Acute aortic syndromes: suspect, slow, repair.
Dissection, intramural hematoma and penetrating ulcer: classification, ADD-RS plus D-dimer, imaging, anti-impulse targets and doses, type A vs type B repair, malperfusion and follow-up (2022 ACC/AHA, 2024 ESC).
Reviewed October 2026 · verify against current guidelines
Working a case now — open the aortic dissection tool: ADD-RS with the D-dimer step and ADvISED failure rates, plus a heart rate and blood pressure target checker with capped label doses. Scope — adults, per the 2022 ACC/AHA aortic disease guideline (still the current US guideline in October 2026) and the 2024 ESC guideline on peripheral arterial and aortic diseases; where they differ, both are shown. Notes from the ESVS 2026 descending thoracic guideline (European vascular) are labeled as such; ACC/AHA remains the primary US guidance. Doses come from FDA labeling, not from any guideline.
Acute aortic syndromes · 1 of 6
One wall, three ways to fail.
A breach in the aortic wall: three lesions, all can rupture (ACC/AHA 2.4)
| Dissection | An intimal tear lets blood split the media, leaving a flap between a true and a false lumen. The most common AAS: 80% to 90% of cases in the ESC text. |
|---|---|
| Intramural hematoma | Blood in the media with no visible tear and no flow in a false lumen. On CT, MRI or echo: crescentic or circular wall thickening of more than 5 mm without flow. Of IMH cases, 16% to 47% progress to dissection; under 10% resolve on their own (ACC/AHA). |
| Penetrating ulcer | An ulcerated atherosclerotic plaque that breaks through the internal elastic lamina into the media, often with an IMH. Older patients with diffuse atherosclerosis; usually the mid to distal descending aorta. About 2% to 7% of AAS (ACC/AHA). |
Naming the dissection
| Stanford A | Any involvement of the ascending aorta, wherever the tear starts. Equals DeBakey I and II. |
|---|---|
| Stanford B | Ascending aorta spared, including arch involvement that spares it (ACC/AHA). Equals DeBakey IIIa (above the diaphragm) and IIIb (extends below it). |
| Non-A non-B | Flap begins in the arch, or runs retrograde from the descending aorta into the arch, and stops before the ascending aorta (2019 EACTS/ESVS consensus; ESC 2024). |
| SVS/STS 2020 | Type by entry tear: A if the tear is in zone 0; B if in zone 1 or beyond; I (indeterminate) if zone 0 is involved but no tear is found. Subscripts give the proximal and distal zones. Both guidelines describe it. |
| TEM (ESC 2024) | Type (A, B, non-A non-B) + Entry (E0 not seen, E1 ascending, E2 arch, E3 descending) + Malperfusion (M0 none, M1 coronary, M2 supra-aortic, M3 spinal, visceral, renal or iliac (limb)), marked + if clinical and − if imaging-only. A European update of Stanford, recommended by EACTS (Sievers 2020). |
| Timing | Hyperacute under 24 h, acute 1 to 14 days, subacute 15 to 90 days, chronic beyond 90 days (SVS/STS, used by both guidelines). |
AAS acute aortic syndromeIMH intramural hematomaPAU penetrating atherosclerotic ulcerSVS/STS Society for Vascular Surgery / Society of Thoracic SurgeonsEACTS / ESVS European cardiothoracic / vascular surgery societiesTEM Type, Entry, Malperfusion
Acute aortic syndromes · 2 of 6
Suspect it before it declares itself.
Untreated ascending dissection kills 1% to 2% of patients per hour after symptom onset (ACC/AHA section 2.4.1.1). It is missed because it borrows the presentation of more common emergencies.
