The Region of Aquitaine France - 677 Words

In the southwestern region lies Aquitaine, France that covers about 15,949 square miles (Dordogne). In all of those miles, you can experiences varying geography from beaches to vineyards, Aquitaine has it all. This section of France has gone through many leaders, changing but always coming back stronger than ever. There are many properties with just as much past as the entire region itself. No matter where you travel to in the region, you will always experience the same weather. The people in this area have very active hobbies that are much different than the hobbies that we have here in North America. Most Aquitaine is covered in vineyards and small villages but there are a few larger cities. Aquitaine, France has a vast variety of geography, a deep history, many properties, a generally consistent climate, an odd leisure life, and a mixture in city mood. The region of Aquitaine. France is bounded by many landforms and consists of vineyards or chà ¢teaux, beaches, and The Landes. Bo unding Aquitaine, you can find Limousin to the northeast, the Atlantic ocean to the west, Midi-Pyrà ©neà ©es to the east, and Spain to the south (Dordogne, Bordeaux the Southwest Coast). An hour drive south of Bordeaux, the sixth largest city in France, is home to several wine-producing properties, or chà ¢teaux. Chà ¢teau Haut-Brion, the most famous chà ¢teau in France, is the first vineyard that you will travel upon (Morley 238). This chà ¢teau is a mansion dating back to around 1533 when Jean de PontacShow MoreRelatedThe Hundred Years War1503 Words   |  7 PagesThe Hundred Years War began in May, 1337. It was a series of wars in Europe. France and England had been old enemies. The war was started for many reasons. The first reason is that King Phillip VI tried to seize the English territories in the duchy of Aquitaine. England tried to take the French throne. The second reason is that because of their historical feudal orders, France and England broke away from one another (Allmand 7). The third reason was The Battle for Flanders. Flanders was theRead MoreEssay on Eleanor of Aquitaine1310 Words   |  6 PagesEleanor of Aquitaine When viewing the Middle Ages, it is often assumed that women had little if no political power. However, there are certain women that still stand out in the minds of historians, regardless of whether they are queens or commoners. These women ruled vast domains either directly or indirectly, and have influenced many other women to do the same. One such figure was Eleanor of Aquitaine. Although her name is rarely mentioned in history books, her lineage can be found in almostRead MoreFrench Cuisine1598 Words   |  7 Pages Bouillabaisse is a fish stew that derives from the coast of France. 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Discuss the early history of the development of each region, including the specific examples. Then review the location, Climate and Terroir, and Grapes that rank the wines as among the best in the world. To conclude, look into the future of each region to analyze prospects for continued succes s. The history of Bordeaux Wine The history of the Bordeaux wine region dates backRead MoreComparison of Elenor of Aquitaine, Queen Elizabeth I, and Catherine the Great2169 Words   |  9 PagesEleanor of Aquitaine was one of the most influential women in the history of Europe, having been a queen to rulers of both France and England, along with having significant political and economic power in her own right. She served as an example to all women, during a period where there was increasing development in the female s role in society. 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Life of Quaid E Azam Free Essays

string(425) " Evidence B or C Class IIIIIb Benefit Class No orBenefit Risk Class III Harm Procedure/ Additional studies with broad test treatment objectives needed; additional Cor III: Not No Proven be helpful noregistry data would Benefit benefit Helpful Class III No Benefit or Class III Harm Procedure/ test Cor III: Not no benefit Helpful Cor III: harm treatment No Proven Benefit does not imply that the recommendation is weak\." ACCF/AHA Pocket Guideline Adapted from the 2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy November 2011 Developed in Collaboration With the American Association for Thoracic Surgery, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons  © 2011 by the American College of Cardiology Foundation and the American Heart Association, Inc. The following material was adapted from the 2011 ACCF/AHA Guidelines for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy (J Am Coll Cardiol 2011;XX:XX–XX). This pocket guideline is available on the World Wide Web sites of the American College of Cardiology (www. We will write a custom essay sample on Life of Quaid E Azam or any similar topic only for you Order Now cardiosource. org) and the American Heart Association (my. americanheart. org). For copies of this document, please contact Elsevier Inc. Reprint Department, e-mail: reprints@elsevier. com; phone: 212-633-3813; fax: 212-633-3820. Permissions: Multiple copies, modification, alteration, enhancement, and/ ordistribution of this document are not permitted without the express permission of the American College of Cardiology Foundation. Please contact Elsevier’s permission department at healthpermissions@elsevier. com. Contents 1. Introduction †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 3 2. Clinical Definition †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. †¦ 6 3. Genetic Testing Strategies/Family Screening †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 4. Genotype-Positive/Phenotype-Negative Patients †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 9 5. Echoc ardiography †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 10 6. Stress Testing †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 14 7. Cardiac Magnetic Resonance †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 15 8. Detection of Concomitant Coronary Disease †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 17 9. Asymptomatic Patients †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 19 10. Pharmacologic Management†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 21 11. Invasive Therapies †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 26 12. Pacing †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 29 13. Sudden Cardiac Death Risk Stratification †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 30 14. Selection of Patients for Implantable Cardioverter-Defibrillators †¦ 32 15. Participation in Competitive or Recreational Sports and Physical Activity †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢ € ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 6 16. Management of Atrial Fibrillation †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 38 17. Pregnancy/Delivery †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 41 2 1. Introduction The impetus for the guidelines is based on an appreciation of the frequency of this clinical entity and a realization that many aspects of clinical management, including the use of diagnostic modalities, genetic testing, utilization of implantable cardioverter-defibrillators (ICDs), and therapies for refractory symptoms lack consensus. The discussion and recommendations about the various diagnostic modalities apply to patients with established HCM and to a variable extent to patients with a high index of suspicion of the disease. Classification of Recommendations The ACCF/AHA classifications of recommendations and levels of evidence are utilized, and described in more detail in Table 1. 