By K. Taklar. Tennessee Temple University.
The entry site is visualized as focal interruption of the linear image of the intimal flap (arrows) discount top avana 80 mg without a prescription medication that causes erectile dysfunction. Color flow Doppler demonstrates differential flow in the two lumens and can detect intimal tears buy top avana cheap erectile dysfunction foods. When the false lumen is thrombosed buy generic top avana 80 mg erectile dysfunction in diabetes medscape, displacement of intimal calcification or thickening of the aortic wall suggests aortic dissection. Acute type A dissection visualized in longitudinal and short-axis views; arrows indicate dissection lamella (A) and an intimal tear close to the aortic leaflets (B). Aortography Aortography is no longer used for the initial diagnosis of suspected acute aortic dissection and is now used mainly during endovascular repair or coronary angiography. Compared with other imaging modalities, aortography has less accuracy in diagnosing aortic dissection. Role of Coronary Angiography Routine coronary angiography is not recommended before surgery for acute type A aortic dissection 17 because of concern about delay in emergency surgery. Besides the delay incurred, coronary angiography may be technically difficult in the patient with dissection. Arterial access may fail to gain entry into the true lumen, and injury to the aorta from the catheter or guidewire may cause extension of the dissection or perforation of the aorta. In patients undergoing surgery for acute type A dissection, coronary artery involvement by the dissection can most often be corrected intraoperatively, and angiography is not required. Evaluation and Management Algorithms The thoracic aortic disease guidelines provide an algorithm for the management of patients with 17,50 presentations compatible with acute aortic dissection (Fig. The presence of two or more high-risk features strongly suggests aortic dissection. Patients considered highly likely to have acute aortic dissection require emergency surgical consultation and expedited imaging. Patients whose features suggest aortic dissection and who do not have an alternative diagnosis require expedited imaging. Those with lower- risk profiles are evaluated for alternative diagnoses, but when none is considered likely or confirmed, aortic imaging is recommended. Further study is needed prospectively to validate the accuracy of this risk score. These measures should commence immediately while the patient is undergoing diagnostic evaluation. Emergency surgery leads to improved survival in patients with acute type A dissection, with an 18% in-hospital mortality for surgically treated type A dissection and 38 56% mortality for medically treated patients (see Fig. Patients with acute aortic dissection require urgent multidisciplinary evaluation and management. Emergency transfer to a tertiary medical center with access to cardiovascular surgery, vascular surgery, 1,17 interventional radiology, and cardiology is recommended for patients with acute dissection. Hospitals with higher procedural volumes for surgically managed patients with acute type A and B dissections have 1,51 lower mortality rates. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Beta blockers should be administered even if the patient does not have hypertension. Esmolol is given as an initial bolus of 1000 µg/kg and then as a continuous infusion of 150 to 300 µg/kg/min. Labetalol is then administered by continuous infusion at a rate of 2 to 10 mg/min, up to 300 mg total cumulative dose. When evaluating refractory hypertension in acute dissection, the clinician must consider renal artery malperfusion, which may require endovascular therapy (eFig. Persistence of severe hypertension or signs of renal ischemia should prompt evaluation for renal artery involvement. Management of Cardiac Tamponade Cardiac tamponade, which occurs in 8% to 31% of acute type A dissections, is one of the most common 1,17,52 mechanisms of death in patients with dissection (eFig. Patients with tamponade may present with hypotension, syncope, or altered mental status and have double the in- 52 hospital mortality rate as those without tamponade (54% versus 25%). Therefore, in a relatively stable patient with acute type A dissection and cardiac tamponade, the risks associated with pericardiocentesis probably outweigh its benefits. Hypotension or shock from hemopericardium secondary to ascending dissection requires emergency aortic surgery. However, for patients who will not survive until surgery, pericardiocentesis with aspiration of only enough pericardial fluid to stabilize the patient before surgery may be lifesaving and 17,52 should be considered a treatment option in this setting. Definitive Therapy Definitive therapy for acute aortic dissection includes emergency surgery for type A dissection in patients considered surgical candidates (eFig. Compared to medical therapy, immediate surgical treatment improves survival in patients with acute type A aortic 17,38,47 dissection. In experienced centers, 30-day surgical mortality for acute 37,38,47,49 type A dissection is 10% to 35%. Type A aortic dissection surgery had 49 a mortality rate of 16% in septuagenarians and 35% in octogenarians. Although shock in type A dissection is associated with a high mortality rate, survivors with or