AHA guidelines – The Early Career Voice

2021 Chest Pain Guidelines from AHA21

December 28, 2021December 17, 2021 Reza Mohebi, MD

2021 Guideline for the Evaluation and Diagnosis of Chest Pain was released in October 2021 and discussed in multiple sessions during AHA21. It was a collaboration between cardiologists, interventional cardiologists, cardiac intensivists, epidemiologists, and emergency medicine specialists. The team has focused on a symptom rather than a disease, making this approach unique. In the U.S, chest pain is the main reason for about 6.5 million emergency department encounters and the second reason patients seek medical attention in an emergency room. Only 5.1 % of ED visits with chest pain were found to have an acute coronary syndrome. It is imperative to distinguish between life-threatening and benign causes. The new guideline has provided recommendations and algorithms for assessing chest pain based on contemporary evidence. This short blog will summarize the top take-home messages.

In the new guideline, authors refrain from using the term “atypical” chest pain. They have argued that this term may be misinterpreted as benign in nature. They have changed the atypical term to non-cardiac, which is more specific in addressing underlying diagnosis. The guideline emphasizes the uniqueness of chest pain in women. It is estimated that cardiac causes of chest pain are underdiagnosed in this population. Since women are more likely to present with accompanying symptoms, health care professionals should consider these symptoms while obtaining a history. An electrocardiogram should be obtained and reviewed for the presence of ST-elevation myocardial infarction within 10 minutes of ED arrival. Furthermore, in patients with intermediate to high clinical suspicion for acute coronary syndrome (ACS), a supplemental electrocardiogram on leads V7 to V9 is needed to rule out posterior MI. Cardiac troponin is a biomarker of choice for detecting myocardial injury. Authors recommend against the measurement of creatine kinase isoenzyme (CK, CK-MB) and myoglobin for diagnosis of acute myocardial injury.

The guideline panelists have revised the term coronary artery disease (CAD). Previously, CAD was defined as the presence of significant obstructive stenosis (i.e., ≥50%). This revision has broadened the term CAD to those with identified non-obstructive atherosclerotic plaques on prior anatomic and functional testing. This approach may prevent those with non-obstructive CAD from getting overlooked and deprived of optimized preventive measures. The guideline also provides recommendations on selecting optimal diagnostic testing for patients with chest pain. A health care professional should first consider the pretest likelihood of CAD before selecting a cardiac test modality. The guideline emphasizes the lack of need to pursue any diagnostic test in those with low CAD risk. A coronary artery calcium score may be appropriate for atherosclerotic cardiovascular disease risk stratification. In patients at intermediate-high risk of CAD, based on age (≥65 years of age vs. < 65 years of age) and suspicion of a degree of coronary obstruction, the guideline recommends further anatomical testing. Coronary computed tomography angiography is favored among patients at a younger age or less obstructive CAD suspicion, while stress testing is preferred among older patients or more obstructive CAD suspicion. The goal of CCTA is to rule out obstructive CAD or to detect non-obstructive CAD. If an evaluation is required, it will also provide further information about the anomalous coronary arteries, aorta, and pulmonary arteries. Ischemia-guided management is the goal of stress imaging. It can provide information when prior CCTA is inconclusive and about myocardial scar tissue and coronary microvascular dysfunction.

The term CHEST PAIN represents the take-home message of the guideline, as shown in the figure. Each alphabet has a meaning. C: Chest pain means more than a pain in the chest, H: High sensitivity troponin is preferred. E: seek Early care for acute symptoms. S: Share the decision-making, T: Testing not routinely needed in low-risk patients. P: use clinical decision Pathways. Accompanying: women may be more likely to present with Accompanying symptoms. I: Identify patients most likely to benefit from further testing. N: Noncardiac is in, and atypical is out. S: Structured risk assessment should be used.

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

Update on ACC/AHA Valvular Heart Disease Guidelines 2020: Deep Dive into Aortic Stenosis Treatment Options

February 20, 2021February 18, 2021 Purvi Parwani, MBBS, MPH

“2020 ACC/AHA Guideline for the Management of Patients with Valvular Heart Disease” was co-published in the Circulation and in the Journal of the American College of Cardiology on December 17^th, 2020. In this article, I will provide the recommendations and updates from these guidelines particularly the new changes compared to the older valvular disease guideline statement from 2014 and a focused update from 2017 as it pertains to aortic stenosis. In developing these recommendations, the writing committee used the available research through March 1^st, 2020. Given the explosion of trials and studies in aortic stenosis (AS) management, the guidelines serve as a one-stop-shop for clinicians to dive deep for some guidance while taking care of patients with AS.

Aortic valve Recommendations:

The major change from the previous guidelines is that for symptomatic patients with severe AS who are >80 years of age or for younger patients with a life expectancy <10 years, TAVI (transcatheter aortic valve implantation) is recommended (Class 1) while for symptomatic patients with severe AS between age 65-80 with no anatomic contraindication to transfemoral TAVI, shared decision-making is emphasized, and the recommendation is either SAVR (surgical aortic valve replacement) or TAVI (Class 1). Timing of aortic stenosis treatment is still largely decided by symptoms; however, asymptomatic patients with severe AS and low EF <50% are considered Class 1 for treatment. Similarly asymptomatic patients with severe AS and decreased exercise tolerance, or a fall in systolic blood pressure of ≥10 mmHg from baseline to peak exercise, or very severe AS (V2 ≥5 m/s), a BNP level >3 times normal, or serial testing shows an increase in V2 ≥0.3 m/s per year are a Class 2 indication for valve replacement. The guidelines note the evidence from low-risk PARTNER 3 and Evolut trials.

