Acc/aha pocket Guideline Based on the 2010 accf/aha/aats
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Learn and Live SM ACC/AHA Pocket Guideline Based on the 2010 ACCF/AHA/AATS/ ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease
March 2010 i Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease March 2010 Writing Committee Loren F. Hiratzka, MD, Chair George L. Bakris, MD Joshua A. Beckman, MD, MS Robert M. Bersin, MPH, MD Vincent F. Carr, DO Donald E. Casey, Jr, MD, MPH, MBA Kim A. Eagle, MD Luke K. Hermann, MD Eric M. Isselbacher, MD Ella A. Kazerooni, MD, MS Nicholas T. Kouchoukos, MD Bruce W. Lytle, MD Dianna M. Milewicz, MD, PhD David L. Reich, MD Souvik Sen, MD, MS Julie A. Shinn, RN, MA, CCRN Lars G. Svensson, MD, PhD David M. Williams, MD © 2010 American College of Cardiology Foundation and American Heart Association, Inc. The following material was adapted from the 2010 ACCF/AHA/ AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease: Executive Summary (Circulation 2010;121:1544–79). This pocket guideline is available on the World Wide Web sites of the American College of Cardiology (www.acc.org) and the American Heart Association (my.americanheart.org). For copies of this document, please contact Wolters Kluwer Health Medical Research, Lippincott Williams & Wilkins, email:
410.528.4264. Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American Heart Association. Instructions for obtaining permission are located at www.americanheart.org/presenter.jhtml?identifier=4431. A link to the “Permission Request Form” appears on the right side of the page. Contents 1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 2. Critical Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 3. Recommendations for Aortic Imaging Techniques to Determine the Presence and Progression of Thoracic Aortic Disease . . . . . . . 14 4. Recommendations for Genetic Syndromes . . . . . . . . . . . . . . . . . . . . 18 5. Recommendations for Familial Thoracic Aortic Aneurysms and Dissections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 6. Recommendations for Bicuspid Aortic Valve and Associated Congenital Variants in Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 7. Recommendations for Estimation of Pretest Risk of Thoracic Aortic Dissection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 8. Initial Evaluation and Management of Acute Thoracic Aortic Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
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. . . . . . . . . . 37 9. Recommendation for Surgical Intervention for Acute Thoracic Aortic Dissection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
2 3 10. Recommendation for Intramural Hematoma Without Intimal Defect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 11. Recommendation for History and Physical Examination for Thoracic Aortic Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 12. Recommendation for Medical Treatment of Patients With Thoracic Aortic Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
. . . . . . . . . . . 44 13. Recommendations for Asymptomatic Patients With Ascending Aortic Aneurysm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 14. Recommendation for Symptomatic Patients With Thoracic Aortic Aneurysm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 15. Recommendations for Open Surgery for Ascending Aortic Aneurysm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 16. Recommendations for Aortic Arch Aneurysms . . . . . . . . . . . . . . . . . 52 17. Recommendations for Descending Thoracic Aorta and Thoracoabdominal Aortic Aneurysms . . . . . . . . . . . . . . . . . . . . . . . . . 54 18. Recommendations for Counseling and Management of Chronic Aortic Diseases in Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . 56 19. Recommendations for Aortic Arch and Thoracic Aortic Atheroma and Atheroembolic Disease . . . . . . . . . . . . . . . . . . . . . . . . 58
4 5 20. Periprocedural and Perioperative Management . . . . . . . . . . . . . . . . 59
20.1. Recommendations for Brain Protection During Ascending Aortic and Transverse Aortic Arch Surgery . . . . . . . . . . 59
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 21. Recommendations for Surveillance of Thoracic Aortic Disease or Previously Repaired Patients . . . . . . . . . . . . . . . . . . . . . . 62 22. Recommendation for Employment and Lifestyle in Patients With Thoracic Aortic Disease . . . . . . . . . . . . . . . . . . . . . . . . . 64
6 1. Introduction The term “thoracic aortic disease” encompasses a broad range of degenerative, structural, acquired, genetic-based, and traumatic disease states and pre- sentations. According to the Centers for Disease Control and Prevention death certificate data, dis- eases of the aorta and its branches account for 43 000 to 47 000 deaths annually in the United States. The precise number of deaths attributable to thorac- ic aortic diseases is unclear. However, autopsy stud- ies suggest that the presentation of thoracic aortic disease is often death due to aortic dissection (AoD) and rupture, and these deaths account for twice as 7 many deaths as attributed to ruptured abdominal aortic aneurysms (AAAs). This guideline includes diseases involving any or all parts of the thoracic aorta with the exception of aortic valve diseases and includes the abdominal aorta when contiguous tho- racic aortic diseases are present.
