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2009;302:2207 13. 879. Krone RJ, Shaw RE, Klein LW, et al. Evaluation of the American College of Cardiology/American Heart Association and the Society for Coronary Angiography and Interventions lesion classification system in the current stent era of coronary interventions (from the ACC- National Cardiovascular Data Registry). Am J Cardiol. 2003;92:389 94. KEY WORDS: AHA Scientific Statements y acute coronary syndromes y anticoagulants y antiplatelet agents y antiplatelet agents y arrhythmias, cardiac y coronary artery revascularization interventions: stents y coronary angiography y drug therapy y drug delivery systems y heart diseases y myocardial revascularization y platelet aggregation inhibitor y ultrasound Appendix 1.


KEY WORDS: AHA Scientific Statements y acute coronary syndromes y anticoagulants y antiplatelet agents y antiplatelet agents y arrhythmias, cardiac y coronary artery revascularization interventions: stents y coronary angiography y drug therapy y drug delivery systems y heart diseases y myocardial revascularization y platelet aggregation inhibitor y ultrasound Appendix 1. Author Relationships With Industry and Other Entities (Relevant) 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention Committee Member Employer/Title Consultant Speaker s Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness Voting Recusals by Section Number* Glenn N. Levine (Chair) Baylor College of Medicine Professor of Medicine; Director, Cardiac Care Unit None None None None None None None Eric R. Bates (Vice Chair) University of Michigan Professor of Medicine Bristol-Myers Squibb Daiichi-Sankyo Datascope Eli Lilly Merck Sanofi-aventis None None None None None 5.7.2 James C. Blankenship (Vice Chair) Geisinger Medical Center Director of Cardiology and Cardiac Catheterization Laboratories None None None Abiomed AstraZeneca Boston Scientific Conor Medsystems Kai Pharmaceutical Schering-Plough None None 2.1 Steven R. Bailey University of Texas Medical Center-Professor of Medicine and Radiology Volcano None None Boston Scientific None None 5.4.1 John A. Bittl Munroe Heart-Interventional Cardiologist None None None None None None None Bojan Cercek Cedars-Sinai Medical Center-Director, Coronary Care Unit None None None None None None None Charles E. Chambers Penn State Milton S. Hershey Medical Center-Professor of Medicine and Radiology None None None None None None None Stephen G. Ellis Cleveland Clinic Foundation-Section Head, Invasive and Interventional Cardiology Abbott Vascular Boston Scientific Cordis Daiichi-Sankyo Eli Lilly None None Abbott Vascular None None 2.2 Robert A. Guyton Emory Clinic, Inc.-Professor and Chief, Division of Cardiothoracic Surgery None None None Edwards Lifesciences None None 2.1 Steven M. Hollenberg Cooper University Hospital-Director, Coronary Care Unit Eisai None None None None None 5.7.4.3 Umesh N. Khot CV Research Innovations, LLC-President/CEO None None Merck None None None 4.6 Richard A. Lange University of Texas Health Science Center at San Antonio-Professor of Medicine None None None None None None None (Continued) Levine et al 2011 ACCF/AHA/SCAI PCI Guideline e643 Appendix 1.