3 Applying Classification of Recommendations and LevelRecommendations and Level of Evidence Table 1. Applying Classification of of Evidence Table 1. Applying Classification of Recommendations and Level of Evidence S i z e Class I Benefit Risk f T r e a T m eSni T ee f ffe c T e a T z o Tr Class IIb Class IIa Benefit Risk Benefit Risk Additional studies with broad Additional studies with objectives objectives needed focused needed; additional registryreasonable to perIt Is data would be helpful Class IIa Class I Benefit RiskRisk Benefit Additional studies with Procedure/Treatment focused objectives needed should be performed/ Pro cedure/Treatment should be performed/ administered It administered Is reasonable to perform procedure/administer treatment n Recommendation favor n Recommendation in that Procedure/Treatment form procedure/administer may be ConsIdered treatment n n Recommendation Recommendation’s eSTimaTe of cerTainTy (PreciSion) of TreaTmenT effecT a populations d* ived from multiple zed clinical trials analyses Recommendation that level a procedure or treatment Multiple populations is useful/effective evaluated* n Sufficient evidence from Data randomized multiple multiplederived from trials randomized clinical trials or meta-analyses or meta-analyses n of procedure or procedure treatment treatment is useful/effective being useful/effective n Sufficient evidence from n Some conflicting evidence n favor usefulness/efficacy less of treatment or procedure well established being useful/effective conflicting evidence evidence from multiple from multiple randomized randomized trials or trials or meta-analyses meta-analyses in favor of treatment or procedure usefulness/efficacy less being useful/effective well established conflicting evidence from single evidence fro m single randomized trial randomized trial oror nonrandomized studies nonrandomized studies in favor usefulness/efficacy less of treatment or procedure well established being useful/effective opinion, case studies, or opinion, case studies, standard of care care or standard of may/might be considered is reasonable may/might be reasonable can be useful/effective/beneficial usefulness/effectiveness is is probably recommended unknown/unclear/uncertain or indicated or not well established n n Some Greater multiple randomized trials from multiple randomized or or meta-analyses trialsmeta-analyses b populations d* ived from a ndomized trial ndomized studies Recommendation that level b procedure or treatment Limited populations is useful/effective evaluated* n Evidence from single Data derived or randomized trialfrom a single randomized trial nonrandomized studies or nonrandomized studies n n Recommendation in that n Recommendation favor n n Recommendation Recommendation’s of procedure or procedure treatment treatment being useful/effective is useful/effective n Some conflicting single n Evidence from n n Some Greater evidence from trial or randomized single randomized trial or nonrandomized studies nonrandomized studies n Recommendation favor n Recommendation in that C ited populations d* sensus opinion ts, case studies, ard of care Recommendation that level C procedure or treatment is Very limited populations useful/effective evaluated* n Only expert opinion, case Only consensus opinion studies, or standard of care of experts, case studies, or standard of care n n n Recommendation Recommendation’s of procedure or procedure is treatment treatment useful/effective being useful/effective n Only expert expert n Only divergingopinion, case studies, or studies, opinion, casestandard of care or standard of care is reasonable should can be useful/effective/beneficial is recommended is probably recommended is indicated oris useful/effective/beneficial indicated n n Only diverging expert Only diverging expert d phrases for commendations should Suggested phrases for writing recommendations is recommended is ndicated is useful/effective/beneficial s treatment/strategy A is Comparative recommended/indicated in effectiveness phrases†  preference to treatment B treatment/strategy A is probably treatment/strategy A is recommended/indicated in in recommended/indicated preference to to treatment B preference treatment B it is reasonableshould be chosen treatment A to choose treatment A over treatment B over treatment B treatment/strategy A is probably recommended/indicated in preference to treatment B it is reasonable to choose treatment A over treatment B ive ess phrases†  4 treatment A should be chosen over treatment B e T menT e ffe c T A recommendation with Level of Evidence B or C Class IIIIIb Benefit Class No orBenefit Risk Class III Harm Procedure/ Additional studies with broad test treatment objectives needed; additional Cor III: Not No Proven be helpful noregistry data would Benefit benefit Helpful Class III No Benefit or Class III Harm Procedure/ test Cor III: Not no benefit Helpful Cor III: harm treatment No Proven Benefit does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Although randomized trials are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective. Procedure/Treatment Cor III: Excess Cost Harmful harm be w/o Benefit to Patients may ConsIdered or Harmful n n Recommendation’s Recommendation that Excess Cost Harmful w/o Benefit to Patients or Harmful Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as sex, age, histo ry of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use. †  For comparative effectiveness recommendations (Class I and IIa; Level of Evidence A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated. n procedure or treatment is usefulness/efficacy less not useful/effective and may well established be harmful conflicting n Greater n evidence from multiple Sufficient evidence from Recommendation that procedure or treatment is not useful/effective and may be harmful Sufficient evidence from multiple randomized trials or meta-analyses Recommendation that procedure or treatment is not useful/effective and may be harmful Evidence from single randomized trial or nonrandomized studies Recommendation that procedure or treatment is not useful/effective and may be harmful Only expert opinion, case studies, or standard of care COR III: Harm potentially harmful causes harm associated with excess morbidity/mortality should not be performed/ be done administered/ other n multiple randomizedor randomized trials trials or meta-analyses meta-analyses n n Recommendation’s Recommendation that n sefulness/efficacy less procedure or treatment is well established not useful/effective and may be harmful conflicting n Greater n evidence from single Evidence from single randomized trial randomized trial oror nonrandomized studies nonrandomized studies n Recommendation’s Recommendation that usefulness/efficacy less procedure or treatment is well established not useful/effective and may n Only diverging expert be harmful opinion, case studies, or n Only expert opinion, case standard of care studies, or standard of care n n n n COR III: COR III: may/might be considered Nomay/might be reasonable Benefit Harm usefulness/effectiveness is is not potentially unknown/unclear/uncertain recommended harmful or indicated not well established harm is not causes associated with excess morbidity/mortality should not be done COR III: No Benefit is not recommended is not indicated should not be performed/ be done administered/ is not useful/ other beneficial/ is not useful/ effective bene? cial/ effective should not be done s not useful/ beneficial/ effective 5 2. Clinical Definition The generally accepted definition of hypertrophic cardiomyopathy (HCM), is a disease state characterized by unexplained left ventricular (LV) hypertrophy associated with nondilated ven tricular chambers in the absence of another cardiac or systemic disease that itself would be capable of producing the magnitude of hypertrophy evident in a given patient. Clinically, HCM is usually recognized by maximal LV wall thickness ? 15 mm, with wall thickness of 13 to 14 mm considered borderline, particularly in the presence of other compelling information (e. g. , family history of HCM), based on echocardiography. In terms of LV wall-thickness measurements, the literature has been largely focused on echocardiography, although cardiovascular magnetic resonance (CMR) is now used with increasing frequency in HCM. In the case of children, increased LV wall thickness is defined as wall thickness ? 