Stent thrombosis prevention: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{Stent thrombosis}} | {{Stent thrombosis}} | ||
{{CMG}}; '''Associate Editors-In-Chief:''' [[Varun Kumar]], M.B.B.S.; [[Lakshmi Gopalakrishnan]], M.B.B.S. | {{CMG}}; '''Associate Editors-In-Chief:''' Smita Kohli, M.D.; [[Varun Kumar]], M.B.B.S.; [[Lakshmi Gopalakrishnan]], M.B.B.S. | ||
==Overview== | ==Overview== | ||
The main principle of the preventive treatment for stent thrombosis is to perform the best [[PCI]] possible, including good expansion and apposition of the stent. In this context, the role of '''intravascular ultrasound''' has been studied extensively and can be helpful<ref name="pmid18550555">{{cite journal |author=Roy P, Steinberg DH, Sushinsky SJ, ''et al.'' |title=The potential clinical utility of intravascular ultrasound guidance in patients undergoing percutaneous coronary intervention with drug-eluting stents |journal=Eur. Heart J. |volume=29 |issue=15 |pages=1851–7 |year=2008 |month=August |pmid=18550555 |doi=10.1093/eurheartj/ehn249 |url=}}</ref><ref name="pmid18360858">{{cite journal |author=Gerber R, Colombo A |title=Does IVUS guidance of coronary interventions affect outcome? a prime example of the failure of randomized clinical trials |journal=Catheter Cardiovasc Interv |volume=71 |issue=5 |pages=646–54 |year=2008 |month=April |pmid=18360858 |doi=10.1002/ccd.21489 |url=}}</ref>. | The main principle of the preventive treatment for stent thrombosis is to perform the best [[PCI]] possible, including good expansion and apposition of the stent. In this context, the role of '''intravascular ultrasound''' has been studied extensively and can be helpful<ref name="pmid18550555">{{cite journal |author=Roy P, Steinberg DH, Sushinsky SJ, ''et al.'' |title=The potential clinical utility of intravascular ultrasound guidance in patients undergoing percutaneous coronary intervention with drug-eluting stents |journal=Eur. Heart J. |volume=29 |issue=15 |pages=1851–7 |year=2008 |month=August |pmid=18550555 |doi=10.1093/eurheartj/ehn249 |url=}}</ref><ref name="pmid18360858">{{cite journal |author=Gerber R, Colombo A |title=Does IVUS guidance of coronary interventions affect outcome? a prime example of the failure of randomized clinical trials |journal=Catheter Cardiovasc Interv |volume=71 |issue=5 |pages=646–54 |year=2008 |month=April |pmid=18360858 |doi=10.1002/ccd.21489 |url=}}</ref>. | ||
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*There are better outcomes noted with the use of [[aspirin]] plus [[ticlopidine]] or [[clopidogrel]] than with aspirin plus [[warfarin]] or aspirin alone<ref name="pmid9834303">{{cite journal| author=Leon MB, Baim DS, Popma JJ, Gordon PC, Cutlip DE, Ho KK et al.| title=A clinical trial comparing three antithrombotic-drug regimens after coronary-artery stenting. Stent Anticoagulation Restenosis Study Investigators. | journal=N Engl J Med | year= 1998 | volume= 339 | issue= 23 | pages= 1665-71 | pmid=9834303 | doi=10.1056/NEJM199812033392303 | pmc= | url= }} </ref><ref name="pmid8598866">{{cite journal| author=Schömig A, Neumann FJ, Kastrati A, Schühlen H, Blasini R, Hadamitzky M et al.| title=A randomized comparison of antiplatelet and anticoagulant therapy after the placement of coronary-artery stents. | journal=N Engl J Med | year= 1996 | volume= 334 | issue= 17 | pages= 1084-9 | pmid=8598866 | doi=10.1056/NEJM199604253341702 | pmc= | url= }} </ref><ref name="pmid9778323">{{cite journal| author=Bertrand ME, Legrand V, Boland J, Fleck E, Bonnier J, Emmanuelson H et al.| title=Randomized multicenter comparison of conventional anticoagulation versus antiplatelet therapy in unplanned and elective coronary stenting. The full anticoagulation versus aspirin and ticlopidine (fantastic) study. | journal=Circulation | year= 1998 | volume= 98 | issue= 16 | pages= 1597-603 | pmid=9778323 | doi= | pmc= | url= }} </ref><ref name="pmid9815866">{{cite journal| author=Urban P, Macaya C, Rupprecht HJ, Kiemeneij F, Emanuelsson H, Fontanelli A et al.