8 Table 1.
Applying Classification of Recommendations and Level of Evidence LeveL A
LeveL B
Limited populations evaluated* Data derived from a single randomized trial or nonrandomized studies LeveL C
Very limited populations evaluated* Only consensus opinion of experts, case studies, or standard of care CLASS I
Benefit >>> Risk Procedure/Treatment shOuLD be performed/ administered n
procedure or treatment is useful/effective n
sufficient evidence from multiple randomized trials or meta-analyses n
Recommendation that procedure or treatment is useful/effective n
Limited evidence from single randomized trial or nonrandomized studies n
Recommendation that procedure or treatment is useful/effective n
Only expert opinion, case studies, or standard of care CLASS IIA Benefit >> Risk Additional studies with focused objectives needed IT Is ReasOnabLe to per- form procedure/administer treatment n
Recommendation in favor of treatment or procedure being useful/effective n
some conflicting evidence from multiple randomized trials or meta-analyses n
Recommendation in favor of treatment or procedure being useful/effective n
some conflicting evidence from single randomized trial or nonrandomized studies n
Recommendation in favor of treatment or procedure being useful/effective n
Only diverging expert opinion, case studies, or standard of care should
is recommended is indicated is useful/effective/beneficial
is reasonable can be useful/effective/beneficial is probably recommended or indicated S I z E O F T R E A T M E n T E F F E C T E STIMA
TE o F C ERT
AI n T y (P RECISI
on) o F T REA TME
n T E FFECT 9 Class IIb Benefit ≥
Additional studies with broad objectives needed; additional registry data would be helpful Procedure/Treatment May be cOnsIDeReD n
Recommendation’s usefulness/efficacy less well established n
Greater conflicting evidence from multiple randomized trials or meta-analyses n
Recommendation’s usefulness/efficacy less well established n
Greater conflicting evidence from single randomized trial or nonrandomized studies n
Recommendation’s usefulness/efficacy less well established n
Only diverging expert opinion, case studies, or standard of care Class III Risk ≥
Procedure/Treatment should nOT be performed/adminis- tered sInce IT Is nOT heLP- fuL anD May be haRMfuL n
Recommendation that procedure or treatment is not useful/effective and may be harmful n
sufficient evidence from multiple randomized trials or meta-analyses n
Recommendation that procedure or treatment is not useful/effective and may be harmful n
single randomized trial or nonrandomized studies n
Recommendation that procedure or treatment is not useful/effective and may be harmful n
Only expert opinion, case studies, or standard of care may/might be considered may/might be reasonable usefulness/effectiveness is unknown /unclear/uncertain or not well established is not recommended is not indicated should not is not useful/effective/beneficial may be harmful * Data available from clinical trials or registries about the usefulness/ efficacy in different subpopulations, such as sex, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use. A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Even though randomized trials are not available, there may be a very clear clinical consensus that a particular test or therapy is useful or effective. † In 2003, the ACCF/AHA Task Force on Practice Guidelines developed a list of suggested phrases to use when writing recommendations. All guideline recommendations have been written in full sentences that express a complete thought, such that a recommendation, even if separated and presented apart from the rest of the document (including headings above sets of recommendations), would still convey the full intent of the recommendation. It is hoped that this will increase readers’ comprehension of the guidelines and will allow queries at the individual recommendation level. 10 2. Critical Issues As the writing committee developed this guideline, several criti- cal issues emerged: n Thoracic aortic diseases are usually asymptomatic and not easily detectable until an acute and often catastrophic complication occurs. Imaging of the thoracic aorta with computed tomographic imaging (CT), magnetic resonance imaging (MR), or in some cases, echocardiographic examination is the only method to detect thoracic aortic diseases n Radiologic imaging technologies have improved in terms of accuracy of detection of thoracic aortic disease. However risks associated with repeated radiation exposure, as well as contrast medium–related toxicity have also been recognized. The writing committee therefore formulated recommendations on a standard reporting format (Section 3) as well as surveillance schedules (Section 21). n Imaging for asymptomatic patients at high risk based on history or associated disease is expensive and not always covered by payers. n For many thoracic aortic diseases, results of treatment for stable, often asymptomatic, but high-risk conditions are far better than the results of treatment required for acute and often catastrophic