What it looks like
| Pain | Abrupt, severe chest or back pain, sometimes abdominal, maximal at onset. Patients say sharp or stabbing more often than tearing or ripping (ACC/AHA section 7.1). About 6.4% have no pain (ESC 2024). |
|---|---|
| Shock | Tamponade, rupture, acute severe aortic regurgitation or coronary involvement. In AAS, hypotension means one of these until proven otherwise. |
| Branches | Stroke or syncope (carotid or vertebral), paraplegia (intercostals), bowel ischemia or GI bleeding (celiac, SMA), oliguria or hematuria (renal), a cold leg (iliac). |
| Compression | Hoarseness, dysphagia, Horner syndrome, superior vena cava syndrome, airway compression. |
| Exam | Blood pressure in both arms and both legs (ACC/AHA section 7.1); a gap of more than 20 mm Hg between limbs suggests branch compromise. Listen for new aortic regurgitation, and for aortic stenosis as a clue to a bicuspid valve. Full neurologic exam. |
| History | Family history of aneurysm, dissection or unexplained sudden death; connective tissue disease; recent aortic or cardiac procedures; pregnancy (ESC: 50% of pregnancy-related cases in the third trimester, 33% postpartum). |
Pitfalls
- Labeling it an acute coronary syndrome: dissection can involve a coronary ostium, most often the right (ESC 2024). See ACS.
- Trusting the chest film. It is neither sensitive nor specific enough to diagnose or exclude AAS (ACC/AHA section 7.2). Review chest X-ray reading for the mediastinum anyway.
- Waiting for tearing pain. Sharp and stabbing are the more common words.
- Treating a score of 0 as zero risk: in IRAD, 4.3% of 2,538 confirmed dissections had an ADD-RS of 0 (Rogers 2011).
- Stopping at the stroke or the cold leg when there is also chest or back pain.
- One-arm blood pressure. Measure both arms; see BP measurement.
Acute aortic syndromes · 3 of 6
Score, D-dimer, or straight to CT.
ADD-RS: 1 point per category with any feature (0 to 3)
| Conditions | Marfan or another connective tissue disease; family history of aortic disease; known aortic valve disease; recent aortic manipulation; known thoracic aortic aneurysm. |
|---|---|
| Pain | Chest, back or abdominal pain that is abrupt in onset, severe in intensity, or ripping or tearing. |
| Exam | Pulse deficit or systolic pressure differential; focal neurologic deficit with pain; new aortic regurgitation murmur with pain; hypotension or shock. |
| Tiers | ACC/AHA: 0 low, 1 moderate, 2 to 3 high. ESC 2024 splits at 2: under 2 is low risk, 2 or more is high risk. |
ADvISED: ADD-RS plus D-dimer (Nazerian, Circulation 2018)
| Cohort | 1,850 patients in 6 hospitals, 4 countries; 13% had AAS. D-dimer was negative if under 500 ng/mL. |
|---|---|
| D-dimer alone | Sensitivity 96.7%, specificity 64%. Eight patients with AAS had a negative D-dimer. |
| ADD-RS 0 and negative D-dimer | Supported by both ACC/AHA and ESC. 1 AAS in 294 patients. Failure rate 0.3% (95% CI 0.1% to 1.9%). Ruled out 15.9% of all patients. |
| ADD-RS 0 or 1 and negative D-dimer | ESC 2024 / ADvISED practice; ACC/AHA calls a score of 1 moderate risk. 3 AAS in 924 patients. Failure rate 0.3% (95% CI 0.1% to 1.0%). Ruled out 49.9%. |
| ADD-RS 2 or 3 | No D-dimer rule-out was tested. These patients go to imaging. |
The pathway
| Unstable, any score | Bedside TTE or TEE first, then CT when feasible (ESC 2024 algorithm footnote). Hypotension or shock is an ADD-RS exam item: it never enters a D-dimer rule-out. |
|---|---|
| ADD-RS 2 or 3 | CT angiography without delay; ESC adds a focused TTE and an ECG. |
| ADD-RS 0 or 1 | ECG to exclude STEMI, then D-dimer, chest X-ray and point-of-care ultrasound if available (ESC 2024 algorithm). Any finding compatible with AAS: CT. |
| ADD-RS 0, D-dimer under 500 ng/mL, chest X-ray negative | AAS unlikely in both guidelines. Chase the alternative diagnosis and reassess if the story changes. See likelihood ratios for why a residual risk remains. |
| ADD-RS 1, D-dimer under 500 ng/mL, chest X-ray negative | AAS unlikely by ESC 2024 / ADvISED. ACC/AHA labels a score of 1 moderate risk and supports exclusion only with a low score plus a low D-dimer: decide deliberately, and document it. |
| Guideline status | ESC 2024 recommends the ADD-RS multiparametric algorithm (Class I, LOE B). ACC/AHA 2022: scores can aid evaluation but are not uniformly adopted; a low score plus a D-dimer under 500 ng/mL may be a useful way to exclude AAS. |
Check the assay — ADvISED used a 500 ng/mL cutoff. Labs report D-dimer in fibrinogen-equivalent units (FEU) or D-dimer units (DDU), with assay-specific cutoffs; confirm your lab's unit type and cutoff before applying 500. D-dimer is not diagnostic: it also rises in pulmonary embolism, infection and other states (ESC 2024). For PE work-ups use the PE pathway; for chest pain risk, the HEART pathway.