| title=Randomized evaluation of anticoagulation versus antiplatelet therapy after coronary stent implantation in high-risk patients: the multicenter aspirin and ticlopidine trial after intracoronary stenting (MATTIS). | journal=Circulation | year= 1998 | volume= 98 | issue= 20 | pages= 2126-32 | pmid=9815866 | doi= | pmc= | url= }} </ref><ref name="pmid10931801">{{cite journal| author=Bertrand ME, Rupprecht HJ, Urban P, Gershlick AH, CLASSICS Investigators| title=Double-blind study of the safety of clopidogrel with and without a loading dose in combination with aspirin compared with ticlopidine in combination with aspirin after coronary stenting : the clopidogrel aspirin stent international cooperative study (CLASSICS). | journal=Circulation | year= 2000 | volume= 102 | issue= 6 | pages= 624-9 | pmid=10931801 | doi= | pmc= | url= }} </ref>. | *There are better outcomes noted with the use of [[aspirin]] plus [[ticlopidine]] or [[clopidogrel]] than with aspirin plus [[warfarin]] or aspirin alone<ref name="pmid9834303">{{cite journal| author=Leon MB, Baim DS, Popma JJ, Gordon PC, Cutlip DE, Ho KK et al.| title=A clinical trial comparing three antithrombotic-drug regimens after coronary-artery stenting. Stent Anticoagulation Restenosis Study Investigators. | journal=N Engl J Med | year= 1998 | volume= 339 | issue= 23 | pages= 1665-71 | pmid=9834303 | doi=10.1056/NEJM199812033392303 | pmc= | url= }} </ref><ref name="pmid8598866">{{cite journal| author=Schömig A, Neumann FJ, Kastrati A, Schühlen H, Blasini R, Hadamitzky M et al.| title=A randomized comparison of antiplatelet and anticoagulant therapy after the placement of coronary-artery stents. | journal=N Engl J Med | year= 1996 | volume= 334 | issue= 17 | pages= 1084-9 | pmid=8598866 | doi=10.1056/NEJM199604253341702 | pmc= | url= }} </ref><ref name="pmid9778323">{{cite journal| author=Bertrand ME, Legrand V, Boland J, Fleck E, Bonnier J, Emmanuelson H et al.| title=Randomized multicenter comparison of conventional anticoagulation versus antiplatelet therapy in unplanned and elective coronary stenting. The full anticoagulation versus aspirin and ticlopidine (fantastic) study. | journal=Circulation | year= 1998 | volume= 98 | issue= 16 | pages= 1597-603 | pmid=9778323 | doi= | pmc= | url= }} </ref><ref name="pmid9815866">{{cite journal| author=Urban P, Macaya C, Rupprecht HJ, Kiemeneij F, Emanuelsson H, Fontanelli A et al.| title=Randomized evaluation of anticoagulation versus antiplatelet therapy after coronary stent implantation in high-risk patients: the multicenter aspirin and ticlopidine trial after intracoronary stenting (MATTIS). | journal=Circulation | year= 1998 | volume= 98 | issue= 20 | pages= 2126-32 | pmid=9815866 | doi= | pmc= | url= }} </ref><ref name="pmid10931801">{{cite journal| author=Bertrand ME, Rupprecht HJ, Urban P, Gershlick AH, CLASSICS Investigators| title=Double-blind study of the safety of clopidogrel with and without a loading dose in combination with aspirin compared with ticlopidine in combination with aspirin after coronary stenting : the clopidogrel aspirin stent international cooperative study (CLASSICS). | journal=Circulation | year= 2000 | volume= 102 | issue= 6 | pages= 624-9 | pmid=10931801 | doi= | pmc= | url= }} </ref>. | ||
