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: 

Reprintsolutions@wolterskluwer.com; Tel:  410.528.4121; Fax:  

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 

   8.1. Recommendations for Screening Tests

  . . . . . . . . . . . . . . . . . .

34 

   8.2. Recommendations for Diagnostic Imaging Studies

  . . . . . .

35 

   8.3. Recommendations for Initial Management

  . . . . . . . . . . . . . .

36 

   8.4. Recommendations for Definitive Management

  . . . . . . . . . .

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 

12.1. Recommendations for Blood Pressure Control

  . . . . . . . . . . .

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 

20.2.  Recommendations for Spinal Cord Protection During  

   

Descending Aortic Open Surgical and Endovascular  

   Repairs

  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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 



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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

Multiple populations 

evaluated*

Data derived from multi-

ple randomized clinical 

trials or meta-analyses

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

 Recommendation that  



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

suggested phrases for  

writing recommendations



 

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 



 Risk



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 



 Benefit



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

 Limited evidence from  



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:

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 

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).

Imaging for asymptomatic patients at high risk based on 



history or associated disease is expensive and not always 

covered by payers.

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.

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. 

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.

Mid aortic arch (between left common carotid and subclavian 



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 

1. 

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)

 2. 

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)

 3. 

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)

6. 

Techniques to minimize episodic and cumulative 

radiation exposure should be utilized whenever 

possible. (LOE: B) 

Class IIa 

1. 

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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