Sandbox: Kawasaki - ACC -2017

Template:Kawasaki - ACC -2017 Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1],Associate Editor(s)-in-Chief: Arzu Kalayci, M.D. [2]

Diagnosis, Treatment, and Long-Term Management of Kawasaki Disease (KD)

Recommendations for Cardiovascular Assessment for Diagnosis and Monitoring During the Acute Illness

Class I

"1. Echocardiography should be performed when the diagnosis of KD is considered, but unavailability or technical limitations should not delay treatment.(Level of Evidence: B) "

"2. Coronary arteries should be imaged, and quantitative assessment of luminal dimensions, normalized as Z scores adjusted for body surface, should be performed.(Level of Evidence: B) "

"3. For uncomplicated patients, echocardiog- raphy should be repeated both within 1 to 2 weeks and 4 to 6 weeks after treatment.(Level of Evidence: B) "

"4. For patients with important and evolving coronary artery abnormalities (Z score >2.5) detected during the acute illness, more fre- quent echocardiography (at least twice per week) should be performed until luminal dimensions have stopped progressing to determine the risk for and presence of thrombosis.(Level of Evidence: B) "

Class IIa

"1. To detect coronary artery thrombosis, it may be reasonable to perform echocardiography for patients with expanding large or giant aneurysms twice per week while dimensions are expanding rapidly and at least once weekly in the first 45 days of illness, and then monthly until the third month after illness onset, because the failure to escalate thromboprophylaxis in time with the rapid expansion of aneurysms is a primary cause of morbidity and mortality . (Level of Evidence: C) "

Recommendations for Initial Treatment With Intravenous Immunoglobulin (IVIG) and Asetil Salisilat Acid (ASA)

Class I

"1. Patients with complete KD criteria and those who meet the algorithm criteria for incomplete KD should be treated with high-dose IVIG (2 g/kg given as a single intravenous infusion) within 10 days of illness onset but as soon as possible after diagnosis.(Level of Evidence: A) "

Class IIa

"1. It is reasonable to administer IVIG to children presenting after the 10th day of illness (ie, in whom the diagnosis was missed earlier) if they have either persistent fever without other explanation or coronary artery abnormalities together with ongoing systemic inflammation, as manifested by elevation of ESR or CRP (CRP >3.0 mg/dL). (Level of Evidence: B) "

"2. Administrationofmoderate-(30–50mg·kg−1·d−1) to high-dose (80–100 mg·kg−¹·d−¹) ASA is reasonable until the patient is afebrile, although there is no evidence that it reduces coronary artery aneurysms. (Level of Evidence: C) "

Class III

"1. IVIG generally should not be administered to patients beyond the tenth day of illness in the absence of fever, significant elevation of inflammatory markers, or coronary artery abnormalities . (Level of Evidence: C) "

"2. The ESR is accelerated by IVIG therapy and therefore should not be used to assess response to IVIG therapy. A persistently high ESR alone should not be interpreted as a sign of IVIG resistance. (Level of Evidence: C) "

Recommendations for Adjunctive Therapies for Primary Treatment

Class IIb

"1. Administration of a longer course of corticosteroids (eg, tapering over 2–3 weeks), together with IVIG 2 g/kg and ASA, may be considered for treatment of high-risk patients with acute KD, when such high risk can be identified in patients before initiation of treatment. (Level of Evidence: B) "

Class III

"1. Single-dose pulse methylprednisolone should not be administered with IVIG as routine primary therapy for patients with Kawasaki Disease. (Level of Evidence: B) "

Recommendations for Additional Therapy in the IVIG-Resistant Patient

Class IIa

"1. It is reasonable to administer a second dose of IVIG (2 g/kg) to patients with persistent or recrudescent fever at least 36 hours after the end of the first IVIG infusion. (Level of Evidence: B) "