without shock demonstrated a similar 54 long-term mortality. A bedside preoperative and postoperative risk prediction tool for mortality permits 55 estimation of the risks associated with surgery for acute type A aortic dissection (eFig. The aorta has a bluish discoloration (arrow) typical of underlying aortic dissection. Simple risk models to predict surgical mortality in acute type A aortic dissection: the International Registry of Acute Aortic Dissection score. Simple risk models to predict surgical mortality in acute type A aortic dissection: the International Registry of Acute Aortic Dissection score. Acute retrograde type A dissection with a primary intimal tear in the descending aorta is usually treated surgically. A favorable outcome has been reported for a few carefully selected patients treated with initial medical therapy and 56 timely interventions when the ascending aortic extension is thrombosed and not aneurysmal (eFig. Outcomes of acute retrograde type A aortic dissection with an entry tear in descending aorta. In uncomplicated type B dissection, the in-hospital mortality rate is much lower—as low as 1% to 6% in those requiring only 37,38 medical therapy —but complicated type B dissection carries a much higher mortality rate, especially 57 when accompanied by shock or malperfusion. Increasing age, female sex, hypotension/shock, periaortic hematoma, aortic diameter larger than 5. Primary arch dissections are uncommon, and management of this condition must be individualized. Surgical repair of acute arch dissection has a mortality rate between 15% and 29%.
Similarly order top avana 80mg without a prescription strongest erectile dysfunction pills, in humans order 80mg top avana with visa erectile dysfunction 19 year old male, the subcutaneous needle tip is embedded in frm posterior spinal ligamentous tissue compartment will have a different feel from the fbrous tissue and has not entered the epidural or intrathecal spaces order top avana 80mg free shipping erectile dysfunction 30 years old. Tissue feel and loss-of-resistance is The experienced injectionist gains information about best appreciated with the use of an air-flled syringe con- needle tip position by identifying the different feel of the nected to a Tuohy-type spinal needle of 22 gauge or greater. Although tactile feel alone is frequently inadequate to tance from tissues to such a degree that the injectionist can- place needles with consistent accuracy, the combination of not appreciate the different tissue layers. The use of a tactile feel with fuoroscopy allows the injectionist to be water-flled glass syringe was commonplace during the era consistently accurate with needle tip position before injec- of “blind epidural” injections performed without fuoros- tion. Contact of the needle tip with bone is unmistakable, copy, but the use of air-flled plastic syringes is now gener- and if the bone is accurately identifed and the anatomy ally accepted as providing superior tissue feel. Since air is far understood, this bony contact allows the injectionist to more compressible than water, the tissue feel transmitted quickly determine needle tip location. For example, initial through the air column that extends from the needle tip to the contact with the bony lamina is commonly used to deter- syringe plunger is optimized when air alone is used. True loss of resistance is experienced as Pearl the needle tip moves from an embedded position in the frm ligamentum favum to the loose connective tissue of the epi- Needle contact with bone is often helpful and should be reas- dural space. The ligamentum favum has a characteristic rub- suring to the injectionist since bony contact provides an bery feeling due to its relatively dense and uniform excellent opportunity for the injectionist to ascertain needle consistency. The epidural space is flled with loose connec- tip position and assures that the needle tip is not intravascular, tive tissue, blood vessels, and fat, which do not provide resis- intrathecal, or intraneural. When bone is contacted, always tance to the air being pressed out of the needle tip. However, identify exactly which bone the needle is in contact with and variations in tissue feel of both the posterior spinal ligaments use an understanding of anatomy to ascertain needle tip and the epidural space are relatively common, and false loss position. This false loss of resistance can occur as the needle tip passes The Loss-of-Resistance Technique through bands of dense fbrous tissue within the subcutane- ous tissue layer or as the needle tip moves through the liga- The loss-of-resistance technique is a time-honored method mentous interfaces at the junctions of the supraspinous and for placing needles safely into the posterior epidural space interspinous ligaments or the interspinous ligament with the from the dorsal spinal approach. Schultz injection of liquid through the needle usually does not rees- In the prone patient undergoing a fuoroscopically guided tablish a “tissue bounce,” as the liquid quickly dissipates needle procedure, the sagittal and horizontal planes deter- away from the needle tip into the loose tissues that comprise mine, respectively, the latero-medial and cephalocaudal the epidural space. However, when the needle tip enters a coordinates of the needle, and the coronal plane determines relatively confned