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Acute Coronary Syndromes

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General Information

Description

  • acute coronary syndromes refer to a spectrum of acute myocardial ischemia and/or necrosis usually secondary to reduction in coronary blood flow, including unstable angina (UA), non-ST-elevation myocardial infarction (NSTEMI), and ST-elevation myocardial infarction (STEMI)3,4
  • unstable angina and NSTEMI can be indistinguishable at presentation, thus initial evaluation and management are considered together as acute coronary syndromes in clinical practice guidelines3
  • this topic deals only with UA and NSTEMI and information on STEMI can be found in ST-elevation myocardial infarction (STEMI)

Also called

  • acute myocardial infarction
  • heart attack
  • myocardial infarction
  • when used without a qualifier, the terms heart attack, acute myocardial infarction, and myocardial infarction include both non-STEMI and STEMI
  • non-STEMI
    • subendocardial myocardial infarction
    • acute non-Q-wave myocardial infarction
  • unstable angina
    • crescendo angina
    • acute coronary insufficiency
    • preinfarction angina
    • accelerated angina
  • NSTE-ACS - refers to non-ST elevation acute coronary syndrome

Definitions

  • definition of acute coronary syndrome(s)3
    • acute coronary syndrome includes spectrum of ST-elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), and unstable angina (UA)
    • UA/NSTEMI is defined, in an appropriate clinical setting (chest discomfort or anginal equivalent), often accompanied by
      • electrocardiographic (ECG) ST-segment depression or prominent T-wave inversion and/or
      • positive biomarkers of necrosis (for example, troponin) in the absence of ST-segment elevation
    • NSTEMI differentiated from UA by presence of myocardial necrosis
    • STEMI is diagnosed by ECG in the absence of left ventricular hypertrophy or left bundle branch block (LBBB) in the presence of new ST elevation (at J point) and either of:
  • European Society of Cardiology, American College of Cardiology, American Heart Association, and World Heart Federation (ESC/ACC/AHA/WHF) 2018 universal definition of myocardial infarction
    • criteria for myocardial injury - detection of elevated cardiac troponin (cTn) values with ≥ 1 value > 99th percentile of upper reference limit
    • criteria for acute myocardial infarction - evidence of acute myocardial injury in clinical setting consistent with acute myocardial ischemia, as evidenced by any of
      • detection of rise and/or fall of cardiac troponin (cTn) values with ≥ 1 value > 99th percentile of upper reference limit plus at least 1 of
        • symptoms of ischemia
        • new ischemic ECG changes
        • development of pathological Q waves on electrocardiogram (ECG)
        • imaging evidence of new loss of viable myocardium or new regional wall motion abnormality
        • identification of intracoronary thrombus by angiography or autopsy
      • post-mortem finding of acute athero-thrombosis in artery supplying the infarcted myocardium, regardless of cTn values
      • detection of rise and/or fall of cardiac troponin (cTn) values with ≥ 1 value > 99th percentile of upper reference limit plus
        • evidence of imbalance between myocardial oxygen supply and demand unrelated to acute atherothrombosis plus at least 1 of
          • symptoms of ischemia
          • new ischemic ECG changes
          • development of pathological Q waves on electrocardiogram (ECG)
          • imaging evidence of new loss of viable myocardium or new regional wall motion abnormality
      • cardiac death with symptoms suggestive of myocardial ischemia and presumed-new ischemic ECG changes, but death occurring before blood samples obtained or before increases in cardiac biomarkers in blood can be identified
    • criteria for coronary procedure-related myocardial infarction occurring ≤ 48 hours after procedure
      • for percutaneous coronary intervention-related myocardial infarction
        • in patients with normal baseline cTn levels, elevation of cTn values > 5 times 99th percentile of upper reference limit
        • in patients with baseline values elevated and stable (< 20% variation) or falling, rise of cTn values > 20%
        • plus 1 of
          • new ischemic ECG changes
          • new pathological Q waves
          • angiographic findings consistent with procedural flow-limiting complication (such as coronary dissection, major epicardial artery or graft occlusion, side-branch occlusion-thrombus, disruption of collateral flow, or distal embolization)
          • imaging evidence of new loss of viable myocardium
      • stent/scaffold thrombosis-related myocardial infarction detected by coronary angiography or autopsy in setting of myocardial ischemia and with rise and/or fall of cardiac biomarker values with ≥ 1 value > 99th percentile of upper reference limit
      • restenosis-related myocardial infarction detected by coronary angiography or autopsy in setting of myocardial ischemia and with rise and/or fall of cardiac biomarker values with ≥ 1 value > 99th percentile of upper reference limit
      • for coronary artery bypass graft-related myocardial infarction
        • in patients with normal baseline cTn levels, elevations of cardiac biomarkers > 10 times 99th percentile of upper reference limit indicates periprocedural myocardial necrosis
        • in patients with baseline values elevated and stable (< 20% variation) or falling, rise of cTn values > 20%
        • plus 1 of
          • new pathological Q waves
          • angiographic findings consistent with procedural flow-limiting complication (such as coronary dissection, major epicardial artery or graft occlusion, side-branch occlusion-thrombus, disruption of collateral flow, or distal embolization)
          • imaging evidence of new loss of viable myocardium or new regional wall motion abnormality
      • isolated development of new pathological Q waves and cTn values elevated and rising but less than pre-specified thresholds for percutaneous coronary intervention and coronary artery bypass graft
      • post-mortem demonstration of procedure-related thrombus
    • criteria for prior or silent/unrecognized myocardial infarction - any of
      • pathological Q waves with or without symptoms in absence of nonischemic causes
      • imaging evidence of region of loss of viable myocardium that is thinned and fails to contract in absence of nonischemic cause
      • pathological findings of prior myocardial infarction
    • PubMed30165617European heart journalEur Heart J20190114403237-269237 Reference - Eur Heart J 2019 Jan 14;40(3):237OpenInNew

