Jeffrey L. Anderson, MD, FACC, FAHA, Chair 

Jonathan L. Halperin, MD, FACC, FAHA, Chair-Elect 

Nancy M. Albert, PhD, RN, FAHA

Biykem Bozkurt, MD, PhD, FACC, FAHA

Ralph G. Brindis, MD, MPH, MACC

Mark A. Creager, MD, FACC, FAHA[#][1]

Lesley H. Curtis, PhD, FAHA

David DeMets, PhD[#][1]

Robert A

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2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society

The American College of Cardiology (ACC)/American Heart Association (AHA) Task Force on Practice Guidelines was formed to make recommendations regarding the diagnosis and treatment of patients with known or suspected cardiovascular disease. Coronary artery disease (CAD) is the leading cause of death in the United States. Unstable angina (UA) and the closely related condition non–ST-segment elevation myocardial infarction (NSTEMI) are very common manifestations of this disease. These life-threatening disorders are a major cause of emergency medical care and hospitalizations in the United States. In 1996, the National Center for Health Statistics reported 1 433 000 hospitalizations for UA or NSTEMI. In recognition of the importance of the management of this common entity and of the rapid advances in the management of this condition, the need to revise guidelines published by the Agency for Health Care Policy and Research (AHCPR) and the National Heart, Lung and Blood Institute in 1994 was evident. This Task Force therefore formed the current committee to develop guidelines for the management of UA and NSTEMI. The present guidelines supersede the 1994 guidelines.

The customary ACC/AHA classifications I, II, and III summarize both the evidence and expert opinion and provide final recommendations for both patient evaluation and therapy:

Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective .

Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment. 

Class IIa: Weight of evidence/opinion is in favor of usefulness/efficacy. 

Class IIb: Usefulness/efficacy is less well established by evidence/opinion. 

Class III: Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective and in some cases may be harmful. 

The weight of the evidence was ranked highest (A) if the data …

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ACC/AHA guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction: Executive summary and recommendations: A report of the American College of Cardiology/American Heart Association task force on practice guidelines (committee on the management of patients with unstable angina)

Angina/Non-ST-Elevation Myocardial Infarction : ACC/AHA 2007 Guidelines for the Management of Patients With Unstable ISSN: 1524-4539 Copyright © 2007 American Heart Association. All rights reserved. Print ISSN: 0009-7322. Online 72514 Circulation is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TX doi: 10.1161/CIRCULATIONAHA.107.18194

https://cdr.lib.unc.edu/downloads/vd66w2108

ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction)...

Sidney C. Smith, Jr, MD, FACC, FAHA, FESC, Chair; Alice K. Jacobs, MD, FACC, FAHA, Vice-Chair; Cynthia D. Adams, MSN, APRN-BC, FAHA; Jeffery L. Anderson, MD, FACC, FAHA; Elliott M. Antman, MD, FACC, FAHA[‡][1]; Jonathan L. Halperin, MD, FACC, FAHA; Sharon Ann Hunt, MD, FACC, FAHA; Rick Nishimura,

/pdf/acc-aha-esc-2006-guidelines-for-the-management-of-patients-5fc8py53ut.pdf

ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): Developed in Collaboration With the European Heart Rhythm Association and the Heart Rhythm Society

Preamble 2072

1. Introduction 2074

2. Clinical Characteristics and Evaluation of AF 2076

3. Thromboembolic Risk and Treatment 2077

4. Rate Control: Recommendations 2079

5. Rhythm Control: Recommendations 2080

6. Specific Patient Groups and AF: Recommendations 2086

7. Evidence Gaps and Future Research Directions 2089

References 2090

Appendix 1. Author Relationships With Industry and Other Entities (Relevant) 2095

Appendix 2. Reviewer Relationships With Industry and Other Entities (Relevant) 2097

Appendix 3. Initial Clinical Evaluation in Patients With AF 2104

The medical profession should play a central role in evaluating the evidence related to drugs, devices, and procedures for the detection, management, and prevention of disease. When properly applied, expert analysis of available data on the benefits and risks of these therapies and procedures can improve the quality of care, optimize patient outcomes, and favorably affect costs by focusing resources on the most effective strategies. An organized …

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2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive Summary

Some factors affecting stroke volume were investigated in conscious dogs in which left ventricular outflow was measured with an electromagnetic flowmeter. Stimulation of the heart at constant heart rate, by intracoronary injections of calcium gluconate and isopropylnorepinephrine, or postectopic potentiation failed to produce any increase in stroke volume. By contrast, alterations of posture at constant heart rate with the presumed associated changes in end diastolic dimensions, produced large changes in stroke volume. This resulted from a change in late systolic flow.