2 standard deviations above the mean (z score ? 2) for age, sex, or body size. However, it should be underscored that in principle, any degree of wall thickness is compatible with the presence of the HCM genetic substrate and that an emerging subgroup within the broad clinical spectrum is composed of family members with disease-causing sarcomere mutations but without evidence of the disease phenotype (i. e. , LV hypertrophy). 6 3. Genetic Testing Strategies/Family Screening Class I 1. Evaluation of familial inheritance and genetic counseling is recommended as part of the assessment of patients with HCM. (Level of Evidence: B) 2. Patients who undergo genetic testing should also undergo counseling by someone knowledgeable in the genetics of cardiovascular disease so that results and their clinical significance can be appropriately reviewed with the patient. (Level of Evidence: B) 3. Screening (clinical, with or without genetic testing) is recommended in first-degree relatives of patients with HCM. (Level of Evidence: B) 4. Genetic testing for HCM and other genetic causes of unexplained cardiac hypertrophy is recommended in patients with an typical clinical presentation of HCM or when another genetic condition is suspected to be the cause. (Level of Evidence: B) 7 Class IIa 1. Genetic testing is reasonable in the index patient to facilitate the identification of first-degree family members at risk for developing HCM. (Level of Evidence: B) Class IIb 1. The usefulness of genetic testing in the assessment of risk of sudden cardiac death (SCD) in HCM is uncertain. (Level of Evidence: B) Class III: 1. Genetic testing is not indicated in relatives when pathogenic mutation. (Level of Evidence: B) 2. Ongoing clinical screening is not indicated in genotype-negative relatives in families with HCM. Level of Evidence: B) No Benefit the index patient does not have a definitive 8 4. Genotype-Positive/Phenotype-Negative Patients Class I 1. In individuals with pathogenic mutations who do not express the HCM phenotype, it is recommended to perform serial electrocardiogram, transthoracic echocardiogram (TTE), and clinical assessment at periodic intervals (12 to 18 months in children and adolescents and about every 5 years in adults), based on the patient’s age and change in clinical status. (Level of Evidence: B) 9 5. Echocardiography Class I 1. A TTE is recommended in the initial evaluation of all patients with suspected HCM. (Level of Evidence: B) 2. A TTE is recommended as a component of the screening algorithm for family members of patients with HCM unless the family member is genotype negative in a family with known definitive mutations. (Level of Evidence: B) 3. Periodic (12 to 18 months) TTE screening is recommended for children of patients with HCM, starting by age 12 or earlier if a growth spurt or signs of puberty are evident and/or when there are plans for engaging in intense competitive sports or there is a family history of SCD. (Level of Evidence: C) 4. Repeat TTE is recommended for the evaluation of patients with HCM with a change in clinical status or new cardiovascular event. (Level of Evidence: B) 5. A transesophageal echocardiogram (TEE) is recommended for the intraoperative guidance of surgical myectomy. (Level of Evidence: B) 10 6. TTE or TEE with intracoronary contrast injection of the candidate’s septal perforator(s) is recommended for the intraprocedural guidance of alcohol septal ablation. (Level of Evidence: B) 7. TTE should be used to evaluate the effects of surgical myectomy or alcohol septal ablation for obstructive HCM. (Level of Evidence: C) Class IIa 1. TTE studies performed every 1 to 2 years can be useful in the serial evaluation of symptomatically stable patients with HCM to assess the degree of myocardial hypertrophy, dynamic obstruction, and myocardial function. (Level of Evidence: C) 2. Exercise TTE can be useful in the detection and quantification of dynamic left ventricular outflow tract (LVOT) obstruction in the absence of resting outflow tract obstruction in patients with HCM. (Level of Evidence: B) 11 3. TEE can be useful if TTE is inconclusive for clinical decision making about medical therapy and in situations such as planning for myectomy, exclusion of subaortic membrane or mitral regurgitation secondary to structural abnormalities of the mitral valve apparatus, or in assessment for the feasibility of alcohol septal ablation. (Level of Evidence: C) 4. TTE combined with the injection of an intravenous contrast agent is reasonable if the diagnosis of apical HCM or apical infarction or severity of hypertrophy is in doubt, particularly when other imaging modalities such as CMR are not readily available, not diagnostic, or contraindicated. (Level of Evidence: C) 5. Serial TTE studies are reasonable for clinically unaffected patients who have a first-degree relative with HCM when genetic status is unknown. Such follow-up may be considered every 12 to 18 months for children or adolescents from high-risk families and every 5 years for adult family members. (Level of Evidence: C) 12 Class III: 1. TTE studies should not be performed more HCM when it is unlikely that any changes have occurred that would have an impact on clinical decision making. (Level of Evidence: C) 2. Routine TEE and/or contrast echocardiography is not recommended when TTE images are diagnostic of HCM and/or there is no suspicion of fixed obstruction or intrinsic mitral valve pathology. (Level of Evidence: C) No Benefit frequently than every 12 months in patients with 13 6. Stress Testing Class IIa 1. Treadmill exercise testing is reasonable to determine functional capacity and response to therapy in patients with HCM. (Level of Evidence: C) 2. Treadmill testing with monitoring of an electrocardiogram and blood pressure is reasonable for SCD risk stratification in patients with HCM. (Level of Evidence: B) 3. In patients with HCM who do not have a resting peak instantaneous gradient of greater than or equal to 50 mm Hg, exercise echocardiography is reasonable for the detection and quantification of exercise-induced dynamic LVOT obstruction. (Level of Evidence: B) 14 7. Cardiac Magnetic Resonance Class I 1. CMR imaging is indicated in patients with suspected HCM when echocardiography is inconclusive for diagnosis. (Level of Evidence: B) 2. CMR imaging is indicated in patients with known HCM when additional information that may have an impact on management or decision making regarding invasive management, such as magnitude and distribution of hypertrophy or anatomy of the mitral valve apparatus or papillary muscles, is not adequately defined with echocardiography. (Level of Evidence: B) Class IIa 1. CMR imaging is reasonable in patients with HCM to define apical hypertrophy and/or aneurysm if echocardiography is inconclusive. (Level of Evidence: B) 15 Class IIb 1. In selected patients with known HCM, when SCD risk stratification is inconclusive after documentation of the conventional risk factors, CMR imaging with assessment of late gadolinium enhancement may be considered in resolving clinical decision making. (Level of Evidence: C) 2. CMR imaging may be considered in patients with LV hypertrophy and the suspicion of alternative diagnoses to HCM, including cardiac amyloidosis, Fabry disease, and genetic phenocopies such as LAMP2 cardiomyopathy. (Level of Evidence: C) 16 8. Detection of Concomitant Coronary Disease Class I 1. Coronary arteriography (invasive or computed tomographic imaging) is indicated in patients with HCM with chest discomfort who have an intermediate to high likelihood of coronary artery disease (CAD) when the identification of concomitant CAD will change management strategies. (Level of Evidence: C) Class IIa 1. Assessment of coronary anatomy with computed tomographic angiography is reasonable for patients with HCM with chest discomfort