Class IIb

"1. Administration of high-dose pulse steroids (usually methylprednisolone 20–30 mg/kg intravenously for 3 days, with or without a subsequent course and taper of oral prednisone) may be considered as an alternative to a second infusion of IVIG or for retreatment of patients with KD who have had recurrent or recrudescent fever after additional IVIG. (Level of Evidence: B) "

"2. Administration of a longer (eg, 2–3 weeks) tapering course of prednisolone or prednisone, together with IVIG 2 g/kg and ASA, may be considered in the retreatment of patients with KD who have had recurrent or recrudescent fever after initial IVIG treatment. (Level of Evidence: B) "

"3. Administration of infliximab (5 mg/kg) may be considered as an alternative to a second infusion of IVIG or corticosteroids for IVIG-resistant patients. (Level of Evidence: C) "

"4. Administration of cyclosporine may be considered in patients with refractory KD in whom a second IVIG infusion, infliximab, or a course of steroids has failed. (Level of Evidence: C) "

"5. Administration of immunomodulatory monoclonal antibody therapy (except TNF-α block- ers), cytotoxic agents, or (rarely) plasma exchange may be considered in highly refractory patients who have failed to respond to a second infusion of IVIG, an extended course of steroids, or infliximab. (Level of Evidence: C) "

Recommendations for Prevention of Thrombosis During the Acute Illness

Class I

"1. Low-dose ASA (3–5 mg·kg−¹·d−¹) should be administered to patients without evidence of coronary artery changes until 4 to 6 weeks after onset of illness.(Level of Evidence: C) "

Class IIa

"1. For patients with rapidly expanding coronary artery aneurysms or a maximum Z score of ≥10, systemic anticoagulation with LMWH or warfarin (international normalized ratio target 2.0–3.0) in addition to low dose ASA is reasonable. (Level of Evidence: B) "

Class IIb

"1. For patients at increased risk of thrombosis, for example, with large or giant aneurysms (≥8 mm or Z score ≥10) and a recent history of coronary artery thrombosis, “triple therapy” with ASA, a second antiplatelet agent, and anticoagulation with warfarin or LMWH may be considered. (Level of Evidence: C) "

Class III

"1. Ibuprofen and other non steroidal anti-inflammatory drugs with known or potential involvement of cyclooxygenase pathway may be harmful in patients taking ASA for its antiplatelet effects. (Level of Evidence: B) "

Recommendations for Treatment of Coronary Artery Thrombosis

Class I

"1. Coronary artery thrombosis with actual or impending occlusion of the arterial lumen should be treated with thrombolytic therapy or, in patients of sufficient size, by mechanical restoration of coronary artery blood flow at cardiac catheterization.(Level of Evidence: C) "

"2. Thrombolytic agents should be administered together with low-dose ASA and low-dose heparin, with careful monitoring for bleeding.(Level of Evidence: C) "

Class IIb

"1. Treatment of coronary artery thrombosis with substantial thrombus burden and high risk of occlusion with a combination of reduced-dose thrombolytic therapy and abciximab may be considered. (Level of Evidence: C) "

Recommendations for Risk Stratification of Coronary Artery Abnormalities

Class IIa

"1. It is reasonable to use echocardiographic coronary artery luminal dimensions converted to BSA-adjusted Z scores to determine risk stratification. (Level of Evidence: B) "

"2. It is reasonable to incorporate both maximal and current coronary artery involvement in risk stratification. (Level of Evidence: C) "

"3. It is reasonable to incorporate the presence of additional features other than coronary artery luminal dimensions into decisions regarding risk stratification. (Level of Evidence: C) "

No Involvement (Z Score Always <2)

Class IIa

"1. It is reasonable to use echocardiographic coronary artery luminal dimensions converted to BSA-adjusted Z scores to determine risk stratification. (Level of Evidence: B) ". (Level of Evidence: C) "

Type and frequency of additional cardiology assessment (other cardiology testing)

Class IIa

"1. It is reasonable that no additional cardiology assessment be performed. (Level of Evidence: B) ". (Level of Evidence: C) "

