doi=10.1016/j.fertnstert.2008.10.028 |url=}}</ref>
*[[Upper gastrointestinal bleed]]
*[[Suicide]]: Exsanguination is a [[suicide method]] caused by cutting of arteries, notably: [[carotid artery|carotid]], [[radial artery|radial]], [[ulnar artery|ulnar]], and [[femoral artery|femoral]] arteries.
*[[Trauma]]: Injury or trauma can cause exsanguination if bleeding is not stymied. It is the most common cause of deaths ''on'' the battlefield (though the most common cause of death ''from'' battle is infection). Non-battlefield causes can include partial or complete [[amputation]] from use of circular saws (e.g., hand-held circular saw, radial arm saw, table saw).
*Internal hemorrhage: Patients can develop catastrophic internal hemorrhages, such as from a bleeding [[peptic ulcer]] or [[spleen|splenic]] hemorrhage, which can cause exsanguination even without any external bleeding. It is a relatively common cause of unexpected, sudden death in patients who seemed previously well.
*[[Alcoholism]]: Alcoholics can also suffer from exsanguination. Thin-walled dilated veins just below the lower esophageal mucosa called [[esophageal varices]] may ulcerate or be torn ("[[Mallory-Weiss syndrome]]") during the violent [[wikt:retch|retch]]ing of the alcoholic leading to massive bleeding and sometimes exsanguination.
*[[Retroperitoneal hematoma]]
*Ruptured [[aortic aneurysm]]
*Ruptured [[abdominal aortic aneurysm]]
=== Traumatic===
Traumatic bleeding is caused by some type of injury. There are different types of [[wound]]s which may cause traumatic bleeding. These include:

* '''[[Abrasion]]''' - Also called a graze, this is caused by transverse action of a foreign object against the skin, and usually does not penetrate below the [[epidermis]]
* '''[[Excoriation]]''' - In common with Abrasion, this is caused by mechanical destruction of the skin, although it usually has an underlying medical cause
* '''[[Hematoma]]''' - (also called a blood tumor) - caused by damage to a blood vessel that in turn causes blood to collect under the skin.
* '''[[Laceration]]''' - Irregular wound caused by blunt impact to soft tissue overlying hard tissue or tearing such as in childbirth. In some instances, this can also be used to describe an incision.
* '''[[Incision]]''' - A cut into a body tissue or organ, such as by a [[scalpel]], made during surgery.
* '''Puncture Wound''' - Caused by an object penetrated the skin and underlying layers, such as a nail, needle or knife
* '''[[Contusion]]''' - Also known as a bruise, this is a blunt trauma damaging tissue under the surface of the skin
* '''Crushing Injuries''' - caused by a great or extreme amount of force applied over a long period of time. The extent of a crushing injury may not immediately present itself.
* '''[[Gunshot wound]]s''' - Caused by a projectile weapon, this may include two external wounds (entry and exit) and a contiguous wound between the two

The pattern of injury, evaluation and treatment will vary with the mechanism of the injury. Blunt trauma causes injury via a shock effect; delivering energy over an area. Wounds are often not straight and unbroken skin may hide significant injury. Penetrating trauma follows the course of the injurious device. As the energy is applied in a more focused fashion, it requires less energy to cause significant injury. Any body organ, including bone and brain, can be injured and bleed. Bleeding may not be readily apparent; internal organs such as the liver, kidney and spleen may bleed into the abdominal cavity. The only apparent signs may come with blood loss. Bleeding from a bodily orifice, such as the rectum, nose, ears may signal internal bleeding, but cannot be relied upon. Bleeding from a [[medical procedure]] also falls into this category.
=== Due to Underlying Medical Conditions ===

Medical bleeding is that associated with an increased risk of bleeding due to an underlying medical condition. It will increase the risk of bleeding related to underlying anatomic deformities, such as weaknesses in blood vessels ([[aneurysm]] or [[dissection]]), [[arteriovenous malformation]], ulcerations. Similarly, other conditions that disrupt the integrity of the body such as tissue death, cancer, or infection may lead to bleeding.

The underlying scientific basis for blood clotting and hemostasis is discussed in detail in the articles, [[blood coagulation|Coagulation]], [[haemostasis]] and related articles. The discussion here is limited to the common practical aspects of blood clot formation which manifest as bleeding.

Certain medical conditions can also make patients susceptible to bleeding. These are conditions that affect the normal "hemostatic" functions of the body. [[Hemostasis]] involves several components. The main components of the hemostatic system include [[platelets]] and the [[blood coagulation|coagulation]] system.

[[Platelets]] are small blood components that form a plug in the blood vessel wall that stops bleeding. Platelets also produce a variety of substances that stimulate the production of a blood clot. One of the most common causes of increased bleeding risk is exposure to [[non-steroidal anti-inflammatory drugs]] (or "NSAIDs"). The prototype for these drugs is aspirin, which inhibits the production of thromboxane. NSAIDs inhibit the activation of [[platelets]], and thereby increase the risk of bleeding. The effect of aspirin is irreversible; therefore, the inhibitory effect of aspirin is present until the platelets have been replaced (about ten days). Other NSAIDs, such as "ibuprofen" (Motrin) and related drugs, are reversible and therefore, the effect on platelets is not as long-lived.

There are several named coagulation factors that interact in a complex way to form blood clots, as discussed in the article on [[coagulation]]. Deficiencies of coagulation factors are associated with clinical bleeding. For instance, deficiency of Factor VIII causes classic [[Hemophilia A]] while deficiencies of Factor IX cause "Christmas disease"([[hemophilia B]]). Antibodies to Factor VIII can also inactivate the Factor VII and precipitate bleeding that is very difficult to control. This is a rare condition that is most likely to occur in older patients and in those with [[autoimmune]] diseases. [[von Willebrand disease]] is another common bleeding disorder. It is caused by a deficiency of or abnormal function of the "von Willebrand" factor, which is involved in platelet activation. Deficiencies in other factors, such as factor XIII or factor VII are occasionally seen, but may not be associated with severe bleeding and are not as commonly diagnosed.

In addition to NSAID-related bleeding, another common cause of bleeding is that related to the medication, [[warfarin]] ("Coumadin" and others). This medication needs to be closely monitored as the bleeding risk can be markedly increased by interactions with other medications. Warfarin acts by inhibiting the production of [[Vitamin K]] in the gut. Vitamin K is required for the production of the clotting factors, II, VII, IX, and X in the liver. One of the most common causes of warfarin-related bleeding is taking antibiotics. The gut bacteria make vitamin K and are killed by antibiotics. This decreases vitamin K levels and therefore the production of these clotting factors.

Deficiencies of platelet function may require platelet transfusion while deficiciencies of clotting factors may require transfusion of either [[fresh frozen plasma]] of specific clotting factors, such as [[Factor VIII]] for patients with hemophilia.

===Causes by Organ System===
{|style="width:80%; height:100px" border="1"
|style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" |'''Cardiovascular'''
|style="height:100px"; style="width:75%" border="1" bgcolor="Beige" | No underlying causes
|-
|bgcolor="LightSteelBlue"| '''Chemical/Poisoning'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Dental'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Dermatologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Drug Side Effect'''
|bgcolor="Beige"| [[Ceftazidime]], [[Diclofenac (ophthalmic)]], [[diclofenac (patch)]], [[Ibrutinib]], [[Omacetaxine]], [[Sorafenib]], [[Sunitinib]], [[Tiagabine]]
|-
|-bgcolor="LightSteelBlue"
| '''Ear Nose Throat'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Endocrine'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Environmental'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Gastroenterologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Genetic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Hematologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Iatrogenic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Infectious Disease'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Musculoskeletal/Orthopedic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Neurologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Nutritional/Metabolic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Obstetric/Gynecologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Oncologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Ophthalmologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Overdose/Toxicity'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Psychiatric'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Pulmonary'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Renal/Electrolyte'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Rheumatology/Immunology/Allergy'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Sexual'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Trauma'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Urologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Miscellaneous'''
|bgcolor="Beige"| No underlying causes
|-
|}

==References==
{{Reflist|2}}
{{WH}}
{{WS}}

[[Category:Blood]]
[[Category:Hematology]]
[[Category:Medical emergencies]]
[[Category:Needs causes]]
[[Category:Needs content]]
[[Category:Needs overview]]

Bleeding causes

2023-03-02T13:38:58Z

Jair Basantes de la Calle: /* Overview */

__NOTOC__
{{Bleeding}}
{{CMG}}}

==Overview==

==Definition of Multivessel Disease==

For AEGIS-II inclusion criteria #5, multivessel disease criteria can be met by findings on the cardiac catheterization for the index MI, a prior cardiac catheterization, or both:
* Index MI cardiac catheterization: 50% or greater stenosis of the left main or at least 2 coronary artery territories (LAD, LCX, RCA) (prior to any interventions performed)
* Prior cardiac catheterization: 50% or greater stenosis of left main or at least 2 coronary artery territories (LAD, LCx, RCA) (prior to any interventions performed)
* Both: Index MI cardiac catheterization with 1 vessel with 50% or greater stenosis (prior to any interventions performed) AND prior PCI of at least 1 vessel different from index MI vessel
* Prior multivessel CABG

Multivessel disease requires a 50% or greater stenosis in at least 2 of the 3 major epicardial artery territories (LAD, LCx, RCA) or the left main vessel. Branch vessel disease may qualify as part of the territory of that branch vessel (for example, a diagonal vessel is considered part of the LAD territory). For the purpose of this study, the ramus is considered part of the Left Circumflex artery territory. If a branch vessel is used as a qualifying vessel, that branch should be of large enough size to potentially undergo revascularization if clinically indicated, e.g. >2mm vessel size.

==MVD Tool==

{|
{{#Widget:MVD5}}
|}

==Causes==
*[[Hematemesis]] - vomiting fresh blood
*[[Hemoptysis]] - coughing up blood from the lungs
*[[Hematochezia]] - rectal blood
*[[Hematuria]] - blood in the urine from urinary bleeding
*[[Intracranial hemorrhage]] - bleeding in the skull.
*[[Cerebral hemorrhage]] - a type of intracranial hemorrhage, bleeding within the brain tissue itself.
*[[Intracerebral hemorrhage]] - bleeding in the brain caused by the rupture of a blood vessel within the head. See also [[hemorrhagic stroke]].
*[[Subarachnoid hemorrhage]] (SAH) implies the presence of blood within the [[subarachnoid space]] from some pathologic process. The common medical use of the term SAH refers to the nontraumatic types of hemorrhages, usually from rupture of a berry aneurysm or [[arteriovenous malformation]](AVM). The scope of this article is limited to these nontraumatic hemorrhages.
*[[Pulmonary hemorrhage]]
*[[Vaginal bleeding]]
*[[Postpartum hemorrhage]]
*[[Breakthrough bleeding]]
*[[Ovarian]] bleeding. This is a potentially catastrophic and not so rare complication among lean patients with [[polycystic ovary syndrome]] undergoing [[transvaginal oocyte retrieval]].<ref name=Liberty>{{cite journal |author=Liberty G, Hyman JH, Eldar-Geva T, Latinsky B, Gal M, Margalioth EJ |title=Ovarian hemorrhage after transvaginal ultrasonographically guided oocyte aspiration: a potentially catastrophic and not so rare complication among lean patients with polycystic ovary syndrome |journal=Fertil. Steril. |volume= 93|issue= 3|pages= 874–879|year=2008 |month=December |pmid=19064264 |doi=10.1016/j.fertnstert.2008.10.028 |url=}}</ref>
*[[Upper gastrointestinal bleed]]
*[[Suicide]]: Exsanguination is a [[suicide method]] caused by cutting of arteries, notably: [[carotid artery|carotid]], [[radial artery|radial]], [[ulnar artery|ulnar]], and [[femoral artery|femoral]] arteries.
*[[Trauma]]: Injury or trauma can cause exsanguination if bleeding is not stymied. It is the most common cause of deaths ''on'' the battlefield (though the most common cause of death ''from'' battle is infection). Non-battlefield causes can include partial or complete [[amputation]] from use of circular saws (e.g., hand-held circular saw, radial arm saw, table saw).
*Internal hemorrhage: Patients can develop catastrophic internal hemorrhages, such as from a bleeding [[peptic ulcer]] or [[spleen|splenic]] hemorrhage, which can cause exsanguination even without any external bleeding. It is a relatively common cause of unexpected, sudden death in patients who seemed previously well.
*[[Alcoholism]]: Alcoholics can also suffer from exsanguination. Thin-walled dilated veins just below the lower esophageal mucosa called [[esophageal varices]] may ulcerate or be torn ("[[Mallory-Weiss syndrome]]") during the violent [[wikt:retch|retch]]ing of the alcoholic leading to massive bleeding and sometimes exsanguination.
*[[Retroperitoneal hematoma]]
*Ruptured [[aortic aneurysm]]
*Ruptured [[abdominal aortic aneurysm]]
=== Traumatic===
Traumatic bleeding is caused by some type of injury. There are different types of [[wound]]s which may cause traumatic bleeding. These include:

* '''[[Abrasion]]''' - Also called a graze, this is caused by transverse action of a foreign object against the skin, and usually does not penetrate below the [[epidermis]]
* '''[[Excoriation]]''' - In common with Abrasion, this is caused by mechanical destruction of the skin, although it usually has an underlying medical cause
* '''[[Hematoma]]''' - (also called a blood tumor) - caused by damage to a blood vessel that in turn causes blood to collect under the skin.
* '''[[Laceration]]''' - Irregular wound caused by blunt impact to soft tissue overlying hard tissue or tearing such as in childbirth. In some instances, this can also be used to describe an incision.
* '''[[Incision]]''' - A cut into a body tissue or organ, such as by a [[scalpel]], made during surgery.
* '''Puncture Wound''' - Caused by an object penetrated the skin and underlying layers, such as a nail, needle or knife
* '''[[Contusion]]''' - Also known as a bruise, this is a blunt trauma damaging tissue under the surface of the skin
* '''Crushing Injuries''' - caused by a great or extreme amount of force applied over a long period of time. The extent of a crushing injury may not immediately present itself.
* '''[[Gunshot wound]]s''' - Caused by a projectile weapon, this may include two external wounds (entry and exit) and a contiguous wound between the two

The pattern of injury, evaluation and treatment will vary with the mechanism of the injury. Blunt trauma causes injury via a shock effect; delivering energy over an area. Wounds are often not straight and unbroken skin may hide significant injury. Penetrating trauma follows the course of the injurious device. As the energy is applied in a more focused fashion, it requires less energy to cause significant injury. Any body organ, including bone and brain, can be injured and bleed. Bleeding may not be readily apparent; internal organs such as the liver, kidney and spleen may bleed into the abdominal cavity. The only apparent signs may come with blood loss. Bleeding from a bodily orifice, such as the rectum, nose, ears may signal internal bleeding, but cannot be relied upon. Bleeding from a [[medical procedure]] also falls into this category.
=== Due to Underlying Medical Conditions ===

Medical bleeding is that associated with an increased risk of bleeding due to an underlying medical condition. It will increase the risk of bleeding related to underlying anatomic deformities, such as weaknesses in blood vessels ([[aneurysm]] or [[dissection]]), [[arteriovenous malformation]], ulcerations. Similarly, other conditions that disrupt the integrity of the body such as tissue death, cancer, or infection may lead to bleeding.

The underlying scientific basis for blood clotting and hemostasis is discussed in detail in the articles, [[blood coagulation|Coagulation]], [[haemostasis]] and related articles. The discussion here is limited to the common practical aspects of blood clot formation which manifest as bleeding.

Certain medical conditions can also make patients susceptible to bleeding. These are conditions that affect the normal "hemostatic" functions of the body. [[Hemostasis]] involves several components. The main components of the hemostatic system include [[platelets]] and the [[blood coagulation|coagulation]] system.

[[Platelets]] are small blood components that form a plug in the blood vessel wall that stops bleeding. Platelets also produce a variety of substances that stimulate the production of a blood clot. One of the most common causes of increased bleeding risk is exposure to [[non-steroidal anti-inflammatory drugs]] (or "NSAIDs"). The prototype for these drugs is aspirin, which inhibits the production of thromboxane. NSAIDs inhibit the activation of [[platelets]], and thereby increase the risk of bleeding. The effect of aspirin is irreversible; therefore, the inhibitory effect of aspirin is present until the platelets have been replaced (about ten days). Other NSAIDs, such as "ibuprofen" (Motrin) and related drugs, are reversible and therefore, the effect on platelets is not as long-lived.

There are several named coagulation factors that interact in a complex way to form blood clots, as discussed in the article on [[coagulation]]. Deficiencies of coagulation factors are associated with clinical bleeding. For instance, deficiency of Factor VIII causes classic [[Hemophilia A]] while deficiencies of Factor IX cause "Christmas disease"([[hemophilia B]]). Antibodies to Factor VIII can also inactivate the Factor VII and precipitate bleeding that is very difficult to control. This is a rare condition that is most likely to occur in older patients and in those with [[autoimmune]] diseases. [[von Willebrand disease]] is another common bleeding disorder. It is caused by a deficiency of or abnormal function of the "von Willebrand" factor, which is involved in platelet activation. Deficiencies in other factors, such as factor XIII or factor VII are occasionally seen, but may not be associated with severe bleeding and are not as commonly diagnosed.

In addition to NSAID-related bleeding, another common cause of bleeding is that related to the medication, [[warfarin]] ("Coumadin" and others). This medication needs to be closely monitored as the bleeding risk can be markedly increased by interactions with other medications. Warfarin acts by inhibiting the production of [[Vitamin K]] in the gut. Vitamin K is required for the production of the clotting factors, II, VII, IX, and X in the liver. One of the most common causes of warfarin-related bleeding is taking antibiotics. The gut bacteria make vitamin K and are killed by antibiotics. This decreases vitamin K levels and therefore the production of these clotting factors.

