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Revision as of 16:03, 18 May 2022
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Recommendations for percutaneous mitral commissurotomy and mitral valve surgery in moderate or severe mitral stenosis (valve area <1.5 cm2) | |
(Class I, Level of Evidence B): | |
❑ PMC is recommended in symptomatic patients with favourable characteristics for PMC | |
(Class I, Level of Evidence C): | |
❑PMC is recommended in any symptomatic patients who are high risk for surgery
❑Mitral valve surgery is recommended in symptomatic patients who are not appropriate for PMC in the absence of futility | |
(Class IIa, Level of Evidence C): | |
❑PMC should be considered as initial treatment in symptomatic patients with suboptimal anatomy and favourable clinical characteristics for PMC
|
The above table adopted from 2021 ESC Guideline[1] |
---|
Abbreviations:
PMC: Percutaneous mitral commissurotomy;
AF: Atrial fibrillation;
LA: Left atrium;
MVA:Mitral valve area ;
- Contraindications for percutaneous mitral commissurotomy in rheumatic mitral stenosis
- MVA >1.5 cm²
- Left atrial thrombus
- More than mild mitral regurgitation
- Severe or bi-commissural calcification
- Absence of commissural fusion
- Severe concomitant aortic valve disease, or severe combined tricuspid stenosis and tricuspid regurgitation requiring surgery
- Concomitant coronary artery disease requiring bypass surgery
Management of patients with chronic severe secondary mitral regurgitation | |||||||||||||||||||||||||||||||||||||||
Symptomatic despite medical therapy | |||||||||||||||||||||||||||||||||||||||
*Optimazing medical therapy
| |||||||||||||||||||||||||||||||||||||||
Severe comorbidities or life expectancy < 1 year | |||||||||||||||||||||||||||||||||||||||
Yes | NO | ||||||||||||||||||||||||||||||||||||||
Palliative care | Presence of CAD or other cardiac disease | ||||||||||||||||||||||||||||||||||||||
Yes | NO | ||||||||||||||||||||||||||||||||||||||
Appropriate for surgery | Persisting severe symptomatic secondary MR | Valve surgery if fulfilling criteria | |||||||||||||||||||||||||||||||||||||
Yes | NO | ||||||||||||||||||||||||||||||||||||||
CABG, MV surgery | PCI, TAVI | ||||||||||||||||||||||||||||||||||||||
Persisting severe symptomatic secondary MR | |||||||||||||||||||||||||||||||||||||||
Yes | NO
| ||||||||||||||||||||||||||||||||||||||
Yes | NO
| ||||||||||||||||||||||||||||||||||||||
Yes
| NO
| ||||||||||||||||||||||||||||||||||||||
Yes=TEER | NO
| ||||||||||||||||||||||||||||||||||||||
The above algorithm adopted from 2021 ESC Guideline[1] |
---|
Abbreviations:
CABG: Coronary artery bypass grafting;
CRT: Cardiac resynchronization therapy;
LV: Left ventricle;
MV:Mitral valve ;
PCI:Percutaneous coronary intervention;
LVAD: Left ventricular assist devices;
TEER: Transcatheter edge to edge repair;
TAVI: Transcatheter aortic valve implantation;
CAD: Coronary artery disease
Recommendations for intervention in chronic severe secondary mitral regurgitation | |
(Class I, Level of Evidence B): | |
❑ Valve surgery/intervention is recommended in symptomatic severe secondary MR despite GDMT or CRT | |
(Class IIa, Level of Evidence B): | |
❑TEER should be considered in selected symptomatic patients, not suitable for surgery and high likelihood of responding to TEER | |
(Class IIa, Level of Evidence C): | |
❑ In symptomatic inoperable patients, PCI (and/orTAVI) possibly followed by TEER (in case of persisting severe secondary MR) should be considered | |
(Class IIb, Level of Evidence C) : | |
❑ Valve surgery may be considered in symptomatic patients who are appropriate for surgery |
The above table adopted from 2021 ESC Guideline[1] |
---|
Abbreviations:
CABG: Coronary artery bypass grafting;
CRT: Cardiac resynchronization therapy;
LV: Left ventricle;
ERO:Effective regurgitation orifice area ;
PCI:Percutaneous coronary intervention;
LVEF: Left ventricular ejection fraction;
TEER: Transcatheter edge to edge repair;
TAVI: Transcatheter aortic valve implantation
Management of patients with severe chronic primary mitral regurgitation | |||||||||||||||||||||||||||||||||||||||||||||||||||
Symptoms | |||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | NO | ||||||||||||||||||||||||||||||||||||||||||||||||||
