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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/cdn\/css\/http\/css_Xg7z6oCTVgud_Q0huYz9x9iiD5H_2YPSJ5z2ZViSWdY.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EIn 2008, the American College of Cardiology and the American Heart Association updated major guidelines that addressed the diagnosis, risk stratification, and treatment of conditions that span the range of acute coronary syndromes, from unstable angina and non-ST-elevation myocardial infarction to ST-elevation myocardial infarction.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003Ecardiology guidelines\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Einterventional techniques \u0026amp; devices\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Ethrombotic disorders\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Emyocardial infarction\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \n         \u003Cp id=\u0022p-2\u0022\u003EWithin the past year, the American College of Cardiology (ACC) and the American Heart Association (AHA) have updated major guidelines that address the diagnosis, risk stratification, and treatment of conditions that span the range of acute coronary syndromes (ACS), from unstable angina (UA) and non-ST-elevation myocardial infarction (NSTEMI) to ST-elevation myocardial infarction (STEMI).\u003C\/p\u003E\n         \u003Cp id=\u0022p-3\u0022\u003EOn August 6, 2007, the ACC and AHA published updated guidelines on the management of patients with UA\/NSTEMI [Anderson et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2007]. On December 10, 2007, two focused guideline updates were released; the first addressed the management of patients with STEMI [Antman et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2008], and the second addressed treatment decisions related to percutaneous coronary intervention (PCI) [King et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2008].\u003C\/p\u003E\n         \u003Cp id=\u0022p-4\u0022\u003EIn this session at the ACC annual meeting, four leading experts in ACS and authors involved in developing the new guidelines provided insights on key updates.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EAntithrombotic Therapy for NSTEMI\u003C\/h2\u003E\n         \u003Cp id=\u0022p-5\u0022\u003EJeffrey L. Anderson, MD, University of Utah School of Medicine, Salt Lake City, UT, focused on the \u201cdelicate balance between efficacy and bleeding risk\u201d associated with antithrombotic strategies for patients with NSTEMI.\u003C\/p\u003E\n         \u003Cp id=\u0022p-6\u0022\u003E\u201cIn every major epidemiologic study, bleeding\u2014particularly major bleeding\u2014has been shown to have a major impact on cardiovascular outcomes,\u201d Dr. Anderson said. \u201cAt least 15% of the excess major bleeding can be attributed to administering antithrombotic agents at the incorrect doses,\u201d he said.\u003C\/p\u003E\n         \u003Cp id=\u0022p-7\u0022\u003EAccording to Dr. Anderson, antithrombotic therapy dosing errors\u2014and the bleeding events that they may cause\u2014are far too prevalent. In the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC and AHA Guidelines (CRUSADE) registry, 42% of patients with NSTEMI who were given antithrombotic agents received at least one initial dose outside the recommended range [Alexander et al. \u003Cem\u003EJAMA\u003C\/em\u003E 2005].\u003C\/p\u003E\n         \u003Cp id=\u0022p-8\u0022\u003EDosing errors are particularly common when physicians are using unfractionated heparin (UFH), low-molecular weight heparin (LMWH), and glycoprotein IIb\/IIIa inhibitors. Often, these agents require dose adjustment based on body weight and renal function. Therefore, patients with lower body weight, such as women and those with renal insufficiency, are particularly vulnerable to excess dosing.\u003C\/p\u003E\n         \u003Cp id=\u0022p-9\u0022\u003EResults from the CRUSADE registry were practice-changing, Dr. Anderson said. The special dosing requirements for women and patients with renal insufficiency are highlighted in the new guidelines (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E). Similar cautions are listed for patients with baseline chronic kidney disease.\u003C\/p\u003E\n         \u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/8\/2\/24\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Updated ACC\/AHA Recommendation on the Use of Antithrombotic Therapy in Women with NSTEMI. Anderson et al. Circulation 2007; 116:803\u0026#x2013;877. Copyright \u0026#xA9; 2008 American College of Cardiology Foundation and the American Heart Association, Inc.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-746048169\u0022 data-figure-caption=\u0022\u0026amp;lt;div xmlns=\u0026amp;quot;http:\/\/www.w3.org\/1999\/xhtml\u0026amp;quot;\u0026amp;gt;Updated ACC\/AHA Recommendation on the Use of Antithrombotic Therapy in Women with NSTEMI. Anderson et al. \u0026amp;lt;em\u0026amp;gt;Circulation\u0026amp;lt;\/em\u0026amp;gt; 2007; 116:803\u0026#x2013;877. Copyright \u0026#xA9; 2008 American College of Cardiology Foundation and the American Heart Association, Inc.\u0026amp;lt;\/div\u0026amp;gt;\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/8\/2\/24\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/8\/2\/24\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/8\/2\/24\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11097\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-10\u0022 class=\u0022first-child\u0022\u003EUpdated ACC\/AHA Recommendation on the Use of Antithrombotic Therapy in Women with NSTEMI.