tissue compartment between spinal liga- needle depth. Once Planning Prior to Needle Insertion the feeling of frm resistance is regained, the injectionist can again confdently advance the needle against this resistance. Prior to inserting a needle, the injectionist must have an More viscous fuids such as water-soluble x-ray contrast will understanding of the anatomic location and anatomic asso- more readily reestablish resistance when compared to liquids ciations of the targeted structure and must plan out the path of water density but may obscure subsequent imaging. This path should be identifed with fuoroscopy and then visualized in the mind’s eye in order to anticipate important anatomic struc- Pearl tures that may lie within the anticipated path of the needle. Bony elements adjacent to the needle path must be consid- When false loss of resistance is suspected, inject a small amount ered and a needle course plotted that will bypass these of local anesthetic, saline, or x-ray contrast into the needle obstacles. Although it is best to identify a direct needle lumen to reestablish the feeling of frm tissue resistance. For instance, a posterior fusion mass in the lumbar region Using Fluoroscopy for Needle Placement may obstruct the direct fuoroscopic view to the base of the pedicle and targeted nerve root when attempting a transfo- Once the needle tip passes through the skin and into the body, raminal epidural injection. The needle’s course, directly visualized with fuoroscopy, a bent, beveled needle however, can be tracked in multiple planes using fuoroscopic may sometimes be steered around the fusion mass by a imaging. For the purposes of this chapter, the three planes which determine the position of the tip of a needle within the body are: Needle Orientation to the Fluoroscopy Beam 1. The sagittal plane of the needle tip With respect to the orientation of the fuoroscopic beam to 2. The horizontal plane of the needle tip the line of advancement of the needle, the needle may 3. The coronal plane of the needle tip travel either parallel or tangential to the beam. When a direct fuoroscopic path to the target can be visualized with no intervening bony obstacles, the needle may travel directly “down the beam” to the target. This direct approach is sometimes called the “tunnel vision” technique since the injectionist is viewing the target down an unobstructed fuoroscopic tunnel and advancing the needle down this tunnel directly to the target. When the needle is traveling directly down the beam, it appears as a dot on the fuoros- copy monitor. When bony obstacles lie between the skin entry point and the target structure, however, the needle must steer around these obstacles and travel tangential to the fuoroscopy beam for at least a part of its course. Steering needles around obstacles and down irregular and circuitous paths to the target is technically more demand- ing than advancing them along straight paths. Lumbar posterior interlaminar epidural injections tal plane one level or so inferior to the target epidural level. Cervical and lumbar transformational epidural The needle is then advanced with relatively steep angulation injections from the paramedian approach toward the midline into the epi- C. Zygapophysial joint injections advancement along a path that is tangential to the fuoroscopy E. Atlantoaxial joint injections moving cephalad and toward the midline as it advances. Lumbar sympathetic blocks Contact with the bony lamina and the loss-of-resistance tech- nique can be used to determine needle depth. Conversely, the When multiple bony shadows are superimposed on the fuoroscope can be moved to the lateral orientation in order to monitor image, a clear path to the ultimate anatomic target determine needle depth although lateral visualization of nee- cannot be directly visualized with fuoroscopy. Prior to inser- dles in the thoracic spine is sometimes diffcult and lateral tion of the needle, the injectionist must interpret the fuoro- imaging requires additional radiation. Moving needles tangen- scopic image and use an understanding of anatomy to tial to the fuoroscopy beam may be technically diffcult and determine whether or not these superimposed bony elements requires the operator to judge relative needle tip position in lie between the skin insertion point of the needle and the tar- three planes as well as to determine the optimum skin inser- get. In the thoracic spine, for example, the steeply angled tion point and the degree of angulation necessary to assure that laminae are superimposed posteriorly between the epidural the needle tip will arrive at the target in the proper sagittal, space and the skin, and the anterior vertebral body produces horizontal, and coronal planes simultaneously. It is therefore not usually pos- since, in addition to advancing the needle tangential to the sible to visualize a direct interlaminar path on the monitor for fuoroscopy beam for at least part of its course, the operator epidural needle placement into the thoracic epidural space, must steer the needle around bony elements. For example, with lumbar transforaminal epidural injection performed at the L5/S1 level, the iliac crest and the superior articulating process may lie within the needle path to the target at the base of the L5 pedicle (Fig. In this situation, the needle must take a path to the target