Determining the risk of surgery | LVEF ≤ 60% or LVESD ≥ 40 mm | ||||||||||||||||||||||||||||||||||||||||||||||||||
High risk of futility
| High risk for surgery or inoperable | Yes | NO | ||||||||||||||||||||||||||||||||||||||||||||||||
Yes | NO | Surgery | New onset AF or SPAP>50 mmHg | ||||||||||||||||||||||||||||||||||||||||||||||||
TEER if anatomically suitable, optimal heart failure therapy | Surgery (repair whenever possible) | Yes, surgery | NO | ||||||||||||||||||||||||||||||||||||||||||||||||
High likelihood of durable repair, low surgical risk, and LA dilatation | |||||||||||||||||||||||||||||||||||||||||||||||||||
NO | Yes | ||||||||||||||||||||||||||||||||||||||||||||||||||
Follow-up | Surgical mitral valve repair | ||||||||||||||||||||||||||||||||||||||||||||||||||
Abbreviations: AF: Atrial fibrillation; LA: Left atrial; LV: Left ventricle; LVESD:Left ventricular end systolic diameter ; SPAP:Systolic pulmonary arterial pressure; LVEF: Left ventricular ejection fraction; TEER: Transcatheter edge to edge repair;
The above algorithm adopted from 2021 ESC Guideline[1] |
---|
Recommendations for intervention in primary mitral regurgitation | |
Symptomatic aortic stenosis: | |
(Class I, Level of Evidence B): | |
❑ Mitral valve repair is considered when the results of surgical technique are expected to be durable | |
(Class IIa, Level of Evidence B): | |
❑ Surgery is recommended in asymptomatic patients with preserved LV function (LVESD <40 mm and LVEF >60%) and AF secondary to mitral regurgitation or pulmonary hypertension (SPAP at rest >50 mmHg | |
(Class IIb, Level of Evidence B) : | |
❑TEER may be considered in symptomatic patients who are inoperable due to high surgical risk, with echocardiographic criteria of eligibility |
Abbreviations: AF: Atrial fibrillation; LA: Left atrial; LV: Left ventricle; LVESD:Left ventricular end systolic diameter ; SPAP:Systolic pulmonary arterial pressure; LVEF: Left ventricular ejection fraction; TEER: Transcatheter edge to edge repair;
The above table adopted from 2021 ESC Guideline[1] |
---|
Recommendations for intervention in aortic stenosis |
Symptomatic aortic stenosis: |
(Class I, Level of Evidence B): |
❑ Intervention is considered in symptomatic patients with severe, high-gradient aortic stenosis mean gradient ≥ 40 mmHg, peak velocity
≥ 4.0 m/s, and valve area ≤ 1.0 cm2 (or ≤ 0.6 cm2/m2) |
(Class IIa, Level of Evidence C): |
❑ Intervention is recommended in symptomatic severe AS with low-flow, low-gradient (<40 mmHg) aortic stenosis with normal ejection fraction |
(Class III, Level of Evidence C) : |
❑ Intervention is not recommended in patients with severe comorbidities when the intervention is unlikely to improve quality of life or prolong survival >1 year |
Asymptomatic severe aortic stenosis : |
(Class I, Level of Evidence B): |
❑ Intervention is recommended in asymptomatic patients with severe aortic stenosis and systolic LV dysfunction (LVEF < 50%) without another cause |
(Class I, Level of Evidence C): |
❑ Intervention is recommended in asymptomatic patients with severe aortic stenosis, symptomtomatic on exercise testing |
(Class IIa, Level of Evidence B): |
❑ Intervention should be considered in asymptomatic patients with severe aortic stenosis and systolic LV dysfunction (LVEF <55%) without another cause |
(Class IIa, Level of Evidence C): |
❑ Interventin is recommended in asymptomatic patients with severe aortic stenosis and a sustained fall inblood pressure (>20 mmHg) during exercise testing |
(Class IIa, Level of Evidence B): |
❑Intervention is considered in asymptomatic patients with LVEF >55% and a normal exercise test if the procedural risk is low and in the presence of one of the following:
|
Type of intervention: |
(Class I, Level of Evidence C): |
❑Aortic valve interventions should be performed in an experienced center |
(Class I, Level of Evidence B): |
❑SAVR is recommended in younger patients who are low risk for surgery (<75 yearse and STS PROM/EuroSCORE II <4%), or in patients who are operable and unsuitable for transfemoral TAVI |
(Class I, Level of Evidence A): |
❑TAVI is recommended in older patients (≥75 years), or in those who are high risk (STS PROM/EuroSCORE IIf>8%) or unsuitable for surgery |
(Class IIb, Level of Evidence C): |
❑ Non-transfemoral TAVI may be considered in patients who are inoperable and unsuitable for transfemoral TAVI.