Cardiovascular risk factor assessment and management

Class IIa

"1. It is reasonable to provide general counseling regarding healthy lifestyle and activity promotion at every visit; this may be provided by the primary care provider. (Level of Evidence: B) ". (Level of Evidence: C) "

"2. It is reasonable to assess blood pressure, fast- ing lipid profile, body mass index (and plot), waist circumference, dietary and activity assessment, and smoking at least once and ideally at least 1 year from the episode of acute KD; this may be performed by the primary care provider. (Level of Evidence: B) ". (Level of Evidence: C) "

Medical therapy (β-blockers, angiotensin-converting enzyme inhibitor [ACEI], statin)

Class III

"1. No additional medical therapy should be given. (Level of Evidence: C) "

Thromboprophylaxis

Class IIa

"1. It is reasonable to give low-dose ASA for up to 4 to 6 weeks after the episode of acute KD, which should be discontinued thereafter. (Level of Evidence: C) ". (Level of Evidence: C) "

Physical activity

Class IIa

"1. It is reasonable to provide physical activity counseling at every visit with no restrictions or precautions at any time. (Level of Evidence: B) ". (Level of Evidence: C) "

Reproductive counselling

Class IIa

"1. It is reasonable to provide age-appropriate counseling regarding contraception and pregnancy without modification. (Level of Evidence: B) ". (Level of Evidence: C) "

Dilation Only (Z Score ≥2 but <2.5, or a Decrease in Z Score During Follow-up ≥1)

Class IIa

"1. If luminal dimensions have returned to normal by 4 to 6 weeks after KD onset, it is reasonable to discharge the patient from cardiology care, although ongoing follow-up to 12 months may be considered. (Level of Evidence: B) ". (Level of Evidence: C) "

"2. If dilation remains present at 4 to 6 weeks after KD onset, then it is reasonable to continue follow-up to 12 months. If the luminal dimensions return to normal before then, it is reasonable to discharge the patient from ongoing cardiology care. (Level of Evidence: B) ". (Level of Evidence: C) "

"3. Resolution is expected within 1 year. If dilation persists at 1 year, consider whether this represents a dominant branch. If this is a probable explanation, then it is reasonable to discharge the patient from ongoing cardiology care, although ongoing follow-up every 2 to 5 years may be considered. Patients and families should be advised to remember that having had KD is part of the patient’s permanent medical history. (Level of Evidence: C) ". (Level of Evidence: C) "

Type and frequency of additional cardiology assessment (other cardiology testing)

Class IIa

"1. It is reasonable that no additional cardiology assessment be performed. (Level of Evidence: B) ". (Level of Evidence: C) "

Cardiovascular risk factor assessment and management

Class IIa

"1. It is reasonable to provide general counseling regarding healthy lifestyle and activity promotion at every visit; this may be provided by the primary care provider. (Level of Evidence: C) ". (Level of Evidence: C) "

"1. It is reasonable to assess blood pressure, fasting lipid profile, body mass index (and plot), waist circumference, dietary and activity assessment, and smoking at least once and ideally at least 1 year from the episode of acute KD; this may be performed by the primary care provider. (Level of Evidence: C) ". (Level of Evidence: C) "

Medical therapy (β-blockers, ACEI, statin)

Class III

"1. No additional medical therapy should be given. (Level of Evidence: C) "

Thromboprophylaxis

Class IIa

"1. It is reasonable to give low-dose ASA until 4 to 6 weeks after the acute episode, which should be discontinued thereafter. (Level of Evidence: C) ". (Level of Evidence: C) "

Physical activity

Class IIa

"1. It is reasonable to provide physical activity counseling at every visit with no restrictions or precautions at any time. (Level of Evidence: B) "

Reproductive counseling

Class IIa

"1. It is reasonable to provide age-appropriate counseling regarding contraception and pregnancy without modification. (Level of Evidence: B) "