*Preliminary evidence suggests [[prasugrel]] resulted in fewer ischaemic outcomes including stent thrombosis than with standard [[clopidogrel]]<ref name="pmid18377975">{{cite journal| author=Wiviott SD, Braunwald E, McCabe CH, Horvath I, Keltai M, Herrman JP et al.| title=Intensive oral antiplatelet therapy for reduction of ischaemic events including stent thrombosis in patients with acute coronary syndromes treated with percutaneous coronary intervention and stenting in the TRITON-TIMI 38 trial: a subanalysis of a randomised trial. | journal=Lancet | year= 2008 | volume= 371 | issue= 9621 | pages= 1353-63 | pmid=18377975 | doi=10.1016/S0140-6736(08)60422-5 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18377975 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18783188 Review in: ACP J Club. 2008 Sep 16;149(3):12] </ref>. | *Preliminary evidence suggests [[prasugrel]] resulted in fewer ischaemic outcomes including stent thrombosis than with standard [[clopidogrel]]<ref name="pmid18377975">{{cite journal| author=Wiviott SD, Braunwald E, McCabe CH, Horvath I, Keltai M, Herrman JP et al.| title=Intensive oral antiplatelet therapy for reduction of ischaemic events including stent thrombosis in patients with acute coronary syndromes treated with percutaneous coronary intervention and stenting in the TRITON-TIMI 38 trial: a subanalysis of a randomised trial. | journal=Lancet | year= 2008 | volume= 371 | issue= 9621 | pages= 1353-63 | pmid=18377975 | doi=10.1016/S0140-6736(08)60422-5 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18377975 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18783188 Review in: ACP J Club. 2008 Sep 16;149(3):12] </ref>. | ||
==Clinical Trial Data== | |||
==Clinical | |||
*In '''STARS trial'''<ref name="pmid9834303">{{cite journal| author=Leon MB, Baim DS, Popma JJ, Gordon PC, Cutlip DE, Ho KK et al.| title=A clinical trial comparing three antithrombotic-drug regimens after coronary-artery stenting. Stent Anticoagulation Restenosis Study Investigators. | journal=N Engl J Med | year= 1998 | volume= 339 | issue= 23 | pages= 1665-71 | pmid=9834303 | doi=10.1056/NEJM199812033392303 | pmc= | url= }} </ref>, studying 1653 patients showed superiority of [[aspirin]] and [[ticlopidine]] over combination of aspirin and [[warfarin]] or aspirin alone for reducing subacute stent thrombosis, although there were more hemorrhagic complications than with aspirin alone. | *In '''STARS trial'''<ref name="pmid9834303">{{cite journal| author=Leon MB, Baim DS, Popma JJ, Gordon PC, Cutlip DE, Ho KK et al.| title=A clinical trial comparing three antithrombotic-drug regimens after coronary-artery stenting. Stent Anticoagulation Restenosis Study Investigators. | journal=N Engl J Med | year= 1998 | volume= 339 | issue= 23 | pages= 1665-71 | pmid=9834303 | doi=10.1056/NEJM199812033392303 | pmc= | url= }} </ref>, studying 1653 patients showed superiority of [[aspirin]] and [[ticlopidine]] over combination of aspirin and [[warfarin]] or aspirin alone for reducing subacute stent thrombosis, although there were more hemorrhagic complications than with aspirin alone. | ||
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*'''TRITON TIMI-38'''<ref name="pmid18377975">{{cite journal| author=Wiviott SD, Braunwald E, McCabe CH, Horvath I, Keltai M, Herrman JP et al.| title=Intensive oral antiplatelet therapy for reduction of ischaemic events including stent thrombosis in patients with acute coronary syndromes treated with percutaneous coronary intervention and stenting in the TRITON-TIMI 38 trial: a subanalysis of a randomised trial. | journal=Lancet | year= 2008 | volume= 371 | issue= 9621 | pages= 1353-63 | pmid=18377975 | doi=10.1016/S0140-6736(08)60422-5 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18377975 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18783188 Review in: ACP J Club. 2008 Sep 16;149(3):12] </ref>trial analyzing 12,844 patients who underwent stenting for [[ACS]] revealed intensive antiplatelet therapy with [[prasugrel]] resulted in fewer ischaemic outcomes including stent thrombosis than with standard [[clopidogrel]].These findings were statistically robust irrespective of stent type, and the data affirm the importance of intensive platelet inhibition in patients with [[intracoronary stents]]. | *'''TRITON TIMI-38'''<ref name="pmid18377975">{{cite journal| author=Wiviott SD, Braunwald E, McCabe CH, Horvath I, Keltai M, Herrman JP et al.