❑Balloon aortic valvotomy may be considered as a bridge to SAVR or TAVI in hemodynamically unstable patients and (if feasible) in those with
severe aortic stenosis who require urgent high risk non-cardiac surgery |
Abbreviations: BNP: B-type natriuretic peptide; CABG: Coronary artery bypass grafting; LV: Left ventricle; LVEF:Left ventricular ejection fraction ; CCT:Cardiac computed tomography; SAVR: Surgical aortic valve replacement; STS-PROM: Society of Thoracic Surgeons - predicted risk of mortality; SVi: Stroke volume index; TAVI:Transcatheter aortic valve implantation ; Vmax:Peak transvalvular velocity
The above table adopted from 2021 ESC Guideline[1] |
---|
Clinical characteristics | Favours TAVI | Favours SAVR |
---|---|---|
Lower surgical risk | _ | + |
Higher surgical risk | + | _ |
Younger age | _ | + |
Older age | + | _ |
Previous cardiac surgery (CABG) | + | _ |
Severe frailty | + | _ |
Endocarditis | _ | + |
Anatomical and procedural factors | ||
TAVI feasible via transfemoral approach | + | _ |
Inaccessable Transfemoral approach or SAVR feasible | _ | + |
Sequelae of chest radiation | + | _ |
Porcelain aorta | + | _ |
High likelihood of severe patient-prosthesis mismatch (AVA <0.65 cm2/m2 BSA) | + | _ |
Severe chest deformity or scoliosis | + | _ |
Unsuitable aortic annular dimensions for TAVI device | _ | + |
Bisuspid aortic valve | _ | + |
Unfavourable valve morphology for TAVI (high risk of coronary obstruction due to low coronary ostia or heavy leaflet/LVOT calcification | _ | + |
Thrombus in aorta or left ventricle | _ | + |
Concomitant cardiac conditions requiring interventio | ||
Significant multi-vessel CAD requiring surgical revascularization | _ | + |
Severe primary mitral valve disease | _ | + |
Severe tricuspid valve disease | _ | + |
Significant dilatation/aneurysm of the aortic root and/or ascending aorta | _ | + |
Septal hypertrophy requiring myomectomy | _ | + |
Abbreviations: AV: Aortic valve; AVA: Aortic valve area; LVOT: Left ventricular outflow tract ; SAVR: Surgical aortic valve replacement; TAVI: Transcatheter aortic valve implantation; BSA: Body surface area; CAD: Coronary artery disease
The above table adopted from 2021 ESC Guideline[1] |
---|
Valvular AS | |||||||||||||||||||||||||||||||||||||||||||||||||
Low-gradient AS
| High-gradient AS
| ||||||||||||||||||||||||||||||||||||||||||||||||
AVA ≤ 1.0 cm2 | High flow status | ||||||||||||||||||||||||||||||||||||||||||||||||
Yes | NO
| Yes
| NO
| ||||||||||||||||||||||||||||||||||||||||||||||
Normal flow
| Low flow
| ||||||||||||||||||||||||||||||||||||||||||||||||
Severe AS unlikely | LVEF ≥ 50% | ||||||||||||||||||||||||||||||||||||||||||||||||
NO | Yes
| ||||||||||||||||||||||||||||||||||||||||||||||||
NO, CCT to assess AV calcification | Yes, AVA ≤ 1.0 cm2 | ||||||||||||||||||||||||||||||||||||||||||||||||
Yes
| NO
| ||||||||||||||||||||||||||||||||||||||||||||||||
Abbreviations: AS: Aortic stenosis; AV: Aortic valve; AVA: Aortic valve area; LVEF: Left ventricular ejection fraction ; CT: Computed tomography; △Pm: Mean pressure gradient; DSE: Dobutamine stress echocardiography; LV: Left ventricular; SVi: Stroke volume index; Vmax: Peak transvalvular velocity
The above table adopted from 2021 ESC Guideline[1] |
---|
- High flow is reversible in conditions such as anemia, hyperthyroidism orarterio-venous fistula and may also be present in patients with hypertrophic obstructive cardiomyopathy.