Deficiencies of platelet function may require platelet transfusion while deficiciencies of clotting factors may require transfusion of either [[fresh frozen plasma]] of specific clotting factors, such as [[Factor VIII]] for patients with hemophilia.

===Causes by Organ System===
{|style="width:80%; height:100px" border="1"
|style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" |'''Cardiovascular'''
|style="height:100px"; style="width:75%" border="1" bgcolor="Beige" | No underlying causes
|-
|bgcolor="LightSteelBlue"| '''Chemical/Poisoning'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Dental'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Dermatologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Drug Side Effect'''
|bgcolor="Beige"| [[Ceftazidime]], [[Diclofenac (ophthalmic)]], [[diclofenac (patch)]], [[Ibrutinib]], [[Omacetaxine]], [[Sorafenib]], [[Sunitinib]], [[Tiagabine]]
|-
|-bgcolor="LightSteelBlue"
| '''Ear Nose Throat'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Endocrine'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Environmental'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Gastroenterologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Genetic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Hematologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Iatrogenic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Infectious Disease'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Musculoskeletal/Orthopedic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Neurologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Nutritional/Metabolic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Obstetric/Gynecologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Oncologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Ophthalmologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Overdose/Toxicity'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Psychiatric'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Pulmonary'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Renal/Electrolyte'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Rheumatology/Immunology/Allergy'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Sexual'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Trauma'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Urologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Miscellaneous'''
|bgcolor="Beige"| No underlying causes
|-
|}

==References==
{{Reflist|2}}
{{WH}}
{{WS}}

[[Category:Blood]]
[[Category:Hematology]]
[[Category:Medical emergencies]]
[[Category:Needs causes]]
[[Category:Needs content]]
[[Category:Needs overview]]

ST elevation myocardial infarction overview

2023-01-31T14:12:50Z

Jair Basantes de la Calle: /* Overview */

<div style="-webkit-user-select: none;">__NOTOC__
{{ST elevation myocardial infarction}}
{{CMG}}; {{AE}} {{CZ}}

==Overview==
[[Acute myocardial infarction]], more commonly known as a [[heart attack]], is a medical condition that occurs when the [[Blood flow|blood supply]] to a part of the [[heart]] muscle or [[myocardium]] is interrupted. The resulting [[ischemia]] or [[Hypoxia (medical)|oxygen shortage]] causes damage and / or irreversible death (necrosis) of the myocardium (heart muscle). It is a [[medical emergency]], and the leading cause of death for both men and women worldwide, particularly in developed countries.<ref name="WHO-2002">{{cite book | authorlink=http://www.who.int/en/ | title=The World Health Report 2004 - Changing History | publisher=[[World Health Organization]] | date=2004 | pages=120-4 | format=PDF | url=http://www.who.int/entity/whr/2004/en/report04_en.pdf | id= ISBN 92-4-156265-X}}</ref> The termmyocardial infarction is derived from [[myocardium]] (the heart muscle) and [[infarction]] (tissue death due to oxygen starvation). The phrase "heart attack" is sometimes used incorrectly to describe [[sudden cardiac death]], which may or may not be the result of acute myocardial infarction.

There are two types of acute MI: [[ST elevation myocardial infarction]] ([[STEMI]]), the topic of this chapter and [[non ST elevation MI]] ([[NSTEMI]]) which is discussed in another chapter of WikiDoc. [[ST elevation myocardial infarction]] refers to an [[Electrocardiography|electrocardiographic]] pattern in which the ST segments are elevated reflecting complete epicardial vessel occlusion. Once the vessel is opened by percutaneous coronary angioplasty, the ST segments can remain elevated due to absence of perfusion or flow into the myocardium itself. At this point in the evolution of the ST elevation MI, the epicardial artery is open, but the capillary network is occluded due to swelling, embolization, and / or vasospasm.

[[Non ST elevation myocardial infarction]] refers to a disease state in which the epicardial artery is open, but there is inadequate blood flow to the myocardium which results in an [[Electrocardiography|electrocardiographic]] pattern of ST segment depression. While ST elevation reflects transmural injury, ST depression may reflect ongoing subendocardial [[ischemia]]. Inadequate blood flow to the muscle may be due to embolization of material downstream into the myocardium or a restriction of blood flow due to severe narrowing of the epicardial artery. <ref>Hurst’s The Heart, Fuster V, 12th edition, 2008</ref> <ref>Topol’s Textbook of Cardiovascular Medicine, Topol E, 3rd edition, 2007</ref> <ref>Mayo Textbook of Cardiology, 2007</ref>

==Epidemiology and Demographics==
Myocardial infarction is a common presentation of [[ischemic heart disease]]. The World Heart Organization (WHO) estimated in 2002 that, 12.6 percent of deaths worldwide were from [[ischemic heart disease]]. [[Ischemic heart disease]] is the leading cause of death in developed countries, but third to [[AIDS]] and [[lower respiratory infection]]s in developing countries.<ref name="UCatlas">{{cite web | title=Cause of Death - UC Atlas of Global Inequality | publisher=Center for Global, International and Regional Studies (CGIRS) at the University of California Santa Cruz | url=http://ucatlas.ucsc.edu/cause.php | accessmonthday=December 7 | accessyear=2006}}</ref> Although it is difficult to ascertain the true incidence of [[ST elevation myocardial infarction]] ([[STEMI]]), according to the ACC/AHA guidelines, a conservative estimate is that approximately 500,000 patients suffer STEMI each year <ref name="pmid15358047">{{cite journal |author=Antman EM, Anbe DT, Armstrong PW, ''et al'' |title=ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction; A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of patients with acute myocardial infarction) |journal=J. Am. Coll. Cardiol. |volume=44 |issue=3 |pages=E1–E211 |year=2004 |month=August |pmid=15358047 |doi=10.1016/j.jacc.2004.07.014 |url=}}</ref>. The incidence of [[STEMI]] has decreased over time. In an observational study of 5,832 metropolitan patients spanning from 1975 to 1997, the incidence of STEMI decreased from 171/100,000 to 101/100,000 <ref name="pmid11345367">{{cite journal |author=Furman MI, Dauerman HL, Goldberg RJ, Yarzebski J, Lessard D, Gore JM |title=Twenty-two year (1975 to 1997) trends in the incidence, in-hospital and long-term case fatality rates from initial Q-wave and non-Q-wave myocardial infarction: a multi-hospital, community-wide perspective |journal=J. Am. Coll. Cardiol. |volume=37 |issue=6 |pages=1571–80 |year=2001 |month=May |pmid=11345367 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0735109701012037}}</ref>.

==Risk Factors==
Important [[ST elevation myocardial infarction risk factors]] are a previous history of vascular disease such as [[atherosclerosis|atherosclerotic]] [[coronary heart disease]] and/or [[Angina pectoris|angina]], a previous heart attack or [[stroke]], advanced age, [[tobacco smoking|smoking]], the abuse of certain illicit drugs such as [[cocaine]], high [[Low density lipoprotein|LDL]] (Low-density lipoprotein) and low [[High density lipoprotein|HDL]] (High density lipoprotein), [[Diabetes mellitus|diabetes]], [[Hypertension|high blood pressure]], [[obesity]] and family history of [[coronary artery disease]].<ref name="pmid15289388">{{cite journal |author=Antman EM, Anbe DT, Armstrong PW, ''et al'' |title=ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction) |journal=Circulation |volume=110 |issue=5 |pages=588–636 |year=2004 |month=August |pmid=15289388 |doi=10.1161/01.CIR.0000134791.68010.FA |url=}}</ref>
<ref name="pmid18191746">{{cite journal |author=Antman EM, Hand M, Armstrong PW, ''et al'' |title=2007 focused update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines |journal=J. Am. Coll. Cardiol. |volume=51 |issue=2 |pages=210–47 |year=2008 |month=January |pmid=18191746 |doi=10.1016/j.jacc.2007.10.001 |url=}}</ref>

==Risk Stratification==
Two main risk-stratification scores are used when assessing a patient with ST elevation MI and acute coronary syndromes; the [[TIMI]] Risk Score (for [[MI]]), and the GRACE risk score (for [[acute coronary syndrome]].

==Triggers==
A trigger is an activity or environmental condition that produces short-term physiological changes that may lead directly to onset of STEMI. [[ST elevation myocardial infarction triggers]] include physical exertion, psychological stress, sexual activity, diurnal (daily) variations in cortisol and platelet aggregation and circannual (yearly) variations in lipids and infectious etiologies, exposure to pollution and or particulate matter, cocaine and ingestion of a recent fatty meal. <ref name="pmid8113568">{{cite journal |author=Muller JE, Abela GS, Nesto RW, Tofler GH |title=Triggers, acute risk factors and vulnerable plaques: the lexicon of a new frontier |journal=J. Am. Coll. Cardiol. |volume=23 |issue=3 |pages=809–13 |year=1994 |month=March |pmid=8113568 |doi= |url=}}</ref>

==Natural History, Complications and Prognosis==
The natural progression of ST elevation myocardial infarction depends on epicardial artery patency and the risk for early vessel reocclusion. Without treatment, ST elevation myocardial infarction can prove deadly.

===Prognosis===
Despite advances in modern pharmacotherapy and device-based therapy, the short term mortality remains high in modern registry series (15%-20%). The prognosis for patients with myocardial infarction varies greatly depending upon simple demographic variables like age, the presence of signs and symptoms of heart failure, the duration of symptoms, and comorbidities that are present. Several risk stratification tools have been developed to predict a patient's mortality. Most of these risk scores are based upon clinical data obtained at the time of admission rather than at the time of discharge.

While we as physicians often labor under the impression that we can dramatically change a patient's prognosis, it is noteworthy that 90% of the predictive information regarding 30 day mortality is contained in the following 5 baseline variables that can be modified to only a limited degree: <ref name="pmid7882472">{{cite journal |author=Lee KL, Woodlief LH, Topol EJ, ''et al'' |title=Predictors of 30-day mortality in the era of reperfusion for acute myocardial infarction. Results from an international trial of 41,021 patients. GUSTO-I Investigators |journal=Circulation |volume=91 |issue=6 |pages=1659–68|year=1995 |month=March |pmid=7882472 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=7882472}}</ref>
#Advanced age
#[[Sinus tachycardia]]
#Reduced [[Systole (medicine)|systolic]] [[blood pressure]]
#[[Heart failure]] or [[Killip class]] of two or greater
#Anterior myocardial infarction location

Sinus tachycardia, hypotension, Killip class, and anterior MI are all essentially markers of poor pump function on admission. These risk factors for 30 day mortality have been well validated in a multivariate analysis of 41,020 patients in the GUSTO-I trial. Advanced age was the most significant factor associated with higher 30-day mortality. The rate was only 1.1% in the youngest decile (< 45 years) and climbed to 20.5% in patients > 75 (adjusted chi 2 = 717, P < .0001). Other variables most closely associated with an increased risk of mortality were lower systolic blood pressure at randomizaiton (chi 2 = 550, P < .0001), higher Killip class (chi 2 = 350, P < .0001), elevated heart rate (chi 2 = 275, P < .0001), and the presence of an anterior infarction (chi 2 = 143, P < .0001). When taken together, '''''these five baseline characteristics contained 90% of the prognostic information'''''. Other significant though less important factors included previous myocardial infarction, height, time to treatment, [[diabetes]], weight, [[smoking]] status, type of [[thrombolytic]], previous bypass surgery,[[hypertension]], and prior cerebrovascular disease. When these variables were combined, a validated model was created which stratified patients according to their mortality risk and accurately estimated the likelihood of death.

Various risk tools such as [[the GRACE risk score]] have been developed to risk stratify patients.

==Pregnancy==
Physiological changes during pregnancy may increase the woman's risk of developing a myocardial infarction (MI). MI during the antepartum period is usually caused by an atherosclotic plaque rupture, whereas MI during the peripartum and postpartum period is usually caused by coronary artery dissection (commonly in the LAD). Diagnosis of MI among pregnant women is similar to that in the general population and requires clinical suspiccion, as well as ECG changes and troponin elevation. In contrast, elevated CK-MB concentration is unreliable, since CK-MB may normally increase during labor and post-delivery due to non-cardiac causes, namely placental and uterine leaks. During an MI, echocardiography is safe and may be performed to evaluate wall motion abnormalities, and fetal monitoring is recommended. Treatment is usually by percutaneous coronary intervention. If spontaneous coronary artery dissection occurs, a more thorough investigation for connective tissue diseases and vasculitis is warranted.

==Diagnosis==
===Diagnostic Criteria===
The diagnosis of acute MI is based upon the occurence of clinical symptoms such as substernal [[chest pain]], EKG changes such as ST elevation and a rise in the release of very specific [[biomarker]]s into the bloodstream that are normally only found in side the heart muscle cell (the [[myocyte]]).

The diagnosis can be confirmed at the time of autopsy or at the time of angiography if a closed artery is seen. A new clinical evidence based diagnostic and classification system has been introduced by Thygesen K, Alpert JS, White HD, et al. and jointly sponsored by the American College of Cardiology (ACC), American Heart Association (AHA), European Society of Cardiology (ESC), and the World Heart Federation (WHF).<ref name="pmid17951284">{{cite journal |author=Thygesen K, Alpert JS, White HD, ''et al''|title=Universal definition of myocardial infarction |journal=Circulation |volume=116 |issue=22 |pages=2634–53 |year=2007|month=November |pmid=17951284|doi=10.1161/CIRCULATIONAHA.107.187397 |url=}}</ref>

===History and Symptoms===
One third of patients who experience [[ST Elevation Myocardial Infarction|ST Segment Elevation Myocardial Infarction]] ([[STEMI]]) will die within 24 hours of the onset of ischemia, and many of the survivors will suffer significant morbidity. Morbidity and mortality from [[STEMI]] can be reduced significantly if patients and bystanders recognize symptoms early, activate the [[EMS]], and thereby shorten the time to definitive treatment.

Classical symptoms of [[acute myocardial infarction]] include [[chest pain]] (which in some patients may radiate to the left arm), [[dyspnea|shortness of breath]], [[nausea]], [[vomiting]], [[palpitation]]s, [[sweating]], and [[anxiety]] or a feeling of impending doom.

Many patients will state that there was no chest pain, but rather a sense of chest discomfort that they may describe as a squeezing sensation or a sense of chest heaviness or fullness.

Patients frequently feel suddenly ill. Women may experience different symptoms from men. Common associated symptoms of MI in women include[[shortness of breath]], [[weakness]], and [[fatigue (physical)|fatigue]].

Serial electrocardiographic studies from the Framingham study have shown that approximately one quarter of all myocardial infarctions (the appearance of new pathologic q waves) are silent, without [[chest pain]] or other symptoms.<ref name="pmid3779719">{{cite journal |author=Kannel WB |title=Silent myocardial ischemia and infarction: insights from the Framingham Study |journal=Cardiol Clin |volume=4 |issue=4 |pages=583–91 |year=1986 |month=November |pmid=3779719 |doi= |url=}}</ref> The prognosis of patients with a silent MI was as bad as those with a symptomatic MI.

===Physical Examination===
The [[physical examination]] in patients who have suspected [[acute myocardial infarction]] may reveal [[arrhythmia]], evidence of [[heart failure]], a new [[murmur]], or cardiovascular compromise and [[shock]]. A systems focused examination is probably most appropriate at the time of presentation so as to not delay decisions regarding and implementation of reperfusion therapy. Following these initial stages of management, a more through examination is then warranted. Throughout the patient's course, detailed serial examinations should be performed in an effort to remain vigilant for the development of [[ST elevation myocardial infarction complications|mechanical complications of acute MI]]. The approach to the physical examination in the patient with ST elevation MI is divided into two phases: The initial physical examination and then the more thorough examination of the patient after the initial assessment and treatment of the patient.

===Laboratory Findings===
A new clinical evidence based classification system has been jointly introduced by the American College of Cardiology (ACC), American Heart Association (AHA), European Society of Cardiology (ESC), and the World Heart Federation (WHF)<ref name=" Thygesen-2007">{{cite journal | author= Thygesen K, Alpert JS, White HD |title=Task Force for the Redefinition of Myocardial Infarction. Universal definition of myocardial infarction Joint ESC/ACCF/AHA/WHF| journal=Circulation |year=2007 | volume=2007 | pages=2634–2653 | id=PMID 17951284}}</ref>. The primary diagnostic tests include the [[ST elevation myocardial infarction electrocardiogram|electrocardiogram]] (ECG, EKG) and [[ST elevation myocardial infarction cardiac markers|blood test]]s to detect elevated [[creatine kinase]] or [[troponin]] levels (these are chemical markers released by damaged tissues, especially the myocardium).

===Electrocardiogram===
A primary purpose of the [[electrocardiogram]] is to detect [[ischemia]] or acute coronary injury in broad, symptomatic [[emergency department]] populations. Common EKG findings in STEMI include ST segment elevation, new LBBB pattern and hyperacute T waves.

===Imaging===
====Coronary Angiography====
The goal of coronary angiography in STEMI patients is to identify the obstructed culprit artery and to open it as quickly as possible. The goal is to achieve a [[door to balloon time]] in under 90 minutes. This is the time from when a patient arrives at the door of the emergency room until the time that the first device is activated in the coronary artery.