| title=Intensive oral antiplatelet therapy for reduction of ischaemic events including stent thrombosis in patients with acute coronary syndromes treated with percutaneous coronary intervention and stenting in the TRITON-TIMI 38 trial: a subanalysis of a randomised trial. | journal=Lancet | year= 2008 | volume= 371 | issue= 9621 | pages= 1353-63 | pmid=18377975 | doi=10.1016/S0140-6736(08)60422-5 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18377975 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18783188 Review in: ACP J Club. 2008 Sep 16;149(3):12] </ref>trial analyzing 12,844 patients who underwent stenting for [[ACS]] revealed intensive antiplatelet therapy with [[prasugrel]] resulted in fewer ischaemic outcomes including stent thrombosis than with standard [[clopidogrel]].These findings were statistically robust irrespective of stent type, and the data affirm the importance of intensive platelet inhibition in patients with [[intracoronary stents]]. | ||
==Guidelines for Prevention== | ==Guidelines for Prevention== | ||
The 2008 American College of Chest Physician illustrates the following guidelines for primary and secondary prevention of coronary artery disease<ref name="pmid18574278">{{cite journal| author=Becker RC, Meade TW, Berger PB, Ezekowitz M, O'Connor CM, Vorchheimer DA et al.| title=The primary and secondary prevention of coronary artery disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). | journal=Chest | year= 2008 | volume= 133 | issue= 6 Suppl | pages= 776S-814S | pmid=18574278 | doi=10.1378/chest.08-0685 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18574278 }} </ref>. | The 2008 American College of Chest Physician illustrates the following guidelines for primary and secondary prevention of coronary artery disease<ref name="pmid18574278">{{cite journal| author=Becker RC, Meade TW, Berger PB, Ezekowitz M, O'Connor CM, Vorchheimer DA et al.| title=The primary and secondary prevention of coronary artery disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). | journal=Chest | year= 2008 | volume= 133 | issue= 6 Suppl | pages= 776S-814S | pmid=18574278 | doi=10.1378/chest.08-0685 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18574278 }} </ref>. | ||
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'''4.''' For patients undergoing [[PCI]] with a [[DES]], we recommend [[aspirin]] (75–100 mg/d) plus [[clopidogrel]] (75 mg/d for at least 12 months) [Grade 1A for 3 to 4 months; Grade 1B for 4 to 12 months]. Beyond 1 year, we suggest continued treatment with [[aspirin]] plus [[clopidogrel]] indefinitely if no bleeding or other tolerability issues (Grade 2C).}} | '''4.''' For patients undergoing [[PCI]] with a [[DES]], we recommend [[aspirin]] (75–100 mg/d) plus [[clopidogrel]] (75 mg/d for at least 12 months) [Grade 1A for 3 to 4 months; Grade 1B for 4 to 12 months]. Beyond 1 year, we suggest continued treatment with [[aspirin]] plus [[clopidogrel]] indefinitely if no bleeding or other tolerability issues (Grade 2C).}} | ||
==References== | ==References== | ||
{{reflist|2}} | {{reflist|2}} | ||
Latest revision as of 15:10, 5 March 2013
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Coronary stent thrombosis Microchapters |
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Epidemiology and Demographics |
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Stent thrombosis prevention On the Web |
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Risk calculators and risk factors for Stent thrombosis prevention |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Smita Kohli, M.D.; Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.