Types

  • types of myocardial infarction in European Society of Cardiology, American College of Cardiology Foundation, American Heart Association, and World Heart Federation (ESC/ACCF/AHA/WHF) 2018 universal definition of myocardial infarction
    • Type 1 - spontaneous myocardial infarction
      • caused by atherothrombotic coronary artery disease (CAD)
      • typically related to atherosclerotic plaque rupture or erosion
    • Type 2 - myocardial infarction secondary to ischemic imbalance
      • myocardial injury with necrosis due to condition other than atherothrombotic plaque disruption contributing to imbalance between myocardial oxygen supply and/or demand
      • causes include coronary atherosclerosis, coronary endothelial dysfunction, coronary artery spasm, coronary embolism, tachyarrhythmias, bradyarrhythmias, anemia, respiratory failure, hypotension/shock, and hypertension with or without left ventricular hypertrophy
    • Type 3 - myocardial infarction resulting in death when biomarker values are unavailable
    • Type 4 - myocardial infarction associated with percutaneous coronary intervention (Type 4a), with stent thrombosis (Type 4b), or with in-stent restenosis (Type 4c)
    • Type 5 - myocardial infarction associated with coronary artery bypass grafting
  • myocardial infarction with nonobstructive coronary arteries (MINOCA)
    • refers to acute myocardial infarction (AMI) with demonstration of nonobstructive coronary arteries
    • European Society of Cardiology (ESC) diagnostic criteria
      • diagnosis of MINOCA is made immediately after coronary angiography in patients presenting with features consistent with acute myocardial infarction and requires 3 diagnostic criteria to be met, including AMI criteria, nonobustructive coronary arteries on coronary angiography criteria, and no clinically overt specific cause for acute presentation criteria
      • AMI criteria
        • positive cardiac biomarker (preferably cardiac troponin) defined as risk and/or fall in serial levels with ≥ 1 value > 99th percentile upper limit reference
        • corroborative clinical evidence of infarction evidenced by ≥ 1 of the following
          • symptoms of ischemia
          • new, or presumed new, significant ST-T changes or new left bundle branch block (LBBB)
          • development of pathological Q waves
          • imaging evidence of new loss of viable myocardium or new regional wall motion abnormality
          • intracoronary thrombus evidence on coronary angiography or autopsy
      • nonobstructive coronary arteries on coronary angiography criteria
        • defined as absence of obstructive coronary artery disease (CAD) on angiography (no coronary artery stenosis ≥ 50%) in any potential infarct-related artery, which may include either
          • normal coronary arteries (no stenosis > 30%)
          • mild coronary atheromatosis (stenosis > 30% but < 50%)
      • no clinically overt specific cause for acute presentation criteria
        • cause and specific diagnosis for clinical presentation not apparent at time of coronary angiography
        • necessity to further evaluate for underlying cause of MINOCA presentation
    • Reference - 28158518Eur Heart J 2017 Jan 14;38(3):143OpenInNewfull-textOpenInNew