==Treatment==
===Medical Therapy===
Immediate treatment for suspected [[acute myocardial infarction]] includes [[ST elevation myocardial infarction oxygen therapy|oxygen]], full dose non-enteric coated [[ST elevation myocardial infarction aspirin therapy|aspirin]], [[ST elevation myocardial infarction nitrate therapy|nitroglycerin]] (also known as glyceryl trinitrate) and [[ST elevation myocardial infarction analgesic therapy|pain relief]], using an analgesic agent such [[ST elevation myocardial infarction analgesic therapy|morphine sulfate]]. Among patients who do not have signs or symptoms of [[cardiogenic shock]], [[ST elevation myocardial infarction beta blocker therapy|beta blocker administration]] has been associated with improved clinical outcomes among patients with ST elevation myocardial infarction<ref name="pmid11356434">{{cite journal |author=Dargie HJ |title=Effect of carvedilol on outcome after myocardial infarction in patients with left-ventricular dysfunction: the CAPRICORN randomised trial |journal=Lancet |volume=357 |issue=9266 |pages=1385–90 |year=2001 |month=May |pmid=11356434 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0140673600045608}}</ref>. These agents exert their benefit via several mechanisms: They reduce myocardial oxygen demands; they reduce contractility which in turn reduces the risk of mechanical complications; they reduce the risk of lethal [[ventricular arrhythmias]].

A cornerstone in the management of STEMI is reperfusion or opening of the closed epicardial coronary artery. This can be achieved with either drugs such as a [[fibrinolytic]] agent, or mechanically with inflation of a balloon to puch the clot aside (percutaneous coronary intervention or PCI). A decade of expereince has shown that if it can be accomplished in a timely manner (a [[door-to-balloon]] time < 90 minutes), then PCI offers superior outcomes to [[fibrinolytic]] administration.
In under 5% of patients, [[Coronary artery bypass surgery|bypass surgery]] may be required given the extent of disease. A common practice is to perform urgent conventional balloon angioplasty of the culprit vessel as a bridge to a more definitive CABG operation.

Antiplatelet therapy is a mainstay of STEMI management. [[ST elevation myocardial infarction aspirin therapy|Aspirin]] is a cornerstone of STEMI management. Given that the majority of patients undergoing primary PCI are treated with an intracoronary stent, [[ST elevation myocardial infarction thienopyridine therapy|thienopyridine therapy]] is also essential. Depending upon a variety of factors, [[ST elevation myocardial infarction glycoprotein IIbIIIa inhibition|glycoprotein IIbIIIa inhibition]] is administered in approximately 70% of STEMI patients undergoing primary PCI.

Likewise, [[ST elevation myocardial infarction anticoagulant and antithrombotic therapy|antithrombin therapy]] is also a mainstay of STEMI management. Frequent choices among patients treated with fibrinolytic agents include unfractionated heparin in the United States, and enoxaparin and fondaparinux in other countries. Among patients undergoing primary PCI, frequent choices include bivalirudin and unfractionated heparin.

==Monitoring of the Patient to Reduce post MI Complications==
Admission of patients to the modern [[coronary care unit]] has been associated with rapid treatment of and reduced complications from fatal arrhythmias such as [[ventricular tachycardia]] or [[ventricular fibrillation]].

[[ST elevation myocardial infarction complications|Other complications of STEMI]] include [[reinfarction]], infarct extension, postinfarction angina, [[ST elevation myocardial infarction complications#Rupture of Ventricular Septum|rupture of the ventricular septum causing a ventricular septal defect]], acute [[ST elevation myocardial infarction complications#Acute Mitral Regurgitation|mitral regurgitation]], [[ST elevation myocardial infarction complications#Myocardial Rupture|myocardial rupture]], development of a [[ST elevation myocardial infarction complications#Pseudoaneurysm|pseudoaneurysm]], development of [[ST elevation myocardial infarction complications#Left Ventricular Failure and Cardiogenic Shock|cardiogenic shock]], development of a [[ST elevation myocardial infarction complications#Ventricular Aneurysm|ventricular aneurysm]], [[ST elevation myocardial infarction complications#D. Embolic Complications|embolic complications]], and [[ST elevation myocardial infarction complications#E. Pericarditis|pericarditis]].

==References==
{{reflist|2}}
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AHA/ASA guidelines for the management of spontaneous intracerebral hemorrhage

2023-01-19T16:10:37Z

Jair Basantes de la Calle: Jair Basantes de la Calle moved page AHA/ASA guidelines for the management of spontaneous intracerebral hemorrhage to AHA, ASA guidelines for the management of spontaneous intracerebral hemorrhage

#REDIRECT [[AHA, ASA guidelines for the management of spontaneous intracerebral hemorrhage]]

AHA, ASA guidelines for the management of spontaneous intracerebral hemorrhage

2023-01-19T16:10:36Z

__NOTOC__
{{Intracerebral hemorrhage}}
{{CMG}} {{AE}} {{SaraM}}

==2015 AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage<ref name=ASA/AHA-ICH-Guid> 2015 AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhagehttp://stroke.ahajournals.org/content/early/2015/05/28/STR.0000000000000069 Accessed on November 10, 2016</ref>==
===Emergency Diagnosis and Assessment: Recommendations===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.'''A baseline severity score should be performed as part of the initial evaluation of patients with [[intracerebral hemorrhage|intracerebral hemorrhage (ICH)]] ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.'''Rapid neuroimaging with [[CT]] or [[MRI]] is recommended to distinguish [[ischemic stroke]] from [[intracerebral hemorrhage|intracerebral hemorrhage (ICH)]] ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|}

{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''[[CT angiography]], CT venography, contrast-enhanced CT, contrast-enhanced MRI, [[MRA]] and MRV can be useful to evaluate for underlying structural lesions including vascular malformations and [[tumors]] when there is clinical or radiologic suspicion ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}

{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''[[CT angiography]] and contrast-enhanced CT may be considered to help identify patients at risk for [[hematoma|hematoma expansion]] ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}

===Hemostasis and Coagulopathy, Antiplatelet Agents, and DVT Prophylaxis: Recommendations===
====Patients with a severe coagulation factor deficiency or severe thrombocytopenia====
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.'''Patients with a severe [[coagulation factor deficiency]] or severe [[thrombocytopenia]] should receive appropriate factor replacement therapy or platelets, respectivel ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
====Patients with ICH whose INR is elevated because of VKA====
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.'''Patients with ICH whose INR is elevated because of VKA should have their VKA withheld, receive therapy to replace vitamin K–dependent factors and correct the INR, and receive intravenous vitamin K ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}

{|class="wikitable"
|-
|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm)
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.'''rFVIIa does not replace all clotting factors, and although the INR may be lowered, clotting may not be restored in vivo; therefore, rFVIIa is not recommended for VKA reversal in ICH ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}

{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''PCCs may have fewer complications and correct the INR more rapidly than FFP and might be considered over FFP ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}

====Patients with ICH who are taking dabigatran, rivaroxaban, or apixaban====
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''For patients with ICH who are taking dabigatran, rivaroxaban, or apixaban, treatment with FEIBA, other PCCs, or rFVIIa might be considered on an individual basis. Activated charcoal might be used if the most recent dose of dabigatran, apixaban, or riva- roxaban was taken <2 hours earlier. Hemodialysis might be considered for dabigatran ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}

====Reverse heparin in patients with acute ICH====
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' [[Protamine sulfate]] may be considered to reverse [[heparin]] in patients with acute ICH ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}

====Patients with a history of anti platelet and ICH====
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''The usefulness of platelet transfusions in ICH patients with a history of antiplatelet use is uncertain ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
====Hematoma expansion====
{|class="wikitable"
|-
|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm)
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' Although rFVIIa can limit the extent of hematoma expansion in noncoagulopathic ICH patients, there is an increase in thromboembolic risk with rFVIIa and no clear clinical benefit in unselected patients. Thus, rFVIIa is not recommended ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|}

====prevention of venous thromboembolism====
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.'''Patients with ICH should have intermittent pneu- matic compression for prevention of venous throm- boembolism beginning the day of hospital admission ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|}
{|class="wikitable"
|-
|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm)
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.'''Graduated compression stockings are not beneficial to reduce DVT or improve outcome ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''After documentation of cessation of bleeding, low- dose subcutaneous low-molecular-weight heparin or unfractionated heparin may be considered for pre- vention of venous thromboembolism in patients with lack of mobility after 1 to 4 days from onset ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
====ICH patients with symptom- atic DVT or PE ====
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''Systemic anticoagulation or IVC filter placement is probably indicated in ICH patients with symptom- atic DVT or PE ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' The decision between these 2 options should take into account several factors, including time from hem- orrhage onset, hematoma stability, cause of hemor- rhage, and overall patient condition ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}

===BP-Lowering: Recommendations===
====ICH patients presenting with SBP between 150 and 220 mmHg====
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.'''For ICH patients presenting with SBP between 150 and 220 mmHg and without contraindication to acute BP treatment, acute lowering of SBP to 140 mm Hg is safe ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''For ICH patients presenting with SBP between 150 and 220 mmHg and without contraindication to acute BP treatment, acute lowering of SBP to 140 mm Hg ) can be effective for improving functional outcome ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
====ICH patients presenting with SBP >220 mmHg====
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' For ICH patients presenting with SBP >220 mm Hg, it may be reasonable to consider aggressive reduction of BP with a continuous intravenous infusion and frequent BP monitoring ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
===General Monitoring and Nursing Care: Recommendation===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.'''Initial monitoring and management of ICH patients should take place in an intensive care unit or dedicated stroke unit with physician and nursing neuroscience acute care expertis ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}

===Glucose Management: Recommendation===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.'''Glucose should be monitored. Both [[hyperglycemia]] and [[hypoglycemi]]a should be avoided ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
===Temperature Management: Recommendation===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''Treatment of fever after ICH may be reasonable ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
===Seizures and Antiseizure Drugs: Recommendations===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.'''Clinical seizures should be treated with antiseizure drugs ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.'''Patients with a change in mental status who are found to have electrographic seizures on EEG should be treated with antiseizure drugs ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}

{|class="wikitable"
|-
|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm)
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.'''Prophylactic antiseizure medication is not recommended ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}

{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''Continuous EEG monitoring is probably indicated in ICH patients with depressed mental status that is out of proportion to the degree of brain injury ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
===Management of Medical Complications: Recommendations===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.'''A formal screening procedure for [[dysphagia]] should be performed in all patients before the initiation of oral intake to reduce the risk of [[pneumonia]] ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Systematic screening for [[myocardial ischemia]] or infarction with [[electrocardiogram]] and [[cardiac enzyme testing]] after ICH is reasonable ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
===ICP Monitoring and Treatment: Recommendations===
{|class="wikitable"
|-
|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm)
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.'''[[Corticosteroids]] should not be administered for treatment of elevated ICP in ICH ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}

{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''Ventricular drainage as treatment for [[hydrocephalus]] is reasonable, especially in patients with decreased level of consciousness ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}

{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Patients with a GCS score of ≤8, those with clinical evidence of [[transtentorial herniation]], or those with significant IVH or [[hydrocephalus]] might be considered for ICP monitoring and treatment. A CPP of 50 to 70 mm Hg may be reasonable to maintain depending on the status of cerebral autoregulation ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
===IVH: Recommendations===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''Although intraventricular administration of rtPA in IVH appears to have a fairly low complication rate, the efficacy and safety of this treatment are uncertain ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.'''The efficacy of endoscopic treatment of IVH is uncertain ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}

===Surgical Treatment of ICH: Recommendations===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.'''Patients with cerebellar hemorrhage who are deteriorating neurologically or who have brainstem compression and/or hydrocephalus from ventricular obstruction should undergo surgical removal of the hemorrhage as soon as possible ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}

{|class="wikitable"
|-
|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm)
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' Initial treatment of patients with cerebellar hemorrhage who are deteriorating neurologically or who have brainstem compression and/or hydrocephalus from ventricular obstruction is not recommended ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}

{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' For most patients with supratentorial ICH, the usefulness of surgery is not well established ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' A policy of early hematoma evacuation is not clearly beneficial compared with hematoma evacution when patients deteriorate ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' Supratentorial hematoma evacuation in deteriorating patients might be considered as a life-saving measure ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4.'''Decompressive hemicraniectomy (DC) with or without hematoma evacuation might reduce mortality for patients with supratentorial ICH who are in a [[coma]], have large hematomas with significant midline shift, or have elevated ICP refractory to medical management ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''5.''' The effectiveness of minimally invasive clot evacuation with stereotactic or endoscopic aspiration with or without [[thrombolytic]] usage is uncertain ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
===Outcome Prediction and Withdrawal of Technological Support: Recommendation===
{|class="wikitable"
|-
|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm)
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' Current prognostic models for individual patients early after ICH are biased by failure to account for the influence of withdrawal of support and early DNAR orders. DNAR status should not limit appropriate medical and surgical interventions unless otherwise explicitly indicated ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}

{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Aggressive care early after ICH onset and postponement of new DNAR orders until at least the second full day of hospitalization is probably recommended. Patients with preexisting DNAR orders are not included in this recommendation ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}

==References==
{{reflist|2}}

[[Category:Neurology]]
[[Category:Cardiology]]
[[Category:Neurosurgery]]
[[Category:Emergency medicine]]

{{WS}}
{{WH}}

AHA, ASA guidelines for stroke

2023-01-19T16:06:44Z

Jair Basantes de la Calle: /* Hyperhomocysteinemia */

__NOTOC__
{{AHA, ASA stroke guidelines}}
{{CMG}}; {{AE}}; {{TarekNafee}}

== 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association ==

=== DIAGNOSTIC EVALUATION FOR SECONDARY STROKE PREVENTION ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' In patients suspected of having a stroke or TIA, an ECG is recommended to screen for atrial fibrillation (AF) and atrial flutter and to assess for other concomitant cardiac conditions. (Level of evidence: B-R)<nowiki>"</nowiki>
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''2.''' In patients with ischemic stroke or TIA, a diagnostic evaluation is recommended for gaining insights into the etiology of and planning optimal strategies for preventing recurrent stroke, with testing completed or underway within 48 hours of onset of stroke symptoms ''(Level of evidence: B-NR)'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''3.''' In patients with symptomatic anterior circulation cerebral infarction or TIA who are candidates for revascularization, noninvasive cervical carotid imaging with carotid ultrasonography, CT angiography (CTA), or magnetic resonance angiography (MRA) is recommended to screen for stenosis ''(Level of evidence: B-NR)'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen" | <nowiki>"</nowiki>'''4.''' In patients suspected of having a stroke or TIA, CT or MRI of the brain is recommended to confirm the diagnosis of symptomatic ischemic cerebral vascular disease ''(Level of evidence: B-NR)'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen" | <nowiki>"</nowiki>5'''.''' In patients with a confirmed diagnosis of symptomatic ischemic cerebrovascular disease, blood tests, including complete blood count, prothrombin time, partial thromboplastin time, glucose, HbA1c, creatinine, and fasting or non-fasting lipid profile, are recommended to gain insight into risk factors for stroke and to inform therapeutic goals ''(Level of evidence: B-NR)'' <nowiki>"</nowiki>
|}
<ref name="pmid34024117" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |" 6'''.''' In patients with cryptogenic stroke, echocardiography with or without contrast is reason-able to evaluate for possible cardiac sources of or transcardiac pathways for cerebral embolism
(Level of Evidence B-R)".
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki> 7. In patients with cryptogenic stroke who do not have a contraindication to anticoagulation, long-term rhythm monitoring with mobile cardiac outpatient telemetry, implantable loop recorder, or other approach is reasonable to detect intermittent AF.
(Level of Evidence B R)<nowiki>''</nowiki>
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki> 8. In patients suspected of having an ischemic stroke, if CT or MRI does not demonstrate symptomatic cerebral infarct, follow-up CT or MRI of the brain is reasonable to confirm a diagnosis.
(Level of Evidence B- NR)<nowiki>''</nowiki>
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki> 9. In patients suspected of having had a TIA, if the initial head imaging (CT or MRI) does not demonstrate a symptomatic cerebral infarct, follow-up MRI is reasonable to predict the risk of early stroke and to support the diagnosis.
(Level of Evidence B- NR)<nowiki>''</nowiki>
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki> 10. In patients with cryptogenic stroke, tests for inherited or acquired hypercoagulable state, bloodstream or cerebral spinal fluid infections, infections that can cause central nervous system (CNS) vasculitis (eg, HIV and syphilis), drug use (eg, cocaine and amphetamines), and markers of systemic inflammation and genetic tests for inherited diseases associated with stroke are reason-able to perform as clinically indicated to identify contributors to or relevant risk factors for stroke.
(Level of Evidence C-LD)<nowiki>''</nowiki>
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki> 11. In patients with ischemic stroke or TIA, noninvasive imaging of the intracranial large arteries and imaging of the extracranial vertebro-basilar arterial system with MRA or CTA can be effective to identify atherosclerotic disease, dissection, moyamoya, or other etiologically relevant vasculopathies.
(Level of Evidence C-LD)<nowiki>''</nowiki>
|}
<ref name="pmid34024117" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |" 12'''.''' In patients with ischemic stroke and a treatment plan that includes anticoagulant therapy, CT or MRI of the brain before therapy is started may be considered to assess for hemorrhagic transformation and final size of infarction
(Level of Evidence B-NR)".
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki> 13. In patients with ESUS, transesophageal echocardiography (TEE), cardiac CT, or cardiac MRI might be reasonable to identify possible cardioaortic sources of or transcardiac pathways for cerebral embolism.
(Level of Evidence C-LD)<nowiki>''</nowiki>
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki> 14. In patients with ischemic stroke or TIA in whom patent foramen ovale (PFO) closure would be contemplated, TCD (transcranial Doppler) with embolus detection might be reasonable to screen for right-to-left shun.
(Level of Evidence C LD)<nowiki>''</nowiki>
|}
<ref name="pmid34024117">{{cite journal| author=Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D | display-authors=etal| title=2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. | journal=Stroke | year= 2021 | volume= 52 | issue= 7 | pages= e364-e467 | pmid=34024117 | doi=10.1161/STR.0000000000000375 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34024117 }}</ref>

