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2010 ACCF/AHA Guidelines for Thoracic Aortic Disease ACCF/AHA Guideline 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine Endorsed by the North American Society for Cardiovascular Imaging WRITING GROUP MEMBERS Loren F. Hiratzka, MD, Chair*; George L. Bakris, MD†; Joshua A. Beckman, MD, MS‡; Robert M. Bersin, 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#*** ACCF/AHA TASK FORCE MEMBERS Alice K. Jacobs, MD, FACC, FAHA, Chair 2009–2011; Sidney C. Smith, Jr, MD, FACC, FAHA, Immediate Past Chair 2006–2008†††; Jeffery L. Anderson, MD, FACC, FAHA, Chair-Elect; Cynthia D. Adams, MSN, PhD, FAHA†††; Christopher E. Buller, MD, FACC; Mark A. Creager, MD, FACC, FAHA; Steven M. Ettinger, MD, FACC; Robert A. Guyton, MD, FACC, FAHA; Jonathan L. Halperin, MD, FACC, FAHA; Sharon A. Hunt, MD, FACC, FAHA†††; Harlan M. Krumholz, MD, FACC, FAHA†††; Frederick G. Kushner, MD, FACC, FAHA; Bruce W. Lytle, MD, FACC, FAHA†††; Rick Nishimura, MD, FACC, FAHA†††; Richard L. Page, MD, FACC, FAHA†††; Barbara Riegel, DNSc, RN, FAHA***; William G. Stevenson, MD, FACC, FAHA; Lynn G. Tarkington, RN; Clyde W. Yancy, MD, FACC, FAHA *ACCF/AHA Representative. †AHA Representative. ‡SVM Representative. §SCAI Representative. ࿣ACCF Board of Governors Representative. ¶American College of Physicians Representative. #Recused from Section 9.2.2.3.1. Recommendations for Descending Thoracic Aorta and Thoracoabdominal Aortic Aneurysms. **American College of Emergency Physicians Representative. ††ACR Representative. ‡‡STS Representative. §§ACCF/AHA Task Force Liaison. ࿣࿣SCA Representative. ¶¶ASA Representative. ##AATS Representative. ***SIR Representative. †††Former Task Force member during this writing effort. Authors with no symbol by their name were included to provide additional content expertise apart from organizational representation. This document was approved by the American College of Cardiology Foundation Board of Trustees and the American Heart Association Science Advisory and Coordinating Committee in January 2010. All other cosponsoring organizations approved in February 2010. The online-only Data Supplement is available with this article at http://circ.ahajournals.org/cgi/content/full/CIR.0b013e3181d4739e/DC1. The American Heart Association requests that this document be cited as follows: Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE Jr, Eagle KA, Hermann LK, Isselbacher EM, Kazerooni EA, Kouchoukos NT, Lytle BW, Milewicz DM, Reich DL, Sen S, Shinn JA, Svensson LG, Williams DM. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the diagnosis and management of patients with thoracic aortic disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation. 2010;121:e266–e369. This article has been copublished in the Journal of the American College of Cardiology. Copies: This document 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). A copy of the document is also available at http://www.americanheart.org/presenter.jhtml?identifierϭ3003999 by selecting either the “topic list” link or the “chronological list” link (No. KB-0022). To purchase additional reprints, call 843-216-2533 or e-mail [email protected]. Expert peer review of AHA Scientific Statements is conducted at the AHA National Center. For more on AHA statements and guidelines development, visit http://www.americanheart.org/presenter.jhtml?identifierϭ3023366. 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 http://www.americanheart.org/presenter.jhtml? identifierϭ4431. A link to the “Permission Request Form” appears on the right side of the page. (Circulation. 2010;121:e266-e369.) © 2010 by the American College of Cardiology Foundation and the American Heart Association, Inc. Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIR.0b013e3181d4739e e266 Hiratzka et al 2010 Guidelines on Thoracic Aortic Disease e267 TABLE OF CONTENTS 5.1.4. Turner Syndrome ................e288 Preamble ..................................