References

General references used

  1. Anderson JL, Adams CD, Antman EM, et al. 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) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. J Am Coll Cardiol. 2007 Aug 14;50(7):e1-e157OpenInNewfull-textOpenInNew, correction can be found in J Am Coll Cardiol 2008 Mar 4;51(9):974, commentary can be found in J Am Coll Cardiol 2009 May 26;53(21):1965OpenInNew
  2. Jneid H, Anderson JL, Wright RS, et al. 2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/non-ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update): a report of the American College of Cardiology Foundation/American Heart Association Task Force Practice Guidelines. Circulation. 2012 Aug 14;126(7):875-910OpenInNewfull-textOpenInNew, or in J Am Coll Cardiol 2012 Aug 14;60(7):645-81OpenInNew
  3. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014 Dec 23;130(25):e344-426OpenInNewfull-textOpenInNew or in J Am Coll Cardiol. 2014 Dec 23;64(24):e139OpenInNew
  4. Braunwald E. Unstable angina and non-ST elevation myocardial infarction. Am J Respir Crit Care Med. 2012 May 1;185(9):924-32OpenInNew

Recommendation grading systems used

  • European Society of Cardiology (ESC) grading system for recommendations
    • classifications of recommendations
      • Class I - procedure or treatment should be performed or administered
      • Class IIa - reasonable to perform procedure or administer treatment, but additional studies with focused objectives needed
      • Class IIb - procedure or treatment may be considered; additional studies with broad objectives needed, additional registry data would be useful
      • Class III - procedure or treatment should not be performed or administered because it is not helpful or may be harmful
        • Class III ratings may be subclassified as Class III No Benefit or Class III Harm
    • levels of evidence
      • Level A - data derived from multiple randomized clinical trials or meta-analyses
      • Level B - data derived from single randomized trial or nonrandomized studies
      • Level C - only expert opinion, case studies, or standard of care
    • References
  • American College of Chest Physicians (ACCP) grades
    • Grade 1 - strong recommendation based on clear risk/benefit balance
    • Grade 2 - weak recommendation based on unclear or close risk/benefit balance
    • Grade A - high-quality evidence based on consistent evidence from randomized trials without important limitations or exceptionally strong evidence from observational studies
    • Grade B - moderate-quality evidence based on randomized trials with important limitations (inconsistent results, methodologic flaws, indirect or imprecise results) or very strong evidence from observational studies
    • Grade C - low- or very low-quality evidence based on evidence for ≥ 1 critical outcome from observational studies, case series, or randomized trials with serious flaws or indirect evidence
    • Reference - ACCP evidence-based clinical practice guideline on methodology for development of antithrombotic therapy and prevention of thrombosis (22315256Chest 2012 Feb;141(2 Suppl):53SOpenInNewfull-textOpenInNew), commentary can be found in 23546508Chest 2013 Apr;143(4):1190OpenInNew