that may correspond to a cylindrical corridor with a diameter of 1 cm or less and a length of 8 cm or more. To successfully navigate a needle down such a tunnellike path, the injection- ist must choose the skin insertion point carefully since the wrong skin insertion point may make subsequent steering angles untenable. Once the needle is inserted, it must frst be directed slightly medial to avoid the ilium at shallow depth, then lateral to avoid the deeper superior articulating process, and fnally medial again to arrive at the base of the pedicle. To succeed at this type of more technically demanding nee- dle placement, the injectionist must master the techniques of needle steering discussed in the next section. Needle Density as It Pertains to Visibility Since the degree of fuoroscopic visibility of a needle Fig. A second fuoroscopic view from a perspective that is body habitus, the region of the body being visualized, and oblique or perpendicular to the initial view the presence of spinal hardware. Contact of the needle tip with a bony or soft tissue land- ally easy to visualize in most patients, whereas 25-gauge mark that is at a known anatomical position needles are sometimes diffcult to see on the fuoroscopic monitor, especially with lateral imaging in larger patients. The experienced intervention- alist obtains useful information on needle tip position from the feel of needle contact with known bony and tissue land- Pearl marks, and this is a time-tested method for safe needle place- ment which provides a powerful adjunct to fuoroscopy. The Whenever a spinal needle becomes diffcult to see on the following are a few examples of procedures in which the fuoroscopy monitor because of its relative density, insert the tactile feel of contact with bone and/or soft tissue can be used stylet to increase needle density and improve visibility.
Intestinal blood flow in patients with chronic heart failure: a link with bacterial growth discount top avana 80mg fast delivery erectile dysfunction medications generic, gastrointestinal symptoms cheap top avana generic erectile dysfunction caused by nerve damage, and cachexia purchase top avana master card impotence medication. Bedside assessment of cardiac hemodynamics: the impact of noninvasive testing and examiner experience. Prognostic significance of ultrasound- assessed jugular vein distensibility in heart failure. Diagnosing acute heart failure in the emergency department: a systematic review and meta-analysis. Detection and prognostic value of pulmonary congestion by lung ultrasound in ambulatory heart failure patients. The limited reliability of physical signs for estimating hemodynamics in chronic heart failure. A novel method for assessing cardiac output with the use of oxygen circulation time. Prognostic value of the change in heart rate from the supine to the upright position in patients with chronic heart failure. Prevalence of undiagnosed asymptomatic aortic valve stenosis in the general population older than 65 years. A screening strategy using cardiac auscultation followed by Doppler-echocardiography. When and how aortic stenosis is first diagnosed: a single-center observational study. Diagnostic accuracy of a hand-held ultrasound scanner in routine patients referred for echocardiography. Low-grade systolic murmurs in healthy middle- aged individuals: innocent or clinically significant? Computerized automatic diagnosis of innocent and pathologic murmurs in pediatrics: a pilot study. Cardiac limited ultrasound examination techniques to augment the bedside cardiac physical examination. The 200th anniversary of the stethoscope: can this low-tech device survive in the high-tech 21st century? Usefulness of a new miniaturized echocardiographic system in outpatient cardiology consultations as an extension of physical examination. Prevalence of subclinical rheumatic heart disease in eastern Nepal: a school-based cross-sectional study. Does the clinical examination predict lower extremity peripheral arterial disease? Association between phonocardiographic third and fourth heart sounds and objective measures of left ventricular function. Relationship between accurate auscultation of a clinically useful third heart sound and level of experience. Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes. Competency in cardiac examination skills in medical students, trainees, physicians, and faculty: a multicenter study. The cost of perioperative myocardial injury adds substantially to the total health care expenditure, with an average increased length of stay of 6. Perioperative cardiovascular complications not only affect the immediate period but may also the influence outcome over subsequent years. The evidence base for managing patients with cardiovascular disease in the context of noncardiac surgery has grown in recent decades, beginning with identification of those at greatest risk and progressing to randomized trials to identify strategies for reducing perioperative cardiovascular complications. Guidelines provide information for the management of high-risk patients and disseminate best practices. Indeed, over the last decade, mortality rates for all major surgeries have decreased in parallel with implementation of these practices. Since none of his perioperative papers was withdrawn, the committee chose to include the published papers in the discussion, but