Class 1 indication for SAVR

Class 1/A: Symptomatic severe AS

Class 1/B-NR: Symptomatic low flow low gradient severe AS with reduced LV EF (left ventricular ejection fraction)

Class 1/B-NR: Symptomatic low flow low gradient severe AS with normal EF when AS is the cause of the symptoms.

Class 1/B-NR: Asymptomatic severe AS and an LVEF <50%

Class1/B-NR: Asymptomatic going for other cardiac surgery

Class 1 for SAVR or TAVI

Class 1/A: Symptomatic severe AS patients 65 to 80 with no contraindication to TAVI either SAVR or TAVI

Class 1 for TAVI (transcatheter aortic valve implantation)

Class 1/A: Symptomatic severe AS patients >80 or for younger patients with a life expectancy <10 years, TAVI recommended

Class 1/B-NR Asymptomatic patients with age >80 years with severe AS and an LVEF<50

The guidelines put much emphasis on “shared decision making with the patient” taking into account the patient’s values and preferences and include the discussion of the risk of anticoagulation therapy and the potential need for and risk associated with aortic valve interventions. Another point to note from the guidelines is that the differences in the treatment approaches are driven by the overall risk of the patient. Risk assessment involves but is not limited to the STS(Society of Thoracic Surgeons) score. Per the new guidelines, low risk is defined by an STS score of <3%. A risk assessment also includes the determination of frailty, cardiac and other system compromises, and procedure-specific impediments. These are nicely outlined in the guidelines, and in my opinion, every general cardiologist should dive deep into these risk assessment tools to determine the risk associated with aortic valve procedural treatment accurately for an individual patient. Table 9 in the guidelines includes examples of procedure-specific risk factors for interventions not incorporated into existing risk scores. As the options for the treatment of aortic valve heart disease has broadened, the value of the multidisciplinary heart valve team and heart valve centers has become apparent and this is clearly recognized in the guidelines. Primary and comprehensive heart valve centers are defined by the expertise and treatment options offered in the management of patients with valvular heart disease.

Another point to note is that asymptomatic severe AS category, SAVR versus TAVI options are only available for patients with severe AS and low EF <50%. For other factors that indirectly identify LV decompensation or faster progression of AS like decreased exercise tolerance or a fall in systolic blood pressure of ≥10 mmHg from baseline to peak exercise or a BNP level i>3 times normal or serial testing shows an increase in V2 ≥0.3 m/s per year, SAVR is recommended in preference to TAVI. As the level of evidence builds up for role of TAVI in an asymptomatic category, it has the potential to be truly be a game changer treatment option for AS patients.

References:

Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP 3rd, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O’Gara PT, Rigolin VH, Sundt TM 3rd, Thompson A, Toly C. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines [published online ahead of print December 17, 2020]. Circulation. doi: 10.1161/CIR.0000000000000923

The Key Messages from 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease

May 28, 2019July 8, 2019 Sivabaskari Pasupathy, PhD

The newest ACC/AHA guidelines were just published and is exclusively discusses the primary prevention of CVDs and excludes the care of patients with known atherosclerotic cardiovascular diseases as they are classified as “secondary prevention.”¹

Here are the most important messages from the 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease.¹

Promotion of healthy lifestyle.

nutrition

physical fitness to promote healthy lifestyle

Prevention in patients with known cardiovascular risk factors.

high blood pressure in prevention

high blood cholesterol in prevention

overweight and obesity

prevention in type 2 diabetes

prevention with smoking

Aspirin Use

Aspirin is well established for secondary prevention of ASCVD and is widely recommended for those with existing heart disease². As per the new guideline, most adults without a history of heart disease should not take low-dose daily aspirin to prevent a first heart attack or stroke. Alow dose daily aspirin is recommended in the following instances.

aspirin use

References

Arnett Donna K, Blumenthal Roger S, Albert Michelle A, Buroker Andrew B, Goldberger Zachary D, Hahn Ellen J, Himmelfarb Cheryl D, Khera A, Lloyd-Jones D, McEvoy JW, Michos Erin D, Miedema Michael D, Muñoz D, Smith Sidney C, Virani Salim S, Williams Kim A, Yeboah J and Ziaeian B. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease. Circulation. 2019;0:CIR.0000000000000678.

Piepoli MF, Hoes AW, Agewall S, Albus C, Brotons C, Catapano AL, Cooney MT, Corra U, Cosyns B, Deaton C, Graham I, Hall MS, Hobbs FDR, Lochen ML, Lollgen H, Marques-Vidal P, Perk J, Prescott E, Redon J, Richter DJ, Sattar N, Smulders Y, Tiberi M, van der Worp HB, van Dis I, Verschuren WMM and Binno S. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts)Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J. 2016;37:2315-2381.