Author Relationships With Industry and Other Entities (Relevant) 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention Committee Member Employer/Title Consultant Speaker s Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness Voting Recusals by Section Number* Glenn N. Levine (Chair) Baylor College of Medicine Professor of Medicine; Director, Cardiac Care Unit None None None None None None None Eric R. Bates (Vice Chair) University of Michigan Professor of Medicine Bristol-Myers Squibb Daiichi-Sankyo Datascope Eli Lilly Merck Sanofi-aventis None None None None None 5.7.2 James C. Blankenship (Vice Chair) Geisinger Medical Center Director of Cardiology and Cardiac Catheterization Laboratories None None None Abiomed AstraZeneca Boston Scientific Conor Medsystems Kai Pharmaceutical Schering-Plough None None 2.1 Steven R. Bailey University of Texas Medical Center-Professor of Medicine and Radiology Volcano None None Boston Scientific None None 5.4.1 John A. Bittl Munroe Heart-Interventional Cardiologist None None None None None None None Bojan Cercek Cedars-Sinai Medical Center-Director, Coronary Care Unit None None None None None None None Charles E. Chambers Penn State Milton S. Hershey Medical Center-Professor of Medicine and Radiology None None None None None None None Stephen G. Ellis Cleveland Clinic Foundation-Section Head, Invasive and Interventional Cardiology Abbott Vascular Boston Scientific Cordis Daiichi-Sankyo Eli Lilly None None Abbott Vascular None None 2.2 Robert A. Guyton Emory Clinic, Inc.-Professor and Chief, Division of Cardiothoracic Surgery None None None Edwards Lifesciences None None 2.1 Steven M. Hollenberg Cooper University Hospital-Director, Coronary Care Unit Eisai None None None None None 5.7.4.3 Umesh N. Khot CV Research Innovations, LLC-President/CEO None None Merck None None None 4.6 Richard A. Lange University of Texas Health Science Center at San Antonio-Professor of Medicine None None None None None None None (Continued) Levine et al 2011 ACCF/AHA/SCAI PCI Guideline e643 Appendix 1. Continued Committee Member Employer/Title Consultant Speaker s Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness Voting Recusals by Section Number* Laura Mauri Brigham and Women s Hospital-Associate Professor of Medicine, Harvard Medical School Abbott Conor Medsystems (Johnson & Johnson) Cordis Medtronic None None Lutonix Abbott Abiomed Boston Scientific Bristol-Myers Squibb Conor Medsystems Cordis Daiichi-Sankyo Eli Lilly Medtronic Cardiovascular Sanofi-aventis Defendant, Conor, interpretation of clinical trial Roxana Mehran Columbia University Medical Center-Associate Professor of Medicine; Director, Data Coordinating Analysis Center Abbott Vascular Abiomed AlphaMedical AstraZeneca Bracco BMS/ sanofi-aventis DataScope Eli Lilly/Daichii-Sankyo Guerbet The Medicines Company Medtronic Vascular St. Jude None None None None None 4.7 Issam D. Moussa Mayo Clinic-Professor of Medicine; Chair, Division of Cardiovascular Diseases None None None None None None None Debabrata Mukherjee Texas Tech University-Chief, Cardiovascular Medicine None None None None None None None Brahmajee K. Nallamothu University of Michigan-Assistant Professor of Medicine None None None None None None None Henry H. Ting Mayo Clinic-Professor of Medicine; Assistant Dean for Quality None None None None None None None This table represents the relationships of committee members with industry and other entities that were determined to be relevant to this document.


Continued Committee Member Employer/Title Consultant Speaker s Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness Voting Recusals by Section Number* Laura Mauri Brigham and Women s Hospital-Associate Professor of Medicine, Harvard Medical School Abbott Conor Medsystems (Johnson & Johnson) Cordis Medtronic None None Lutonix Abbott Abiomed Boston Scientific Bristol-Myers Squibb Conor Medsystems Cordis Daiichi-Sankyo Eli Lilly Medtronic Cardiovascular Sanofi-aventis Defendant, Conor, interpretation of clinical trial Roxana Mehran Columbia University Medical Center-Associate Professor of Medicine; Director, Data Coordinating Analysis Center Abbott Vascular Abiomed AlphaMedical AstraZeneca Bracco BMS/ sanofi-aventis DataScope Eli Lilly/Daichii-Sankyo Guerbet The Medicines Company Medtronic Vascular St. Jude None None None None None 4.7 Issam D. Moussa Mayo Clinic-Professor of Medicine; Chair, Division of Cardiovascular Diseases None None None None None None None Debabrata Mukherjee Texas Tech University-Chief, Cardiovascular Medicine None None None None None None None Brahmajee K. Nallamothu University of Michigan-Assistant Professor of Medicine None None None None None None None Henry H. Ting Mayo Clinic-Professor of Medicine; Assistant Dean for Quality None None None None None None None This table represents the relationships of committee members with industry and other entities that were determined to be relevant to this document. These relationships were reviewed and updated in conjunction with all meetings and/or conference calls of the writing committee during the document development process. The table does not necessarily reflect relationships with industry at the time of publication.