studies by Poldermans were not used to make formal recommendations. Assessment of Risk Numerous points of entry lead to evaluation of patients before they undergo noncardiac surgery. History and physical examination represent the cornerstone of surgical risk evaluation, but risk assessment testing is rarely performed unless it changes management. Many patients undergo evaluation only immediately before surgery by the surgeon or anesthesiologist. Importantly, several cardiovascular conditions require assessment independent of the time before surgery. Ischemic Heart Disease The stress related to noncardiac surgery increases metabolic requirements and activates the sympathetic nervous system and may raise the heart rate preoperatively, which is associated with a high incidence of symptomatic and asymptomatic myocardial ischemia. If the noncardiac surgery is truly an emergency, several older case series have shown that intra-aortic balloon pump counterpulsation can provide short-term myocardial protection beyond that afforded by maximal medical therapy, although this measure is seldom used today. In determining the extent of preoperative evaluation, it is important not to perform testing unless the results will affect perioperative management. In addition, the use of medications or interventions should mirror those that would be implemented in the absence of surgery. As discussed later, few evidence-based therapies are available independent of treating the underlying atherosclerotic risk, and except in the case of left main coronary artery stenosis, current data challenge the benefit of preoperative coronary revascularization. Thus, the primary reason to perform risk assessment is to determine clinical cardiovascular instability. Finks and colleagues reported a 36% decrease in death after open abdominal aortic aneurysm repair from 2000 to 2008, to a risk-adjusted mortality of 2. Although these events, characterized by increases in troponin, are strongly associated with death, the interval between troponin elevation and adverse events and the higher rate of nonvascular than cardiovascular mortality suggest that this is a marker of illness rather than a mechanism of mortality. After this period, risk stratification is based on the features of the disease (i. Hypertension In the 1970s a series of case studies changed the prevailing thought that the use of antihypertensive agents should be discontinued before surgery. The reports suggested that poorly controlled hypertension was associated with untoward hemodynamic responses and that antihypertensives should be continued perioperatively. The approach to patients with hypertension therefore relies mostly on management strategies from the nonsurgical literature. Iatrogenic precipitants of hypertensive crises include abrupt withdrawal of clonidine or beta-blocker therapy before surgery, chronic use of monoamine oxidase inhibitors with or without sympathomimetic drugs, and inadvertent discontinuation of antihypertensive therapy. Although postulated to predict an increased rate of myocardial ischemia, none of the recent large clinical trials has shown that chronic hypertension predisposes patients to perioperative cardiovascular 4 events. This finding likely reflects the excellent perioperative management of hypertension in the current era.
Further details about digitalis discount top avana online mastercard erectile dysfunction treatment food, including mechanism of action best buy for top avana erectile dysfunction after testosterone treatment, pharmacokinetics buy top avana overnight erectile dysfunction psychological treatment, and interaction with other common drugs, can be found in the online supplement for this chapter (Digoxin). As noted, these side effects can generally be minimized by maintaining trough levels of 0. However, serum K levels must be monitored carefully to avoid hyperkalemia, especially in patients with renal failure or those taking aldosterone receptor antagonists. Potentially life-threatening digoxin toxicity can be reversed by antidigoxin immunotherapy using purified Fab fragments (see online supplement). The concomitant use of quinidine, verapamil, spironolactone, flecainide, propafenone, and amiodarone can increase serum digoxin levels and may increase the risk of adverse reactions. Patients with advanced heart block should not receive the digitalis unless a pacemaker is in place. Pharmacogenomics and Personalized Medicine As discussed in Chapter 8, pharmacogenomics is the study of how genetic variations affect drug response, including genetic variants of enzymes that metabolize drugs, variants in drug receptors or drug transporters, and variants in drug targets. These variations can result in gain or loss of therapeutic efficacy, can influence optimal drug dosing, or can favor alternative drug treatment. An overview of the major genetic variations in these pathways and the proposed functional impact of these polymorphisms is presented in the online supplement for this chapter (Pharmacogenomics in Heart Failure). Personalized medicine seeks to use genetic information to “personalize” and improve diagnosis, prevention, and therapy. Special Populations Wom en Although women account for a significant proportion of the growing heart failure epidemic, they have been poorly represented in clinical trials. In contrast, post hoc