Regression to Normal Z Score or Dilation Only

Frequency of cardiology assessment (to include history and physical examination, echocardiography, electrocardiography)

Class IIa

"1. It is reasonable to assess every 1 to 3 years. It is reasonable not to perform echocardiogra- phy unless there is evidence for inducible myocardial ischemia or the patient has symptoms suggestive of ischemia or signs suggestive of ventricular dysfunction. (Level of Evidence: B) "

Type and frequency of additional cardiology assessment (other cardiology testing)

Class IIa

"1. It is reasonable to assess for inducible myocardial ischemia (stress echocardiography, stress with MRI, stress NM perfusion imaging, PET) every 3 to 5 years or if the patient has symptoms suggestive of ischemia or signs suggestive of ventricular dysfunction. (Level of Evidence: B) "

Class IIb

"1. Further imaging with angiography (CT, MRI, invasive) may be considered only if there is evidence for inducible myocardial ischemia or ventricular dysfunction. (Level of Evidence: C) "

Cardiovascular risk factor assessment and management

Class IIa

"1. It is reasonable to provide general counseling regarding healthy lifestyle and activity promotion at every visit; this may additionally be provided by the primary care provider.(Level of Evidence: C) "

"1. It is reasonable to assess blood pressure, fasting lipid profile, body mass index (and plot), waist circumference, dietary and activity assessment, and smoking every 2 years; this may be performed by the primary care provider. It is reasonable to obtain a follow- up fasting lipid profile. (Level of Evidence: C) "

Medical therapy (β-blockers, ACEI, statin)

Class IIb

"1. Empirical statin therapy for non–lipid-lowering (pleiotropic) effects may be considered.(Level of Evidence: C) "

Class III

"1. Empirical treatment with β-blockers is not indicated.(Level of Evidence: C) "

Thromboprophylaxis

Class IIb

"1. Ongoing treatment with low-dose ASA may be considered, although it is reasonable to discontinue.(Level of Evidence: C) "

Class IIa

"1. Use of an alternative antiplatelet agent (eg, a thienopyridine such as clopidogrel) instead of ASA is reasonable if the patient is intol- erant or resistant to ASA.(Level of Evidence: C) "

Physical activity

Class IIa

"1. It is reasonable to provide physical activity counseling at every visit with no restrictions or precautions at any time .(Level of Evidence: C) "

Reproductive counselling

Class IIa

"1. It is reasonable to provide age-appropriate counseling regarding contraception and pregnancy without modification.(Level of Evidence: B) "

Current or Persistent Medium Aneurysms

Frequency of cardiology assessment (to include history and physical examination, echocardiography, electrocardiography)

Class IIa

"1. It is reasonable to provide physical activity counseling at every visit with no restrictions or precautions at any time .(Level of Evidence: B) "

Type and frequency of additional cardiology assessment (other cardiology testing)

Class IIa

"1. It is reasonable to assess for inducible myo- cardial ischemia (stress echocardiography, stress with MRI, stress NM perfusion imaging, PET) every 1 to 3 years or if the patient has symptoms suggestive of ischemia or signs suggestive of ventricular dysfunction.(Level of Evidence: B) "

Class IIb

"1. Further imaging with angiography (CT, MRI, invasive) may be considered for periodic sur- veillance every 2 to 5 years.(Level of Evidence: C) "

Cardiovascular risk factor assessment and management

Class IIa

"1. It is reasonable to provide general counseling regarding healthy lifestyle and activity promotion at every visit; this may additionally be provided by the primary care provider.(Level of Evidence: C) "

"2. It is reasonable to assess blood pressure, fasting lipid profile, body mass index (and plot), waist circumference, dietary and activity assessment, and smoking at least once and ideally at least 1 year from the episode of acute KD; this may be performed by the primary care provider. It is reasonable to obtain a follow-up fasting lipid profile.(Level of Evidence: C) "

Medical therapy (β-blockers, ACEI, statin)