=== '''NUTRITION''' ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |" 1'''.''' In patients with stroke and TIA, it is reasonable to counsel individuals to follow a Mediterranean type diet, typically with empha-sis on monounsaturated fat, plant-based foods, and fish consumption, with either high extra virgin olive oil or nut supplementation, in preference to a low-fat diet, to reduce risk of recurrent stroke
(Level of Evidence B-R)".
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki> 2. In patients with stroke or TIA and hypertension who are not currently restricting their dietary sodium intake, it is reasonable to recommend that individuals reduce their sodium intake by at least 1g/d sodium (2.5 g/d salt) to reduce the risk of cardiovascular disease (CVD) events (including stroke).
(Level of Evidence B R)<nowiki>''</nowiki>
|}
<ref name="pmid34024117" />

=== PHYSICAL ACTIVITY ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' In patients with stroke or TIA who are capable of physical activity, engaging in at least moderate-intensity aerobic activity for a minimum of 10 min-utes 4 times a week or vigorous-intensity aerobic activity for a minimum of 20 minutes twice a week is indicated to lower the risk of recurrent stroke and the composite cardiovascular end point of recurrent stroke, MI, or vascular death. (Level of evidence: C-LD)<nowiki>"</nowiki>
|}
<ref name="pmid34024117" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |" 2'''.''' In patients with stroke or TIA who are able and willing to increase physical activity, engaging in an exercise class that includes counseling to change physical activity behavior can be beneficial for reducing cardiometabolic risk factors and increasing leisure time physical activity participation.
(Level of Evidence B-R)".
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki> 3. In patients with deficits after a stroke that impair their ability to exercise, supervision of an exercise program by a health care professional such as a physical therapist or cardiac rehabilitation professional, in addition to routine rehabilitation, can be beneficial for secondary stroke prevention.
(Level of Evidence C-EO)<nowiki>''</nowiki>
|}
<ref name="pmid34024117" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |" 4'''.''' In individuals with stroke or TIA who sit for long periods of uninterrupted time during the day, it may be reasonable to recommend breaking up sedentary time with intervals as short as 3 minutes of standing or light exercise every 30 minutes for their cardiovascular health
(Level of Evidence B-NR)".
|}
<ref name="pmid34024117" />

=== SMOKING CESSATION ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' In patients with stroke or TIA who smoke tobacco, counseling with or without drug therapy (nicotine replacement, bupropion, or varenicline) is recommended to assist in quitting smoking. (Level of evidence: A)<nowiki>"</nowiki>
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''2.''' Patients with stroke or TIA who continue to smoke tobacco should be advised to stop smoking (and, if unable, to reduce their daily smoking) to lower the risk of recurrent stroke ''(Level of evidence: B-NR)'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''3.''' In patients with stroke or TIA. avoidance of environmental (passive) tobacco smoke is recommended to reduce the risk of recurrent stroke. ''(Level of evidence: B-NR)'' <nowiki>"</nowiki>
|}
<ref name="pmid34024117" />

=== SUBSTANCE USE ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' Patients with ischemic stroke or TIA who drink >2 alcoholic drinks a day for men or >1 alcoholic drink a day for women should be counseled to eliminate or reduce their consumption of alcohol to reduce stroke risk. (Level of evidence: B-NR)<nowiki>"</nowiki>
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''2.''' In patients with stroke or TIA who use stimulants (eg, amphetamines, amphetamine derivatives, cocaine, or khat) and in patients with infective endocarditis (IE) in the context of intravenous drug use, it is recommended that health care providers inform them that this behavior is a health risk and counsel them to stop. ''(Level of evidence: C-EO)'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''3.''' In patients with stroke or TIA who have a substance use disorder (drugs or alcohol), specialized services are recommended to help manage this dependenc. ''(Level of evidence: C-EO)'' <nowiki>"</nowiki>
|}
<ref name="pmid34024117" />

=== HYPERTENTION ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' Patients with ischemic stroke or TIA who drink >2 alcoholic drinks a day for men or >1 alco-holic drink a day for women should be coun-seled to eliminate or reduce their consumption of alcohol to reduce stroke risk. (Level of evidence: A)<nowiki>"</nowiki>
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''2.''' In patients with hypertension who experience a stroke or TIA, an office BP goal of <130/80 mm Hg is recommended for most patients to reduce the risk of recurrent stroke and vascular events.
''(Level of evidence: B-R)'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''3.''' In patients with hypertension who experience a stroke or TIA, individualized drug regimens that take into account patient comorbidities, agent pharmacological class, and patient preference are recommended to maximize drug efficacy ''(Level of evidence: B-NR)'' <nowiki>"</nowiki>
|}

=== <ref name="pmid34024117" /> ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |" 4'''.''' In patients with no history of hypertension who experience a stroke or TIA and have an aver-age office BP of ≥130/80 mm Hg, antihypertensive medication treatment can be beneficial to reduce the risk of recurrent stroke, ICH, and other vascular events
(Level of Evidence B-R)".
|}
<ref name="pmid34024117" />

=== TREATMENT AND MONITORING OF BLOOD LIPIDS FOR SECONDARY STROKE PREVENTION ===

=== Treatment ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' In patients with ischemic stroke with no known coronary heart disease, no major cardiac sources of embolism, and LDL cholesterol (LDL-C) >100 mg/dL, atorvastatin 80 mg daily is indicated to reduce risk of stroke recurrence. (Level of evidence: A)<nowiki>"</nowiki>
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''2.''' In patients with ischemic stroke or TIA and ath-erosclerotic disease (intracranial, carotid, aortic, or coronary), lipid-lowering therapy with a statin and also ezetimibe, if needed, to a goal LDL-C of <70 mg/dL is recommended to reduce the risk of major cardiovascular events. ''(Level of evidence: A)'' <nowiki>"</nowiki>
|}
<ref name="pmid34024117" />

=== Monitoring ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' In patients with stroke or TIA and hyperlipidemia, patients’ adherence to changes in lifestyle and the effects of LDL-C–lowering medication should be assessed by measurement of fasting lipids and appropriate safety indicators 4 to 12 weeks after statin initiation or dose adjustment and every 3 to 12 months thereafter, based on the need to assess adherence or safety. (Level of evidence: A)<nowiki>"</nowiki>
|}
<ref name="pmid34024117" />

=== Treatment of Hypertriglyceridemia ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |" 1. In patients with ischemic stroke or TIA, with fasting triglycerides 135 to 499 mg/dL and LDL-C of 41 to 100 mg/dL, on moderate- or high-intensity statin therapy, with HbA1c <10%, and with no history of pancreatitis, AF, or severe heart failure, treatment with icosapentethyl (IPE) 2 g twice a day is reasonable to reduce risk of recurrent stroke.
(Level of Evidence B-R)".
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki> 2. In patients with severe hypertriglyceridemia (ie, fasting triglycerides ≥500 mg/dL [≥5.7 mmol/L]), it is reasonable to identify and address causes of hypertriglyceridemia and, if triglycerides are persistently elevated or increasing, to further reduce triglycerides in order to lower the risk of ASCVD events by the implementation of a very low-fat diet, avoidance of refined carbohydrates and alcohol, consumption of omega-3 fatty acids, and, if necessary to prevent acute pancreatitis, fibrate therapy.
(Level of Evidence B-NR)<nowiki>''</nowiki>
|}
<ref name="pmid34024117" />

=== Glucose ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>1. In patients with an ischemic stroke or TIA who also have diabetes, the goal for glycemic control should be individualized based on the risk for adverse events, patient characteristics, and preferences, and, for most patients, especially those <65 years of age and without life-limiting comorbid illness, achieving a goal of HbA1c ≤7% is recommended to reduce the risk for microvascular complications. (Level of evidence: A)<nowiki>"</nowiki>
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>2. In patients with an ischemic stroke or TIA who also have diabetes, treatment of diabetes should include glucose-lowering agents with proven cardiovascular benefit to reduce the risk for future major adverse cardiovas-cular events (ie, stroke, MI, cardiovascular death)
''(Level of evidence: B-R)'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''3.''' In patients with an ischemic stroke or TIA who also have diabetes, multidimensional care (ie, lifestyle counseling, medical nutritional therapy, diabetes self-management education, support, and medication) is indicated to achieve glycemic goals and to improve stroke risk factors ''(Level of evidence: C-EO)'' <nowiki>"</nowiki>
|}
<ref name="pmid34024117" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |" 4. In patients with prediabetes and ischemic stroke or TIA, lifestyle optimization (ie, healthy diet, regular physical activity, and smoking cessation) can be beneficial for the preven-tion of progression to diabetes
(Level of Evidence B-R)".
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki> 5. In patients with TIA or ischemic stroke, it is reasonable to screen for prediabetes/dia-betes using HbA1c which, among available methods (HbA1c, fasting plasma glucose, oral glucose tolerance), has the advantage of convenience because it does not require fasting and is measured in a single blood sample. (Level of Evidence C-EO)<nowiki>''</nowiki>
|}
<ref name="pmid34024117" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |" 6'''.''' In patients with an ischemic stroke or TIA who also have diabetes, the usefulness of achieving intensive glucose control (ie, HbA1c ≤7%) beyond the acute phase of the ischemic event for prevention of recurrent stroke is unknown.
(Level of Evidence B-R)".
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki> 7. In patients with prediabetes and ischemic stroke or TIA, particularly those with a body mass index (BMI) ≥35 kg/mP2, ≥35 kg/m2those <60 years of age, or women with a history of gestational diabetes, metformin may be beneficial to control blood sugar and to prevent progression to diabetes
(Level of Evidence B-R)<nowiki>''</nowiki>
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki> 8. In patients ≤6 months after TIA or ischemic stroke with insulin resistance, HbA1c <7.0%, and without heart failure or bladder cancer, treatment with pioglitazone may be consid-ered to prevent recurrent stroke
(Level of Evidence B-R)<nowiki>''</nowiki>
|}
<ref name="pmid34024117" />

=== Obesity ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>1. In patients with ischemic stroke or TIA and who are overweight or obese, weight loss is recommended to improve the ASCVD risk factor profile. (Level of evidence: B-R)<nowiki>"</nowiki>
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>2. In patients with ischemic stroke or TIA who are obese, referral to an intensive, multicompo-nent, behavioral lifestyle-modification program is recommended to achieve sustained weight loss
''(Level of evidence: B-R)'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''3.''' In patients with ischemic stroke or ASCVD, calculation of BMI is recommended at the time of their event and annually thereafter, to screen for and to classify obesity. ''(Level of evidence: C-EO)'' <nowiki>"</nowiki>
|}
<ref name="pmid34024117" />

=== Obstructive sleep apnea ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |" 1. In patients with an ischemic stroke or TIA and OSA, treatment with positive airway pressure (eg, continuous positive airway pressure [CPAP]) can be beneficial for improved sleep apnea, BP, sleepiness, and other apnea-related outcomes.
(Level of Evidence B-R)".
|}
<ref name="pmid34024117" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |" 2. In patients with an ischemic stroke or TIA, an evaluation for OSA may be considered for diagnosing sleep apnea
(Level of Evidence B-R)".
|}
<ref name="pmid34024117" />

== Management of Intracranial Large Artery Atherosclerosis. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association ==

=== Antithombotic Therapy: ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>1. In patients with a stroke or TIA caused by 50% to 99% stenosis of a major intracranial artery, aspirin 325 mg/d is recommended in preference to warfarin to reduce the risk of recurrent ischemic stroke and vascular death. (Level of evidence: B-R)<nowiki>"</nowiki>
|}
<ref name="pmid34024117" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |" 2. In patients with recent stroke or TIA (within 30 days) attributable to severe stenosis (70%–99%) of a major intracranial artery, the addition of clopidogrel 75 mg/d to aspirin for up to 90 days is reasonable to further reduce recurrent stroke risk.
(Level of Evidence B-NR)".
|}
<ref name="pmid34024117" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |" 3'''.''' In patients with recent (within 24 hours) minor stroke or high-risk TIA and concomitant ipsilateral >30% stenosis of a major intracranial artery, the addition of ticagrelor 90 mg twice a day to aspirin for up to 30 days might be considered to further reduce recurrent stroke risk.
(Level of Evidence B-R)".
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki> 4. In patients with stroke or TIA attributable to 50% to 99% stenosis of a major intracranial artery, the addition of cilostazol 200 mg/day to aspirin or clopidogrel might be considered to reduce recurrent stroke risk.
(Level of Evidence C-LD)<nowiki>''</nowiki>
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki> 5. In patients ≤6 months after TIA or ischemic stroke with insulin resistance, HbA1c <7.0%, and without heart failure or bladder cancer, treatment with pioglitazone may be consid-ered to prevent recurrent stroke
(Level of Evidence C-EO)<nowiki>''</nowiki>
|}
<ref name="pmid34024117" />

=== Risk factor Managment: ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |"6. In patients with a stroke or TIA attributable to 50% to 99% stenosis of a major intracranial artery, maintenance of SBP below 140 mm Hg, high-intensity statin therapy, and at least moderate physical activity are recom-mended to prevent recurrent stroke and vascular events. (Level of evidence: B-NR)<nowiki>"</nowiki>
|}
<ref name="pmid34024117" />

'''Angioplasty and Stenting'''
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |" 7'''.''' In patients with severe stenosis (70%-99%) of a major intracranial artery and actively progressing symptoms or recurrent TIA or stroke after the institution of aspirin and clopidogrel therapy, achievement of SBP <140 mm Hg, and high-intensity statin therapy (so-called medical failures), the usefulness of angioplasty alone or stent placement to prevent ischemic stroke in the territory of the stenotic artery is unknown
(Level of Evidence C-LD)".
|}
<ref name="pmid34024117" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightCoral" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm)
|-
| bgcolor="LightCoral" |"8'''.''' In patients with stroke or TIA attributable to severe stenosis (70%–99%) of a major intracranial artery, angioplasty and stenting should not be performed as an initial treatment, even for patients who were taking an antithrombotic agent at the time of the stroke or TIA. (''[[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:A]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightCoral" |" 9. In patients with a stroke or TIA attributable to moderate stenosis (50%–69%) of a major intracranial artery, angioplasty or stenting is associated with excess morbidity and mortality compared with medical management alone.
(Level of Evidence B-NR)".
|}
<ref name="pmid34024117" />

'''Other Procedures'''
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightCoral" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit)
|-
| bgcolor="LightCoral" |"10'''.''' In patients with stroke or TIA attributable to 50% to 99% stenosis or occlusion of a major intracranial artery, extracranial-intracra-nial bypass surgery is not recommended (''[[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B-R]])'' <nowiki>"</nowiki>
|}
<ref name="pmid34024117" />

=== EXTRACRANIAL CAROTID STENOSIS ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' In patients with a TIA or nondisabling ischemic stroke within the past 6 months and ipsilateral severe (70%–99%) carotid artery stenosis, carotid endarterectomy (CEA) is recommended to reduce the risk of future stroke, provided that perioperative morbidity and mortality risk is estimated to be <6%. (Level of evidence: A)<nowiki>"</nowiki>
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''2.''' In patients with ischemic stroke or TIA and symptomatic extracranial carotid stenosis who are scheduled for carotid artery stent-ing (CAS) or CEA, procedures should be performed by operators with established periprocedural stroke and mortality rates of <6% to reduce the risk of surgical adverse events.''(Level of evidence: A)'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''3.''' In patients with carotid artery stenosis and a TIA or stroke, intensive medical therapy, with antiplatelet therapy, lipid-lowering therapy, and treatment of hypertension, is recom-mended to reduce stroke risk (''Level of evidence: A)'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen" | <nowiki>"</nowiki>4. In patients with recent TIA or ischemic stroke and ipsilateral moderate (50%–69%) carotid steno-sis as documented by catheter-based imaging or noninvasive imaging, CEA is recommended to reduce the risk of future stroke, depending on patient-specific factors such as age, sex, and comorbidities, if the perioperative morbidity and mortality risk is estimated to be <6% ''(Level of evidence: B-R)'' <nowiki>"</nowiki>
|}
<ref name="pmid34024117" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |" 5'''. '''In patients ≥70 years of age with stroke or TIA in whom carotid revascularization is being considered, it is reasonable to select CEA over CAS to reduce the periprocedural stroke rate (Level of Evidence B-R)".
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki> 6. In patients in whom revascularization is planned within 1 week of the index stroke, it is reasonable to choose CEA over CAS to reduce the periprocedural stroke rate.
(Level of Evidence B-R)<nowiki>''</nowiki>
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki> 7. In patients with TIA or nondisabling stroke, when revascularization is indicated, it is reasonable to perform the procedure within 2 weeks of the index event rather than delay surgery to increase the likelihood of stroke-free outcome.
(Level of Evidence C-LD)<nowiki>''</nowiki>
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki> 8. In patients with symptomatic severe stenosis (≥70%) in whom anatomic or medical condi-tions are present that increase the risk for surgery (such as radiation-induced stenosis or restenosis after CEA) it is reasonable to choose CAS to reduce the periprocedural complication rate.
(Level of Evidence C-LD)<nowiki>''</nowiki>
|}
<ref name="pmid34024117" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |" 9'''.''' In symptomatic patients at average or low risk of complications associated with endovascular intervention, when the ICA stenosis is ≥70% by noninvasive imaging or >50% by catheter-based imaging and the anticipated rate of periprocedural stroke or death is <6%, CAS may be considered as an alternative to CEA for stroke prevention, particularly in patients with significant cardiovascular comorbidities predisposing to cardiovascular complications with endarterectomy
(Level of Evidence A)".
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki> 10. In patients with a recent stroke or TIA (past 6 months), the usefulness of transcarotid artery revascularization (TCAR) for prevention of recurrent stroke and TIA is uncertain.
(Level of Evidence B-NR)<nowiki>''</nowiki>
|}
<ref name="pmid34024117" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightCoral" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit)
|-
| bgcolor="LightCoral" |"11. In patients with recent TIA or ischemic stroke and when the degree of stenosis is <50%, revascularization with CEA or CAS to reduce the risk of future stroke is not recommended.. (''[[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:A]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightCoral" |" 12. In patients with a recent (within 120 days) TIA or ischemic stroke ipsilateral to atherosclerotic stenosis or occlusion of the middle cerebral or carotid artery, extracranial intracranial bypass surgery is not recommended.
(Level of Evidence B-NR)".
|}
<ref name="pmid34024117" />