analysis of studies with approved beta blockers have shown that African American patients benefit from beta-blocker therapy, although the 47 magnitude of the effect appears to be diminished. Although they typically present with the classic symptoms of dyspnea and fatigue, elderly are more likely than younger patients to present with atypical symptoms such as altered mental status, depression, or poor executive 6 functioning. Other complicating factors may include blunting of baroreceptor function and orthostatic dysregulation of blood pressure, which may make it difficult to use target doses of some neurohormonal antagonists. Interestingly, the rates of intracerebral and intracranial hemorrhage did not differ significantly between the two treatment groups. Importantly, the combination of digoxin and a beta blocker is more effective than a beta blocker alone in controlling the ventricular rate at rest. When beta-adrenergic blockers cannot be used, amiodarone has been used by some physicians, but chronic use has potentially significant risks, including thyroid disease and lung toxicity (see later). Most antiarrhythmic agents, with the exception of amiodarone and dofetilide, have negative inotropic effects and are proarrhythmic. Therefore, it is often necessary to reduce the dose of these drugs by as much as 50% when initiating therapy with amiodarone. The risk of adverse events, such as hyperthyroidism, hypothyroidism, pulmonary fibrosis, and hepatitis, are relatively low, particularly when lower doses of amiodarone are used (100 to 200 mg/day). The resulting pulmonary congestion activates lung vagal irritant receptors, which stimulate hyperventilation and hypocapnia. Central sleep apneas are sustained by recurrent arousal resulting from apnea-induced hypoxia and the increased effort to breathe during the ventilatory phase because of pulmonary congestion and reduced lung compliance. There was no difference in the primary endpoint of death or transplantation (P = 0. Thus the data remain unclear whether elimination of apnea will lead to improved clinical outcomes. However, the optimum approach to noninvasive remote monitoring is uncertain, and the data from randomized clinical trials have been inconsistent and are not recommended by current practice guidelines. Although disease management strategies can lead to improved survival, it is not clear that these strategies are necessarily more cost-effective. Accordingly, the greatest challenge to disease management programs will be to determine how to support the additional personnel required in this model of care. However, for reasons that are not clear, some patients do not improve or will experience a rapid recurrence of symptoms despite optimal medical and device therapies. When no further therapies are appropriate, careful discussion of the prognosis and options for end-of-life care should be initiated (see Chapter 31). Ongoing approaches with small molecules that modulate contractility and gene therapy (see Chapter 30), accompanied by growing appreciation of the role of pharmacogenomics (Chapter 8), may lead to further advances in the field. Guidelines Management of Heart Failure with a Reduced Ejection Fraction Douglas L. These were updated in two sequential guidelines in 2016 that focused on changes in medical therapies but did not provide new guidelines for devices in diagnosing and treating heart 2 failure. A I In patients at increased risk, stage A, the optimal blood pressure in those with hypertension should be less than 130/80 mm Hg. In contrast, the guidelines discourage use of calcium channel blockers with negative inotropic action in this population. Treatment of Patients With Left Ventricular Dysfunction and Current or Prior Symptoms (Stage C) Fig. Physical activity and cardiac rehabilitation are recommended for stage C patients. For all medical therapies, dosing should be optimized and serial assessment exercised. B Pharmacologic Interventions I Measures listed as class I recommendations for patients in stages A and B are recommended where appropriate. Digitalis remains a reasonable approach to decrease hospitalizations in symptomatic patients. Use of parenteral inotropic agents in hospitalized patients without documented severe systolic dysfunction, low blood pressure, or impaired perfusion, B and evidence of significantly depressed cardiac output, with or without congestion, is potentially harmful. Surgical aortic valve replacement is reasonable for patients with critical aortic stenosis and a predicted surgical mortality of no greater than 10%. B Transcatheter aortic valve replacement after careful candidate consideration is reasonable for patients with critical aortic stenosis who are deemed B inoperable. A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Alcohol consumption and risk for congestive heart failure in the Framingham Heart Study. Heart disease and stroke statistics–2013 update: a report from the American Heart Association. Arginine vasopressin antagonists for the treatment of heart failure and hyponatremia. Rates of hyperkalemia after publication of the Randomized Aldactone Evaluation Study. Non-steroidal anti-inflammatory drugs and risk of heart failure in four European countries: nested case-control study. Meta-analysis: angiotensin-receptor blockers in chronic heart failure and high-risk acute myocardial infarction.