Synthesized Recommendation Grading System for DynaMed

  • DynaMed systematically monitors clinical evidence to continuously provide a synthesis of the most valid relevant evidence to support clinical decision-making (see 7-Step Evidence-Based MethodologyOpenInNew).
  • Guideline recommendations summarized in the body of a DynaMed topic are provided with the recommendation grading system used in the original guideline(s), and allow DynaMed users to quickly see where guidelines agree and where guidelines differ from each other and from the current evidence.
  • In DynaMed (DM), we synthesize the current evidence, current guidelines from leading authorities, and clinical expertise to provide recommendations to support clinical decision-making in the Overview & Recommendations section.
  • We use the Grading of Recommendations Assessment, Development and Evaluation (GRADE)OpenInNew to classify synthesized recommendations as Strong or Weak.
    • Strong recommendations are used when, based on the available evidence, clinicians (without conflicts of interest) consistently have a high degree of confidence that the desirable consequences (health benefits, decreased costs and burdens) outweigh the undesirable consequences (harms, costs, burdens).
    • Weak recommendations are used when, based on the available evidence, clinicians believe that desirable and undesirable consequences are finely balanced, or appreciable uncertainty exists about the magnitude of expected consequences (benefits and harms). Weak recommendations are used when clinicians disagree in judgments of relative benefit and harm, or have limited confidence in their judgments. Weak recommendations are also used when the range of patient values and preferences suggests that informed patients are likely to make different choices.
  • DynaMed (DM) synthesized recommendations (in the Overview & Recommendations section) are determined with a systematic methodology:
    • Recommendations are initially drafted by clinical editors (including ≥ 1 with methodological expertise and ≥ 1 with content domain expertise) aware of the best current evidence for benefits and harms, and the recommendations from guidelines.
    • Recommendations are phrased to match the strength of recommendation. Strong recommendations use "should do" phrasing, or phrasing implying an expectation to perform the recommended action for most patients. Weak recommendations use "consider" or "suggested" phrasing.
    • Recommendations are explicitly labeled as Strong recommendations or Weak recommendations when a qualified group has explicitly deliberated on making such a recommendation. Group deliberation may occur during guideline development. When group deliberation occurs through DynaMed-initiated groups:
      • Clinical questions will be formulated using the PICO (Population, Intervention, Comparison, Outcome) framework for all outcomes of interest specific to the recommendation to be developed.
      • Systematic searches will be conducted for any clinical questions where systematic searches were not already completed through DynaMed content development.
      • Evidence will be summarized for recommendation panel review including for each outcome, the relative importance of the outcome, the estimated effects comparing intervention and comparison, the sample size, and the overall quality rating for the body of evidence.
      • Recommendation panel members will be selected to include at least 3 members that together have sufficient clinical expertise for the subject(s) pertinent to the recommendation, methodological expertise for the evidence being considered, and experience with guideline development.
      • All recommendation panel members must disclose any potential conflicts of interest (professional, intellectual, and financial), and will not be included for the specific panel if a significant conflict exists for the recommendation in question.
      • Panel members will make Strong recommendations if and only if there is consistent agreement in a high confidence in the likelihood that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. Panel members will make Weak recommendations if there is limited confidence (or inconsistent assessment or dissenting opinions) that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. No recommendation will be made if there is insufficient confidence to make a recommendation.
      • All steps in this process (including evidence summaries which were shared with the panel, and identification of panel members) will be transparent and accessible in support of the recommendation.
    • Recommendations are verified by ≥ 1 editor with methodological expertise, not involved in recommendation drafting or development, with explicit confirmation that Strong recommendations are adequately supported.
    • Recommendations are published only after consensus is established with agreement in phrasing and strength of recommendation by all editors.
    • If consensus cannot be reached then the recommendation can be published with a notation of "dissenting commentary" and the dissenting commentary is included in the topic details.
    • If recommendations are questioned during peer review or post publication by a qualified individual, or reevaluation is warranted based on new information detected through systematic literature surveillance, the recommendation is subject to additional internal review.

DynaMed Editorial Process

Special acknowledgements

  • The American College of Physicians (Marjorie Lazoff, MD, FACP; ACP Deputy Editor, Clinical Decision Resource) provided review in a collaborative effort to ensure DynaMed provides the most valid and clinically relevant information in internal medicine.
  • DynaMed topics are written and edited through the collaborative efforts of the above individuals. Deputy Editors, Section Editors, and Topic Editors are active in clinical or academic medical practice. Recommendations Editors are actively involved in development and/or evaluation of guidelines.
  • Editorial Team role definitions
    Topic Editors define the scope and focus of each topic by formulating a set of clinical questions and suggesting important guidelines, clinical trials, and other data to be addressed within each topic. Topic Editors also serve as consultants for the internal DynaMed Editorial Team during the writing and editing process, and review the final topic drafts prior to publication.
    Section Editors have similar responsibilities to Topic Editors but have a broader role that includes the review of multiple topics, oversight of Topic Editors, and systematic surveillance of the medical literature.
    Recommendations Editors provide explicit review of DynaMed Overview and Recommendations sections to ensure that all recommendations are sound, supported, and evidence-based. This process is described in "Synthesized Recommendation Grading."
    Deputy Editors are employees of DynaMed and oversee DynaMed internal publishing groups. Each is responsible for all content published within that group, including supervising topic development at all stages of the writing and editing process, final review of all topics prior to publication, and direction of an internal team.