and a low likelihood of CAD to assess for possible concomitant CAD. (Level of Evidence: C) 2. Assessment of ischemia or perfusion abnormalities suggestive of CAD with single-photon emission computed tomography or positron emission tomography myocardial perfusion imaging (because of excellent negative predictive value) is reasonable in patients with HCM with chest discomfort and a low likelihood of CAD to rule out possible concomitant CAD. (Level of Evidence: C) 17 Class III: 1. Routine single-photon emission computed echocardiography is not indicated for detection of â€Å"silent† CAD-related ischemia in patients with HCM who are asymptomatic. (Level of Evidence: C) 2. Assessment for the presence of blunted flow reserve (microvascular ischemia) using quantitative myocardial blood flow measurements by positron emission tomography is not indicated for the assessment of prognosis in patients with HCM. (Level of Evidence: C) No Benefit tomography myocardial perfussion imaging or stress 18 9. Asymptomatic Patients Class I 1. For patients with HCM, it is recommended that comorbidities that may contribute to cardiovascular disease (e. g. , hypertension, diabetes, hyperlipidemia, obesity) be treated in compliance with relevant existing guidelines. (Level of Evidence: C) Class IIa 1. Low-intensity aerobic exercise is reasonable as part of a healthy lifestyle for patients with HCM. (Level of Evidence: C) Class IIb 1. The usefulness of beta blockade and calcium channel blockers to alter clinical outcome is not well established for the management of asymptomatic patients with HCM with or without obstruction. (Level of Evidence: C) Class III: Harm 1. Septal reduction therapy should not be performed for asymptomatic adult and pediatric patients with HCM with normal effort tolerance regardless of the severity of obstruction. (Level of Evidence: C) 2. In patients with HCM with resting or provocable outflow tract obstruction, regardless of symptom status, pure vasodilators and high-dose diuretics are potentially harmful. (Level of Evidence: C) 19 Figure 1. Treatment Algorithm HCM Patients ACE indicates angiotensin-converting enzyme; ARB, angiotensin receptor blocker; DM, diabetes mellitus; EF, ejection fraction; GL, guidelines; HCM, hypertrophic cardiomyopathy; HTN, hypertension; and LV, left ventricular. Treat comorbidities according to GL [HTN, Lipids, DM] Obstructive Physiology No Heart Failure Symptoms or Angina No Yes Yes Avoid vasodilator therapy and highdose diuretics Systolic Function Annual clinical evaluation No Heart Failure Symptoms or Angina LV EF 50% LV EF ? 50% Yes Beta Blockade Verapamil Disopyramide Therapy as outlined in Heart Failure GL Persistent Symptoms Diuretics ACE Inhibitor or ARB Beta Blockade Verapamil Yes Invasive Therapy Yes Acceptable surgical candidate Yes Surgical Myectomy Legend Alcohol Ablation Class I Class IIa Class IIb No Acceptable candidate for alcohol ablation Yes Alcohol Ablation No Consider DDD Pacing 20 10. Pharmacologic Management Class I 1. Beta-blocking drugs are recommended for the treatment of symptoms (angina or dyspnea) in adult patients with obstructive or nonobstructive HCM but should be used with caution in patients with sinus bradycardia or severe conduction disease. (Level of Evidence: B) 2. If low doses of beta-blocking drugs are ineffective for controlling symptoms (angina or dyspnea) in patients with HCM, it is useful to titrate the dose to a resting heart rate of less than 60 to 65 bpm (up to generally accepted and recommended maximum doses of these drugs). (Level of Evidence: B) 3. Verapamil therapy (starting in low doses and titrating up to 480 mg/d) is recommended for the treatment of symptoms (angina or dyspnea) in patients with obstructive or nonobstructive HCM who do not respond to beta-blocking drugs or who have side effects or contraindications to betablocking drugs. However, verapamil should be used with caution in patients with high gradients, advanced heart failure, or sinus bradycardia. (Level of Evidence: B) 21 4. Intravenous phenylephrine (or another pure vasoconstricting agent) is recommended for the treatment of acute hypotension in patients with obstructive HCM who do not respond to fluid administration. (Level of Evidence: B) Class IIa 1. It is reasonable to combine disopyramide with a beta-blocking drug or verapamil in the treatment of symptoms (angina or dyspnea) in patients with obstructive HCM who do not respond to betablocking drugs or verapamil alone. (Level of Evidence: B) 2. It is reasonable to add oral diuretics in patients with nonobstructive HCM when dyspnea persists despite the use of beta blockers or verapamil or their combination. (Level of Evidence: C) 22 Class IIb 1. Beta-blocking drugs might be useful in the treatment of symptoms (angina or dyspnea) in children or adolescents with HCM, but patients treated with these drugs should be monitored for side effects, including depression, fatigue, or impaired scholastic performance. (Level of Evidence: C) 2. It may be reasonable to add oral diuretics with caution to patients with obstructive HCM when congestive symptoms persist despite the use of beta blockers or verapamil or their combination. (Level of Evidence: C) 3. The usefulness of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers in the treatment of symptoms (angina or dyspnea) in patients with HCM with preserved systolic function is not well established, and these drugs should be used cautiously (if at all) in patients with resting or provocable LVOT obstruction. (Level of Evidence: C) 4. In patients with HCM who do not tolerate verapamil or in whom verapamil is contraindicated, diltiazem may be considered. (Level of Evidence: C) 23 Class III: Harm 1. Nifedipine or other dihydropyridine calcium channel-blocking drugs are potentially harmful for treatment of symptoms (angina or dyspnea) in patients with HCM who have resting or provocable LVOT obstruction. (Level of Evidence: C) 2. Verapamil is potentially harmful in patients with obstructive HCM in the setting of systemic hypotension or severe dyspnea at rest. (Level of Evidence: C) 3. Digitalis is potentially harmful in the treatment of dyspnea in patients with HCM and in the absence of atrial fibrillation (AF). (Level of Evidence: B) 4. The use of disopyramide alone without beta blockers or verapamil is potentially harmful in the treatment of symptoms (angina or dyspnea) in patients with HCM with AF because disopyramide may enhance atrioventricular conduction and increase the ventricular rate during episodes of AF. (Level of Evidence: B) 5. Dopamine, dobutamine, norepinephrine, and other intravenous positive inotropic drugs are potentially harmful for the treatment of acute hypotension in patients with obstructive HCM. (Level of Evidence: B) 24 11. Invasive Therapies Class I 1. Septal reduction therapy should be performed only by experienced operators* in the context of a comprehensive HCM clinical program and only for the treatment of eligible patients with severe drugrefractory symptoms and LVOT obstruction† . (Level of Evidence: C) *Experienced operators are defined as an individual operator with a cumulative case volume of at least 20 procedures or an individual operator who is working in a dedicated HCM program with a cumulative total of at least 50 procedures. Eligible patients are defined by all of the following: a. Clinical: Severe dyspnea or chest pain (usually New York Heart Association functional classes III or IV) or occasionally other exertional symptoms (such as syncope or near syncope) that interfere with everyday activity or quality of life despite optimal medical therapy. b. Hemodynamic: Dynamic LVOT gradient at rest or with physiologic provocation greater than or equal to 50 mm Hg associated with septal hypertrophy and systolic anterior motion of the mitral valve. c. Anatomic: Targeted anterior septal thickness sufficient to perform the procedure safely and effectively in the judgment of the individual operator. 