The table does not necessarily reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of 5% of the voting stock or share of the business entity, or ownership of $10 000 of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the person s gross income for the previous year. Relationships that exist with no financial benefit are also included for the purpose of transparency. Relationships in this table are modest unless otherwise noted. According to the ACCF/AHA, a person has a relevant relationship IF: a) The relationship or interest relates to the same or similar subject matter, intellectual property or asset, topic, or issue addressed in the document; or b) The company/entity (with whom the relationship exists) makes a drug, drug class, or device addressed in the document, or makes a competing drug or device addressed in the document; or c) The person or a member of the person s household has a reasonable potential for financial, professional, or other personal gain or loss as a result of the issues/content addressed in the document. *Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply. Significant relationship. Appendix 2.


*Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply. Significant relationship. Appendix 2. Reviewer Relationships With Industry and Other Entities (Relevant) 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention Peer Reviewer Representation Consultant Speaker s Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness Deepak L. Bhatt Official Reviewer AHA None None None AstraZeneca* Bristol-Myers Squibb* Eisai* Eli Lilly Ethicon* The Medicines Company* PLx Pharma Sanofi-aventis* None None Mauricio G. Cohen Official Reviewer AHA AstraZeneca* Momenta Pharma Xoma Terumo Medical None Invitrox* None None John P. Erwin III Official Reviewer ACCF/AHA Task Force on Performance Measures None None None None None None Kirk Garratt Official Reviewer SCAI Boston Scientific Cordis/Johnson & Johnson The Medicines Company Boston Scientific BMS/ sanofi-aventis* Daiichi-Sankyo/ Eli Lilly* Medtronic The Medicines Company Abbott Vascular Boston Scientific None None None Steven L. Goldberg Official Reviewer SCAI AGA Bristol-Myers Squibb Sanofi-aventis None None None Plaintiff, patient litigation, Alice K. Jacobs Official Reviewer ACCF/AHA Task Force on Practice Guidelines None None Wyeth* Abbott Vascular* Abiomed* Accumetrics* Cardiovascular Research Foundation (DSMB) Harvard Clinical Research Institute TIMI Study Group (DSMB) None None G.B. John Mancini Official Reviewer ACCF Board of Governors GlaxoSmithKline Merck Pfizer Sanofi-aventis None None Merck* None None (Continued) Levine et al 2011 ACCF/AHA/SCAI PCI Guideline e645 Appendix 2.


John Mancini Official Reviewer ACCF Board of Governors GlaxoSmithKline Merck Pfizer Sanofi-aventis None None Merck* None None (Continued) Levine et al 2011 ACCF/AHA/SCAI PCI Guideline e645 Appendix 2. Continued Peer Reviewer Representation Consultant Speaker s Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness W. Douglas Weaver Official Reviewer ACCF Board of Trustees None None None Boehringher Ingelheim (DSMB) Boston Scientific (DSMB) Duke Clinical Research Institute (Johnson & Johnson/Schering Plough)* GlaxoSmithKline NHLBI (DSMB) TIMI Study Group (Johnson & Johnson/ Bayer DSMB) None None Thomas M. Bashore Content Reviewer None None None None None None Christopher E. Buller Content Reviewer Abbott Vascular Toshiba Medical None None Novartis Regado Biosciences None None James A. Burke Content Reviewer ACCF Interventional Scientific Council None None None None None None John G. Byrne Content Reviewer ACCF Surgeons Scientific Council Edwards Lifesciences None None None None None T. Bruce Ferguson Content Reviewer ACCF Surgeons Scientific Council None None None Novadaq Technologies* None None Victor A. Ferrari Content Reviewer None None None NHLBI (DSMB) National Institute for Aging/NIH (DSMB) None None John G. Harold Content Reviewer None None None None None None Biswajit Kar Content Reviewer None None None AstraZeneca Boston Scientific Medtronic VA Cooperative Study None Morton J. Kern Content Reviewer Infraredex Merit Medical* St. Jude Medical* Volcano Therapeutics* None None None None Spencer B. King III Content Reviewer Celonova Biosciences None None Merck (DSMB) Wyeth (DSMB) None None Frederick G. Kushner Content Reviewer None None None Novartis None None David J. Maron Content Reviewer None None Cardiovascular Care Affiliates* None None Plaintiff, acute coronary syndrome, Douglass A. Morrison Content Reviewer None None None None None None (Continued) Appendix 2.