How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T116779, Acute Coronary Syndromes; [updated 2018 Nov 30, cited place cited date here]. Available from https://www.dynamed.com/topics/dmp~AN~T116779. Registration and login required.
  • KeyboardArrowRight

    Overview and Recommendations

    • Background

    • Evaluation

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      Management

      • Early hospital care

      • Invasive versus ischemia-guided (conservative) strategy

      • Preparation for hospital discharge

  • Related Summaries

  • KeyboardArrowRight

    General Information

    • Description

    • Also called

    • Definitions

    • Types

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    Epidemiology

    • Who is most affected

    • Incidence/Prevalence

    • Risk factors

    • Possible risk factors

    • Associated conditions

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    Etiology and Pathogenesis

    • Causes

    • Pathogenesis

  • KeyboardArrowRight

    History and Physical

    • KeyboardArrowRight

      History

      • Chief concern (CC)

      • History of present illness (HPI)

      • Medication history

      • Past medical history (PMH)

      • Family history (FH)

      • Social history (SH)

    • KeyboardArrowRight

      Physical

      • General physical

      • Skin

      • Neck

      • Chest

      • Cardiac

      • Lungs

      • Extremities

      • Rectal

  • KeyboardArrowRight

    Diagnosis

    • Making the diagnosis

    • KeyboardArrowRight

      Differential diagnosis

      • Other causes of chest pain

      • Other causes of elevated troponin levels

      • Other causes of elevated creatine kinase-myocardial band (CK-MB)

      • Other causes of electrocardiogram abnormalities

    • Testing overview

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      Clinical prediction rules

      • Vancouver chest pain rule

      • 2-hour accelerated diagnostic protocols (ADPs)

      • Other clinical prediction rules

    • KeyboardArrowRight

      Blood tests

      • KeyboardArrowRight

        Cardiac biomarkers

        • Recommendations

        • Algorithms based on cardiac biomarkers for diagnosing and ruling out ACS

        • Troponins

        • Combinations of biomarkers

        • Other biomarkers

      • Glucose

      • Other tests

    • KeyboardArrowRight

      Imaging studies

      • Echocardiography

      • Coronary angiography

      • Computed tomography (CT) angiography

      • Myocardial perfusion imaging

      • Coronary artery calcium scoring

      • Coronary artery thrombus burden

    • Electrocardiography (ECG)

    • KeyboardArrowRight

      Other diagnostic testing

      • Chest pain unit for observation

      • Cardiac stress testing

  • KeyboardArrowRight

    Management

    • Management overview

    • KeyboardArrowRight

      Short-term risk assessment

      • Recommendations and general information

      • Global Registry of Acute Coronary Events (GRACE) score

      • Thrombolysis in Myocardial Infarction (TIMI) score

      • Acute Myocardial Infarction in Switzerland (AMIS) score

      • Canada acute coronary syndrome risk score

      • History, ECG, Age, Risk factors, Troponin (HEART) score

      • Risk scores for predicting bleeding risk

    • Treatment setting

    • Diet

    • Activity

    • Counseling

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      Medications

      • Antiplatelet and anticoagulant therapy

      • Nitrates

      • Oxygen

      • KeyboardArrowRight

        Beta blockers

      • Calcium channel blockers

      • Renin-angiotensin inhibitors

      • Morphine

      • Nonsteroidal anti-inflammatory drugs (NSAIDs)

      • KeyboardArrowRight

        Lipid-lowering agents

        • Statins

        • Ezetimibe

        • Proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors

      • KeyboardArrowRight

        Interventions without sufficient evidence for routine use

        • Antibiotics

        • Ranolazine

        • Succinobucol

        • Investigational agents

      • Treatments not recommended

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      Surgery and procedures