25 Class IIa 1. Consultation with centers experienced in performing both surgical septal myectomy and alcohol septal ablation is reasonable when discussing treatment options for eligible patients with HCM with severe drug-refractory symptoms and LVOT obstruction. (Level of Evidence: C) 2. Surgical septal myectomy, when performed in experienced centers, can be beneficial and is the first consideration for the majority of eligible patients with HCM with severe drug-refractory symptoms and LVOT obstruction. (Level of Evidence: B) 3. Surgical septal myectomy, when performed at experienced centers, can be beneficial in symptomatic children with HCM and severe resting obstruction (50 mm Hg) for whom standard medical therapy has failed. (Level of Evidence: C) 4. When surgery is contraindicated or the risk is considered unacceptable because of serious comorbidities or advanced age, alcohol septal ablation, when performed in experienced centers, can be beneficial in eligible adult patients with HCM with LVOT obstruction and severe drug-refractory symptoms (usually New York Heart Association functional classes III or IV). (Level of Evidence: B) 26 Class IIb 1. Alcohol septal ablation, when performed in experienced centers, may be considered as an alternative to surgical myectomy for eligible adult patients with HCM with severe drug-refractory symptoms and LVOT obstruction when, after a balanced and thorough discussion, the patient expresses a preference for septal ablation. (Level of Evidence: B) 2. The effectiveness of alcohol septal ablation is uncertain in patients with HCM with marked (i. e. , 30 mm) septal hypertrophy, and therefore the procedure is generally discouraged in such patients. (Level of Evidence: C) Class III: Harm 1. Septal reduction therapy should not be done for adult patients with HCM who are asymptomatic with normal exercise tolerance or whose symptoms are controlled or minimized on optimal medical therapy. (Level of Evidence: C) 2. Septal reduction therapy should not be done unless performed as part of a program dedicated to the longitudinal and multidisciplinary care of patients with HCM. (Level of Evidence: C) 27 3. Mitral valve replacement for relief of LVOT obstruction should not be performed in patients with HCM in whom septal reduction therapy is an option. (Level of Evidence: C) 4. Alcohol septal ablation should not be done in patients with HCM with concomitant disease that independently warrants surgical correction (e. g. coronary artery bypass grafting for CAD, mitral valve repair for ruptured chordae) in whom surgical myectomy can be performed as part of the operation. (Level of Evidence: C) 5. Alcohol septal ablation should not be done in patients with HCM who are less than 21 yea rs of age and is discouraged in adults less than 40 years of age if myectomy is a viable option. (Level of Evidence: C) 28 12. Pacing Class IIa 1. In patients with HCM who have had a dualchamber device implanted for non-HCM indications, it is reasonable to consider a trial of dual-chamber atrial-ventricular pacing (from the right ventricular apex) for the relief of symptoms attributable to LVOT obstruction. (Level of Evidence: B) Class IIb 1. Permanent pacing may be considered in medically refractory symptomatic patients with obstructive HCM who are suboptimal candidates for septal reduction therapy. (Level of Evidence: B) Class III: 1. Permanent pacemaker implantation for the performed in patients with HCM who are asymptomatic or whose symptoms are medically controlled. (Level of Evidence: C) 2. Permanent pacemaker implantation should not be performed as a first-line therapy to relieve symptoms in medically refractory symptomatic patients with HCM and LVOT obstruction in patients who are candidates for septal reduction. (Level of Evidence: B) No Benefit purpose of reducing gradient should not be 29 13. Sudden Cardiac Death Risk Stratification Class I 1. All patients with HCM should undergo comprehensive SCD risk stratification at initial evaluation to determine the presence of: (Level of Evidence: B) a. A personal history for ventricular fibrillation, sustained ventricular tachycardia, or SCD events, including appropriate ICD therapy for ventricular tachyarrhythmias. * b. A family history for SCD events, including appropriate ICD therapy for ventricular tachyarrhythmias. * c. Unexplained syncope. d. Documented nonsustained ventricular tachycardia (NSVT) defined as 3 or more beats at greater than or equal to120 bpm on ambulatory (Holter) electrocardiogram. e. Maximal LV wall thickness greater than or equal to 30 mm. Appropriate ICD discharge is defined as ICD therapy triggered by VT or ventricular fibrillation, documented by stored intracardiac electrogram or cycle-length data, in conjunction with the patient’s symptoms immediately before and after device discharge. 30 Class IIa 1. It is reasonable to assess blood pressure res ponse during exercise as part of SCD risk stratification in patients with HCM. (Level of Evidence: B) 2. SCD risk stratification is reasonable on a periodic basis (every 12 to 24 months) for patients with HCM who have not undergone ICD implantation but would otherwise be eligible in the event that risk factors are identified (12 to 24 months). (Level of Evidence: C) Class IIb 1. The usefulness of the following potential SCD risk modifiers is unclear but might be considered in selected patients with HCM for whom risk remains borderline after documentation of conventional risk factors: a. CMR imaging with late gadolinium enhacement. (Level of Evidence: C) b. Double and compound mutations (i. e. , 1). (Level of Evidence: C) c. Marked LVOT obstruction. (Level of Evidence: B) Class III: Harm 1. Invasive electrophysiologic testing as routine SCD risk stratification in patients with HCM should not be performed. (Level of Evidence: C) 31 14. Selection of Patients for Implantable Cardioverter-Defibrillators Class I 1. The decision to place an ICD in patients with HCM should include application of individual clinical judgment, as well as a thorough discussion of the strength of evidence, benefits, and risks to allow the informed patient’s active participation in decision making. (Level of Evidence: C) 2. ICD placement is recommended for patients with HCM with prior documented cardiac arrest, ventricular fibrillation, or hemodynamically significant ventricular tachycardia. (Level of Evidence: B) Class IIa 1. It is reasonable to recommend an ICD for patients with HCM with: a. Sudden death presumably caused by HCM in 1 or more first-degree relatives. (Level of Evidence: C) b. A maximum LV wall thickness greater than or equal to 30 mm. (Level of Evidence: C) c. One or more recent, unexplained syncopal episodes. (Level of Evidence: C) 2. An ICD can be useful in select patients with NSVT (particularly those 30 years of age) in the presence of other SCD risk factors or modifiers*. (Level of Evidence: C) 32 *See Section 6. 3. 1. 2 of the full-text guideline for SCD risk factors or modifiers. 3. An ICD can be useful in select patients with HCM with an abnormal blood pressure response with exercise in the presence of other SCD risk factors or modifiers. * (Level of Evidence: C) 4. It is reasonable to recommend an ICD for high-risk children with HCM, based on unexplained syncope, massive LV hypertrophy, or family history of SCD, after taking into account the relatively high complication rate of long-term ICD implantation. (Level of Evidence: C) Class IIb 1. The usefulness of an ICD is uncertain in patients with HCM with isolated bursts of nonsustained ventricular tachycardia when in the absence of any other SCD risk factors or modifiers. * (Level of Evidence: C) 2. The usefulness of an ICD is uncertain in patients with HCM with an abnormal blood pressure response with exercise when in the absence of any other SCD risk factors or modifiers*, particularly in the presence of significant outflow obstruction. (Level of Evidence: C) *See Section 6. 3. 1. 2 of the full-text guideline for SCD risk factors or modifiers. 