King III Content Reviewer Celonova Biosciences None None Merck (DSMB) Wyeth (DSMB) None None Frederick G. Kushner Content Reviewer None None None Novartis None None David J. Maron Content Reviewer None None Cardiovascular Care Affiliates* None None Plaintiff, acute coronary syndrome, Douglass A. Morrison Content Reviewer None None None None None None (Continued) Appendix 2. Continued Peer Reviewer Representation Consultant Speaker s Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness Thomas C. Piemonte Content Reviewer ACCF Board of Governors None None None None None Defendant, stent perforation, Peter K. Smith Content Reviewer Eli Lilly None None None None None Sidney C. Smith Content Reviewer None None None None None None Richard W. Snyder Content Reviewer ACCF Board of Governors None None None None Hospital Corporation of America None Patrick L. Whitlow Content Reviewer Edwards Lifesciences* eValve* Medtronic* None None None ICON None David O. Williams Content Reviewer Light Lab/St. Jude Medical None None None None None R. Scott Wright Content Reviewer Hoffman LaRoche* None None None None None This table represents the relationships of reviewers with industry and other entities that were disclosed at the time of peer review and determined to be relevant. It does not necessarily reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of 5% of the voting stock or share of the business entity, or ownership of $10 000 of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the person s gross income for the previous year. A relationship is considered to be modest if it is less than significant under the preceding definition.


A relationship is considered to be modest if it is less than significant under the preceding definition. Relationships that exist with no financial benefit are also included for the purpose of transparency. Relationships in this table are modest unless otherwise noted. Names are listed in alphabetical order within each category of review. According to the ACCF/AHA, a person has a relevant relationship IF: a) The relationship or interest relates to the same or similar subject matter, intellectual property or asset, topic, or issue addressed in the document; or b) The company/entity (with whom the relationship exists) makes a drug, drug class, or device addressed in the document, or makes a competing drug or device addressed in the document; or c) The person or a member of the person s household has a reasonable potential for financial, professional, or other personal gain or loss as a result of the issues/content addressed in the document. *Significant relationship. No financial benefit. ACCF indicates American College of Cardiology Foundation; AHA, American Heart Association; DSMB, data safety and monitoring board; NHLBI, National Heart, Lung, and Blood Institute; NIH, National Institutes of Health; SCAI, Society for Cardiovascular Angiography and Interventions; and TIMI, Thrombolysis In Myocardial Infarction. Levine et al 2011 ACCF/AHA/SCAI PCI Guideline e647 Appendix 3.