      • Revascularization for acute coronary syndrome

      • Intra-aortic balloon pump (IABP)

      • Transmyocardial revascularization

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      Other management

      • Complementary and alternative treatments

      • Use of guidelines and protocols

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        Recommendations for special populations

        • Women

        • Older adults

        • Heart failure

        • Cardiogenic shock

        • Atrial fibrillation

        • Ventricular arrhythmias

        • Diabetes mellitus

        • Post-coronary artery bypass graft (CABG)

        • Perioperative

        • Chronic kidney disease

        • Cocaine and methamphetamine users

        • Vasospastic (Prinzmetal's) angina

        • Cardiovascular syndrome X

        • Stress (Takotsubo) Cardiomyopathy

        • Thrombocytopenia

      • Management of depression related to cardiac illness

      • Other treatments

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      Follow-up

      • Risk stratification prior to discharge

      • Discharge recommendations

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        Rehabilitation

      • Resumption of activities

      • Secondary prevention

  • KeyboardArrowRight

    Complications and Prognosis

    • Complications

    • KeyboardArrowRight

      Prognosis

      • Mortality

      • KeyboardArrowRight

        Long-term risk stratification and risk scores

        • Killip class score

        • Bleeding Academic Research Consortium (BARC) score

        • Other predictive scoring methods

      • Electrocardiogram (ECG)/telemetry risk factors

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        Biomarkers

        • Cardiac troponin

        • Brain natriuretic peptide (BNP)

        • Creatinine kinase-myocardial band (CK-MB)

        • Inflammatory markers

        • Other markers

      • Age, gender, ethnicity

      • Anemia and hemoglobin

      • Diabetes or elevated glucose

      • Readmission

      • Ventricular arrhythmias

      • Other prognostic factors

      • Prognosis related to myocardial infarction unspecified

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    Prevention and Screening

    • Prevention

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    Quality Improvement

    • Medicare/Joint Commission National Hospital Inpatient Quality Measures

    • Medicare Hospital Outpatient Department Quality Measures

    • Physician Quality Reporting System Quality Measures

    • Choosing Wisely

    • American College of Cardiology (ACC)/American Heart Association (AHA) Performance Measures

  • KeyboardArrowRight

    Guidelines and Resources

    • KeyboardArrowRight

      Guidelines

      • International guidelines

      • United States guidelines

      • United Kingdom guidelines

      • Canadian guidelines

      • European guidelines

      • Asian guidelines

      • Australian and New Zealand guidelines

      • Middle Eastern guidelines

    • Review articles

    • MEDLINE search

  • Patient Information

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    ICD Codes

    • ICD-10 codes

  • KeyboardArrowRight

    References

    • General references used

    • Recommendation grading systems used

    • Synthesized Recommendation Grading System for DynaMed

    • DynaMed Editorial Process

    • Special acknowledgements

    • How to cite

Topic Editor
Jinnette Dawn Abbott MD, FACC, FSCAI
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Affiliations

Professor of Medicine, Brown University; Rhode Island, United States; Director of Interventional Cardiology, Rhode Island Hospital, Miriam Hospital; Rhode Island, United States

Conflicts of Interest

Dr. Abbott declares no relevant financial conflicts of interest.

Recommendations Editor
Eddy Lang MDCM, CCFP(EM), CSPQ
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Affiliations

Zone Clinical and Academic Department Head for Emergency Medicine and Professor of Emergency Medicine, University of Calgary; Alberta, Canada; Senior Researcher, Alberta Health Services; Alberta, Canada

Conflicts of Interest

Dr. Lang declares no relevant financial conflicts of interest.

Deputy Editor
Peter Oettgen MD
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Affiliations

Editor in Chief, DynaMed; Cardiologist, Beth Israel Deaconess Medical Center; Massachusetts, United States; Associate Professor of Medicine, Harvard Medical School; Massachusetts, United States

Conflicts of Interest

Dr. Oettgen declares no relevant financial conflicts of interest.

Produced in collaboration with American College of Physicians

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