Which imaging test
| CT angiography | First line in both guidelines (ACC/AHA Class 1; ESC Class I). ESC: ECG-gated, neck to pelvis, cited at 100% sensitivity and 98% specificity. Shows extent, entry tear, branches, malperfusion, hemopericardium and periaortic blood. Contrast concerns: see contrast. |
|---|---|
| TEE | First choice when unstable at any score, with bedside TTE (ESC). Also: too unstable to travel, contrast allergy, or already in the OR. ACC/AHA: reasonable alternative (Class 2a). ESC: recommended in unstable patients who cannot go to CT (Class I) and to guide surgery (Class I). |
| TTE / POCUS | ESC recommends a focused TTE at first evaluation (Class I): effusion, aortic regurgitation, root size, wall motion, sometimes a flap. A normal study does not exclude AAS; ESC puts TTE sensitivity for IMH below 40%. |
| MRI | Accurate, but slow and hard to monitor in. ACC/AHA: usually third choice; the study of choice for a stable patient who cannot have iodinated contrast. ESC: alternative if CT is unavailable (Class IIa). |
| IMH tip | Get noncontrast images first: IMH is a high-attenuation crescent before contrast (ACC/AHA section 7.5). |
ADD-RS aortic dissection detection risk scoreCI confidence intervalCTA CT angiographyTTE / TEE transthoracic / transesophageal echocardiographyPOCUS point-of-care ultrasoundIRAD International Registry of Acute Aortic Dissection
Acute aortic syndromes · 4 of 6
Rate first, then pressure.
Targets
| ACC/AHA 2022 | Heart rate 60 to 80 bpm and SBP under 120 mm Hg, or the lowest pressure that keeps the end-organs perfused (Class 1). |
|---|---|
| ESC 2024 | Heart rate 60 bpm or less and SBP under 120 mm Hg (Class I). Spinal cord ischemia or brain injury: keep MAP higher (Class I). With malperfusion, a higher pressure may be tolerated. |
| ESVS 2026 (European vascular) | Acute type B: SBP under 120 mm Hg and heart rate under 60 bpm, adjustable to keep organs perfused (Rec 36, Class I, LOE C). It warns that rapid lowering can cause renal, cardiac and cerebral ischemia. |
| Hypotension | Shock, or SBP under 90 mm Hg (a conventional hypotension threshold; AAS guidelines give no number): anti-impulse therapy targets wall stress, not shock. Look for tamponade, rupture, severe aortic regurgitation and coronary involvement, and call the surgeon. ESC: for impending arrest from tamponade, consider emergency pericardial puncture as a bridge to the OR. |
| Monitoring | Arterial line and ICU (ACC/AHA Class 1; ESC Class I, with continuous ECG). See arterial lines. |
Sequence
| 1. Rate | IV beta-blocker first (ACC/AHA Class 1; ESC Class I). ESC calls labetalol the first choice (alpha and beta blockade) and esmolol useful for fast titration. |
|---|---|
| Beta-blocker not possible | IV diltiazem or verapamil for rate control (ACC/AHA Class 2a; ESC Class IIa). ACC/AHA flags acute aortic regurgitation, heart block and bradycardia as reasons for caution. |
| 2. Pressure | SBP still 120 or more after the beta-blocker is started: add an IV vasodilator such as nicardipine, clevidipine or nitroprusside (ACC/AHA Class 1). |
| 3. Pain | IV opioids, titrated (ACC/AHA Class 1; ESC Class I). Pain drives both rate and pressure. See pain. |
| Step-down | ESC: once targets are met in a patient managed medically with working gut transit, switch to an oral beta-blocker after 24 h (Class I). |
| For life | Long-term beta-blocker unless contraindicated, adding an ARB or ACE inhibitor as needed (ACC/AHA Class 1). |
IV doses from FDA labels (titrate to the targets)
| Esmolol | Load 500 mcg/kg over 1 min, then 50 mcg/kg/min. Titrate at intervals of at least 4 min, stepping 50 mcg/kg/min with optional reloads. Above 200 mcg/kg/min adds little rate control; for hypertension the label allows 250 to 300. Doses above 300 mcg/kg/min have not been studied. Label: maintenance infusions may continue up to 48 h. |
|---|---|
| Labetalol | 20 mg IV over 2 min, then 40 or 80 mg every 10 min, to a total of 300 mg. Or infuse 2 mg/min until response, then stop and start oral. Usual effective total 50 to 200 mg. |