- The definition of Normal flow by pulsed Doppler echocardiography is :
- DSE flow reserve is defined as > 20% increase in stroke volume in response to low-dose dobutamine.
- Pseudo-severe aortic stenosis is defined as AVA >1.0 cm2 with increased flow.
- CT measurement of aortic valve calcification (Agatston units) for definition of high likely severe AS:
Management of aortic regurgitation | |||||||||||||||||||||||||||||||||||||||||
Significant enlargement of ascending aorta | Severe aortic regurgitation | ||||||||||||||||||||||||||||||||||||||||
Surgery | Symptoms | ||||||||||||||||||||||||||||||||||||||||
Yes | NO
| ||||||||||||||||||||||||||||||||||||||||
Yes | |||||||||||||||||||||||||||||||||||||||||
The above algorithm adopted from 2021 ESC Guideline[1] |
---|
Recommendations for surgery in severe aortic regurgitation and aortic root or tubular ascending aortic aneurysm |
Severe aortic regurgitation (Class I, Level of Evidence B): |
❑ Surgery is recommended in symptomatic patients regardless of LV function |
(Class IIb, Level of Evidence C): |
❑ Surgery may be considered in asymptomatic patients with LVESD >20 mm/m2 BSA (especially in patients with small body size) or resting LVEF ≤ 55%, in low risk condition |
(Class I, Level of Evidence C) : |
❑ Surgery is recommended in symptomatic and asymptomatic patients with severe aortic regurgitation undergoing CABG or surgery of the ascending aorta or of another valve |
Aortic root or tubular ascending aortic aneurysmc (irrespective of the severity of aortic regurgitation (Class I, Level of Evidence B): |
❑ Valve-sparing aortic root replacement is recommended in young patients with aortic root dilation |
(Class I, Level of Evidence C): |
❑ Ascending aortic surgery is recommended in patients with Marfan syndrome and ascending aortic diameter ≥ 50 mm |
(Class IIa, Level of Evidence C): |
❑ Ascending aortic surgery is recommended with ascending aorta size of:
Risk factors: family history of aortic dissection (or personal history of spontaneous vascular dissection), severe aortic or mitral regurgitation, desire for pregnancy, uncontrolled systemic arterial hypertension , aortic size increase >3 mm/year
❑ In the presence of primarily indication for the surgery of aortic valve, replacement of the aortic root or tubular ascending aorta should be considered
when ≥ 45 mm |
Abbreviations: BSA: Body surface area; CABG: Coronary artery bypass grafting; LV: Left ventricle; LVEF:Left ventricular ejection fraction ; LVESV:Left ventricular end-systolic diamete
The above table adopted from 2021 ESC Guideline[1] |
---|
Recommendations for management of atrial fibrillation in valvular heart disease |
NOAC (Class I, Level of Evidence A): |
❑ In AF patients and mitral regurgitation, aortic regurgitation, and aortic stenosis, NOACs are preferred to VKAs for prevention of stroke |
NOAC (Class III, Level of Evidence C): |
❑ NOACs is not recommended in patients with AF and moderate to severe mitral stenosis |
AF ablation:(Class IIa, Level of Evidence A) : |
❑ Concomitant AF ablation should be considered in patients undergoing valve surgery with respect to risk factors of recurrence (LA dilatation, years in AF, age, renal dysfunction, and other cardiovascular risk factors |
LAA occlusion : (Class IIa, Level of Evidence B) |
❑ LAA occlusion should be considered to reduce the thromboembolic risk in patients with AF and a CHA2DS2VASc score ≥ 2 undergoing valve surgery |
Abbreviations: AF: Atrial fibrillation; LA: Left atrium; LAA: Left atrial appendage; NOAC:Non vitamin-K antagonist oral anticoagulant ; OAC:Oral anticoagulation; VKA: Vitamin-K antagonist
The above table adopted from 2021 ESC Guideline[1] |
---|
Recommendations for management of CAD in valvular heart disease |
Coronary angiography (Class I, Level of Evidence C): |
❑ Coronary angiography is recommended before valve surgery in patients with severe VHD and any of the following:
|
Coronary CT angiography (Class I, Level of Evidence C): |
❑ Coronary CT angiography is recommended as an alternative to coronary angiography before valve surgery in patients with severe VHD and low probability of CAD |
CABG:(Class I, Level of Evidence C) : |
❑ CABG is considered in patients undergone aortic/mitral/tricuspid valve surgery and coronary artery diameter stenosis ≥ 70% |
CABG : (Class IIa, Level of Evidence C) |
❑ CABG is recommended in patients undergone aortic/mitral/tricuspid valve surgery and coronary artery diameter stenosis ≥ 50-70% |
PCI : (Class IIa, Level of Evidence C) |
❑ PCI is recommended in patients undergoing TAVI and coronary artery diameter stenosis > 70% in proximal segments |
Abbreviations: CAD: Coronary artery disease; CABG: Coronary artery bypass grafting; PCI: Percutaneous coronary intervention; TAVI:Transcatheter aortic valve implantation; VHD:Valvular heart disease
The above table adopted from 2021 ESC Guideline[1] |
---|
Endocarditis prophylaxis
- Antibiotic prophylaxis should be considered for high-risk procedures in patients with prosthetic valves including:
- Transcatheter valves
- Valve repaired using prosthetic material
- History of previous episode(s) of infective endocarditis
- Specific attention to dental and cutaneous hygiene and strict aseptic measures during any invasive procedure are recommended.