33 Class III: Harm 1. ICD placement as a routine strategy in patients with HCM without an indication of increased risk is potentially harmful. (Level of Evidence: C) 2. ICD placement as a strategy to permit patients with HCM to participate in competitive athletics is potentially harmful. (Level of Evidence: C) 3. ICD placement in patients who have an identified HCM genotype in the absence of clinical manifestations of HCM is potentially harmful. (Level of Evidence: C) 34 Figure 2. Indications for ICDs in HCM Prior cardiac arrest or Sustained VT Yes ICD recommended No Family history-SD in first-degree relative or LV wall thickness 30 mm or Recent unexplained syncope No Yes ICD reasonable Nonsustained VT or Abnormal BP response Yes Other SCD Risk Modifiers* Present? Yes No ICD can be useful Legend Class I Class IIa No ICD not recommended Class IIb Class III Role of ICD uncertain Regardless of the level of recommendation put forth in these guidelines, the decision for placement of an ICD must involve prudent application of individual clinical judgment, thorough discussions of the strength of evidence, the benefits, and the risks (including but not limited to inappropriate discharges, lead and procedural complications) to allow active participation of the fully informed patient in ultimate decision making. BP indicates blood pressure; ICD, implantable cardioverter-defibrillator; LV, left ventricular; SCD, sudden cardiac death; SD, sudden death; and VT, ventricular tachycardia. 35 15. Participation in Competitive or Recreational Sports and Physical Activity Class IIa 1. It is reasonable for patients with HCM to participate in low-intensity competitive sports (e. g. , golf and bowling). (Level of Evidence: C) 2. It is reasonable for patients with HCM to participate in a range of recreational sporting activities as outlined in Table 2. (Level of Evidence: C) Class III: Harm 1. Patients with HCM should not participate in intense competitive sports regardless of age, sex, race, presence or absence of LVOT obstruction, prior septal reduction therapy, or implantation of a cardioverterdefibrillator for high-risk status. (Level of Evidence: C) 36 Table 2. Recommendations for the Acceptability of Recreational Noncompetitive) Sports Activities and Exercise in Patients With HCM* Intensity Level High Basketball (full court) Basketball (half court) Body building†¡ Gymnastics Ice hockey†¡ Racquetball/squash Rock climbing†¡ Running (sprinting) Skiing Soccer Tennis (singles) Touch (flag) football Windsurfing § Moderate Baseball/softbal l Biking Modest hiking Motorcycling†¡ Jogging Sailing § Surfing § Swimming (laps) § Tennis (doubles) Treadmill/stationary bicycle Weightlifting (free weights)†¡|| Hiking 2 4 4 3 3 3 2 5 4 5 1 3 (downhill)†¡ Skiing (cross-country) 0 0 1 2 0 0 1 0 2 2 0 0 1 1 Eligibility Scale for HCM†  Intensity Level Low Bowling Golf Horseback riding†¡ Scuba diving § Skating ¶ Snorkeling § Weights (nonfree weights) Brisk walking 5 5 3 0 5 5 4 5 Eligibility Scale for HCM†  *Recreational sports are categorized according to high, moderate, and low levels of exercise and graded on a relative scale (from 0 to 5) for eligibility, with 0 to 1 indicating generally not advised or strongly discouraged; 4 to 5, probably permitted; and 2 to 3, intermediate and to be assessed clinically on an individual basis. The designations of high, moderate, and low levels of exercise are equivalent to an estimated 6, 4 to 6, and 4 metabolic equivalents, respectively. † Assumes absence of laboratory DNA genotyping data; therefore, limited to clinical diagnosis. These sports involve the potential for traumatic injury, which should be taken into consideration for individuals with a risk for impaired consciousness.  §The possibility of impaired consciousness occurring during water-related activities should be taken into account with respect to the individual patient’s clinical profile. ||Recommendations generally differ from those for weighttraining machines (nonfree weights), based largely on the potential risk of traumatic injury associated with episodes of impaired consciousness during bench-press maneuvers; otherwise, the physiologic effects of all weight-training activities are regarded as similar with respect to the present recommendations.  ¶Individual sporting activity not associated with the team sport of ice hockey. 37 16. Management of Atrial Fibrillation Class I 1. Anticoagulation with vitamin K antagonists (i. e. , warfarin, to an international normalized ratio of 2. 0 to 3. 0) is indicated in patients with paroxysmal, persistent, or chronic AF and HCM. (Anticoagulation with direct thrombin inhibitors [i. e. , dabigatran*] may represent another option to reduce the risk of thromboembolic events, but data for patients with HCM are not available). (Level of Evidence: C) 2. Ventricular rate control in patients with HCM with AF is indicated for rapid ventricular rates and can require high doses of beta antagonists and nondihydropyridine calcium channel blockers. Level of Evidence: C) * Dabigatran should not be used in patients with prosthetic valves, hemodynamically significant valve disease, advanced liver failure, or severe renal failure (creatinine clearance 15 mL/min). 38 Figure 3. Management of AF in HCM Atrial Fibrillation Anticoagulation according to AF guidelines (INR 2-3) Rate Control or Rhythm Control strategy? Rate Control Rhythm Control Beta Blockade Verapamil or diltiazem Amiodarone Sotalol Disopyramide Dronedarone Dofetilide Persistent symptoms or poor rate control Persistent or Recurrent AF Legend Class I AV node ablation and PPM placement Radiofrequency ablation (PVI) Surgical maze (if undergoing operation for other indication) Class IIa Class IIb AF indicates atrial fibrillation; AV, atrioventricular; INR, international normalized ratio; PPM, permanent pacemaker; and PVI, pulmonary vein isolation. 39 Class IIa 1. Disopyramide (with ventricular rate-controlling agents) and amiodarone are reasonable antiarrhythmic agents for AF in patients with HCM. (Level of Evidence: B) 2. Radiofrequency ablation for AF can be beneficial in patients with HCM who have refractory symptoms or who are unable to take antiarrhythmic drugs. (Level of Evidence: B) 3. Maze procedure with closure of left atrial appendage is reasonable in patients with HCM with a history of AF, either during septal myectomy or as an isolated procedure in selected patients. Level of Evidence: C) Class IIb 1. Sotalol, dofetilide, and dronedarone might be considered alternative antiarrhythmic agents in patients with HCM, especially in those with an ICD, but clinical experience is limited. (Level of Evidence: C) 40 17. Pregnancy/Delivery Class I 1. In women with HCM who are asymptomatic or whose symptoms are controlled with beta-blocking drugs, the drugs should be continued during pregnancy, but increased surveillance for fetal bradycardia or other complications is warranted. (Level of Evidence: C) 2. For patients (mother or father) with HCM, genetic counseling is indicated before planned conception. (Level of Evidence: C) 3. In women with HCM and resting or provocable LVOT obstruction greater than or equal to 50 mm Hg and/or cardiac symptoms not controlled by medical therapy alone, pregnancy is associated with increased risk, and these patients should be referred to a highrisk obstetrician. (Level of Evidence: C) 4. The diagnosis of HCM among asymptomatic women is not considered a contraindication for pregnancy, but patients should be carefully evaluated in regard to the risk of pregnancy. (Level of Evidence: C) 41 Class IIa 1. For women with HCM whose symptoms are controlled (mild to moderate), pregnancy is reasonable, but expert maternal/fetal medical specialist care, including cardiovascular and prenatal monitoring, is advised. (Level of Evidence: C) Class III: Harm 1. For women with advanced heart failure symptoms and HCM, pregnancy is associated with excess morbidity/mortality. (Level of Evidence: C) 42 The ACCF/AHA would like to acknowledge and thank our volunteer writing committee members for their time and contributions in support of the missions of our organizations. 2011 ACCF/AHA Writing Committee Bernard J. Gersh, MB, ChB, DPhil, FACC, FAHA, Co-Chair Barry J. Maron, MD, FACC, Co-Chair Robert O. Bonow, MD, MACC, FAHA Joseph A. Dearani, MD, FACC Michael A. Fifer, MD, FACC, FAHA Mark S. Link, MD, FACC, FHRS Srihari S. Naidu, MD, FACC, FSCAI Rick A. Nishimura, MD, FACC, FAHA Steve R. Ommen, MD, FACC, FAHA Harry Rakowski, MD, FACC, FASE Christine E. Seidman, MD, FAHA Jeffrey A. Towbin, MD, FACC, FAHA James E. Udelson, MD, FACC, FASNC Clyde W. Yancy, MD, FACC, FAHA 43 How to cite Life of Quaid E Azam, Essay examples