| Nicardipine | 5 mg/h, up 2.5 mg/h every 5 to 15 min, maximum 15 mg/h. After rapid titration to goal, drop to 3 mg/h. At 0.1 mg/mL, 15 mg/h is 150 mL/h. |
| Clevidipine | 1 to 2 mg/h. Double every 90 seconds at first, then smaller steps every 5 to 10 min near goal. Usual 4 to 6 mg/h; most patients needed 16 mg/h or less; limited data up to 32 mg/h. Lipid load: no more than 1,000 mL per 24 h (0.5 mg/mL, so about 20.8 mg/h; the label rounds to an average of 21 mg/h). |
What to avoid — a vasodilator before rate control: reflex tachycardia (ACC/AHA advises against it as initial therapy). IV verapamil close to esmolol: fatal arrests reported (esmolol label contraindication). Ketorolac and other IV NSAIDs: can raise pressure and harm the kidneys (ACC/AHA). Nicardipine or clevidipine with severe aortic stenosis; clevidipine with soy or egg allergy or defective lipid metabolism (labels). Esmolol with severe sinus bradycardia, heart block beyond first degree, sick sinus syndrome, decompensated heart failure, cardiogenic shock or pulmonary hypertension; labetalol with bronchial asthma, overt cardiac failure, heart block beyond first degree, cardiogenic shock or severe bradycardia (labels). For drip mechanics see the drips tool and inpatient hypertension.
SBP / MAP systolic / mean arterial pressurebpm beats per minuteICU intensive care unitARB / ACE angiotensin receptor blocker / angiotensin-converting enzymeNSAID nonsteroidal anti-inflammatory drugTEVAR thoracic endovascular aortic repairSMA / AKI superior mesenteric artery / acute kidney injury
Acute aortic syndromes · 5 of 6
Type A operates. Type B earns it.
Type A dissection
| Now | Emergency surgical consultation and immediate surgery for suspected or confirmed type A (ACC/AHA Class 1; ESC Class I). |
|---|---|
| Why | Medical therapy alone carries 2 to 3 times the mortality of surgery (ACC/AHA). In IRAD from 1995 to 2013, surgical mortality fell from 25% to 18% while medical mortality stayed at 57%. |
| Transfer | Stable enough? Low- to high-volume aortic center (ACC/AHA Class 2a; ESC Class IIa). ACC/AHA defines high volume as at least 7 aortic dissection repairs (root, ascending or arch) a year. |
| Stroke | Nonhemorrhagic stroke favors surgery over medical therapy (ACC/AHA Class 2a): mortality 25% to 27% with surgery vs 76% without. See stroke. |
| Age | ESC: age alone should not exclude surgery. |
Type B dissection
| Uncomplicated | Medical therapy first (ACC/AHA Class 1; ESC Class I). |
|---|---|
| Complicated means | Rupture (free or contained), branch occlusion or malperfusion, extension including retrograde into the ascending aorta, enlargement in the acute phase, intractable pain, uncontrolled hypertension. ESC: refractory pain beyond 12 h; hypertension despite more than 3 drug classes. |
| Complicated: act | Intervention (ACC/AHA Class 1; ESC Class I). Rupture with suitable anatomy: TEVAR over open repair (ACC/AHA Class 1). Other complications: endovascular is reasonable (ACC/AHA Class 2a). ESC: TEVAR first line (Class I), except known or suspected heritable aortic disease. |
| High-risk features | Maximal aortic diameter over 40 mm; false lumen over 20 to 22 mm; entry tear over 10 mm or on the lesser curvature; growth of more than 5 mm between scans; bloody pleural effusion; imaging-only malperfusion; hypertension despite more than 3 drug classes or pain beyond 12 h at maximal doses; readmission (ACC/AHA). |
| High-risk uncomplicated | Endovascular repair may be considered (ACC/AHA Class 2b). ESC: TEVAR in the subacute phase, 14 to 90 days, in selected patients (Class IIa). |
| Where they disagree | Refractory hypertension and pain beyond 12 h make type B complicated in ESC 2024, with intervention at Class I. ACC/AHA lists them among high-risk features of uncomplicated type B, where endovascular repair is only Class 2b. |
| ESVS 2026 (European vascular) | No routine TEVAR for uncomplicated acute type B outside trials (Rec 37, Class IIIa, LOE B). Selected uncomplicated patients with suitable anatomy and early expansion or a diameter over 4.0 cm: TEVAR may be considered, preferably subacute (Rec 39, IIb, C). Complicated means rupture or malperfusion: immediate TEVAR covering the primary entry tear (Rec 40, I, C). |