Levine et al 2011 ACCF/AHA/SCAI PCI Guideline e647 Appendix 3. Abbreviation List ACS acute coronary syndromes AKI acute kidney injury BMS bare-metal stent(s) CABG coronary artery bypass graft surgery CAD coronary artery disease CKD chronic kidney disease CTO chronic total occlusion DAPT dual antiplatelet therapy DES drug-eluting stent(s) ECG electrocardiogram EF ejection fraction EPD embolic protection device FDA US Food and Drug Administration FFR fractional flow reserve GDMT guideline-directed medical therapy GI gastrointestinal GP glycoprotein IABP intra-aortic balloon pump IV intravenous IVUS intravascular ultrasound LAD left anterior descending LIMA left internal mammary artery LV left ventricular LVEF left ventricular ejection fraction MACE major adverse cardiac event MI myocardial infarction MRI magnetic resonance imaging NCDR National Cardiovascular Data Registry PCI percutaneous coronary intervention PPI proton pump inhibitor RCT randomized controlled trial SIHD stable ischemic heart disease STEMI ST-elevation myocardial infarction SVG saphenous vein graft TIMI Thrombolysis In Myocardial Infarction TMR transmyocardial laser revascularization UA/NSTEMI unstable angina/non-ST-elevation myocardial infarction UFH unfractionated heparin Appendix 4. Additional Tables/Figures Appendix 4A. The NCDR CathPCI Risk Score System Variable Scoring Response Categories Risk Score Calculation Total Points Risk of In-Patient Mortality (%) Cardiogenic shock No Yes 10 0.1 Prior CHF No Yes 20 0.3 Peripheral vascular disease No Yes 30 1.1 Chronic lung disease No Yes 40 3.6 NYHA functional class IV No Yes 60 29.0 PCI status (STEMI) Elective Urgent Emergent Salvage 70 57.6 PCI status (no STEMI) Elective Urgent Emergent Salvage 80 81.0 CathPCI indicates catheterization percutaneous coronary intervention; CHF, congestive heart failure; GFR, glomerular filtration rate; NCDR, National Cardiovascular Data Registry; NYHA, New York Heart Association; and STEMI, ST-elevation myocardial infarction. Reproduced with permission from Peterson et al.236 Levine et al 2011 ACCF/AHA/SCAI PCI Guideline e649 Appendix 4C.


Reproduced with permission from Peterson et al.236 Levine et al 2011 ACCF/AHA/SCAI PCI Guideline e649 Appendix 4C. Strategies to Reduce Radiation Exposure to Patient and Operator Precautions to minimize exposure to patient and operator Use radiation only when imaging is necessary to support clinical care Minimize use of cine Minimize use of steep angles of x-ray beam Minimize use of magnification modes Minimize frame rate of fluoroscopy and cine Keep the image receptor close to the patient Utilize collimation to the fullest extent possible Monitor radiation dose in real time to assess patient risk-benefit during procedure Precautions to specifically minimize exposure to operator Use and maintain appropriate protective garments Maximize distance of operator from x-ray source and patient Keep above-table and below-table shields in optimal position at all times Keep all body parts out of field of view at all times Precautions to specifically minimize exposure to patient Keep table height as high as comfortably possible for operator Vary imaging beam angle to minimize exposure to any single skin area Keep patient s extremities out of beam Appendix 4D. Patient Care Consideration Based on Procedural Radiation Dose Ka,r* PKA FT Action 60 min Physician charts documentation about why exposure at this level occurred, documents whether multiple skin entry angles were used, assesses risk, educates patient about potential for skin injury, and arranges for appropriate follow-up within 30 d. Phone calls may be sufficient with an office visit arranged if issues/questions arise or a potential tissue injury is suspected. 10 Gray Physician contacts radiation safety officer/medical physicist. The radiation safety officer/medical physicist should perform a detailed analysis of PSD. Document a) FOV, b) skin entrance port number, c) known geometry, with a rough geometric setup required. Educate patient about the potential for skin injury and document this in chart.


Educate patient about the potential for skin injury and document this in chart. Schedule an office visit in 2 to 4 wk. Gray If calculated PSD is indeed 15 Gray, the physician and/or radiation safety officer/medical physicist should contact hospital risk management within 24 h. Report the event to the Joint Commission and as needed to the appropriate State Department of Health. *Ka,r is total air kerma at reference point; PKA is air kerma-area product; FT is total fluoroscopy time, does not include cine; PSD is peak skin dose, which requires calculations made by a qualified physicist. FOV indicates field of view; and FT, fluoroscopy time. Adapted with permission from Chambers et al.317 Appendix 4B. The SCAI Lesion Classification System Type I lesions (highest success expected, lowest risk) 1. Does not meet criteria for C lesion Type II lesions 1. Meets any of these criteria for ACC/AHA C lesion Diffuse ( 2 cm length) Excessive tortuosity of proximal segment Extremely angulated segments, 90 Inability to protect major side branches Degenerated vein grafts with friable lesions Type III lesions 1. Does not meet criteria for C lesion Type IV lesions 1. Meets any of these criteria for ACC/AHA C lesion Diffuse ( 2 cm length) Excessive tortuosity of proximal segment Extremely angulated segments, 90 Inability to protect major side branches Degenerated vein grafts with friable lesions Occluded for 3 mo ACC indicates American College of Cardiology; AHA, American Heart Association; and SCAI, Society for Cardiovascular Angiography and Interven- tions. Reprinted with permission from Krone et al.879 Appendix 4E.