Airline Industry Competition-Free-Samples for Students-Myassignment

Question: Discuss about the Factors Contributing to Stiff Competition in Airline Industry. Answer: Introduction Airline industry began to have continuous drastic growth after the and during the both world wars. The commercial airline began operation in Europe where it has since spread throughout the entire world and has become a great dependence as means of fast and safe transportation. There are over 2000 airlines in the global market serving also approximately over 3700 airports in the world. As the world is changing in the diversity of different cultures and the business world, the airline industry has also continued to grow with an average of about 5% growth per year in the last 30 to 35 years. The statistics record show that it is set to hit double the growth in the coming 10 to 5 years. Airlines are governed by the international body known as IATA (International Air Transport Association) with about 247 member airlines that belong to 117 countries in the world. It formed in the year 1919 and was formally known as International Air Traffic Association but as it expanded it was later changed to International Air Transport Association in the year 1945. The body is mandated major airlines priorities such as safety, security, environmental standards, services, provision and management of strategic partners (Barnhart, et al., 2012). Factors Contributing to Stiff Competition in Airline Industry The airline industry is a key back bone structure to many country economies where apart from becoming a key source of revenue generation many countries. Many business, organizations and non-governmental and governmental corporates rely on air transportation in daily business activities such as importation and exporting of cargo, business trips and also governments rely a lot on the airline transport for tourism growth and development. The airline industry faces a great competition and challenge which act as set back in the airline transport system. A major increasing threat in the airline industry is the ability of every individual airline to maintain its customer loyalty from the continuous growth of customer expectation. The airlines have a dramatic change of events in the service offering of their customers; some even offer their customer hotel accommodation at their various stopping points. The class and standard of an airline have been the greatest field that the airlines compete for one another and also through offering their customers a great discount price. Through this advantage given to the customer, they have high bargaining power due to the even being able to get access information easily. Oil price is one major factor that affects the price tickets of the airlines, and thus this may become a unseeingly fair competition to the airline industry. The oil price is a direct factor that creates the price of a flight to be either high or low; the operating cost of fuel in airlines with the oil dominating regions can be ve ry different in comparison to one another. A good example, North American airlines, and Middle East airlines enjoy favorable economic scale which as compared to other airlines in non-oil producing regions. The operational cost has also been a great challenge to the entire airline industry, and its a huge task for every airline to have the ability to cut down its cost and also to continuously improve the efficiency in the operation and high-quality standards. For the airlines to have proper cost reduction, the airline should be able to implement efficient operation structure and technological advancement that will also enhance efficiency (Ishii et al., 2009). According to the research the entry of airline industry is very open although the existing airlines continue to enjoy the low entry competition in the market. Airline service requires a very great amount of capital to start and be able to operate effectively. Although the existing airlines enjoy low entry of competition in the market, airlines have formed alliances to maximize their profits and also compete effectively with other airlines. The joint airline ventures have given the strong airline that has a great number of customer loyalty ability to explore even more on the market on another airline customer through the extension of airline routes. Also, good examples of airlines that greatly rely on joint tariffs are the Middle East countries airlines that have a low population that provides very poor market. The airline industry also in general faces stiff competition from other substitutes of transport and communication such as trains, ships, yacht, ferry, and most widely used transport through vehicles. The improvement of the technology and communication has also greatly been a great competition to the airline industry. A good example, through telecommunications and internet the world has been made like a global village where it does not require one to move from one place to another to carry their usual business activities. Also, people may prefer to use the other means of transport such trains which are far much cheaper than air transport and also very fast especially the electric trains. Findings and Discussion Other Challenges that Affect Airlines Operation The other major challenges that will affect the operating system of airline and also even create competition are the improvement and the purchasing power of airlines, airport development with the required set standards, weather, government support and regulation, and the ability to cope with change in the customer preferences and technology. The issue of safety is also a major concern to all the airline industries; this also reflects directly to environmental management hazard where the high expansion of airline industry this means the environment is also at a much higher risk of destruction. Conclusion In summary, the airline industry is a very competitive economic sector, and this to have good records of performance, the airlines should be able to have good customer relation thus as to know how best to maintain customer loyalty. Also, the technological advancement is a major great factor in maintaining competition through meeting customer expectation. Through joint tariffs, airlines should be able to have good customer advertising and maintain its customer loyalty. The challenges also can curb through proper strategies that will enable the airlines to operate effectively and also gain good customer loyalty (Clemes et al., 2008). References An, M. and Noh, Y., (2009). Airline customer satisfaction and loyalty: impact of in-flight service quality. Service Business, 3(3), pp.293-307. (theory research). Barnhart, C., Fearing, D., Odoni, A., Vaze, V. (2012). Demand and capacity management in air transportation. EURO Journal on Transportation and Logistics, 1(1-2), 135-155. (quantitative research). Clemes, M.D., Gan, C., Kao, T.H. and Choong, M., (2008). An empirical analysis of customer satisfaction in international air travel. Innovative Marketing, 4(2), pp.50-62. (qualitative research). Ishii, J., Jun, S. and Van Dender, K., (2009). Air travel choices in multi-airport markets. Journal of Urban Economics, 65(2), pp.216-227. (qualitative and quantitative research).