=== EXTRACRANIAL VERTEBRAL ARTERY STENOSIS ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' In patients with recently symptomatic extra-cranial vertebral artery stenosis, intensive medical therapy (antiplatelet therapy, lipid lowering, BP control) is recommended to reduce stroke risk. (Level of evidence: A)<nowiki>"</nowiki>
|}
<ref name="pmid34024117" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |" 2. In patients with ischemic stroke or TIA and extracranial vertebral artery stenosis who are having symptoms despite optimal medical treatment, the usefulness of stenting is not well established.
(Level of Evidence B-R)".
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki> 3. In patients with ischemic stroke or TIA and extracranial vertebral artery stenosis who are having symptoms despite optimal medical treatment, the usefulness of open surgical procedures, including vertebral endarterectomy and vertebral artery transposition, is not well established.
(Level of Evidence C-EO)<nowiki>''</nowiki>
|}
<ref name="pmid34024117" />

=== AORTIC ARCH ATHEROSCLEROSIS ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |"1. In patients with a stroke or TIA and evidence of an aortic arch atheroma, intensive lipid management to an LDL cholesterol target <70 mg/dL is recommended to prevent recur-rent stroke(Level of evidence: B-R)<nowiki>"</nowiki>
|-
| bgcolor="LightGreen" |"2. In patients with a stroke or TIA and evidence of an aortic arch atheroma, antiplatelet therapy is recommended to prevent recurrent stroke..''(Level of evidence: C-LD)'' <nowiki>"</nowiki>
|}

=== <ref name="pmid34024117" /> ===

== 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. ==

=== Moyamoya disease ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |" 1. In patients with moyamoya disease and a history of ischemic stroke or TIA, surgical revascularization with direct or indirect extracranial intracranial bypass can be beneficial for the prevention of ischemic stroke or TIA.
(Level of Evidence C-LD)".
|}
<ref name="pmid34024117" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |" 2. In patients with moyamoya disease and a history of ischemic stroke or TIA, the use of antiplatelet therapy, typically aspirin monotherapy, for the prevention of ischemic stroke or TIA may be reasonable.
(Level of Evidence C-LD)".
|}
<ref name="pmid34024117" />

=== Ischemic Stroke Caused by Small Vessel Disease ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |" 1. In patients with ischemic stroke related to small vessel disease, the usefulness of cilostazol for secondary stroke prevention is uncertain.
(Level of Evidence B-R)".
|}

=== <ref name="pmid34024117" /> ===

=== Cardioembolism: Atrial Fibrillation ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1. ''' In patients with nonvalvular AF and stroke or TIA, oral anticoagulation (eg, apixaban, dabigatran, edoxaban, rivaroxaban, or warfarin) is recommended to reduce the risk of recurrent stroke. (Level of evidence: A)<nowiki>"</nowiki>
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''2.''' In patients with AF and stroke or TIA, oral anticoagulation is indicated to reduce the risk of recurrent stroke regardless of whether the AF pattern is paroxysmal, persistent, or permanent. ''(Level of evidence: B-R)'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''3.''' In patients with stroke or TIA and AF who do not have moderate to severe mitral stenosis or a mechanical heart valve, apixaban, dabigatran, edoxaban, or rivaroxaban is recommended in preference to warfarin to reduce the risk of recurrent stroke.
''(Level of evidence: B-R)'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen" | <nowiki>"</nowiki>'''4.''' In patients with atrial flutter and stroke or TIA, anticoagulant therapy similar to that in AF is indicated to reduce the risk of recurrent stroke. ''(Level of evidence: B-NR)'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen" | <nowiki>"</nowiki>5'''.''' In patients with AF and stroke or TIA, without moderate to severe mitral stenosis or a mechanical heart valve, who are unable to maintain a therapeutic INR level with warfarin, use of dabigatran, rivaroxaban, apixaban, or edoxaban is recommended to reduce the risk of recurrent stroke ''(Level of evidence: C-EO)'' <nowiki>"</nowiki>
|}
<ref name="pmid34024117" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |" 6. In patients with stroke at high risk of hemor-rhagic conversion in the setting of AF, it is reasonable to delay initiation of oral antico-agulation beyond 14 days to reduce the risk of ICH.
(Level of Evidence B-NR)".
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki> 7. In patients with TIA in the setting of nonvalvular AF, it is reasonable to initiate anticoagulation immediately after the index event to reduce the risk of recurrent stroke.
(Level of Evidence C-EO)<nowiki>''</nowiki>
|}
<ref name="pmid34024117" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |" 8'''. '''In patients with stroke or TIA in the setting of nonvalvular AF who have contraindications for lifelong anticoagulation but can tolerate at least 45 days, it may be reasonable to consider percutaneous closure of the left atrial appendage with the Watchman device to reduce the chance of recurrent stroke and bleeding. (Level of Evidence B-R)".
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki> 9. In patients with stroke at low risk for hemorrhagic conversion in the setting of AF, it may be reasonable to initiate anticoagulation 2 to 14 days after the index event to reduce the risk of recurrent stroke.
(Level of Evidence B-NR)<nowiki>''</nowiki>
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki> 10. In patients with AF and stroke or TIA who have end-stage renal disease or are on dialysis, it may be reasonable to use warfarin or apixaban (dose adjusted if indicated) for anticoagulation to reduce the chance of recurrent stroke.
(Level of Evidence B-NR)<nowiki>''</nowiki>
|}
<ref name="pmid34024117" />

=== Valvular disease ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>1. In patients with ischemic stroke or TIA and valvular AF (moderate to severe mitral steno-sis or any mechanical heart valve), warfarin is recommended to reduce the risk of recurrent stroke or TIA. (Level of evidence: B-R)<nowiki>"</nowiki>
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''2.''' In patients with AF and stroke or TIA, oral anticoagulation is indicated to reduce the risk of recurrent stroke regardless of whether the AF pattern is paroxysmal, persistent, or permanent. ''(Level of evidence: C-LD)'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''3.''' In patients with ischemic stroke or TIA and native aortic or nonrheumatic mitral valve disease (eg, mitral annular calcification or mitral valve prolapse) who do not have AF or another indication for anticoagulation, anti-platelet therapy is recommended to reduce the risk of recurrent stroke or TIA.
''(Level of evidence: C-EO)'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen" | <nowiki>"</nowiki>'''4.''' In patients with a bioprosthetic aortic or mitral valve, a history of ischemic stroke or TIA before valve replacement, and no other indication for anticoagulation therapy beyond 3 to 6 months from the valve placement, long-term therapy with aspirin is recommended in preference to long-term anticoagulation to reduce the risk of recur-rent stroke or TIA. ''(Level of evidence: C-EO)'' <nowiki>"</nowiki>
|}
<ref name="pmid34024117" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |" 5. In patients with ischemic stroke or TIA and IE who present with recurrent emboli and persistent vegetations despite appropriate antibiotic therapy, early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) is reasonable to reduce the risk of recurrent embolism if there is no evidence of intracranial hemorrhage or extensive neurological damage.
(Level of Evidence B-NR)".
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki> 6. In patients with history of ischemic stroke or TIA and a mechanical aortic valve, anti-coagulation with higher-intensity warfarin to achieve an INR of 3.0 (range, 2.5–3.5) or the addition of aspirin (75–100 mg/d) can be beneficial to reduce the risk of thromboem-bolic events.
(Level of Evidence C-EO)<nowiki>''</nowiki>
|}
<ref name="pmid34024117" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |" 7'''. '''In patients with ischemic stroke or TIA and native left-sided valve endocarditis who exhibit mobile vegetations >10 mm in length, early surgery (during initial hospitalization before completion of a full therapeutic course of anti-biotics) may be considered to reduce the risk of recurrent embolism if there is no evidence of intracranial hemorrhage or extensive neurologi-cal damage. (Level of Evidence B-NR)".
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki>8. In patients with ischemic stroke or TIA and IE, early valve surgery (during initial hospital-ization before completion of a full therapeutic course of antibiotics) may be considered in patients with an indication for surgery who have no evidence of intracranial hemorrhage or extensive neurological damage.
(Level of Evidence B-NR)<nowiki>''</nowiki>
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki> 9. In patients with IE and major ischemic stroke, delaying valve surgery for at least 4 weeks may be considered for patients with IE and major ischemic stroke or intracranial hemorrhage if the patient is hemodynamically stable
(Level of Evidence B-NR)<nowiki>''</nowiki>
|}
<ref name="pmid34024117" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightCoral" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm)
|-
| bgcolor="LightCoral" |"10. In patients with ischemic stroke or TIA and mechanical heart valves, treatment with dabigatran causes harm. (''[[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])'' <nowiki>"</nowiki>
|}
<ref name="pmid34024117" />

=== Left Ventricular Thrombus ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>1. In patients with stroke or TIA and LV thrombus, anticoagulation with therapeutic warfarin for at least 3 months is recommended to reduce the risk of recurrent stroke. (Level of evidence: B-NR)<nowiki>"</nowiki>
|}
<ref name="pmid34024117" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |" 2. In patients with stroke or TIA in the setting of acute MI, it is reasonable to perform advanced cardiac imaging (eg, contrasted echocardiogram or cardiac MRI) to assess for the presence of LV thrombus.
(Level of Evidence C-EO)".
|}
<ref name="pmid34024117" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |" 3. In patients with stroke or TIA and new LV thrombus (<3 months), the safety of anticoagulation with a direct oral anticoagulant to reduce the risk of recurrent stroke is uncertain. (Level of Evidence B-NR)".
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki>4. In patients with stroke or TIA in the setting of acute anterior MI with reduced ejection fraction (EF; <50%) but no evidence of LV thrombus, empirical anticoagulation for at least 3 months might be considered to reduce the risk of recurrent cardioembolic stroke.
(Level of Evidence B-NR)<nowiki>''</nowiki>
|}
<ref name="pmid34024117" />

=== Cardiomyopathy ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>1. In patients with ischemic stroke or TIA and left atrial or left atrial appendage thrombus in the setting of ischemic, nonischemic, or restrictive cardiomyopathy and LV dysfunction, anticoagulant therapy with warfarin is recommended for at least 3 months to reduce the risk of recurrent stroke or TIA (Level of evidence: C-EO)<nowiki>"</nowiki>
|}
<ref name="pmid34024117" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |" 2. In patients with ischemic stroke or TIA in the setting of a mechanical assist device, treatment with warfarin and aspirin can be beneficial to reduce the risk of recurrent stroke or TIA. (Level of Evidence C-LD)".
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki>3. In patients with ischemic stroke or TIA in the setting of LV noncompaction, treatment with warfarin can be beneficial to reduce the risk of recurrent stroke or TIA.
(Level of Evidence C-EO)<nowiki>''</nowiki>
|}

<ref name="pmid34024117" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |" 4. In patients with ischemic stroke or TIA in sinus rhythm with ischemic or nonischemic cardio-myopathy and reduced EF without evidence of left atrial or LV thrombus, the effectiveness of anticoagulation compared with antiplatelet therapy is uncertain, and the choice should be individualized. (Level of Evidence B-R)".
|}

<ref name="pmid34024117" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightCoral" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm)
|-
| bgcolor="LightCoral" |"5. In patients with stroke or TIA and LV assist devices (LVADs), treatment with dabigatran instead of warfarin for the primary or secondary prevention of ischemic stroke or TIA causes harm.
(''[[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])'' <nowiki>"</nowiki>
|}

<ref name="pmid34024117" />

=== Patent Foramen Ovale ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>1. In patients with a non-lacunar ischemic stroke of undetermined cause and a PFO, recommendations for PFO closure versus medical management should be made jointly by the patient, a cardiologist, and a neurologist, taking into account the probability of a causal role for the PFO. (Level of evidence: C-EO)<nowiki>"</nowiki>
|}
<ref name="pmid34024117" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |" 2. In patients 18 to 60 years of age with a non-lacunar ischemic stroke of undetermined cause despite a thorough evaluation and a PFO with high-risk anatomic features, it is reasonable to choose closure with a transcatheter device and long-term antiplatelet therapy over antiplatelet therapy alone for preventing recurrent stroke. (Level of Evidence B-R)".
|}

<ref name="pmid34024117" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |" 3. In patients 18 to 60 years of age with a nonlacunar ischemic stroke of undetermined cause despite a thorough evaluation and a PFO without high risk anatomic features, the benefit of closure with a transcatheter device and long-term antiplatelet therapy over antiplatelet therapy alone for preventing recurrent stroke is not well established. (Level of Evidence C-LD)".
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki>4. In patients 18 to 60 years of age with a nonlacunar ischemic stroke of undetermined cause despite a thorough evaluation and a PFO, the comparative benefit of closure with a transcatheter device versus warfarin is unknow.
(Level of Evidence C-LD)<nowiki>''</nowiki>
|}
<ref name="pmid34024117" />

=== Congenital Heart Disease ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>1. In patients with ischemic stroke or TIA and Fontan palliation, anticoagulation with warfarin is recommended to reduce the risk of recur-rent stroke or TIA. (Level of evidence: C-LD)<nowiki>"</nowiki>
|}
<ref name="pmid34024117" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |" 2. In patients with cyanotic congenital heart disease and other complex lesions, ischemic stroke, or TIA of presumed cardioembolic origin, therapy with warfarin is reasonable to reduce the risk of recurrent stroke or TIA. (Level of Evidence: C-EO)".
|}
<ref name="pmid34024117" />

=== Cardiac Tumors ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |" 1. In patients with stroke or TIA found to have a left sided cardiac tumor, resection of the tumor can be beneficial to reduce the risk of recurrent stroke. (Level of Evidence: C-LD)".
|}
<ref name="pmid34024117" />

=== Dissection ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>1. In patients with ischemic stroke or TIA after an extracranial carotid or vertebral arterial dissection, treatment with antithrombotic therapy for at least 3 months is indicated to prevent recurrent stroke or TIA. (Level of evidence: C-EO)<nowiki>"</nowiki>
|}
<ref name="pmid34024117" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |" 2. In patients with ischemic stroke or TIA who are <3 months after an extracranial carotid or vertebral arterial dissection, it is reasonable to use either aspirin or warfarin to prevent recurrent stroke or TIA. (Level of Evidence: B-R)".
|}
<ref name="pmid34024117" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |" 3. In patients with stroke or TIA and extracranial carotid or vertebral artery dissection who have recurrent events despite antithrombotic therapy, endovascular therapy may be considered to prevent recurrent stroke or TIA.. (Level of Evidence: C-LD)".
|}
<ref name="pmid34024117" />

== Hypercoagulable States. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. ==

=== Hematologic Traits ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |" 1. In patients with ischemic stroke or TIA of unknown source despite thorough diagnostic evaluation and no other thrombotic history who are found to have prothrombin 20210A mutation, activated protein C resistance, elevated factor VIII levels, or deficiencies of protein C, protein S, or antithrombin III, anti-platelet therapy is reasonable to reduce the risk of recurrent stroke or TIA.. (Level of Evidence: C-LD)".
|}
<ref name="pmid34024117" />

=== Antiphospholipid Syndrome ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>1. In patients with ischemic stroke or TIA who have an isolated antiphospholipid antibody but do not fulfill the criteria for antiphospholipid syndrome, antiplatelet therapy alone is recommended to reduce the risk of recurrent stroke (Level of evidence: B-NR)<nowiki>"</nowiki>
|}
<ref name="pmid34024117" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |" 2. In patients with ischemic stroke or TIA with confirmed antiphospholipid syndrome treated with warfarin, it is reasonable to choose a target INR between 2 and 3 over a target INR >3 to effectively balance the risk of excessive bleeding against the risk of thrombosis. (Level of Evidence B-R)".
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki>3. In patients with ischemic stroke or TIA who meet the criteria for the antiphospholipid syndrome, it is reasonable to anticoagulate with warfarin to reduce the risk of recurrent stroke or TIA.
(Level of Evidence C-LD)<nowiki>''</nowiki>
|}
<ref name="pmid34024117" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightCoral" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm)
|-
| bgcolor="LightCoral" |"4. In patients with ischemic stroke or TIA, antiphospholipid syndrome with a history of thrombosis and triple-positive antiphospholipid antibodies (ie, lupus anticoagulant, anticardiolipin, and anti– β2 glycoprotein-I), rivaroxaban is not recommended because it is associated with excess thrombotic events compared with warfarin
(''[[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])'' <nowiki>"</nowiki>
|}
<ref name="pmid34024117" />

=== Hyperhomocysteinemia ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightCoral" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit)
|-
| bgcolor="LightCoral" |"1. In patients with ischemic stroke or TIA with hyperhomocysteinemia, supplementation with folate, vitamin B6, and vitamin B12 is not effective for preventing subsequent stroke.
(''[[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])'' <nowiki>"</nowiki>
|}

<ref name="pmid34024117" />

=== Malignancy ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |" 1. In patients with ischemic stroke or TIA in the setting of AF and cancer, it is reasonable to consider anticoagulation with DOACs in preference to warfarin for stroke prevention (Level of Evidence B-NR)".
|}