Meets any of these criteria for ACC/AHA C lesion Diffuse ( 2 cm length) Excessive tortuosity of proximal segment Extremely angulated segments, 90 Inability to protect major side branches Degenerated vein grafts with friable lesions Occluded for 3 mo ACC indicates American College of Cardiology; AHA, American Heart Association; and SCAI, Society for Cardiovascular Angiography and Interven- tions. Reprinted with permission from Krone et al.879 Appendix 4E. General Considerations in Deciding Between Early Invasive Strategy and Initial Conservative Strategy Early Invasive Strategy Generally Preferred Initial Conservative Strategy Generally Preferred or Reasonable Recurrent angina or ischemia at rest or with low-level activities despite intensive medical therapy Elevated cardiac biomarkers (TnT or TnI) New or presumably new ST-segment depression Signs or symptoms of heart failure Hemodynamic instability High-risk score (eg, GRACE, TIMI) Sustained ventricular tachycardia PCI within 6 mo Prior CABG Diabetes mellitus Mild to moderate renal dysfunction Reduced LV function (LVEF 40%) Low-risk score (eg, GRACE, TIMI) Absence of high-risk features High risk for catheterization-related complications Patient not a candidate for revascularization (with either PCI or CABG) Patient prefers conservative therapy CABG indicates coronary artery bypass graft surgery; GRACE, Global Registry of Acute Coronary Events; LV, left ventricular; LVEF, left ventricular ejection fraction; PCI, percutaneous coronary intervention; TIMI, Thrombolysis In Myocardial Infarction; TnI, troponin I; and TnT, troponin T. Appendix 4F. Agents for Procedural Sedation and Analgesia Drug Clinical Effects Dose Onset Duration Comments Midazolam Sedation, anxiolysis. No analgesia. Initial 0.5 to 1 mg IV, then titrated. 2 to 3 min 45 to 60 min Reduce dose when used in combination with opioids. May produce paradoxical excitement. Reversible with flumazenil. Fentanyl Analgesia 50 mcg IV. May repeat every 3 min, titrate to effect. 3 to 5 min 30 to 60 min Reduce dosing when combined with benzodiazepines. Reversible with naloxone.


3 to 5 min 30 to 60 min Reduce dosing when combined with benzodiazepines. Reversible with naloxone. Etomidate Sedation, anxiolysis. No analgesia. Sedation: 0.1 mg/kg IV; repeat if inadequate response. 1 min 5 to 15 min Respiratory depression may occur; institutional guidelines vary about administration to nonintubated patients by nonanesthesiologists. May cause myoclonus, nausea, and vomiting. Adrenocortical suppression occurs but is rarely of clinical significance. Not reversible. Propofol Sedation, anxiolysis. No analgesia. Load 1 mg/kg IV; may administer additional 0.5 mg/kg doses as needed to enhance or prolong sedation. 1 min 5 to 15 min Frequent hypotension and respiratory depression; institutional guidelines vary concerning administration to nonintubated patients by nonanesthesiologists. Avoid with egg or soy allergies. Not reversible. Reversal Agents Naloxone Opioid reversal 0.4 to 2 mg IV 2 min 20 to 40 min If shorter acting than reversed drug, serial doses may be required. Flumazenil Benzodiazepine reversal 0.2 mg IV. May repeat every 1 min up to 1 mg. 1 to 2 min 30 to 60 min If shorter acting than reversed drug, serial doses may be required. Do not use in patients receiving long-term benzodiazepines, cyclosporine, isoniazid, lithium, propoxyphene, theophylline, or tricyclic antidepressants. IV indicates intravenous. Levine et al 2011 ACCF/AHA/SCAI PCI Guideline e651