\nAnderson et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2007; 116:803\u2013877. Copyright \u00a9 2008 American College of Cardiology Foundation and the American Heart Association, Inc.\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-11\u0022\u003E\u201cThere is an important piece of the puzzle regarding the relationship between bleeding and risk that has not yet been solved,\u201d said Elliott M. Antman, MD, Brigham and Women\u0027s Hospital, Boston, MA. \u201cThat is: What are the causes of death over the long term in people who had an acute bleed? This question has important implications for therapeutic decision-making,\u201d Dr. Antman continued.\u003C\/p\u003E\n         \u003Cp id=\u0022p-12\u0022\u003EIf the link between an acute bleed and a long-term adverse outcome can be confirmed, using agents that are less likely to cause bleeding is important, Dr. Antman explained. On the other hand, \u201cif the bleed is simply identified in someone who is high-risk and is destined to have an adverse outcome, I believe that the therapeutic decision-making may be different,\u201d Dr. Antman said.\u003C\/p\u003E\n         \u003Cp id=\u0022p-13\u0022\u003E\u201cCertainly, all of us have to agree that bleeding is a bad complication, and it has some serious implications\u2014whether it explains all or just part of the excess risk,\u201d Dr. Anderson said. The updated UA\/NSTEMI guidelines were developed to help physicians minimize the risk for bleeding in this patient population, Dr. Anderson concluded.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-3\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ETiming of Reperfusion Therapy for STEMI\u003C\/h2\u003E\n         \u003Cp id=\u0022p-14\u0022\u003EEric R. Bates, MD, University of Michigan, Ann Arbor, MI, described the updated recommendations related to reperfusion therapy\u2014including pharmacologic reperfusion and primary PCI\u2014for patients who experience an episode of STEMI.\u003C\/p\u003E\n         \u003Cp id=\u0022p-15\u0022\u003E\u201cOne of the most controversial points in the guidelines for STEMI has been the timing of reperfusion therapy,\u201d Dr. Bates said. Indeed, the most dramatic update of the STEMI guidelines focuses on the first 60\u2013120 minutes following symptom onset.\u003C\/p\u003E\n         \u003Cp id=\u0022p-16\u0022\u003E\u201cThere is a \u2018golden hour\u2019 for reperfusion therapy for myocardial infarction (MI), just like there is a golden hour for shock,\u201d Dr. Bates said. \u201cIf one can get treatment initiated within the golden two hours\u2014which is probably more feasible than one hour\u2014that is a wonderful treatment strategy with excellent outcomes,\u201d he said.\u003C\/p\u003E\n         \u003Cp id=\u0022p-17\u0022\u003EThe updated STEMI guidelines outline the optimal timing of treatment for patients, beginning at the onset of symptoms (\u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E). The goals include contact between the patient and emergency medical services (EMS) within five minutes of symptom onset, dispatch of EMS within one minute of the EMS call, and arrival of EMS to the patient\u0027s location within eight minutes.\u003C\/p\u003E\n         \u003Cdiv id=\u0022F2\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/8\/2\/24\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Recommended Timing of Patient Assessment and Treatment Initiation in STEMI.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-746048169\u0022 data-figure-caption=\u0022Recommended Timing of Patient Assessment and Treatment Initiation in STEMI.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 2.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/8\/2\/24\/F2.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/8\/2\/24\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 2.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/8\/2\/24\/F2.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11100\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 2.\u003C\/span\u003E \n               \u003Cp id=\u0022p-18\u0022 class=\u0022first-child\u0022\u003ERecommended Timing of Patient Assessment and Treatment Initiation in STEMI.\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EAntman et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2008;117:296\u2013329. Copyright \u00a9 2008 American College of Cardiology Foundation and the American Heart Association, Inc.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-19\u0022\u003E\u201cThe biggest problem we have is getting patients to access the health care system [quickly],\u201d Dr. Bates said. Education regarding the symptoms of MI has decreased the degree to which patients rationalize their symptoms\u2014patients may tell themselves that they are not having a heart attack, despite characteristic signs and symptoms\u2014and thus fail to call EMS. However, despite these gains, many patients still do not call for help in a timely manner. In addition, more than half of patients with STEMI symptoms are being driven to the hospital by a friend or loved one. This postpones vital treatment that EMS, had they been called for help, would be able to initiate prior to arriving at the hospital. Nitroglycerin and aspirin, which are recommended at first medical contact, are now routinely administered by EMS en route to the hospital.\u003C\/p\u003E\n         \u003Cp id=\u0022p-20\u0022\u003EMost of the deaths related to STEMI occur within the first hour of symptom onset, Dr. Bates explained, and \u201cthere is still a time delay in getting contact with a defibrillator, which is the most important intervention that we have to offer.