<ref name="pmid34024117" />

=== Sickle Cell Disease ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |"1. In patients with sickle cell disease (SCD) and prior ischemic stroke or TIA, chronic blood transfusion(s) to reduce hemoglobin S to <30% of total hemoglobin is recommended for the prevention of recurrent ischemic stroke.(Level of evidence: B-NR)<nowiki>"</nowiki>
|}
<ref name="pmid34024117" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |" 2. In patients with SCD with prior ischemic stroke or TIA for whom transfusion therapy is not available or practical, treatment with hydroxyurea is reasonable for the prevention of recurrent ischemic stroke. (Level of Evidence B-R)".
|}

<ref name="pmid34024117" />

=== Autoinmune Vasculitis ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |"1. In patients with ischemic stroke or TIA and symptoms attributed to giant cell arteritis, immediate initiation of oral high-dose glucocorticoids is recommended to reduce recurrent stroke risk..(Level of evidence: B-NR)<nowiki>"</nowiki>
|}
<ref name="pmid34024117" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |" 2. . In patients with ischemic stroke or TIA and diagnosis of giant cell arteritis, methotrexate or tocilizumab therapy adjunctive to steroids is reasonable to lower the risk of recurrent stroke. (Level of Evidence B-NR)".
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki>3. In patients with ischemic stroke or TIA and diagnosis of primary CNS angiitis, induction therapy with glucocorticoids and/or immunosuppressants followed by long-term maintenance therapy with steroid-sparing immunosuppressants is reasonable to lower the risk of stroke recurrence.
(Level of Evidence C-LD)<nowiki>''</nowiki>
|}
<ref name="pmid34024117" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightCoral" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm)
|-
| bgcolor="LightCoral" |"4. In patients with ischemic stroke or TIA and confirmed diagnosis of giant cell arteritis, infliximab is associated with recurrent ocular symptoms and markers of disease activity and should not be administered.
(''[[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])'' <nowiki>"</nowiki>
|}
<ref name="pmid34024117" />

=== Infectious Vasculitis ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |"1. In patients with ischemic stroke or TIA and infectious vasculitides such as a varicella-zoster virus (VZV) cerebral vasculitis, neurosyphilis, or bacterial meningitis, treating the underlying infectious etiology is indicated to reduce the risk of stroke.7(Level of evidence: B-NR)<nowiki>"</nowiki>
|}

=== <ref name="pmid34024117" /> ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |" 2. In patients with ischemic stroke or TIA in the context of HIV vasculopathy, daily aspirin plus HIV viral control with combined antiretroviral therapy is reasonable to reduce the risk of recurrent stroke (Level of Evidence C-LD)".
|}

=== <ref name="pmid34024117" /> ===

=== Other Genetic disorders ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |"1. In patients with ischemic stroke or TIA and cystathionine β-synthase deficiency, pyridoxine (in responsive patients) and a low-methionine, a cysteine-enhanced diet supplemented with pyridoxine, vitamin B12, and folate are recommended to reduce plasma homocysteine to population normal levels and thereby reduce the risk of recurrent ischemic stroke.(Level of evidence: C-LD)<nowiki>"</nowiki>
|}

=== <ref name="pmid34024117" /> ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |" 2. In patients with ischemic stroke or TIA and Anderson-Fabry disease, agalsidase alfa or agalsidase beta is of uncertain value in preventing recurrent stroke or TIA. (Level of Evidence B-NR)".
|}

=== <ref name="pmid34024117" /> ===

=== Carotid Web ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |"1. In patients with a carotid web in the distribution of ischemic stroke and TIA, without other attributable causes of stroke, antiplatelet therapy is recommended to prevent recurrent ischemic stroke or TIA. (Level of evidence: B-NR)<nowiki>"</nowiki>
|}
<ref name="pmid34024117" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |" 2. In patients with the carotid web in the distribution of ischemic stroke refractory to medical management, with no other attributable cause of stroke despite comprehensive workup, carotid stenting or CEA may be considered to prevent recurrent ischemic stroke. (Level of Evidence C-LD)".
|}

=== <ref name="pmid34024117" /> ===

=== Fibromuscular Dysplasia ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |"1. In patients with fibromuscular dysplasia (FMD) and a history of ischemic stroke or TIA without other attributable causes, antiplatelet therapy, BP control, and lifestyle modification are recommended for the prevention of future ischemic events (Level of evidence: C-LD)<nowiki>"</nowiki>
|}
<ref name="pmid34024117" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |" 2. In patients with a history of ischemic stroke or TIA attributable to dissection, with FMD, and no evidence of intraluminal thrombus, it is reasonable to administer antiplatelet therapy for the prevention of future ischemic events. (Level of Evidence C-EO)".
|}
<ref name="pmid34024117" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |" 3. In patients with cervical carotid artery FMD and recurrent ischemic stroke without other attributable causes despite optimal medical management, carotid angioplasty with or without stenting may be reasonable to prevent ischemic stroke. (Level of Evidence C-LD)".
|}

=== <ref name="pmid34024117" /> ===

=== Dolichoectasia ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |" 1. In patients with vertebrobasilar dolichoectasia and a history of ischemic stroke or TIA without other attributable causes, the use of antiplatelet or anticoagulant therapy is reasonable for the prevention of recurrent ischemic events. (Level of Evidence C-LD)".
|}
<ref name="pmid34024117" />

=== Embolic Stroke of Undetermined Source ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightCoral" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit)
|-
| bgcolor="LightCoral" |".1 In patients with ESUS, treatment with direct oral anticoagulants is not recommended to reduce risk of secondary stroke. (''[[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightCoral" |" 2. In patients with ESUS, treatment with ticagrelor is not recommended to reduce the risk of secondary stroke
(Level of Evidence B-NR)".
|}
<ref name="pmid34024117" />

== Antithrombotic Medications in Secondary Stroke Prevention. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. ==
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>1. In patients with noncardioembolic ischemic stroke or TIA, antiplatelet therapy is indicated in preference to oral anticoagulation to reduce the risk of recurrent ischemic stroke and other cardiovascular events while minimizing the risk of bleeding. (Level of evidence: A)<nowiki>"</nowiki>
|-
| bgcolor="LightGreen" |"2. For patients with noncardioembolic ischemic stroke or TIA, aspirin 50 to 325 mg daily, clopidogrel 75 mg, or the combination of aspi-rin 25 mg and extended-release dipyridamole 200 mg twice daily is indicated for secondary prevention of ischemic stroke. ''(Level of evidence: A)'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen" |" 3. For patients with recent minor (NIHSS score ≤3) noncardioembolic ischemic stroke or high-risk TIA (ABCD2 score ≥4), DAPT (aspirin plus clopidogrel) should be initiated early (ideally within 12–24 hours of symptom onset and at least within 7 days of onset) and continued for 21 to 90 days, followed by SAPT, to reduce the risk of recurrent ischemic stroke.
''(Level of evidence: A)'' <nowiki>"</nowiki>
|}

=== <ref name="pmid34024117" /> ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |" 4. For patients with recent (< 24 hours) minor to moderate stroke (NIHSS score ≤5), high-risk TIA (ABCD2 score ≥6), or symptomatic intracranial or extracranial ≥30% stenosis of an artery that could account for the event, DAPT with ticagrelor plus aspirin for 30 days may be considered to reduce the risk of 30-day recur-rent stroke but may also increase the risk of serious bleeding events, including ICH. (Level of Evidence B-NR)".
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki>5. For patients already taking aspirin at the time of non-cardioembolic ischemic stroke or TIA, the effectiveness of increasing the dose of aspirin or changing to another antiplatelet medication is not well established.
(Level of Evidence C-LD)<nowiki>''</nowiki>
|}

=== <ref name="pmid34024117" /> ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightCoral" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm)
|-
| bgcolor="LightCoral" |".6. For patients with non-cardioembolic ischemic stroke or TIA, the continuous use of DAPT (aspirin plus clopidogrel) for >90 days or the use of triple antiplatelet therapy is associated with excess risk of hemorrhage. (''[[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki>
|}

=== <ref name="pmid34024117" /> ===

== Secondary Prevention. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. ==

=== Health Systems–Based Interventions for Secondary Stroke Prevention ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>1. In patients with ischemic stroke or TIA, voluntary hospital-based or outpatient-focused quality monitoring and improvement programs are recommended to improve short-term and long-term adherence to nationally accepted, evidence-based guidelines for secondary stroke prevention. (Level of evidence: C-EO)<nowiki>"</nowiki>
|}
<ref name="pmid34024117" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |"2. In patients with ischemic stroke or TIA, a multidisciplinary outpatient team-based approach (ie, care provision with active medication adjustment from advanced practice providers, nurses, or pharmacists) can be effective to control BP, lipids, and other vascular risk factors.
(Level of Evidence B-R)".
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki>3. In patients presenting to their primary care provider as the first contact after TIA or minor stroke, it is reasonable to use a decision sup-port tool that improves diagnostic accuracy, stratifies patients in risk categories to support appropriate triage, and prompts the initiation of medications and counseling for lifestyle modification for secondary stroke prevention to reduce the 90-day risk of recurrent stroke or TIA.
(Level of Evidence B-R)<nowiki>''</nowiki>
|}
<ref name="pmid34024117" />

=== Interventions Aimed at Changing Patient Behavior ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>1. In patients with ischemic stroke or TIA, behavior change interventions targeting stroke literacy, lifestyle factors, and medication adherence are recommended to reduce cardiovascular events. (Level of evidence: B-R)<nowiki>"</nowiki>
|}
<ref name="pmid34024117" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |"2. In patients with ischemic stroke or TIA, teaching self-management skills or using behavior change theory (eg, motivational interviewing) can be beneficial in improving medication adherence (Level of Evidence B-R)".
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki>3. In patients with stroke or TIA, combined exercise-based and behavior change interventions are probably indicated in preference to behavior interventions alone, exercise interventions alone, or usual care to reduce physiological stroke risk factors such as SBP
(Level of Evidence B-R)<nowiki>''</nowiki>
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki> 4. In patients with TIA or nondisabling stroke, engagement in targeted secondary prevention programs (eg, cardiac rehabilitation programs or exercise and lifestyle counseling programs) can be beneficial to reduce risk factors and recurrent ischemic events. (Level of Evidence B-R)<nowiki>''</nowiki>
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki>5. For patients with disabling stroke who are discharged from acute services, engaging in targeted secondary prevention programs (eg, an adapted cardiac rehabilitation program or structured exercise including aerobic activity and healthy lifestyle counseling) can be beneficial to reduce vascular risk factors and mortality.
(Level of Evidence B-NR)<nowiki>''</nowiki>
|}
<ref name="pmid34024117" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightCoral" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit)
|-
| bgcolor="LightCoral" |"6. In patients with stroke or TIA, provision of health information or advice about stroke prevention is essential; however, information or advice alone, in the absence of a behavioral intervention, is not an effective means to change modifiable, lifestyle-related risk factors in order to reduce future ischemic events (''[[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])'' <nowiki>"</nowiki>
|}
<ref name="pmid34024117" />

=== Health Equity ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>1. In patients with stroke or TIA, evaluating and addressing social determinants of health (eg, literacy level, language proficiency, medication affordability, food insecurity, housing, and transportation barriers) when managing stroke risk factors is recommended to reduce healthcare disparities. (Level of evidence: C-EO)<nowiki>"</nowiki>
|-
| bgcolor="LightGreen" |"2. In patients with stroke or TIA, monitoring the achievement of nationally accepted, evidence-based performance measures is recommended to allow inequities to be identified and addressed. ''(Level of evidence: C-EO)'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen" |"3. In patients with stroke or TIA, systematic adoption of the Agency for Healthcare Research and Quality Universal Precautions Toolkit for Health Literacy is recommended to integrate health literacy into the secondary prevention of stroke.
''(Level of evidence: C-EO)'' <nowiki>"</nowiki>
|}
<ref name="pmid34024117" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |"4. In patients from urban, predominantly minority, or low-socioeconomic-status groups with stroke or TIA, the optimal intervention model for improving stroke risk factor control and reducing disparities is unknown. (Level of Evidence B-R)".
|}
<ref name="pmid34024117" />

== References: ==

AHA, ASA guidelines for stroke

2023-01-19T15:03:08Z

Jair Basantes de la Calle: /* Left Ventricular Thrombus */

AHA, ASA guidelines for stroke

2023-01-19T14:30:06Z

Jair Basantes de la Calle: /* Ischemic Stroke Caused by Small Vessel Disease */

AHA, ASA guidelines for stroke

2023-01-19T01:09:59Z

Jair Basantes de la Calle: /* Moyamoya disease */

AHA, ASA guidelines for stroke

2023-01-19T00:49:04Z

Jair Basantes de la Calle: /* [1] */

AHA, ASA guidelines for stroke

2023-01-19T00:43:37Z

Jair Basantes de la Calle: /* EXTRACRANIAL VERTEBRAL ARTERY STENOSIS */

AHA, ASA guidelines for stroke

2023-01-19T00:41:52Z

Jair Basantes de la Calle: /* EXTRACRANIAL CAROTID STENOSIS */

AHA, ASA guidelines for stroke

2023-01-19T00:35:28Z

Jair Basantes de la Calle: /* EXTRACRANIAL CAROTID STENOSIS */

AHA, ASA guidelines for stroke

2023-01-19T00:32:04Z

Jair Basantes de la Calle: /* DIAGNOSTIC EVALUATION FOR SECONDARY STROKE PREVENTION */

AHA, ASA guidelines for stroke

2023-01-19T00:11:20Z

Jair Basantes de la Calle: /* References: */

AHA, ASA guidelines for stroke

2023-01-19T00:04:31Z

Jair Basantes de la Calle: /* Risk factor Managment: */

AHA, ASA guidelines for stroke

2023-01-19T00:03:36Z

Jair Basantes de la Calle: /* References: */

AHA, ASA guidelines for stroke

2023-01-18T23:44:44Z

Jair Basantes de la Calle: /* References: */

AHA, ASA guidelines for stroke

2023-01-18T22:51:57Z

Jair Basantes de la Calle: /* References: */

AHA, ASA guidelines for stroke

2023-01-18T22:43:04Z

Jair Basantes de la Calle: /* DIAGNOSTIC EVALUATION FOR SECONDARY STROKE PREVENTION */

AHA, ASA guidelines for stroke

2023-01-18T21:31:39Z

Jair Basantes de la Calle: /* References: */

AHA, ASA guidelines for stroke

2023-01-18T21:23:38Z

Jair Basantes de la Calle: /* DIAGNOSTIC EVALUATION FOR SECONDARY STROKE PREVENTION */

AHA, ASA guidelines for stroke

2023-01-18T21:23:12Z

Jair Basantes de la Calle: /* DIAGNOSTIC EVALUATION FOR SECONDARY STROKE PREVENTION */

AHA, ASA guidelines for stroke

2023-01-18T21:21:42Z

Jair Basantes de la Calle: /* DIAGNOSTIC EVALUATION FOR SECONDARY STROKE PREVENTION */

AHA, ASA guidelines for stroke

2023-01-18T21:17:46Z

Jair Basantes de la Calle: /* DIAGNOSTIC EVALUATION FOR SECONDARY STROKE PREVENTION

AHA, ASA guidelines for stroke

2023-01-18T21:17:12Z

Jair Basantes de la Calle: /* DIAGNOSTIC EVALUATION FOR SECONDARY STROKE PREVENTION */

AHA, ASA guidelines for stroke

2023-01-18T21:16:27Z

Jair Basantes de la Calle: /* DIAGNOSTIC EVALUATION FOR SECONDARY STROKE PREVENTION */

AHA, ASA guidelines for stroke

2023-01-18T21:15:32Z

Jair Basantes de la Calle: /* DIAGNOSTIC EVALUATION FOR SECONDARY STROKE PREVENTION */

AHA, ASA guidelines for stroke

2023-01-18T21:09:43Z

Jair Basantes de la Calle: /* DIAGNOSTIC EVALUATION FOR SECONDARY STROKE PREVENTION */

AHA, ASA guidelines for stroke

2023-01-18T21:09:25Z

Jair Basantes de la Calle: /* DIAGNOSTIC EVALUATION FOR SECONDARY STROKE PREVENTION */

AHA, ASA guidelines for stroke

2023-01-18T21:09:11Z

Jair Basantes de la Calle: /* DIAGNOSTIC EVALUATION FOR SECONDARY STROKE PREVENTION */

AHA, ASA guidelines for stroke

2023-01-18T21:08:33Z

Jair Basantes de la Calle: /* DIAGNOSTIC EVALUATION FOR SECONDARY STROKE PREVENTION */

AHA, ASA guidelines for stroke

2023-01-18T21:02:30Z

Jair Basantes de la Calle: /* DIAGNOSTIC EVALUATION FOR SECONDARY STROKE PREVENTION */

AHA, ASA guidelines for stroke

2023-01-18T21:02:11Z

Jair Basantes de la Calle: /* DIAGNOSTIC EVALUATION FOR SECONDARY STROKE PREVENTION */

AHA, ASA guidelines for stroke

2023-01-18T21:01:37Z

Jair Basantes de la Calle: /* Overview */

AHA, ASA guidelines for stroke

2023-01-18T20:51:36Z

Jair Basantes de la Calle: /* AHA/ASA Guideline Recommendations For Prevention of Stroke in Women (2014) */

__NOTOC__
{{AHA, ASA stroke guidelines}}
{{CMG}}; {{AE}}; {{TarekNafee}}
==Overview==
==Guidelines==
== AHA/ASA Guideline Recommendations==

{{Reflist|2}}

{{WH}}{{WS}}
[[Category:Cardiology]]
[[Category:Neurology]]

AHA/ASA guidelines for stroke

2023-01-18T20:46:21Z

Jair Basantes de la Calle: Jair Basantes de la Calle moved page AHA/ASA guidelines for stroke to AHA, ASA guidelines for stroke

#REDIRECT [[AHA, ASA guidelines for stroke]]