- Antibiotic prophylaxis should be considered in dental procedures including the manipulation of the gingival or periapical region of the teeth or manipulation of the oral mucosa
Recommendations for anticoagulant therapy in valvular heart disease |
NOAC (Class I, Level of Evidence A): |
❑ Except those with rheumatic mitral stenosis, NOAC is recommended in patients with AF and VHD , or who received a bioprothesis valve > 3 months ago on the basis of CHA2DS2-VASc score |
VKA (Class I, Level of Evidence C): |
❑ Long term VKA oral anticoagulation is recommended in patients with AF and rheumatic MS |
VKA:(Class IIa, Level of Evidence B) : |
❑ Anticoagulation with VKA is reasonable in patients with new onset AF ≤ 3 months after surgical or transcatheter bioprothetic valve replacement |
NOAC : (Class III: Harm, Level of Evidence B) |
❑ NOAC is not recommended in patients with mechanical valve with or without AF, and VKA should be continued for prevention of valve thrombosis formation |
Abbreviations:
CAD: Coronary artery disease;
VKA: Vitamin-K antagonist;
AF: Artial fibrillation
The above table adopted from 2020 AHA Guideline[2] |
---|
Prophylaxis for rheumatic fever
- Antibiotic therapy of group A Streptococcus infection throat is necessary in primary prevention of rheumatic fever.
- Screening with [[Echocardiographic] in combination with secondary prevention by antibiotic prophylaxis in children with evidence of latent rheumatic heart disease are considered to reduce the prevalence of disease in endemic regions.
- Recommendation for secondary long-term prophylaxis against rheumatic fever in patients with established rheumatic heart disease is benzathine benzyl penicillin 1.2 MUI every 3 to 4 weeks over 10 years.
- Lifelong prophylaxis is recommended in high-risk patients based upon the severity of VHD and exposure to group A Streptococcus.
Recommendations for anticoagulation for atrial fibrillation in valvular heart disease |
NOAC (Class I, Level of Evidence A): |
❑ Except those with rheumatic mitral stenosis, NOAC is recommended in patients with AF and VHD , or who received a bioprothesis valve > 3 months ago on the basis of CHA2DS2-VASc score |
VKA (Class I, Level of Evidence C): |
❑ Long term VKA oral anticoagulation is recommended in patients with AF and rheumatic MS |
VKA:(Class IIa, Level of Evidence B) : |
❑ Anticoagulation with VKA is reasonable in patients with new onset AF ≤ 3 months after surgical or transcatheter bioprothetic valve replacement |
NOAC : (Class III: Harm, Level of Evidence B) |
❑ NOAC is not recommended in patients with mechanical valve with or without AF, and VKA should be continued for prevention of valve thrombosis formation |
Abbreviations:
NOAC: Novel oral anticoagulant;
VKA: Vitamin-K antagonist;
AF: Artial fibrillation
The above table adopted from 2020 AHA Guideline[2] |
---|
Median OperativeMortality Rates for Specific Surgical Procedures
Procedure | Mortality rate (%) |
---|---|
AVR | 2.2 |
AVR + CABG | 4 |
AVR + Mitral valve replacement | 9 |
Mitral valve replacement | 5 |
Mitral valve replacement + CABG | 9 |
Mitral valve repair | 1 |
Mitral valve repair +CABG | 5 |
Management of HFrEF | |||||||||||||||||||||||||||||||||||||||||||
(Class I) | |||||||||||||||||||||||||||||||||||||||||||
LVEF ≤35% and QRS <130 ms | LVEF >35% or device
therapy not indicated or inappropriate | Sinus rhythm and LVEF ≤35% and QRS ≥130 ms | |||||||||||||||||||||||||||||||||||||||||
ICD implantation
| If symptoms persist, consider therapies (class II) | CRT-D/-P
| |||||||||||||||||||||||||||||||||||||||||
Management of patients with pulmonary edema | |||||||||||||||||||||||||||||
Oxygen (Class I) or ventilatory support (Class IIa) | |||||||||||||||||||||||||||||
Systolic blood pressure ≥110 mmHg | |||||||||||||||||||||||||||||
Yes | NO | ||||||||||||||||||||||||||||