Class IIb

"1. Empirical statin therapy for non–lipid-lowering (pleiotropic) effects may be considered.(Level of Evidence: C) "

Class III

"1. Empirical treatment with β-blockers is not indicated.(Level of Evidence: C) "

Thromboprophylaxis

Class I

"1. Patients should be treated with low-dose ASA.(Level of Evidence: C) "

Class IIa

"1. Use of an alternative antiplatelet agent (eg, a thienopyridine such as clopidogrel) instead of ASA is reasonable if the patient is intoler- ant or resistant to ASA.(Level of Evidence: C) "

Class IIb

"1. Additional patient and coronary artery characteristics may be considered in decision making regarding intensification of thromboprophylaxis.(Level of Evidence: C) "

"1. Dual-antiplatelet therapy with an additional antiplatelet agent (eg, a thienopyridine such as clopidogrel) may be considered.(Level of Evidence: C) "

Class III

"1. Use of anticoagulation (warfarin, LMWH) is not indicated.(Level of Evidence: C) "

Physical activity

Class I

"1. For patients taking dual-antiplatelet therapy, activities involving a risk of bodily contact, trauma, or injury should be restricted or modified.(Level of Evidence: B) "

Class IIa

"1. It is reasonable to provide physical activity counseling at every visit without restrictions or precautions. Participation in competitive sports or high-intensity activities should be guided by results from testing for inducible myocardial ischemia or exercise-induced arrhythmias.(Level of Evidence: C) "

Reproductive counselling

Class IIa

"1. It is reasonable to discourage use of oral contraceptive drugs that increase thrombosis risk, to recommend that pregnancy be supervised by a multidisciplinary team including a cardiologist, and to alter thromboprophylaxis management during pregnancy and delivery.(Level of Evidence: B) "

Regression to Small Aneurysms

Frequency of cardiology assessment (to include history and physical examination, echocardiography, electrocardiography)

Class IIa

"1. Ongoing follow-up assessment every year is reasonable.(Level of Evidence: B) "

Type and frequency of additional cardiology assessment (other cardiology testing)

Class IIa

"1. It is reasonable to assess for inducible myocardial ischemia (stress echocardiography, stress with MRI, stress NM perfusion imaging, PET) every 2 to 3 years or if the patient has symptoms suggestive of ischemia or signs suggestive of ventricular dysfunction.(Level of Evidence: B) "

Class IIb

"1. Further imaging with angiography (CT, MRI, invasive) may be considered for periodic surveillance every 3 to 5 years.(Level of Evidence: C) "

Cardiovascular risk factor assessment and management

Class IIa

"1. It is reasonable to provide general counseling regarding healthy lifestyle and activity promotion at every visit; this may additionally be provided by the primary care provider.(Level of Evidence: C) "

"2. It is reasonable to assess blood pressure, fasting lipid profile, body mass index (and plot), waist circumference, dietary and activ- ity assessment, and smoking every year; this may be performed by the primary care provider. It is reasonable to obtain a follow- up fasting lipid profile.(Level of Evidence: C) "

Medical therapy (β-blockers, ACEI, statin)

Class IIb

"1. Empirical statin therapy for non–lipid-lowering (pleiotropic) effects may be considered.(Level of Evidence: C) "

Class III

"1. Empirical treatment with β-blockers is not indicated.(Level of Evidence: C) "

Thromboprophylaxis

Class I

"1. Patients should be treated with low-dose ASA.(Level of Evidence: C) "

Class IIa

"1. Use of an alternative antiplatelet agent (eg, a thienopyridine such as clopidogrel) instead of ASA is reasonable if the patient is intolerant or resistant to ASA.(Level of Evidence: C) "

Class IIb

"1. Dual-antiplatelet therapy with an additional antiplatelet agent (eg, a thienopyridine such as clopidogrel) may be considered.(Level of Evidence: C) "

"1. Additional patient and coronary artery characteristics may be considered in decision making regarding intensification or discontinuation of thromboprophylaxis.(Level of Evidence: C) "