\u201d\u003C\/p\u003E\n         \u003Cp id=\u0022p-21\u0022\u003EOnce EMS is on the scene, they are encouraged to use 12-lead electrocardiogram (ECG) and consider pre-hospital fibrinolytic therapy. Ideally, patients should have fibrinolytic therapy initiated within 30 minutes of EMS contact and should be undergoing primary PCI within 90 minutes. Patients who are taken to facilities that do not perform PCI should be transferred to PCI-capable hospitals.\u003C\/p\u003E\n         \u003Cp id=\u0022p-22\u0022\u003E\u201cThere\u0027s no question that reperfusion should be given as soon as possible. The best reperfusion strategy might be the one that can be initiated the quickest,\u201d Dr. Bates concluded.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-4\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EInterventional Strategies After Admission for STEMI and NSTEMI\u003C\/h2\u003E\n         \u003Cp id=\u0022p-23\u0022\u003EJudith S. Hochman, MD, MA, New York University, New York, NY, emphasized the importance of risk stratification in the treatment of patients with NSTEMI or STEMI.\u003C\/p\u003E\n         \u003Cp id=\u0022p-24\u0022\u003EThe updated UA\/NSTEMI guidelines describe risk stratification as an \u201cintegral prerequisite to decision-making\u201d (Level of Evidence: Class I). Moreover, risk stratification is an ongoing process that includes intensive initial patient assessment coupled with ongoing assessment throughout clinical treatment. Targeted ECG and biomarker data are used at each stage of the process.\u003C\/p\u003E\n         \u003Cp id=\u0022p-25\u0022\u003EIn the new guidelines, clinicians are asked to approach risk stratification with two questions in mind. First, what is the probability of having obstructive coronary artery disease (CAD) based on the patient\u0027s history of ischemia and presenting symptoms? Second, given the presence of obstructive CAD and the diagnosis of ACS, what is the risk of an adverse clinical outcome?\u003C\/p\u003E\n         \u003Cp id=\u0022p-26\u0022\u003E\u201cRisk stratification is very important for selecting a management strategy, and it needs to be done up front. Based on that, you proceed with an initial invasive strategy or an initial conservative strategy,\u201d Dr. Hochman said.\u003C\/p\u003E\n         \u003Cp id=\u0022p-27\u0022\u003EThe routine use of risk scores for risk stratification also is a new recommendation in the updated UA\/NSTEMI guidelines. According to the guidelines, \u201crisk scores should be a routine part of assessment throughout the hospital course and periodically after discharge\u201d (Level of Evidence: Class IIa B). The Thrombolysis in Myocardial Infarction (TIMI) risk score (\u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E) and the Global Registry of Acute Coronary Events (GRACE) risk score and nomogram are valid, appropriate tools for the assessment of patients with UA\/NSTEMI.\u003C\/p\u003E\n         \u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/11107\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/11107\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11107\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-28\u0022 class=\u0022first-child\u0022\u003ECalculation and Interpretation of TIMI Risk Score for UA\/STEMI.\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-31\u0022\u003EFor both STEMI and NSTEMI, \u201cthere is a spectrum from very stable, low-risk patients to unstable, high-risk patients, based on symptoms, anatomy, and ischemia,\u201d Dr. Hochman said. For these patients, initial risk stratification is an essential component of clinical management. \u201cThat\u0027s what\u0027s going to guide you, and that\u0027s how the guidelines are developed based on the evidence,\u201d she said.\u003C\/p\u003E\n         \u003Cp id=\u0022p-32\u0022\u003EComplete guideline information is available at \u003Ca href=\u0022http:\/\/circ.ahajournals.org\/cgi\/reprint\/CIRCULATIONAHA.107.185752\u0022\u003Ehttp:\/\/circ.ahajournals.org\/cgi\/reprint\/CIRCULATIONAHA.107.185752\u003C\/a\u003E\n         \u003C\/p\u003E\n         \u003Cdiv id=\u0022F3\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/8\/2\/24\/F3.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022The editors would like to thank the many members of the ACC 2008 presenting faculty who generously gave their time to ensure the accuracy and quality of the articles in this publication.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-746048169\u0022 data-figure-caption=\u0022The editors would like to thank the many members of the ACC 2008 presenting faculty who generously gave their time to ensure the accuracy and quality of the articles in this publication.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure3\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/8\/2\/24\/F3.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/8\/2\/24\/F3.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure3\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/8\/2\/24\/F3.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11104\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption\u0022\u003E\n               \u003Cp id=\u0022p-33\u0022 class=\u0022first-child\u0022\u003EThe editors would like to thank the many members of the ACC 2008 presenting faculty who generously gave their time to ensure the accuracy and quality of the articles in this publication.\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2008 MD Conference Express\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/8\/2\/24.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzmghd\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzmghd\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzmghd\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}