AHA, ASA guidelines for stroke

2023-01-18T20:46:21Z

Jair Basantes de la Calle: Jair Basantes de la Calle moved page AHA/ASA guidelines for stroke to AHA, ASA guidelines for stroke

__NOTOC__
{{AHA, ASA stroke guidelines}}
{{CMG}}; {{AE}}; {{TarekNafee}}
==Overview==
==Guidelines==
== AHA/ASA Guideline Recommendations For Prevention of Stroke in Women (2014)==
===[[AHA/ASA guideline recommendations for prevention of stroke in women overview|Overview]]===
===Risk Factors===
====Sex-Specific Risk Factors====
[[AHA/ASA guideline recommendations for prevention of stroke in women pregnancy and complications|Pregnancy and Complications]] | [[AHA/ASA guideline recommendations for prevention of stroke in women cerebral venous thrombosis|Cerebral Venous Thrombosis]] | [[AHA/ASA guideline recommendations for prevention of stroke in women oral contraceptives|Oral Contraceptives]] | [[AHA/ASA guideline recommendations for prevention of stroke in women menopause and postmenopausal hormonal therapy|Menopause and Postmenopausal Hormonal Therapy]]
====Risk Factors Commoner Among Women====
[[AHA/ASA guideline recommendations for prevention of stroke in women migraine with aura|Migraine with Aura]] | [[AHA/ASA guideline recommendations for prevention of stroke in women obesity, metabolic syndrome, and lifestyle factors|Obesity, Metabolic Syndrome, and Lifestyle Factors]] | [[AHA/ASA guideline recommendations for prevention of stroke in women atrial fibrillation|Atrial Fibrillation]]
===[[AHA/ASA guideline recommendations for prevention of stroke in women prevention|Prevention]]===

==References==
{{Reflist|2}}

{{WH}}{{WS}}
[[Category:Cardiology]]
[[Category:Neurology]]

AHA, ASA guidelines for stroke

2023-01-18T20:44:42Z

Jair Basantes de la Calle:

Lower gastrointestinal bleeding initial resuscitation

2023-01-18T19:52:18Z

Jair Basantes de la Calle: /* Risk stratification */

__NOTOC__
{{Lower gastrointestinal bleeding}}
{{CMG}} ; {{AE}} {{ADG}}
==Overview==
The aims of treatment in a patient presenting with lower gastrointestinal bleeding are to resuscitate the patient, identify the source of blood loss and stop any ongoing bleeding, and reduce the risk of a recurrent bleed. It is essential to identify patients who are high risk. This would include elderly patients; those with severe ongoing bleeding or recurrent bleeding; and patients with multiple comorbid conditions, in particular, those patients with cardiac, renal, respiratory, and liver disease. Treatment depends on the mode of presentation, the severity of the bleed, and the underlying pathology. Bleeding points can be treated with endoscopy, interventional radiology, or surgery. After identification of the source of bleeding using endoscopy, therapeutic options include monopolar or bipolar diathermy, argon plasma coagulation (APC), epinephrine injections, and endoloops and hemoclips, used individually or in combination. These methods can be used to treat many of the causes of LGIB, including diverticular bleeding, angiodysplasia, radiation proctitis, and post-polypectomy bleeding
interventional radiology can be used to visualize a bleeding vessel and to stop the bleeding through embolization of the vessel. Surgery may be required if less invasive measures cannot be applied or are not effective.

==Initial Resuscitation==
===Initial Evaluation===
*In patients with acute lower gastrointestinal bleeding who are unstable rapid assessment and resuscitation should be initiated even before diagnostic evaluation.<ref name="pmid26925883">{{cite journal |vauthors=Strate LL, Gralnek IM |title=ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding |journal=Am. J. Gastroenterol. |volume=111 |issue=4 |pages=459–74 |year=2016 |pmid=26925883 |pmc=5099081 |doi=10.1038/ajg.2016.41 |url=}}</ref><ref name="pmid19881516">{{cite journal |vauthors=Barnert J, Messmann H |title=Diagnosis and management of lower gastrointestinal bleeding |journal=Nat Rev Gastroenterol Hepatol |volume=6 |issue=11 |pages=637–46 |year=2009 |pmid=19881516 |doi=10.1038/nrgastro.2009.167 |url=}}</ref><ref name="pmid18346685">{{cite journal |vauthors=Barnert J, Messmann H |title=Management of lower gastrointestinal tract bleeding |journal=Best Pract Res Clin Gastroenterol |volume=22 |issue=2 |pages=295–312 |year=2008 |pmid=18346685 |doi=10.1016/j.bpg.2007.10.024 |url=}}</ref><ref name="pmid26925883">{{cite journal |vauthors=Strate LL, Gralnek IM |title=ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding |journal=Am. J. Gastroenterol. |volume=111 |issue=4 |pages=459–74 |year=2016 |pmid=26925883 |pmc=5099081 |doi=10.1038/ajg.2016.41 |url=}}</ref><ref name="pmid24294124">{{cite journal |vauthors=Raphaeli T, Menon R |title=Current treatment of lower gastrointestinal hemorrhage |journal=Clin Colon Rectal Surg |volume=25 |issue=4 |pages=219–27 |year=2012 |pmid=24294124 |pmc=3577609 |doi=10.1055/s-0032-1329393 |url=}}</ref><ref name="pmid23737154">{{cite journal |vauthors=Ghassemi KA, Jensen DM |title=Lower GI bleeding: epidemiology and management |journal=Curr Gastroenterol Rep |volume=15 |issue=7 |pages=333 |year=2013 |pmid=23737154 |pmc=3857214 |doi=10.1007/s11894-013-0333-5 |url=}}</ref><ref name="pmid21603524">{{cite journal |vauthors=Beck DE, Margolin DA, Whitlow CB, Hammond KL |title=Evaluation and management of gastrointestinal bleeding |journal=Ochsner J |volume=7 |issue=3 |pages=107–13 |year=2007 |pmid=21603524 |pmc=3096402 |doi= |url=}}</ref><ref name="pmid23018607">{{cite journal |vauthors=Triadafilopoulos G |title=Management of lower gastrointestinal bleeding in older adults |journal=Drugs Aging |volume=29 |issue=9 |pages=707–15 |year=2012 |pmid=23018607 |doi=10.1007/s40266-012-0008-1 |url=}}</ref>
*The initial steps in the management of a patient with lower gastrointestinal bleeding are to assess the severity of bleeding, and then institute fluid and blood resuscitation as needed.
*Once hemodynamic stability is achieved, nasogastric lavage should be performed to rule of upper GI source.
*Equilibration between the intravascular and extravascular volumes cannot be achieved until 24 to 72 hours after bleeding has occurred.

===Role of Nasogastric tube (NGT)===
*Nasogastric tube (NGT) lavage is recommended in all patients with lower gastrointestinal bleeding once the patient is stabilized.
*A carefully placed nasogastric tube (NGT) with irrigation and aspiration of bile is necessary to ensure sampling of duodenal contents.
*If there is a bloody NGT aspirate then an esophagogastroduodenoscopy (EGD) is warranted (11 to 15% of patients despite “negative” NGT aspirates are due to upper GI bleeding).
*Obtaining clear fluid favors a lower GI source of bleeding.
{| border="1" cellpadding="5" cellspacing="0" align="center" |class="wikitable"
! colspan="2" style="background:#efefef;" | Workup and Initial Management
|-
|I'''nitial Evaluation'''
|
* Airway Breathing, Circulation
|-
|'''Supportive Therapy'''
|
* Ensure patent and protected airway

* [[Intubation|Intubate]] if needed
* Consider [[mechanical ventilation]]

* 2 large-bore, peripheral intravenous lines

* Can consider [[Central venous catheter|large-bore central venous catheter]] or intraosseous line if rapid transfuser will be needed
|-
|'''Blood transfusion'''
|
* Resuscitate with 1:1:1 of packed red blood cells (PRBCs) to fresh frozen plasma (FFP) to platelets.

* Consider massive transfusion protocol

* Res:Low riskto a target hemoglobin of 7 mg/dL.

* Consider Sengstaken-Blakemore tube for control of immediately life-threatening upper GI bleeding
|}
===Assessment of severity of bleeding===
{| border="1" cellpadding="5" cellspacing="0" align="center" |class="wikitable"
! colspan="1" style="background:#efefef;" | Bleeding severity
! colspan="1" style="background:#efefef;" | Vital signs
! colspan="1" style="background:#efefef;" | Blood loss
|-
|Minor
|Normal
|<10%
|-
|Moderate
|Postural hypotension
|10-20%
|-
|Severe
|Shock
|>25%
|}
===Fluid resuscitation===
*Two large caliber (16-gauge) peripheral catheters or a [[Central venous catheter|central venous line]] should be inserted in patients who are [[hemodynamically unstable]].
*The rate of fluid resuscitation is proportional to the severity of [[bleeding]] with the goal of restoring and maintaining the patient’s [[blood pressure]].
*Infusion of 500 mL of [[normal saline]] or lactated [[Ringer's lactate|Ringer's solution]] over 30 minutes is preferred treatment for patients with [[Bleeding|active bleeding]] before [[Blood type|blood type matching]] and blood [[transfusion]].
*Intensive monitoring with a [[pulmonary artery catheter]] is recommended to monitor the response of initial resuscitation efforts and any complications of fluid overload.
*If the blood pressure fails to respond to initial resuscitation, the rate of fluid administration should be increased and urgent intervention (eg, angiography) considered.

===Blood transfusion===
*Patients with severe [[bleeding]] need to be transfused.<ref name="pmid24063362">{{cite journal |vauthors=Al-Jaghbeer M, Yende S |title=Blood transfusion for upper gastrointestinal bleeding: is less more again? |journal=Crit Care |volume=17 |issue=5 |pages=325 |year=2013 |pmid=24063362 |pmc=4056793 |doi=10.1186/cc13020 |url=}}</ref><ref name="pmid23281973">{{cite journal |vauthors=Villanueva C, Colomo A, Bosch A, Concepción M, Hernandez-Gea V, Aracil C, Graupera I, Poca M, Alvarez-Urturi C, Gordillo J, Guarner-Argente C, Santaló M, Muñiz E, Guarner C |title=Transfusion strategies for acute upper gastrointestinal bleeding |journal=N. Engl. J. Med. |volume=368 |issue=1 |pages=11–21 |year=2013 |pmid=23281973 |doi=10.1056/NEJMoa1211801 |url=}}</ref>
*[[Fresh frozen plasma|Fresh frozen plasma,]] [[platelets]], or both should be given to patients with [[coagulopathy]] who are actively bleeding and to those who have received more than 10 units of packed [[erythrocytes]].

{| border="1" cellpadding="5" cellspacing="0" align="center" |class="wikitable"
! colspan="2" style="background:#efefef;" |Indications for transfusion
|-
! colspan="1" style="background:#efefef;" |Age
! colspan="1" style="background:#efefef;" |Target Hematocrit
|-
|Elderly patient ( >45)
|30%
|-
|Younger patient (<45)
|25%
|-
|Patients with portal hypertension
|28%
|}

===Triage and consultations ===
*All patients with visible rectal bleeding warrants an immediate evaluation in all cases. The timing and setting of the evaluation depends upon the severity of bleeding and the patient's comorbid illnesses.
*A gastroenterology consultation should be obtained early in the hospital course of patients with acute lower GI bleeding.
{| border="1" cellpadding="5" cellspacing="0" align="center" |class="wikitable"
!colspan="1" style="background:#efefef;" |Evaluation setting
!colspan="1" style="background:#efefef;" |Patient catagories
|-
|ICU
|Patients with high-risk features.
|-
|Outpatient
|Patients with low-risk features.†
|-
|Regular Ward
|Most other patients can be admitted to a regular medical ward.♦

|-
| colspan="2" style="background:#efefef;"|
* '''†''': Low-risk features include a young, otherwise healthy patient with minor, self-limited rectal bleeding suspected to be from an anal source)

* ♦: Requires continuous electrocardiogram monitoring and pulse oximetry.
|}

===Risk stratification===
*Clinical features can predict the risk of complications in patients with presumed acute lower GI bleeding. These features can also be used to categorize patients as either low or high risk.
*The presence of more number of high-risk features directly correlates with the likelihood of a poor outcome.
{| border="1" cellpadding="5" cellspacing="0" align="center" |class="wikitable"
! colspan="1" style="background:#efefef;" |High-risk features
|-
|
*Hemodynamic instability (hypotension, tachycardia, orthostasis, syncope)
*Persistent bleeding
*Significant comorbid illnesses
*Advanced age
*Bleeding that occurs in a patient who is hospitalized for another reason
*A prior history of bleeding from diverticulosis or angiodysplasia
*Current aspirin use
*Prolonged prothrombin time
*A non-tender abdomen
*Anemia
*An elevated blood urea nitrogen level
*An abnormal white blood cell count
|}
[[File:Lower GI bleeding.png|alt=Lower GI bleeding|thumb|Lower GI bleeding]]

==References==
{{reflist|2}}

File:Lower GI bleeding.png

2023-01-18T19:52:05Z

Jair Basantes de la Calle:

Lower GI bleeding

Commotio cordis primary prevention

2023-01-11T23:49:19Z

Jair Basantes de la Calle: /* Primary Prevention */

__NOTOC__
{{Commotio cordis}}
{{CMG}}

Please help WikiDoc by adding more content here. It's easy! Click [[Help:How_to_Edit_a_Page|here]] to learn about editing.
==Primary Prevention==
[[Image:Sports-dress-codes.jpg|thumb|left|300px|Equipment and dress used in several sports. clearly demonstrating the lack of protection against chest concussion. From left to right, top to bottom: boxing, field hockey, baseball, karate, cricket, lacrosse and soccer.]] The mandatory use of heavily padded special vests in front of the thorax is generally sufficient to prevent high energy impacts to the precordium. The problem with many sports such as soccer, baseball and karate is that, despite the danger posed by a multitude of punches, kicks, pads, mallets, bats, pucks and balls moving at high speeds, etc., their dress codes represent an obstacle to the use of mechanical protection to the precordium for all players, or at least for goalkeepers, batters, ball catchers, etc.

For example, boxing traditionally requires a naked chest, cricket gear protects the legs but not the chest, and soccer has practically no protection gear at all; although the ball weighs 450 grams, may reach speeds of 30 meters per second, and barrier defenses actually encourage the reception of the ball against the chest.

Parents of children active in these sports are advised to adopt simple protective measures, particularly in informal "backyard" games, which are often much more dangerous than formal ones, which require some protection.

According to data from the Commotio Cordis Registry, chest guards and safety baseballs are not a guarantee against commotio cordis. In 37% of commotio cordis incidents in competitive sports, chest protection was used. Again, it is impossible to evaluate these results in terms of danger without knowing the proportional frequency of impacts with or without chest protection. It is obvious that commotio cordis cannot be completely avoided, even with chest protection <ref name="pmid266216532">{{cite journal| author=Link MS, Estes NA, Maron BJ, American Heart Association Electrocardiography and Arrhythmias Committee of Council on Clinical Cardiology, Council on Cardiovascular Disease in Young, Council on Cardiovascular and Stroke Nursing, Council on Functional Genomics and Translational Biology, and American College of Cardiology| title=Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 13: Commotio Cordis: A Scientific Statement From the American Heart Association and American College of Cardiology. | journal=Circulation | year= 2015 | volume= 132 | issue= 22 | pages= e339-42 | pmid=26621653 | doi=10.1161/CIR.0000000000000249 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26621653 }}</ref>

== Resume of activities ==
In order to rule out structural heart disease, commotio cordis patients must have a cardiac workup. This includes stress tests, ambulatory ECG monitoring, echocardiograms, magnetic resonance imaging, and ECGs. In the presence of characteristic electrocardiographic signs, pharmacological testing for Brugada and long-QT syndromes should also be taken into consideration. Even genetic testing might be taken into consideration when long-QT syndrome is a possible differential diagnosis. Implantable cardioverter defibrillators are not advised for commotio cordis survivors if there is no underlying cardiac illness <ref name="pmid266216532" />

== References ==
{{reflist|2}}
{{WH}}
{{WS}}
[[Category:Cardiology]]
[[Category:Emergency medicine]]
[[Category:Sports medicine]]
[[Category:Death]]
[[Category:Chest trauma]]
[[Category:Needs overview]]
[[Category:Needs content]]

Commotio cordis primary prevention

2023-01-11T23:42:53Z

Jair Basantes de la Calle: /* Primary Prevention */

__NOTOC__
{{Commotio cordis}}
{{CMG}}

Please help WikiDoc by adding more content here. It's easy! Click [[Help:How_to_Edit_a_Page|here]] to learn about editing.
==Primary Prevention==
[[Image:Sports-dress-codes.jpg|thumb|left|300px|Equipment and dress used in several sports. clearly demonstrating the lack of protection against chest concussion. From left to right, top to bottom: boxing, field hockey, baseball, karate, cricket, lacrosse and soccer.]] The mandatory use of heavily padded special vests in front of the thorax is generally sufficient to prevent high energy impacts to the precordium. The problem with many sports such as soccer, baseball and karate is that, despite the danger posed by a multitude of punches, kicks, pads, mallets, bats, pucks and balls moving at high speeds, etc., their dress codes represent an obstacle to the use of mechanical protection to the precordium for all players, or at least for goalkeepers, batters, ball catchers, etc.

For example, boxing traditionally requires a naked chest, cricket gear protects the legs but not the chest, and soccer has practically no protection gear at all; although the ball weighs 450 grams, may reach speeds of 30 meters per second, and barrier defenses actually encourage the reception of the ball against the chest.

Parents of children active in these sports are advised to adopt simple protective measures, particularly in informal "backyard" games, which are often much more dangerous than formal ones, which require some protection.