Loop diuretics (Class I) and/or vasodilators (Class IIb) | Signs of hypoperfusion | ||||||||||||||||||||||||||||
Yes | NO | ||||||||||||||||||||||||||||
Loop diuretics (Class I) and inotropes/vasopressors(Class IIb) | Loop diuretics (Class I) | ||||||||||||||||||||||||||||
Congestion relief | |||||||||||||||||||||||||||||
Yes | NO | ||||||||||||||||||||||||||||
Optimized medical therapy | Renal replacement therapy | ||||||||||||||||||||||||||||
The above algorithm adopted from 2021 ESC Guideline |
---|
Recommendations for initial treatment of acute heart failure |
Oxygen, ventilation support (Class I, Level of Evidence C): |
❑ Oxygen is recommended in hypoxic patients with SpO2<90% or PaO2 <60 mmHg |
Oxygen, ventilation support (Class IIa, Level of Evidence B): |
❑ In patients with respiratory distress (respiratory rate >25 breaths/min, SpO2<90%), non-invasive positive pressure ventilation is recommended to decrease respiratory distress and reduce the rate of mechanical endotracheal intubation |
Diuretics :(Class I, Level of Evidence C) : |
❑ Intravenous loop diuretics are considered for all admitted patients with acute heart failure presented with signs, symptoms of fluid overload |
Diuretics : (Class IIa, Level of Evidence B) |
❑ In patients with resistant edema who do not respond to an increase in loop diuretic doses, combination of a loop diuretic with thiazide type diuretic should be considered |
Vasodilators: (Class IIb, Level of Evidence B) |
❑ In order to improve symptoms and reduce congestion in patients with AHF and SBP >110 mmHg, vasodilators may be considered as initial therapy |
Inotropic agents : (Class 2b, Level of Evidence C) |
❑ Inotropic agents may be considered in patients with SBP <90 mmHg and evidence of hypoperfusion without response to fluid challenge, to improve [[peripheral
perfusion]] and maintain end-organ function |
Inotropic agents]] (Class III, Level of Evidence C): |
❑ Routinely administration of inotropic agents are not recommended , due to safety concerns, unless the patient has symptomatic hypotension and evidence of hypoperfusion |
Vasopressors: (ClassIIb, Level of Evidence B) |
❑ In patients with cardiogenic shock, a vasopressor, preferably norepinephrine, may be indicated to increase blood pressure and vital organ perfusion |
Anticoagulant therapy: (ClassI, Level of Evidence A) |
❑ Thromboembolism prophylaxis such as LMWH is recommended in patients not already anticoagulated and no contraindication to anticoagulation, to prevent the risk of deep venous thrombosis and pulmonary embolism |
Opiates: (ClassIII, Level of Evidence C) |
❑ Opiates is not routinely recommended, unless in selected patients with severe, intractable pain or anxiety |
Abbreviations:
AHF: Acute heart failure;
LMWH: Low-molecular-weight heparin;
PaO2: Partial pressure of oxygen ;
SpO2: Transcutaneous oxygen saturation;
The above table adopted from 2021 ESC Guideline |
---|
Approach to stable chest pain and ischemia and no obstructive CAD (INOCA)
{{familytree| | |E5 | | E01 | |E7 | | |f | | E0
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W (February 2022). "2021 ESC/EACTS Guidelines for the management of valvular heart disease". Eur Heart J. 43 (7): 561–632. doi:10.1093/eurheartj/ehab395. PMID 34453165 Check
|pmid=
value (help). - ↑ 2.0 2.1 Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C (February 2021). "2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 143 (5): e35–e71. doi:10.1161/CIR.0000000000000932. PMID 33332149 Check
|pmid=
value (help).
Stable chest pain suspected INOCA | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Non-invasive test more prevalent
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Invasive coronary functional testing | Stress PET, Stress CMR, Stress echocardiography | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||