Malperfusion
| Mechanism | Dynamic: the flap prolapses across a branch ostium, usually in systole. Static: the dissection runs into the branch and narrows or thromboses it (ACC/AHA section 2.4.1.3). Both can coexist. |
|---|---|
| By organ | Heart: ischemic ECG, troponin. Brain: stroke, coma, confusion. Cord: paraplegia. Gut: abdominal pain, lactic acidosis, rising liver tests. Kidney: AKI, oliguria. Limb: lost pulse, sensory or motor loss (ACC/AHA). See lactate. |
| Stakes | Malperfusion syndrome mortality 30.5% vs 6.2% without it; mesenteric malperfusion 63.2% (ACC/AHA). Imaging signs alone appear in up to 25% of type A. |
| Type A | Renal, mesenteric or limb malperfusion: immediate ascending repair (ACC/AHA Class 1; ESC Class I). Significant mesenteric malperfusion: repair first or revascularize first, by experts (ACC/AHA Class 2a; ESC Class IIa). |
| Type B | Malperfusion makes it complicated: TEVAR, adding fenestration or branch stenting if flow does not return (ACC/AHA). |
Acute aortic syndromes · 6 of 6
IMH, ulcers, and the long tail.
Intramural hematoma (ACC/AHA)
| Complicated | Malperfusion, periaortic hematoma, tamponade, persistent or recurrent pain, or rupture: urgent repair, type A or B (Class 1). |
|---|---|
| Type A, uncomplicated | Prompt open repair (Class 1). Medical management may be considered in selected high-operative-risk patients without high-risk imaging (Class 2b). ESC: urgent surgery. |
| Type B, uncomplicated | Medical therapy first (Class 1). With high-risk imaging, intervention may be reasonable (Class 2b); endovascular if anatomy suits (Class 2a). |
| High-risk imaging | Type A: diameter over 45 to 50 mm, hematoma 10 mm or thicker, ulcer-like projection in the ascending aorta or arch, pericardial effusion. Type B: diameter over 47 to 50 mm, hematoma 13 mm or thicker, ulcer-like projection arising in the acute phase, growing pleural effusion. Either: progression to dissection, growing diameter or hematoma. |
Penetrating ulcer (ACC/AHA)
| Rupture | Urgent repair (Class 1). |
|---|---|
| With IMH | Ascending: urgent repair (Class 1). Arch or descending: reasonable (Class 2a). Abdominal: may be considered (Class 2b). |
| Isolated, symptomatic | Persistent pain that matches the imaging: repair (Class 1). |
| Isolated, asymptomatic | Elective repair may be considered with high-risk features: diameter 13 to 20 mm or more, depth 10 mm or more, growth, saccular aneurysm, growing pleural effusion (Class 2b). |
Follow-up imaging
| Dissection or IMH (ACC/AHA) | After open or endovascular repair with residual aortic disease, or after medical therapy alone: CT or MRI at 1, 6 and 12 months, then yearly if stable (Class 1). |
|---|---|
| Medically treated type B or IMH (ESC) | 1, 3, 6 and 12 months, then yearly if stable (Class I). The early scan catches subacute change while TEVAR still remodels well. |
| After TEVAR (ESC) | 1, 6 and 12 months, then yearly to year 5 (Class I). The 1-month scan looks for retrograde type A dissection. |
| After open repair (ESC) | CT and TTE within 6 months, CT at 12 months, then yearly if stable (Class IIa). Frequent scans after year 1: MRI instead of CT (Class IIa). |
| PAU, medical | ACC/AHA: CT at 1 month, then every 6 months for 2 years (Class 2a). ESC: 1 month, then every 6 months (Class I). |
| ESVS 2026, acute type B (European vascular) | Uncomplicated, managed medically: serial imaging suggested at 48 h, 1 week, 1 month and 3 months (Rec 38, IIa, C). |
| Repair threshold | Chronic residual dissection with total diameter of 5.5 cm or more: elective repair (ACC/AHA Class 1). ESVS 2026 for chronic type B: consider repair at 6.0 cm or more (Rec 52, IIa, C), or 5.5 cm or more in selected patients (Rec 53, IIb, C). |
| ESVS 2026, chronic type B | Lifelong antihypertensives to under 130/80 mm Hg; imaging at 6 and 12 months, then individualized (Rec 49, I, C). |
| Why bother | Delayed expansion in 20% to 50% of medically managed uncomplicated type B over 4 years; the dissected aorta grows about 1 mm a year (ACC/AHA). |
Common errors
- Starting nicardipine or clevidipine before the beta-blocker.