According to data from the Commotio Cordis Registry, chest guards and safety baseballs are not a guarantee against commotio cordis. In 37% of commotio cordis incidents in competitive sports, chest protection was used. Again, it is impossible to evaluate these results in terms of danger without knowing the proportional frequency of impacts with or without chest protection. It is obvious that commotio cordis cannot be completely avoided, even with chest protection <ref name="pmid266216532">{{cite journal| author=Link MS, Estes NA, Maron BJ, American Heart Association Electrocardiography and Arrhythmias Committee of Council on Clinical Cardiology, Council on Cardiovascular Disease in Young, Council on Cardiovascular and Stroke Nursing, Council on Functional Genomics and Translational Biology, and American College of Cardiology| title=Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 13: Commotio Cordis: A Scientific Statement From the American Heart Association and American College of Cardiology. | journal=Circulation | year= 2015 | volume= 132 | issue= 22 | pages= e339-42 | pmid=26621653 | doi=10.1161/CIR.0000000000000249 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26621653 }}</ref>
==References==
{{reflist|2}}
{{WH}}
{{WS}}
[[Category:Cardiology]]
[[Category:Emergency medicine]]
[[Category:Sports medicine]]
[[Category:Death]]
[[Category:Chest trauma]]
[[Category:Needs overview]]
[[Category:Needs content]]

Commotio cordis causes

2023-01-11T23:29:05Z

Jair Basantes de la Calle: /* Causes */

__NOTOC__
{{Commotio cordis}}
{{CMG}}

Please help WikiDoc by adding more content here. It's easy! Click [[Help:How_to_Edit_a_Page|here]] to learn about editing.
==Causes==
Commotio cordis may occur also in other situations, such as in children who are punished with blows over the precordium, cases of torture, frontal collisions of motor vehicles (the impact of the steering wheel against the thorax, although this has decreased substantially with the use of safety belts and air bags).

Cases of commotio cordis have been recorded in people who were shot by firearms over the precordium and were using body armour<ref>Cannon L. Behind armour blunt trauma--an emerging problem. ''J R Army Med Corps.'' 2001 Feb;147(1):87-96. Review. PMID 11307682</ref>, thus stopping the bullet but causing a mechanical impact to the thorax (the so-called Behind Armour Blunt Trauma or BABT); or after being hit by less-lethal crowd control firearm shots using rubber bullets or plastic bullets<ref>Hiss J, Hellman FN, Kahana T. Rubber and plastic ammunition lethal injuries: the Israeli experience. ''Med Sci Law.'' 1997 Apr;37(2):139-44. PMID 9149508</ref>. The incidence of commotio codis is less than 30 cases per year<ref name="pmid30252270">{{cite journal| author=| title=StatPearls | journal= | year= 2022 | volume= | issue= | pages= | pmid=30252270 | doi= | pmc= | url= }}</ref>. It is estimated that about 50% of cases are related to competitive sports. Another 25% of events are related to recreational activities, especially for those younger than 10 years old. Contrasty, the other percent of cases are related with another kind of chest trauma <ref name="pmid: 20220186"><pmid>20220186</pmid></ref>.

In contrast, the [[precordial thump]] (hard blows given over the precordium with a closed fist in order to revert [[cardiac arrest]]) is a sanctioned procedure for emergency resuscitation by trained health professionals witnessing a monitored arrest when no equipment is at hand, endorsed by the latest guidelines of the International Liaison Committee on Resuscitation. It has been discussed controversially, as - in particular in severe hypoxia- it may cause the opposite effect (i.e., a worsening of rhythm- commotio cordis). In a normal adult, the energy range involved in the [[precordial thump]] is 5-10 times below that associated with commotio cordis<ref>Kohl P, Sachs F & Franz M (eds): ''Cardiac Mechano-Electric Feedback and Arrhythmias: from Pipette to Patient''. Elsevier (Saunders), Philadelphia 2005 ISBN 9781416000341 </ref>.
==References==
{{reflist|2}}
{{WH}}
{{WS}}
[[Category:Cardiology]]
[[Category:Emergency medicine]]
[[Category:Sports medicine]]
[[Category:Death]]
[[Category:Chest trauma]]
[[Category:Needs content]]
[[Category:Needs causes]]

Upper gastrointestinal bleeding initial resuscitation

2022-12-29T13:56:00Z

Jair Basantes de la Calle: /* National Institute for Health and Care Excellence (NICE) guidline */

__NOTOC__
{{Upper gastrointestinal bleeding}}
{{CMG}} ; {{AE}} {{ADG}}
==Overview==
In patients with acute upper GI bleeding who are unstable rapid assessment and [[resuscitation]] should be initiated even before diagnostic evaluation. The initial steps in the management of a patient with [[Upper gastrointestinal bleeding|UGIB]] is to assess the [[Bleeding (Excessive)|severity of bleeding,]] and then institute fluid and blood resuscitation as needed. Once hemodynamic stability is achieved, a proper clinical history, [[physical examination]], and initial laboratory findings are crucial not only in determining the likely sources of bleeding but also in directing the appropriate intervention. Equilibration between the intravascular and extravascular volumes cannot be achieved until 24 to 72 hours after bleeding has occurred. [[Nasogastric tube|Nasogastric lavage]] should be performed if the presence or source of bleeding is unknown. Upper gastrointestinal endoscopy is the primary diagnostic tool, performed for both diagnosis and treatment of active bleeding. The American Society for Gastrointestinal Endoscopy guidelines recommends upper [[endoscopy]] within 24 hours of presentation in all patients with UGIB. [[Angiography]] and tagged [[erythrocyte]] scan are rarely needed but may be used to diagnose active [[Upper gastrointestinal bleeding|UGIB]], particularly in patients where [[EGD]] is contraindicated. Also, upper [[gastrointestinal tract]] radiographic studies using [[barium]] are generally not advised, as they may obscure visualization during [[Esophagogastroduodenoscopy|EGD]].

==Initial Management==
Management of upper GI bleeding includes:<ref name="pmid29043071">{{cite journal |vauthors=Beales I |title=Recent advances in the management of peptic ulcer bleeding |journal=F1000Res |volume=6 |issue= |pages=1763 |year=2017 |pmid=29043071 |pmc=5621101 |doi=10.12688/f1000research.11286.1 |url=}}</ref><ref name="pmid25090451">{{cite journal |vauthors=Bethea ED, Travis AC, Saltzman JR |title=Initial assessment and management of patients with nonvariceal upper gastrointestinal bleeding |journal=J. Clin. Gastroenterol. |volume=48 |issue=10 |pages=823–9 |year=2014 |pmid=25090451 |doi=10.1097/MCG.0000000000000194 |url=}}</ref><ref name="pmid25692808">{{cite journal |vauthors=Klein A, Gralnek IM |title=Acute, nonvariceal upper gastrointestinal bleeding |journal=Curr Opin Crit Care |volume=21 |issue=2 |pages=154–62 |year=2015 |pmid=25692808 |doi=10.1097/MCC.0000000000000185 |url=}}</ref>

===Initial resuscitation===
*The initial steps in the management of a patient with [[Upper gastrointestinal bleeding|UGIB]] is to assess the severity of [[bleeding]], and then institute fluid and blood resuscitation as needed.<ref name="pmid15703679">{{cite journal |vauthors=Wassef W |title=Upper gastrointestinal bleeding |journal=Curr. Opin. Gastroenterol. |volume=20 |issue=6 |pages=538–45 |year=2004 |pmid=15703679 |doi= |url=}}</ref><ref name="pmid19006607">{{cite journal |vauthors=Kovacs TO |title=Management of upper gastrointestinal bleeding |journal=Curr Gastroenterol Rep |volume=10 |issue=6 |pages=535–42 |year=2008 |pmid=19006607 |doi= |url=}}</ref><ref name="pmid26417980">{{cite journal |vauthors=Gralnek IM, Dumonceau JM, Kuipers EJ, Lanas A, Sanders DS, Kurien M, Rotondano G, Hucl T, Dinis-Ribeiro M, Marmo R, Racz I, Arezzo A, Hoffmann RT, Lesur G, de Franchis R, Aabakken L, Veitch A, Radaelli F, Salgueiro P, Cardoso R, Maia L, Zullo A, Cipolletta L, Hassan C |title=Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline |journal=Endoscopy |volume=47 |issue=10 |pages=a1–46 |year=2015 |pmid=26417980 |doi=10.1055/s-0034-1393172 |url=}}</ref>
*Any patient with [[hemodynamic instability]] or who is [[Bleeding (Excessive)|actively bleeding]] should be admitted to the [[ICU]] for monitoring and [[resuscitation]]
*The patient’s hemodynamic status is of great importance in determining the degree of severity and triage status.
{| border="1" cellpadding="5" cellspacing="0" align="center" |class="wikitable"
! style="background:#efefef;" |Criteria for Admission of patient
|-
|
*Age >60yr
*Transfusion required.
*Initial Sys [[Systolic blood pressure|BP]] < 100.
*Red blood in NG lavage.
*History of [[cirrhosis]] or [[ascites]] on examination.
|}

===Supportive Therapy===
*Supportive care includes administration of s[[Oxygen|upplemental oxygen]], IV fluid administration, and monitoring of [[urine output]].<ref name="pmid26417980">{{cite journal |vauthors=Gralnek IM, Dumonceau JM, Kuipers EJ, Lanas A, Sanders DS, Kurien M, Rotondano G, Hucl T, Dinis-Ribeiro M, Marmo R, Racz I, Arezzo A, Hoffmann RT, Lesur G, de Franchis R, Aabakken L, Veitch A, Radaelli F, Salgueiro P, Cardoso R, Maia L, Zullo A, Cipolletta L, Hassan C |title=Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline |journal=Endoscopy |volume=47 |issue=10 |pages=a1–46 |year=2015 |pmid=26417980 |doi=10.1055/s-0034-1393172 |url=}}</ref>
*Two large caliber (16-gauge) peripheral catheters or a [[Central venous catheter|central venous line]] should be inserted in patients who are [[hemodynamically unstable]].<ref name="pmid26417980" />
*The rate of fluid resuscitation is proportional to the severity of [[bleeding]] with the goal of restoring and maintaining the patient’s [[blood pressure]].<ref name="pmid26417980" />
*Infusion of 500 mL of [[normal saline]] or lactated [[Ringer's lactate|Ringer's solution]] over 30 minutes is preferred treatment for patients with [[Bleeding|active bleeding]] before [[Blood type|blood type matching]] and blood [[transfusion]].<ref name="pmid26417980" />
*Intensive monitoring with a [[pulmonary artery catheter]] is recommended to monitor the response of initial resuscitation efforts and any falls in [[blood pressure]]:<ref name="pmid26417980" />
{| border="1" cellpadding="5" cellspacing="0" align="center" |class="wikitable"
! colspan="4" style="background:#efefef;" |Correlation between physical signs and the severity of upper gastrointestinal bleeding
|-
! rowspan="2" style="background:#efefef;" |Physical signs
! colspan="3" style="background:#efefef;" |Bleeding severity
|-
! style="background:#efefef;" |Mild
! style="background:#efefef;" |Moderate
! style="background:#efefef;" |Severe
|-
|[[Blood loss]]
|<1L
|1-2L
|>2L
|-
|[[Systolic blood pressure]]
|<120
|100-119
|<99
|-
|[[Orthostasis]]
|'''-'''
|'''-'''
|'''+'''
|-
|[[Tachycardia]]
|<100
|101-120
|>140
|-
|[[Skin]]
|Warm, well perfused
|Diaphoretic
|Cool–cold, clammy
|-
|[[Urine output|Urine outpu]]<nowiki/>t(ml/hour)
|>25
|10-25
|Negligible
|-
|[[Respiratory rate]]
|14-20
|20-30
|>35
|-
|[[Sensorium]]
|Alert
|Anxious
|Confused/Drowsy
|}

===Blood transfusion===
*Patients with severe [[bleeding]] will need to be transfused:<ref name="pmid24063362">{{cite journal |vauthors=Al-Jaghbeer M, Yende S |title=Blood transfusion for upper gastrointestinal bleeding: is less more again? |journal=Crit Care |volume=17 |issue=5 |pages=325 |year=2013 |pmid=24063362 |pmc=4056793 |doi=10.1186/cc13020 |url=}}</ref><ref name="pmid23281973">{{cite journal |vauthors=Villanueva C, Colomo A, Bosch A, Concepción M, Hernandez-Gea V, Aracil C, Graupera I, Poca M, Alvarez-Urturi C, Gordillo J, Guarner-Argente C, Santaló M, Muñiz E, Guarner C |title=Transfusion strategies for acute upper gastrointestinal bleeding |journal=N. Engl. J. Med. |volume=368 |issue=1 |pages=11–21 |year=2013 |pmid=23281973 |doi=10.1056/NEJMoa1211801 |url=}}</ref>
{| border="1" cellpadding="5" cellspacing="0" align="center" |class="wikitable"
! colspan="2" style="background:#efefef;" |Indications for transfusion
Based on the patient’s age and presence of comorbid conditions.
|-
!AGE
!Target Hematocrit
|-
|Elderly patient ( >45)
|30%
|-
|Younger patient (<45)
|25%
|-
|patients with portal hypertension
|28%
|}
*[[Fresh frozen plasma|Fresh frozen plasma,]] [[platelets]], or both should be given to patients with [[coagulopathy]] who are actively bleeding and to those who have received more than 10 units of packed [[erythrocytes]]:
{| border="1" cellpadding="5" cellspacing="0" align="center" |class="wikitable"
! colspan="2" style="background:#efefef;" | WORKUP AND INITIAL TREATMENT Initial Resuscitation
|-
|I'''nitial Evaluation'''
|
* Airway Breathing, Circulation
|-
|'''Supportive Therapy'''
|
* Ensure patent and protected airway.

* [[Intubation|Intubate]] if needed.
* Consider [[mechanical ventilation]].

* 2 large-bore, peripheral intravenous lines.

* Can consider [[Central venous catheter|large-bore central venous catheter]] or intraosseous line if rapid transfuser will be needed.
|-
|'''Blood transfusion'''
|
* Resuscitate with 1:1:1 of packed red blood cells (PRBCs) to fresh frozen plasma (FFP) to platelets.

* Consider massive transfusion protocol.

* Resuscitate to a target hemoglobin of 7 mg/dL.

* Consider Sengstaken-Blakemore tube for control of immediately life-threatening upper GI bleeding.
|}

===National Institute for Health and Care Excellence (NICE) guidline===
The National Institute for Health and Care Excellence (NICE) guidline on [[blood]] product management in upper GI bleeding:<ref name="urlAcute upper gastrointestinal bleeding in over 16s: management | Guidance and guidelines | NICE">{{cite web |url=https://www.nice.org.uk/guidance/cg141 |title=Acute upper gastrointestinal bleeding in over 16s: management | Guidance and guidelines | NICE |format= |work= |accessdate=}}</ref>
*[[Platelets]] should only be given if the patient is actively bleeding or hemodynamically unstable and has a platelet count of <50×109/L.
*[[Fresh frozen plasma]] should be given if the [[fibrinogen]] level is <1 g/L or the prothrombin time (PT) or activated partial thromboplastin time is >1.5 times normal.
*[[Prothrombin complex]] should be provided to those on warfarin and actively bleeding.
*Recombinant factor VIIa should only be used when all of the above measures have failed.

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{{Family tree | | | | | B01 | | | |B01= Initial evaluation and resuscitation}}
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{{Family tree | | | | | |!| | | | | }}
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{{Family tree | | C01 | | | | C02 |C01= Source found| C02= Undiagnostic}}
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{{Family tree | | D01 | | | | |!| |D01=Specific Treatment|}}
{{Family tree | | | | | | | | |!| | |}}
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{{Family tree | | | | | E01 | | | | | | E02 |E01=Unstable|E02=Stable|}}
{{Family tree | | | | | |!| | | | | | | |!| | |}}
{{Family tree | | | | | F01 | | | | | | F02 | |F01=Urgent CT|F02=Repeat Endoscopy/Angiograpghy}}
{{Family tree | | | | | |!| | | | | | | |!| | |}}
{{Family tree | | | | | G01 | | |,|-|-|-|+|-|-|-|v|-|-|-|.| |G01=No source identified|}}
{{Family tree | | | | | |!| | | I01 | | I02 | | I03 | | I04 |I01=Angioembolization|I02=Endoscopic intervention|I03=TIPS|I04=Surgery|}}
{{Family tree | | | | | H01 | | | | | | |!| | | | | |H01=Surgery (Laprotomy)}}
{{Family tree | | | | | | | | | | | | | |!| | | | | |}}
{{Family tree | | | | | |,|-|-|-|v|-|-|-|+|-|-|-|v|-|-|-|.| }}
{{Family tree | | | | | J01 | | J02 | | J03 | | J04 | | J05 |J01=Sclerotherapy|J02=Banding|J03=Injection|J04=Thermocoagulation|J05=Clips|}}
{{Family tree/end}}<ref name="pmid33929377">Laine L, Barkun AN, Saltzman JR, Martel M, Leontiadis GI (2021) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=33929377 ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding.] ''Am J Gastroenterol'' 116 (5):899-917. [http://dx.doi.org/10.14309/ajg.0000000000001245 DOI:10.14309/ajg.0000000000001245] PMID: [https://pubmed.gov/33929377 33929377]</ref>

[[File:Upper GI bleeding. Adapted from ACG Clinical Guideline- Upper Gastrointestinal and Ulcer Bleeding.png|thumb|Upper GI bleeding. Adapted from ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding]]

==References==
{{reflist|2}}

File:Upper GI bleeding. Adapted from ACG Clinical Guideline- Upper Gastrointestinal and Ulcer Bleeding.png

2022-12-29T13:54:44Z

Jair Basantes de la Calle:

Upper GI bleeding. Adapted from ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding