CAT2 Valvular Diseases

After completing your assigned readings, can anyone answer the following questions related to the diagnosis and treatment of valvular diseases?

What are the key factors that determine when to proceed to aortic valve replacement for patients with aortic stenosis? What guided decision making relating to aortic surgery for acute and chronic aortic regurgitation?

Which patients with aortic stenosis should be considered for transcatheter therapies such as valvuloplasty or transcatheter aortic valve replacement?

What are the indications for surgery in patients with mitral stenosis? What are the goals of medical therapy for mitral regurgitation and when should patients be considered for mitral valve repair or replacement?

When should patients with mitral regurgitations be considered for transcatheter mitral valve procedures?

What are the objectives of treatment of pulmonic valve disease? When should patients be referred for surgery or transcatheter valve replacement?

What are the factors that determine medical versus surgical treatment of tricuspid stenosis or tricuspid regurgitation?


  • AM

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Cardiovascular Medicine

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Acute Coronary Syndromes

Michael McDaniel, MD, FSCAI

Key Clinical Questions

What is the optimal care and management of patients with ST-segment elevation
myocardial infarction?

What is the optimal care and management of patients with non-ST segment
elevation acute coronary syndrome?


The term acute coronary syndrome (ACS) refers to the spectrum clinical presentations
related to acute myocardial ischemia or infarction due to the abrupt reduction in coronary
blood flow. ACS is divided into ST-segment elevation myocardial infarctions (STEMIs) and
non-ST segment elevation acute coronary syndromes (NSTE-ACSs). The NSTE-ACS is
further subdivided on the basis of elevated cardiac biomarkers of myocardial necrosis.
Patients with elevated cardiac biomarkers are defined as non-ST segment elevation
myocardial infarction (NSTEMI) and those without elevated biomarkers are termed
unstable angina (UA).

This chapter will focus on the diagnosis, risk stratification, and treatment of patients
with ACS based on the American College of Cardiology Foundation and American Heart
Association (ACCF/AHA) practice guidelines for STEMI and NSTE-ACS. All guideline
recommendations will be cited in this chapter and referenced according the American

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College of Cardiology Foundation/American Heart Association classification scheme
(Table 128-1).

TABLE 128-1 ACCF/AHA Classification of Recommendations and Level of Evidence

Class I Class IIa Class IIb Class III
Benefit >>>

Benefit >> Risk
Additional studies
with focused
objectives needed
to perform

Benefit ≥ Risk
Additional studies
with broad objectives
needed; Additional
registry data would
be helpful

Risk ≥ Benefit
No additional studies
should NOT be

Level A: Recommendation based on evidence from multiple randomized trials or meta-analyses
Level B: Recommendation based on evidence from a single randomized trial or non-
randomized studies
Level C: Recommendation based on expert opinion, case studies, or standard of care

From O’Gara PT, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction:
executive summary: a report of the American College of Cardiology Foundation/American Heart Association
Task Force on Practice Guidelines. J Am Coll Cardiol.2013;61(4):485-510.


ACS is common, with ov

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/or cardiogenic shock should undergo immediate angiography within 2 hours of hospital
presentation no matter the ECG findings (Class I, LOE A). However, for patients that are
hemodynamically and electrically stable without ongoing angina, clinicians must select
between an early invasive strategy or an ischemia-guided strategy.

An early invasive strategy is defined as angiography within 72 hours of admission to
risk stratify patients based on coronary anatomy. The advantages to an early invasive
strategy include rapid evaluation, early revascularizaton, and earlier discharge. An early
invasive strategy is indicated for initially stabilized patients with NSTE-ACS without
contraindications to angiography and elevated risk of recurrent events (Table 128-6).
Multiple studies and meta-analyses suggests that an early invasive strategy is preferred to
an ischemia-guided strategy in higher-risk patients with NSTE-ACS as it is associated with
lower rates of repeat hospitalization, myocardial infarction, and mortality. In a combined
analysis of multiple randomized trials, there was an 11.1% absolute reduction (NNT9) in
death and myocardial infarction in the highest risk NSTE-ACS by 5-year follow-up. An early
invasive strategy is also associated with less angina and improved quality of life. It should
be remembered that these are strategy trials, and not a comparisons of revascularization
and medical therapy. Patients undergo revascularization with CABG or PCI
revascularization in about 70% of patients randomized to an early invasive strategy and in
40% to 50% of patients randomized to an ischemia-guided strategy.

TABLE 128-6 Intermediate or High Risk Non–ST-Elevation Acute Coronary Syndrome
(NSTE-ACS) Criteria

Intermediate or High risk NSTE-ACS is defined by one or more of the following:
1. Recurrent angina/ischemia at rest with low-level activities despite intensive medical

2. Elevated troponin
3. New/dynamic ST-segment depression
4. Signs/symptoms of heart failure or new/worsening mitral regurgitation
5. High-risk findings from noninvasive testing
6. Hemodynamic instability
7. Sustained ventricular tachycardia (>30 s and/or hemodynamic instability)
8. PCI within 6 mo
9. TIMI risk score ≥3

10. Newly reduced left ventricular function (LVEF < 40%)

In contrast, an ischemia-guided strategy aims to avoid routine angiography unless
patients experience refractory or recurrent angina, hemodynamic instability, or objective
evidence of severe ischemia. An ischemia-guided strategy is preferred in patients at low
risk for recurrent events, especially in troponin negative NSTE-ACS with low TIMI risk
scores (≤2) (Table 128-7). Patients undergoing an ischemia-guided strategy should
undergo noninvasive testing prior to discharge (Class I, LOE B). The optimal test depends

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