- Chasing an SBP under 120 while urine output falls: the target is the lowest pressure that perfuses the organs.
- Using a negative D-dimer to clear an ADD-RS of 2 or 3, or a patient in shock.
- Sending an unstable patient to the scanner instead of bringing echo to the bedside.
- Delaying type A surgery because of a stroke.
- Discharging medically treated type B without the 1-month scan and a lifelong beta-blocker.
- Long-term calcium channel blockers in Marfan syndrome unless needed for pressure (ACC/AHA).
Educational reference only — not medical advice. Doses are from FDA labeling; confirm with your institution's protocol and pharmacist. Verify against the current ACC/AHA and ESC guidelines.
Sources
Verify against current guidelines and local protocol before acting.
- Isselbacher EM, Preventza O, Hamilton Black J III, et al. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease. Circulation 2022;146(24):e334-e482. doi:10.1161/CIR.0000000000001106. Sections 2.4, 7.1-7.6, 7.8; Tables 3, 22, 24, 26-31.
- Mazzolai L, Teixido-Tura G, Lanzi S, et al. 2024 ESC Guidelines for the management of peripheral arterial and aortic diseases. Eur Heart J 2024;45(36):3538-3700. doi:10.1093/eurheartj/ehae179. Section 9.3; Recommendation Tables 44-49, 51-52, 54; Figures 28-34, 38.
- Nazerian P, Mueller C, Soeiro AM, et al. Diagnostic accuracy of the aortic dissection detection risk score plus D-dimer for acute aortic syndromes: the ADvISED prospective multicenter study. Circulation 2018;137(3):250-258. doi:10.1161/CIRCULATIONAHA.117.029457.
- Wanhainen A, Gombert A, Antoniou GA, et al. European Society for Vascular Surgery (ESVS) 2026 Clinical Practice Guidelines on the Management of Descending Thoracic and Thoraco-Abdominal Aortic Diseases. Eur J Vasc Endovasc Surg 2026;71(2):172-270. doi:10.1016/j.ejvs.2025.12.050. Recommendations 36-40, 49, 52-53. Read from the journal pre-proof.
- Rogers AM, Hermann LK, Booher AM, et al. Sensitivity of the aortic dissection detection risk score: results from the International Registry of Acute Aortic Dissection. Circulation 2011;123(20):2213-2218. doi:10.1161/CIRCULATIONAHA.110.988568.
- Sievers HH, Rylski B, Czerny M, et al. Aortic dissection reconsidered: type, entry site, malperfusion classification. Interact Cardiovasc Thorac Surg 2020;30(3):451-457. doi:10.1093/icvts/ivz281.
- US FDA prescribing information via DailyMed: Brevibloc (esmolol) injection, Baxter, revised 2026; labetalol hydrochloride injection, Hospira, revised 11/2022; nicardipine hydrochloride in sodium chloride injection, 2026; Cleviprex (clevidipine) injectable emulsion, Chiesi, 2025.
- Facts restated in our own words; guideline tables and figures are not reproduced. Not affiliated with or endorsed by the ACC, AHA or ESC.