Left Ventricular Ejection in Conscious Dogs

Objective : To examine the prognostic significance and role in risk stratification of the biochemical marker troponin T in patients admitted with unstable angina. Design : Single centre, blinded, prospective study of patients admitted with chest pain. Setting : Coronary care unit of a district general hospital. Subjects : 460 patients admitted with chest pain and followed up for a median of three years. 183 patients had a final diagnosis of unstable angina. Main outcome measures : Cardiac death, need for coronary revascularisation, or readmission with non-fatal myocardial infarction as first events. Results : 62 (34%) unstable angina patients were troponin T positive. This group had significantly increased incidence rates of subsequent cardiac death (12 cases (19%) v 14 (12%)), coronary revascularisation (22 (35%) v 26 (21%)), death or revascularisation (33 (53%) v 40 (33%)), and death or non-fatal myocardial infarction (18 (29%) v 21 (17%)) compared with the troponin T negative group. In multiple logistic regression troponin T status was a highly significant predictor for the end points coronary revascularisation and cardiac death or revascularisation as first events. Conclusion : Troponin T in the serum of patients with unstable angina identifies a subgroup at higher risk of subsequent cardiac events and its measurement aids in risk factor stratification. The increased risk extends to two years after admission. Prospective randomised trials are required to identify optimum therapeutic strategies for this subgroup. Key messages Stratifying patients with unstable angina for risk remains a difficult clinical problem A new cardiac specific protein, troponin T, can now be measured in serum The detection of troponin T 12-24 hours after admission identifies a high risk subgroup of patients with unstable angina Prospective trials are required to identify optimum therapeutic strategies for this subgroup

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Prospective study of the role of cardiac troponin T in patients admitted with unstable angina.

We have tested the validity of the following indices of myocardial contractility: the maximum acceleration of blood from the left ventricle, the maximum rate of rise of left ventricular pressure (LV dP/dt max), LV dP/dt max/left ventricular pressure at the time of LV dP/dt max (LV dP/dt max)/P, the maximum of the instantaneous ratio of the rate of rise of left ventricular pressure [(LV dP/dt/P) max], and the X-Y plot of LV dP/dt/P against P. In the isolated cat heart, the filling and resistance to ejection of the left ventricle were controlled directly. The other preparations were: the open chest anaesthetized dog, the closed chest anaesthetized dog with and without denervated heart, and the conscious dog with and without denervated heart. In these preparations, the effect of increased load was studied by constricting the aorta between beats and the effect of increased heart size was studied in subsequent beats during ventricular distention. It was found that none of the indices was insensitive to increased load and heart size under all circumstances. We were unable to find a satisfactory method of extrapolating the plot of LV dP/dt/P against P to zero P to obtain Vmax. [f a linear relationship was assumed, P was found to be a complex function of time (t), namely Po/[l+(Po/Pd-1)e-Vmaxt] where Po = P when dP/dt/P=0 and Pd = end-diastolic pressure.

Problems in the use of indices of myocardial contractility.

Background —Although a raised plasma homocysteine is a risk factor for vascular disease, it is not known whether it is associated with an adverse cardiac outcome in patients admitted with acute coronary syndromes. We evaluated the relationship between plasma homocysteine and short-term (28 days) and long-term (median 2.5 years) prognosis in acute coronary syndromes.

Methods and Results —We evaluated the relationship of quintiles of homocysteine to fatal and nonfatal coronary disease early (28 days) and late (29 days to a median of 2.5 years) after admission to a single unit of patients with unstable angina (n=204) and myocardial infarction (n=236). The end points studied were cardiac death (n=67) and/or myocardial (re)infarction (n=30). Cox regression and logistic regression were used to estimate the relationship of homocysteine to coronary events. The event rate within the first 28 days (22 cardiac deaths and 5 nonfatal infarctions) was not related to the admission homocysteine level. In the 203 unstable angina and 214 myocardial infarction survivors, an apparent threshold effect was seen on long-term follow-up, with a significant step-up in the frequency of events between the lowest 3 quintiles (14 cardiac deaths and 11 nonfatal infarctions) and the upper 2 quintiles (31 fatal and 12 nonfatal events). Patients in the upper 2 quintiles (>12.2 μmol/L) had a 2.6-fold increase in the risk of a cardiac event (95% CI, 1.5 to 4.3, P <0.001).

Conclusions —Elevated total homocysteine levels on admission strongly predict late cardiac events in acute coronary syndromes.

Effect of Plasma Homocysteine Concentration on Early and Late Events in Patients With Acute Coronary Syndromes

Background—It has been suggested by clinical, epidemiological, and experimental in vitro studies that homocysteine potentiates thrombin generation. This prothrombotic effect however has not previously been demonstrated in patients presenting with acute coronary syndromes (ACS). Methods and Results—Patients with ACS (n =117) presenting with confirmed acute myocardial infarction (MI) (n =57) or unstable angina pectoris (UAP) (n =60) were consecutively recruited together with patients (n =18) in whom the presenting chest pain was not of cardiac origin (NCP), included as controls. Plasma samples were collected on admission and before clinical intervention. Homocysteine was assayed by high performance liquid chromatography, and both Factor VIIa and prothrombin fragment F1+2 were analyzed by ELISA. There were significant elevations in F1+2 in MI (P<0.001) and UAP (P=0.003), and modest elevations in Factor VIIa in UAP (P<0.05) compared with NCP but no differences in homocysteine levels among those groups. On div...

M. I. M. Noble

Papers

Left Ventricular Ejection in Conscious Dogs

Prospective study of the role of cardiac troponin T in patients admitted with unstable angina.

Problems in the use of indices of myocardial contractility.

Effect of Plasma Homocysteine Concentration on Early and Late Events in Patients With Acute Coronary Syndromes

Relationships Between Homocysteine, Factor VIIa, and Thrombin Generation in Acute Coronary Syndromes