Stroke and transient ischaemic attack in over 16s: diagnosis and initial management NICE guideline NICE 2023. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and- conditions#notice-of-rights). Last updated 13 April 2022 Your responsibility The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian. All problems (adverse events) related to a medicine or medical device used for treatment or in a procedure should be reported to the Medicines and Healthcare products Regulatory Agency using the Yellow Card Scheme. Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties. Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible. 2022 Contents Overview 5 Who is it for?


Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible. 2022 Contents Overview 5 Who is it for? 5 1.1 Rapid recognition of symptoms and diagnosis 6 1.2 Imaging for people who have had a suspected TIA or acute non-disabling stroke 7 1.3 Specialist care for people with acute stroke 9 1.4 Pharmacological treatments and thrombectomy for people with acute stroke 10 1.5 Maintenance or restoration of homeostasis 15 1.6 Nutrition and hydration 17 1.7 Optimal positioning and early mobilisation for people with acute stroke 19 1.8 Avoiding aspiration pneumonia 20 1.9 Surgery for people with acute stroke 20 Terms used in this guideline 22 Additional information 23 Recommendations for research 25 Key recommendations for research 25 Rationale and impact 29 Initial management of suspected and confirmed transient ischaemic attack (aspirin) 29 Initial management of suspected and confirmed transient ischaemic attack 30 Imaging for people who have had a suspected TIA or acute non-disabling stroke 31 Thrombectomy for people with acute ischaemic stroke 33 Blood pressure control for people with acute intracerebral haemorrhage 36 2022 Optimal positioning for people with acute stroke 39 Early mobilisation for people with acute stroke 40 Decompressive hemicraniectomy for people with acute stroke 41 Finding more information and resources 45 Update information 46 2022 This guideline replaces CG68. This guideline is the basis of QS2. Overview This guideline covers interventions in the acute stage of a stroke or transient ischaemic attack (TIA). It offers the best clinical advice on the diagnosis and acute management of stroke and TIA in the 48 hours after onset of symptoms.


It offers the best clinical advice on the diagnosis and acute management of stroke and TIA in the 48 hours after onset of symptoms. In April 2022, we reviewed the evidence and made new recommendations on blood pressure control for people with acute intracerebral haemorrhage. Who is it for? Healthcare professionals in primary and secondary NHS healthcare settings Commissioners and providers of services People aged over 16 who have had a stroke or TIA, their families and carers 2022 Recommendations People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care. Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding. NICE has also produced patient decision aids on decompressive hemicraniectomy. 1.1 Rapid recognition of symptoms and diagnosis Prompt recognition of symptoms of stroke and transient ischaemic attack 1.1.1 Use a validated tool, such as FAST (Face Arm Speech Test), outside hospital to screen people with sudden onset of neurological symptoms for a diagnosis of stroke or transient ischaemic attack (TIA). [2008] 1.1.2 Exclude hypoglycaemia in people with sudden onset of neurological symptoms as the cause of these symptoms. [2008] 1.1.3 For people who are admitted to the emergency department with a suspected stroke or TIA, establish the diagnosis rapidly using a validated tool, such as ROSIER (Recognition of Stroke in the Emergency Room). Initial management of suspected and confirmed TIA 1.1.4 Offer aspirin (300 mg daily), unless contraindicated, to people who have had a suspected TIA, to be started immediately.