Overview
The main principle of the preventive treatment for stent thrombosis is to perform the best PCI possible, including good expansion and apposition of the stent. In this context, the role of intravascular ultrasound has been studied extensively and can be helpful[1][2].
Combined antiplatelet therapy for the preventive treatment has been extensively studied and are routinely recommended.
- There are better outcomes noted with the use of aspirin plus ticlopidine or clopidogrel than with aspirin plus warfarin or aspirin alone[3][4][5][6][7].
- Preliminary evidence suggests prasugrel resulted in fewer ischaemic outcomes including stent thrombosis than with standard clopidogrel[8].
Clinical Trial Data
- In STARS trial[3], studying 1653 patients showed superiority of aspirin and ticlopidine over combination of aspirin and warfarin or aspirin alone for reducing subacute stent thrombosis, although there were more hemorrhagic complications than with aspirin alone.
- A similar benefit for combined aspirin plus ticlopidine was noted in another randomized controlled trial[4].
- Results from double blinded randomized studies- PCI-CURE trial[9], analyzing 2658 patients and CREDO trial[10], analyzing 2116 patients, revealed the benefit of clopidogrel therapy increased with time and provide evidence for at least one year therapy in patients with BMS. However both the studies did not evaluate DES.
- TRITON TIMI-38[8]trial analyzing 12,844 patients who underwent stenting for ACS revealed intensive antiplatelet therapy with prasugrel resulted in fewer ischaemic outcomes including stent thrombosis than with standard clopidogrel.These findings were statistically robust irrespective of stent type, and the data affirm the importance of intensive platelet inhibition in patients with intracoronary stents.
Guidelines for Prevention
The 2008 American College of Chest Physician illustrates the following guidelines for primary and secondary prevention of coronary artery disease[11].
| “ |
1. For patients after myocardial infarction, after ACS, and those with stable CAD and patients after percutaneous coronary intervention (PCI) with stent placed, we recommend daily aspirin (75–100 mg) as indefinite therapy. (Grade 1A). 2. For patients who undergo bare metal stent placement, we recommend the combination of aspirin and clopidogrel for at least 4 weeks (Grade 1A). 3. For patients undergoing PCI with BMS placement following ACS, we recommend 12 months of aspirin (75–100 mg/d) plus clopidogrel (75 mg/d) over aspirin alone (Grade 1A). 4. For patients undergoing PCI with a DES, we recommend aspirin (75–100 mg/d) plus clopidogrel (75 mg/d for at least 12 months) [Grade 1A for 3 to 4 months; Grade 1B for 4 to 12 months]. Beyond 1 year, we suggest continued treatment with aspirin plus clopidogrel indefinitely if no bleeding or other tolerability issues (Grade 2C). |
” |
References
- ↑ Roy P, Steinberg DH, Sushinsky SJ; et al. (2008). "The potential clinical utility of intravascular ultrasound guidance in patients undergoing percutaneous coronary intervention with drug-eluting stents". Eur. Heart J. 29 (15): 1851–7. doi:10.1093/eurheartj/ehn249. PMID 18550555. Unknown parameter
|month=ignored (help) - ↑ Gerber R, Colombo A (2008). "Does IVUS guidance of coronary interventions affect outcome? a prime example of the failure of randomized clinical trials". Catheter Cardiovasc Interv. 71 (5): 646–54. doi:10.1002/ccd.21489. PMID 18360858. Unknown parameter
|month=ignored (help) - ↑ 3.0 3.1 Leon MB, Baim DS, Popma JJ, Gordon PC, Cutlip DE, Ho KK; et al. (1998). "A clinical trial comparing three antithrombotic-drug regimens after coronary-artery stenting. Stent Anticoagulation Restenosis Study Investigators". N Engl J Med. 339 (23): 1665–71. doi:10.1056/NEJM199812033392303. PMID 9834303.
