n Aortic Disease Clinical Practice Guidelines (ACC/AHA, 2022)

n American College of Cardiology/American Heart Association (2022, Dec 9). https://reference.medscape.com/viewarticle/985190

The following are highlights of recently published guidelines on the diagnosis and management of aortic disease by the American College of Cardiology (ACC) and the American Heart Association. These recommendations replace the 2010 ACC Foundation (ACCF)/AHA guidelines for diagnosing and managing thoracic aortic disease and the 2015 ACC/AHA clarifying statement on surgery for aortic dilation in patients with bicuspid aortic valves. The new guidelines focus on considerations in surgical intervention, consistent imaging practices, genetic and familial screenings, and the importance of multidisciplinary care. They are intended be used with the 2020 ACC/AHA guideline managing patients with valvular heart disease. Full guidelines may be accessed in the ACC/AHA publication, https://www.jacc.org/doi/10.1016/j. jacc.2022.08.004.

Key guidelines

 Screen first-degree relatives of individuals diagnosed with aneurysms of the aortic root or ascending thoracic aorta, or those with aortic dissection to identify individuals most at risk for aortic disease. Screening would include genetic testing and imaging.

 Use consistency in obtaining and reporting computed tomography (CT) scanning, magnetic resonance imaging (MRI), or echocardiography findings; in measuring aortic size and features; and in how often images are used for monitoring before and after repair surgery or other intervention. Ideally, all surveillance imaging for an individual should be performed using the same modality and in the same lab.

 For individuals who require aortic intervention, note that outcomes are optimized when surgery is performed by an experienced surgeon working in a multidisciplinary aortic team.

 At centers with multidisciplinary aortic teams and experienced surgeons, the threshold for surgical intervention for sporadic aortic root and ascending aortic aneurysms is now 5.0 cm (from 5.5 cm) in select individuals, and it is even lower in specific settings among patients with heritable thoracic aortic aneurysms.

 In patients who are significantly smaller or taller than average, surgical thresholds may incorporate indexing of the aortic root or ascending aortic diameter to either patient body surface area or height, or aortic cross-sectional area to patient height.

 Rapid aortic growth is a risk factor for rupture, and the definition for rapid aneurysm growth rate has been updated. Surgery is recommended for patients with aneurysms of aortic root and ascending thoracic aorta with a confirmed growth rate of ≥0.3 cm per year across 2 consecutive years or ≥0.5 cm in 1 year.

 It is reasonable for patients undergoing aortic root replacement surgery to receive valve-sparing aortic root replacement if the valve is suitable for repair and when performed by experienced surgeons in a multidisciplinary aortic team.

 Consider transferring clinically stable patients with acute type A aortic dissection to a high-volume aortic center to improve survival. Operative repair of type A aortic dissection should entail at least an open distal anastomosis rather than just a simple supracoronary interposition graft.

 An increasing role exists for thoracic endovascular aortic repair in the management of uncomplicated type B aortic dissection. For patients with suitable anatomy, a potential option might be endovascular repair of thoracoabdominal aortic aneurysms with endografts.

Shared decision-making between the patient and multidisciplinary aortic team is highly encouraged in the following patients:

 Those on the borderline of thresholds for repair or those who are eligible for different types of surgical repair.

 Individuals with aortic disease who are pregnant or may become pregnant, for consideration of their risks of pregnancy.

n opioids for Pain Clinical Practice Guidelines (CDC, 2022)

n U.S. Centers for Disease Control and Prevention (2022, Dec 8). https://reference.medscape.com/viewarticle/985106

Guidelines for prescribing opioids for adults with acute and chronic pain were published in November 2022 by the U.S. Centers for Disease Control and Prevention (CDC) in the Morbidity and Mortality Weekly Report (MMWR). These are some of the highlights of the guidelines.

Initiating opioids for pain

 Before initiating opioid therapy, clinicians should discuss with patients the realistic benefits and known risks of opioid therapy.

 Clinicians should maximize use of nondrug and nonopioid drug therapies, as these are at least as effective as opioids for many common types of acute pain and are preferred for subacute and chronic pain.

Selecting opioids for pain

 When initiating opioid therapy for acute, subacute, or chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release and long-acting (ER/LA) opioids.

 Clinicians should prescribe the lowest effective dosage when opioids are initiated for opioid-naïve patients with acute, subacute, or chronic pain.