Initial management of suspected and confirmed TIA 1.1.4 Offer aspirin (300 mg daily), unless contraindicated, to people who have had a suspected TIA, to be started immediately. [2019] 2022 For a short explanation of why the committee made this 2019 recommendation and how it might affect practice, see the rationale and impact section on initial management of suspected and confirmed transient ischaemic attack (aspirin). Full details of the evidence and the committee's discussion are in evidence review A: aspirin. 1.1.5 Refer immediately people who have had a suspected TIA for specialist assessment and investigation, to be seen within 24 hours of onset of 1.1.6 Do not use scoring systems, such as ABCD2, to assess risk of subsequent stroke or to inform urgency of referral for people who have had a suspected or confirmed TIA. [2019] 1.1.7 Offer secondary prevention, in addition to aspirin, as soon as possible after the diagnosis of TIA is confirmed. [2008, amended 2019] For a short explanation of why the committee made these 2019 recommendations and how they might affect practice, see the rationale and impact section on initial management of suspected and confirmed transient ischaemic attack. Full details of the evidence and the committee's discussion are in evidence review B: TIA prediction rules. 1.2 Imaging for people who have had a suspected TIA or acute non-disabling stroke Suspected TIA 1.2.1 Do not offer CT brain scanning to people with a suspected TIA unless there is clinical suspicion of an alternative diagnosis that CT could 2022 1.2.2 After specialist assessment in the TIA clinic, consider MRI (including diffusion-weighted and blood-sensitive sequences) to determine the territory of ischaemia, or to detect haemorrhage or alternative pathologies.


1.2 Imaging for people who have had a suspected TIA or acute non-disabling stroke Suspected TIA 1.2.1 Do not offer CT brain scanning to people with a suspected TIA unless there is clinical suspicion of an alternative diagnosis that CT could 2022 1.2.2 After specialist assessment in the TIA clinic, consider MRI (including diffusion-weighted and blood-sensitive sequences) to determine the territory of ischaemia, or to detect haemorrhage or alternative pathologies. If MRI is done, perform it on the same day as the For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on imaging for people who have had a suspected TIA or acute non-disabling stroke. Full details of the evidence and the committee's discussion are in evidence review C: TIA imaging. Carotid imaging 1.2.3 Everyone with TIA who after specialist assessment is considered as a candidate for carotid endarterectomy should have urgent carotid Urgent carotid endarterectomy 1.2.4 Ensure that people with stable neurological symptoms from acute non- disabling stroke or TIA who have symptomatic carotid stenosis of 50% to 99% according to the NASCET (North American Symptomatic Carotid Endarterectomy Trial) criteria: are assessed and referred urgently for carotid endarterectomy to a service following current national standards (see the NHS England and NHS Improvement National Stroke Service Model) receive best medical treatment (control of blood pressure, antiplatelet agents, cholesterol lowering through diet and drugs, lifestyle advice).


Carotid imaging 1.2.3 Everyone with TIA who after specialist assessment is considered as a candidate for carotid endarterectomy should have urgent carotid Urgent carotid endarterectomy 1.2.4 Ensure that people with stable neurological symptoms from acute non- disabling stroke or TIA who have symptomatic carotid stenosis of 50% to 99% according to the NASCET (North American Symptomatic Carotid Endarterectomy Trial) criteria: are assessed and referred urgently for carotid endarterectomy to a service following current national standards (see the NHS England and NHS Improvement National Stroke Service Model) receive best medical treatment (control of blood pressure, antiplatelet agents, cholesterol lowering through diet and drugs, lifestyle advice). [2008, amended 1.2.5 Ensure that people with stable neurological symptoms from acute non- disabling stroke or TIA who have symptomatic carotid stenosis of less than 50% according to the NASCET criteria, or less than 70% according 2022 to the European Carotid Surgery Trial (ECST) criteria: do not have surgery receive best medical treatment (control of blood pressure, antiplatelet agents, cholesterol lowering through diet and drugs, lifestyle advice). [2008] 1.2.6 Ensure that carotid imaging reports clearly state which criteria (ECST or NASCET) were used when measuring the extent of carotid stenosis. 1.3 Specialist care for people with acute stroke Specialist stroke units 1.3.1 Admit everyone with suspected stroke directly to a specialist acute stroke unit after initial assessment, from either the community, the emergency department, or outpatient clinics. (An acute stroke unit is a discrete area in the hospital that is staffed by a specialist stroke multidisciplinary team. It has access to equipment for monitoring and rehabilitating patients. Regular multidisciplinary team meetings occur for goal setting.).