Class III

"1. Use of anticoagulation is not indicated.(Level of Evidence: C) "

Physical activity

Class I

"1. For patients taking dual-antiplatelet therapy, activities involving a risk of bodily contact, trauma, or injury should be restricted or modified.(Level of Evidence: B) "

Class IIa

"1. It is reasonable to provide physical activity counseling at every visit without restrictions or precautions. Participation in competitive sports or high-intensity activities should be guided by results from testing for inducible myocardial ischemia or exercise-induced arrhythmias.(Level of Evidence: C) "

Reproductive counselling

Class IIa

"1. It is reasonable to discourage use of oral contraceptive drugs that increase thrombo- sis risk, to recommend that pregnancy be supervised by a multidisciplinary team includ- ing a cardiologist, and to alter thromboprophylaxis management during pregnancy and delivery.(Level of Evidence: B) "

Regression to Normal Z Score or Dilation Only

Frequency of cardiology assessment (to include history and physical examination, echocardiography, electrocardiography)

Class IIb

"1. It is reasonable to discourage use of oral contraceptive drugs that increase thrombo- sis risk, to recommend that pregnancy be supervised by a multidisciplinary team includ- ing a cardiologist, and to alter thromboprophylaxis management during pregnancy and delivery.(Level of Evidence: B) "

Type and frequency of additional cardiology assessment (other cardiology testing)

Class IIa

"1. It is reasonable to assess for inducible myocardial ischemia (stress echocardiography, stress with MRI, stress NM perfusion imaging, PET) every 2 to 4 years or if the patient has symptoms suggestive of ischemia or signs suggestive of ventricular dysfunction.(Level of Evidence: B) "

"1. It is reasonable to perform no further imaging with angiography (CT, MRI, invasive) in the absence of evidence of inducible myocardial ischemia.(Level of Evidence: C) "

Cardiovascular risk factor assessment and management

Class IIa

"1. It is reasonable to provide general counseling regarding healthy lifestyle and activity promotion at every visit; this may additionally be provided by the primary care provider.(Level of Evidence: C) "

"1. It is reasonable to assess blood pressure, fasting lipid profile, body mass index (and plot), waist circumference, dietary and activ- ity assessment, and smoking every 2 years; this may be performed by the primary care provider. It is reasonable to obtain a follow- up fasting lipid profile.(Level of Evidence: C) "

Medical therapy (β-blockers, statin)

Class IIb

"1. Empirical statin therapy for non–lipid-lowering (pleiotropic) effects may be considered.(Level of Evidence: C) "

Class III

"1. Empirical treatment with β-blockers is not indicated.(Level of Evidence: C) "

Thromboprophylaxis

Class IIa

"1. It is reasonable to continue treatment with low-dose ASA.(Level of Evidence: C) "

"1. Use of an alternative antiplatelet agent (eg, a thienopyridine such as clopidogrel) instead of ASA is reasonable if the patient is intolerant or resistant to ASA.(Level of Evidence: C) "

Class IIb

"1. Use of an additional antiplatelet agent (eg, a thienopyridine such as clopidogrel) is not recommended except in the presence of inducible myocardial ischemia.(Level of Evidence: C) "

"1. Additional patient and coronary artery characteristics may be considered in decision making regarding intensification or discontinuation of thromboprophylaxis.(Level of Evidence: C) "

Class III

"1. Use of anticoagulation (warfarin/LMWH) is not indicated.(Level of Evidence: C) "

Physical activity

Class IIa

"1. It is reasonable to provide physical activity counseling at every visit without restrictions or precautions. Participation in competitive sports or high-intensity activities should be guided by results from testing for inducible myocardial ischemia or exercise-induced arrhythmias.(Level of Evidence: C) "

Reproductive counselling

Class IIa

"1. It is reasonable to provide age-appropriate counseling regarding contraception and pregnancy without modification.(Level of Evidence: B) "