disease presentations. Thus, the identification and treatment of patients at risk for acute and 11 catastrophic disease presentations (eg, thoracic AoD and thoracic aneurysm rupture) prior to such an occurrence are paramount to eliminating the high morbidity and mortality associated with acute presentations. n Patients with acute AoD are subject to missed or delayed detection of this catastrophic disease state. Many present with atypical symptoms and findings, making diagnosis even more difficult. Awareness of the varied and complex nature of thoracic aortic disease presentations has been lacking, especially for acute AoD. Risk factors and clinical presentation clues are noted in Section 7. The collaboration of multiple medical specialties for this guideline will provide opportunities to raise the level of awareness among all medical specialties. n There is rapidly accumulating evidence that genetic alterations or mutations predispose some individuals to aortic diseases (see Sections 4-6). Therefore, identification of the genetic alterations leading to these aortic diseases has the potential for early identification of individuals at risk. In addition, biochemical abnormalities involved in the progression of aortic disease are being identified through studies of patients’ aortic samples and animal models of the disease. The biochemical alterations identified in the aortic tissue have the potential to serve as biomarkers for aortic disease. Understanding the molecular pathogenesis may lead to targeted therapy to prevent aortic disease. Medical and gene-based treatments are beginning to show promise for reducing or delaying catastrophic complications of thoracic aortic diseases. 12 Figure 1. normal Anatomy of the Thoracoabdominal Aorta.
13 Anatomic Location 1. Aortic sinuses of Valsalva 2. Sinotubular junction 3. Mid ascending aorta (midpoint in length between Nos. 2 and 4) 4. Proximal aortic arch (aorta at the origin of the innominate artery) 5.
arteries) 6. Proximal descending thoracic aorta (begins at the isthmus, approximately 2 cm distal to left subclavian artery) 7. Mid descending aorta (midpoint in length between Nos. 6 and 8) 8. Aorta at diaphragm (2 cm above the celiac axis origin) 9. Abdominal aorta at the celiac axis origin Normal anatomy of the thoracoabdominal aorta with standard anatomic landmarks for reporting aortic diameter as illustrated on a volume-rendered CT image of the thoracic aorta. CT indicates computed tomographic imaging.
14 3. Recommendations for Aortic Imaging Techniques to Determine the Presence and Progression of Thoracic Aortic Disease Class I
Measurements of aortic diameter should be taken at reproducible anatomic landmarks, perpendicular to the axis of blood flow, and reported in a clear and consistent format. (LOE: C)
For measurements taken by computed tomographic imaging or magnetic resonance imaging, the external diameter should be measured perpendicular to the axis of blood flow. For aortic root measurements, the widest diameter, typically at the mid-sinus level, should be used. (LOE: C)
For measurements taken by echocardiography, the internal diameter should be measured perpendicular to the axis of blood flow. For aortic root measurements the widest diameter, typically at the mid-sinus level, should be used. (LOE: C) 4. Abnormalities of aortic morphology should be recognized and reported separately even when aortic diameters are within normal limits. (LOE: C) 15 5. The finding of aortic dissection, aneurysm, traumatic injury and/or aortic rupture should be immediately communicated to the referring physician. (LOE: C)
Techniques to minimize episodic and cumulative radiation exposure should be utilized whenever possible. (LOE: B) Class IIa
If clinical information is available, it can be useful to relate aortic diameter to the patient’s age and body size. (LOE: C) 16 Table 2. Essential Elements of Aortic Imaging Reports 1. The location at which the aorta is abnormal. 2. The maximum diameter of any dilatation, measured from the external wall of the aorta, perpendicular to the axis of flow, and the length of the aorta that is abnormal. 3. For patients with presumed or documented genetic syndromes at risk for aortic root disease measurements of aortic valve, sinuses of Valsalva, sinotubular junction, and ascending aorta. 4. The presence of internal filling defects consistent with thrombus or atheroma. 5. The presence of IMH, PAU, and calcification. 6. Extension of aortic abnormality into branch vessels, including dissection and aneurysm, and secondary evidence of end-organ injury (eg, renal or bowel hypoperfusion 7. Evidence of aortic rupture, including periaortic and mediastinal hematoma, pericardial and pleural fluid, and contrast extravasation from the aortic lumen. 8. When a prior examination is available, direct image to image comparison to determine if there has been any increase in diameter. IMH indicates intramural hematoma; and PAU, penetrating atherosclerotic ulcer. 17 Table 3. normal Adult Thoracic Aortic Diameters
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