Obstructive sleep apnea (OSA) is characterized by recurrent complete and partial upper airway obstructive events, resulting in intermittent hypoxemia, autonomic fluctuation, and sleep fragmentation. ...Approximately 34% and 17% of middle-aged men and women, respectively, meet the diagnostic criteria for OSA. Sleep disturbances are common and underdiagnosed among middle-aged and older adults, and the prevalence varies by race/ethnicity, sex, and obesity status. OSA prevalence is as high as 40% to 80% in patients with hypertension, heart failure, coronary artery disease, pulmonary hypertension, atrial fibrillation, and stroke. Despite its high prevalence in patients with heart disease and the vulnerability of cardiac patients to OSA-related stressors and adverse cardiovascular outcomes, OSA is often underrecognized and undertreated in cardiovascular practice. We recommend screening for OSA in patients with resistant/poorly controlled hypertension, pulmonary hypertension, and recurrent atrial fibrillation after either cardioversion or ablation. In patients with New York Heart Association class II to IV heart failure and suspicion of sleep-disordered breathing or excessive daytime sleepiness, a formal sleep assessment is reasonable. In patients with tachy-brady syndrome or ventricular tachycardia or survivors of sudden cardiac death in whom sleep apnea is suspected after a comprehensive sleep assessment, evaluation for sleep apnea should be considered. After stroke, clinical equipoise exists with respect to screening and treatment. Patients with nocturnally occurring angina, myocardial infarction, arrhythmias, or appropriate shocks from implanted cardioverter-defibrillators may be especially likely to have comorbid sleep apnea. All patients with OSA should be considered for treatment, including behavioral modifications and weight loss as indicated. Continuous positive airway pressure should be offered to patients with severe OSA, whereas oral appliances can be considered for those with mild to moderate OSA or for continuous positive airway pressure-intolerant patients. Follow-up sleep testing should be performed to assess the effectiveness of treatment.
This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients.
A ...comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. Structure: Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients.
A ...comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered.
Chest pain is a frequent cause for emergency department visits in the United States. The “2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain” provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
Table of Contents Preamble2647 Introduction2649 Methodology and Evidence Review2649 Organization of the GWC2649 Document Review and Approval2649 Scope of the CPG2650 Overview of ACS2650 Initial ...Evaluation and Management: Recommendations2650 Clinical Assessment and Initial Evaluation2650 Emergency Department or Outpatient Facility Presentation2650 Prognosis--Early Risk Stratification2650 Cardiac Biomarkers and the Universal Definition of Myocardial Infarction2654 Biomarkers: Diagnosis2654 Biomarkers: Prognosis2654 Discharge From the ED or Chest Pain Unit2655 Early Hospital Care: Recommendations2655 Standard Medical Therapies2655 Oxygen2655 Nitrates2655 Analgesic Therapy2655 Beta-Adrenergic Blockers2656 Calcium Channel Blockers2657 Cholesterol Management2657 Inhibitors of the Renin-Angiotensin-Aldosterone System2657 Initial Antiplatelet/Anticoagulant Therapy in Patients With Definite or Likely NSTE-ACS2657 Initial Oral and Intravenous Antiplatelet Therapy in Patients With Definite or Likely NSTE-ACS Treated With an Initial Invasive or Ischemia-Guided Strategy2657 Initial Parenteral Anticoagulant Therapy in Patients With Definite NSTE-ACS2659 Ischemia-Guided Strategy Versus Early Invasive Strategies2659 Early Invasive and Ischemia-Guided Strategies2659 Risk Stratification Before Discharge for Patients With an Ischemia-Guided Strategy of NSTE-ACS2661 Myocardial Revascularization: Recommendations2661 PCI--General Considerations2661 PCI--Oral and Intravenous Antiplatelet Agents2661 PCI--GP IIb/IIIa Inhibitors2662 Anticoagulant Therapy in Patients Undergoing PCI2663 Timing of Urgent Coronary Artery Bypass Graft in Patients With NSTE-ACS in Relation to Use of Antiplatelet Agents2663 Late Hospital Care, Hospital Discharge, and Posthospital Discharge Care: Recommendations2663 Medical Regimen and Use of Medications at Discharge2663 Late Hospital and Posthospital Oral Antiplatelet Therapy2664 Combined Oral Anticoagulant Therapy and Antiplatelet Therapy in Patients With NSTE-ACS2664 Risk Reduction Strategies for Secondary Prevention2664 Plan of Care for Patients With NSTE-ACS2665 Special Patient Groups: Recommendations2665 NSTE-ACS in Older Patients2665 Heart Failure and Cardiogenic Shock2665 Diabetes Mellitus2667 Post-CABG2668 Perioperative NSTE-ACS Related to Noncardiac Surgery2668 Chronic Kidney Disease2668 Women2668 Anemia, Bleeding, and Transfusion2668 Cocaine and Methamphetamine Users2668 Vasospastic (Prinzmetal) Angina2668 ACS With Angiographically Normal Coronary Arteries2669 Stress (Takotsubo) Cardiomyopathy2669 Quality of Care and Outcomes for ACS--Use of Performance Measures and Registries: Recommendation2669 Summary and Evidence Gaps2669 References2670 Appendix 1 Author Relationships With Industry and Other Entities (Relevant)2680 Appendix 2 Reviewer Relationships With Industry and Other Entities (Relevant)2683 Preamble The American College of Cardiology (ACC) and the American Heart Association (AHA) are committed to the prevention and management of cardiovascular diseases through professional education and research for clinicians, providers, and patients. Since 1980, the ACC and AHA have shared a responsibility to translate scientific evidence into clinical practice guidelines (CPGs) with recommendations to standardize and improve cardiovascular health.
Relevant preclinical models are necessary for further mechanistic and translational studies of c-kit+ cardiac stem cells (CSCs). The present study was undertaken to determine whether intracoronary ...CSCs are beneficial in a porcine model of chronic ischemic cardiomyopathy.
Pigs underwent a 90-minute coronary occlusion followed by reperfusion. Three months later, autologous CSCs (n=11) or vehicle (n=10) were infused into the infarct-related artery. At this time, all indices of left ventricular (LV) function were similar in control and CSC-treated pigs, indicating that the damage inflicted by the infarct in the 2 groups was similar; 1 month later, however, CSC-treated pigs exhibited significantly greater LV ejection fraction (echocardiography) (51.7±2.0% versus 42.9±2.3%, P<0.01), systolic thickening fraction in the infarcted LV wall, and maximum LV dP/dt, as well as lower LV end-diastolic pressure. Confocal microscopy showed clusters of small α-sarcomeric actin-positive cells expressing Ki67 in the scar of treated pigs, consistent with cardiac regeneration. The origin of these cycling myocytes from the injected cells was confirmed in 4 pigs that received enhanced green fluorescent protein -labeled CSCs, which were positive for the cardiac markers troponin I, troponin T, myosin heavy chain, and connexin-43. Some engrafted CSCs also formed vascular structures and expressed α-smooth muscle actin.
Intracoronary infusion of autologous CSCs improves regional and global LV function and promotes cardiac and vascular regeneration in pigs with old myocardial infarction (scar). The results mimic those recently reported in humans (Stem Cell Infusion in Patients with Ischemic CardiOmyopathy SCIPIO trial) and establish this porcine model of ischemic cardiomyopathy as a useful and clinically relevant model for studying CSCs.
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