…e270 5.1.5. Other Genetic Syndromes With 1. Introduction ..............................e270 Increased Risk for Thoracic Aortic 1.1. Methodology and Evidence Review ........e270 Aneurysms and Dissections ........e289 1.2. Organization of the Writing Committee .....e271 5.1.6. Recommendations for Familial 1.3. Document Review and Approval ..........e271 Thoracic Aortic Aneurysms 1.4. Scope of the Guideline ..................e272 and Dissections..................e289 1.4.1. Critical Issues....................e274 5.2. Summary.............................e290 1.5. Glossary of Terms and Abbreviations 6. Other Cardiovascular Conditions Associated With Used Throughout Guideline ..............e274 Thoracic Aortic Aneurysm and Dissection ..........e291 2. The Thoracic Aorta ........................e275 6.1. Recommendations for Bicuspid Aortic Valve 2.1. The Normal Aorta......................e275 and Associated Congenital Variants in Adults . .e291 6.2. Aberrant Right Subclavian Artery..........e292 2.2. Normal Thoracic Aortic Diameter..........e275 6.3. Coarctation of the Aorta .................e292 3. Thoracic Aortic Histopathology ...............e276 6.4. Right Aortic Arch ......................e292 3.1. Atherosclerosis ........................e276 7. Inflammatory Diseases Associated With 3.2. Aneurysms and Dissections ..............e276 Thoracic Aortic Disease .....................e292 3.3. Vasculitis and Inflammatory Diseases.......e277 7.1. Recommendations for Takayasu Arteritis 4. Imaging Modalities.........................e278 and Giant Cell Arteritis..................e292 4.1. Recommendations for Aortic Imaging 7.2. Takayasu Arteritis......................e293 Techniques to Determine the Presence and 7.3. Giant Cell Arteritis .....................e295 Progression of Thoracic Aortic Disease .....e278 7.4. Behc¸et Disease ........................e296 4.2. Chest X-Ray ..........................e279 7.5. Ankylosing Spondylitis 4.3. Computed Tomographic Imaging ..........e279 (Spondyloarthropathies) .................e296 4.3.1. Computed Tomographic Imaging 7.6. Infective Thoracic Aortic Aneurysms .......e296 Technique.......................e281 8. Acute Aortic Syndromes.....................e297 4.4. Magnetic Resonance Imaging .............e281 8.1. Aortic Dissection ......................e297 4.4.1. Magnetic Resonance Imaging 8.1.1. Aortic Dissection Definition........e297 Technique ......................e282 8.1.2. Anatomic Classification of 4.4.2. Black Blood Imaging ..............e282 Aortic Dissection ................e297 4.4.3. Noncontrast White Blood Imaging . .e282 8.1.3. Risk Factors for Aortic Dissection ......e299 4.4.4. Contrast-Enhanced Magnetic 8.1.4. Clinical Presentation of Acute Resonance Angiography............e282 Thoracic Aortic Dissection .........e300 4.4.5. Phase Contrast Imaging ............e282 8.1.4.1. Symptoms of Acute 4.5. Standards for Reporting of the Thoracic Thoracic Aortic Aorta on Computed Tomography and Dissection ...............e300 Magnetic Resonance Imaging .............e282 8.1.4.2. Perfusion Deficits and 4.6. Angiography ..........................e283 End-Organ Ischemia .......e301 4.7. Echocardiography ......................e284 8.1.5. Cardiac Complications ............e303 4.7.1. Echocardiographic Criteria for 8.1.5.1. Acute Aortic Thoracic Aortic Aneurysms .........e284 Regurgitation.............e303 4.7.2. Echocardiographic Criteria for 8.1.5.2. Myocardial Ischemia or Aortic Dissection .................e284 Infarction ...............e303 4.7.2.1. Diagnostic Accuracy of 8.1.5.3. Heart Failure and Shock . .e303 Echocardiography for 8.1.5.4. Pericardial Effusion and Aortic Dissection ..........e285 Tamponade ..............e303 4.7.2.2. Diagnostic Accuracy of 8.1.6. Syncope .......................e303 Echocardiography for Acute 8.1.7. Neurologic Complications .........e304 Intramural Hematoma .......e285 8.1.8. Pulmonary Complications..........e304 4.7.2.3. Role of Echocardiography in 8.1.9. Gastrointestinal Complications ......e304 Following Patients With Chronic 8.1.10. Blood Pressure and Heart Rate Aortic Disease.............e286 Considerations ..................e304
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