- ↑ 4.0 4.1 Schömig A, Neumann FJ, Kastrati A, Schühlen H, Blasini R, Hadamitzky M; et al. (1996). "A randomized comparison of antiplatelet and anticoagulant therapy after the placement of coronary-artery stents". N Engl J Med. 334 (17): 1084–9. doi:10.1056/NEJM199604253341702. PMID 8598866.
- ↑ Bertrand ME, Legrand V, Boland J, Fleck E, Bonnier J, Emmanuelson H; et al. (1998). "Randomized multicenter comparison of conventional anticoagulation versus antiplatelet therapy in unplanned and elective coronary stenting. The full anticoagulation versus aspirin and ticlopidine (fantastic) study". Circulation. 98 (16): 1597–603. PMID 9778323.
- ↑ Urban P, Macaya C, Rupprecht HJ, Kiemeneij F, Emanuelsson H, Fontanelli A; et al. (1998). "Randomized evaluation of anticoagulation versus antiplatelet therapy after coronary stent implantation in high-risk patients: the multicenter aspirin and ticlopidine trial after intracoronary stenting (MATTIS)". Circulation. 98 (20): 2126–32. PMID 9815866.
- ↑ Bertrand ME, Rupprecht HJ, Urban P, Gershlick AH, CLASSICS Investigators (2000). "Double-blind study of the safety of clopidogrel with and without a loading dose in combination with aspirin compared with ticlopidine in combination with aspirin after coronary stenting : the clopidogrel aspirin stent international cooperative study (CLASSICS)". Circulation. 102 (6): 624–9. PMID 10931801.
- ↑ 8.0 8.1 Wiviott SD, Braunwald E, McCabe CH, Horvath I, Keltai M, Herrman JP; et al. (2008). "Intensive oral antiplatelet therapy for reduction of ischaemic events including stent thrombosis in patients with acute coronary syndromes treated with percutaneous coronary intervention and stenting in the TRITON-TIMI 38 trial: a subanalysis of a randomised trial". Lancet. 371 (9621): 1353–63. doi:10.1016/S0140-6736(08)60422-5. PMID 18377975. Review in: ACP J Club. 2008 Sep 16;149(3):12
- ↑ Mehta SR, Yusuf S, Peters RJ, Bertrand ME, Lewis BS, Natarajan MK; et al. (2001). "Effects of pretreatment with clopidogrel and aspirin followed by long-term therapy in patients undergoing percutaneous coronary intervention: the PCI-CURE study". Lancet. 358 (9281): 527–33. PMID 11520521.
- ↑ Steinhubl SR, Berger PB, Mann JT, Fry ET, DeLago A, Wilmer C; et al. (2002). "Early and sustained dual oral antiplatelet therapy following percutaneous coronary intervention: a randomized controlled trial". JAMA. 288 (19): 2411–20. PMID 12435254. Review in: ACP J Club. 2003 Jul-Aug;139(1):2
- ↑ Becker RC, Meade TW, Berger PB, Ezekowitz M, O'Connor CM, Vorchheimer DA; et al. (2008). "The primary and secondary prevention of coronary artery disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)". Chest. 133 (6 Suppl): 776S–814S. doi:10.1378/chest.08-0685. PMID 18574278.