The Importance of the Great Exhibition of 1851 Example For Students

The Importance of the Great Exhibition of 1851 Supply some inside informations of the Great Exhibition of 1851, and say why it was so of import. The Great Exhibition of 1851 was the world’s first universe expounding. The Great Exhibition of 1851 was an international exhibition that took topographic point in Hyde Park, London. The 1851 was means the old ages and The Great Exhibition of 1851 was from 1 May to 11 October 1851. The Great Exhibition of 1851 was chiefly focal point on the universe s cultural and industrial engineering. In The Great Exhibition 1851, Britain wanted to state all of the populace, the success of the accomplishment after The Industrial Revolution, and that were to go a prevailing 19th-century characteristic. The Great Exhibition was tremendously influential on the development of many facets of society including art and design instruction, international trade and dealingss, and even touristry. We will write a custom essay on The Importance of the Great Exhibition of 1851 specifically for you for only $16.38 $13.9/page Order now The Great Exhibition 1851 was organized by Henry Cole and Prince Albert, hubby of the reigning sovereign, Queen Victoria. The purpose of this activities was to observe the new tendency of modern industrial engineering and design. Possibly due to the Prince and the Queen s Plutos really enthusiastic to advance this carnival can be profitable, eventually persuaded the British authorities on January 3, 1850 Royal Commission was set up to form the Expo 1851, Consequently greatly heighten the feasibleness of the program, and this commission Britain was included most esteemed applied scientists Isambard Kingdom Brunel. The Crystal Palace was really of import for the Great Exhibition of 1851. Joseph Paxton s design is inspired by the Amazon H2O lily Victoria, found the H2O lily can back up immense foliages, when Joseph Paxton look intoing underneath, there are radiation-like extended blade support ribs difficult to obtain a design inspired, and application in architecture. Joseph Paxton s program for the garden, fountains, patios, little waterfalls and other accomplishments was really good, in this Crystal Palace have many elm was planted, acreage about nine estates. The Crystal Palace besides has a batch of little fountains and waterfalls, the highest up to 250 pess height, initial H2O tower building as supporting jobs and prostration, after deliberations, the two powerful towers, is divided into three reservoirs, viz. the North and the south terminal of the topographic point, every bit good as the cardinal portion of the garden, to distribute the weight. The chief thought is to happen the power construction, lastingness, simpleness and velocity. First, The Crystal Palace was a celebrated edifice in the Great Exhibition of 1851, The Crystal Palace was made by Fe and glass. The edifice used the country of nine hundred 1000s square pess, the equivalent of 84 thousand square metres of glass or eight half-standard football field. Included the Fe prop have three thousand three hundred, Iron beams two thousand three hundred and covers 74 thousand square metres, breadth and length are about 408 pess, 1851 pess tantamount to 125 metres, 564 metres, has around 3-story edifice. This is a really extended edifice in 19th-century. Second, This design and edifice were really stylish and originality on 19th-century. Since It is an of import symbol of the Industrial Revolution, it was originally marquee for the first clip in 1851 World Expo held in London, the official name of this World’s Fair Exposition of Great Exhibition of the Works of Industry of all Nations. In five months, from May to October 1851, six million visitants throng the mammoth trade show, wondering over the latest engineering every bit good as shows of artefacts from around the universe. Until to 1936, the Great Exhibition had antecedently attracted legion assorted societal categories of tourers come to see. .ue6273c1c78bf7352d6f6562be2301f50 , .ue6273c1c78bf7352d6f6562be2301f50 .postImageUrl , .ue6273c1c78bf7352d6f6562be2301f50 .centered-text-area { min-height: 80px; position: relative; } .ue6273c1c78bf7352d6f6562be2301f50 , .ue6273c1c78bf7352d6f6562be2301f50:hover , .ue6273c1c78bf7352d6f6562be2301f50:visited , .ue6273c1c78bf7352d6f6562be2301f50:active { border:0!important; } .ue6273c1c78bf7352d6f6562be2301f50 .clearfix:after { content: ""; display: table; clear: both; } .ue6273c1c78bf7352d6f6562be2301f50 { display: block; transition: background-color 250ms; webkit-transition: background-color 250ms; width: 100%; opacity: 1; transition: opacity 250ms; webkit-transition: opacity 250ms; background-color: #95A5A6; } .ue6273c1c78bf7352d6f6562be2301f50:active , .ue6273c1c78bf7352d6f6562be2301f50:hover { opacity: 1; transition: opacity 250ms; webkit-transition: opacity 250ms; background-color: #2C3E50; } .ue6273c1c78bf7352d6f6562be2301f50 .centered-text-area { width: 100%; position: relative ; } .ue6273c1c78bf7352d6f6562be2301f50 .ctaText { border-bottom: 0 solid #fff; color: #2980B9; font-size: 16px; font-weight: bold; margin: 0; padding: 0; text-decoration: underline; } .ue6273c1c78bf7352d6f6562be2301f50 .postTitle { color: #FFFFFF; font-size: 16px; font-weight: 600; margin: 0; padding: 0; width: 100%; } .ue6273c1c78bf7352d6f6562be2301f50 .ctaButton { background-color: #7F8C8D!important; color: #2980B9; border: none; border-radius: 3px; box-shadow: none; font-size: 14px; font-weight: bold; line-height: 26px; moz-border-radius: 3px; text-align: center; text-decoration: none; text-shadow: none; width: 80px; min-height: 80px; background: url(https://artscolumbia.org/wp-content/plugins/intelly-related-posts/assets/images/simple-arrow.png)no-repeat; position: absolute; right: 0; top: 0; } .ue6273c1c78bf7352d6f6562be2301f50:hover .ctaButton { background-color: #34495E!important; } .ue6273c1c78bf7352d6f6562be2301f50 .centered-text { display: table; height: 80px; padding-left : 18px; top: 0; } .ue6273c1c78bf7352d6f6562be2301f50 .ue6273c1c78bf7352d6f6562be2301f50-content { display: table-cell; margin: 0; padding: 0; padding-right: 108px; position: relative; vertical-align: middle; width: 100%; } .ue6273c1c78bf7352d6f6562be2301f50:after { content: ""; display: block; clear: both; } READ: Drinking And Driving Offences EssayThird, World Expo visit twelvemonth merely six months, the edifice was supposed to be disposed. But but the concluding determination was made to overthrow by parliament, Within two old ages, meet once more by Queen Victoria opening ceremonial this was long-run exhibition, for London, particularly the add-on of the two railroad Stationss. this is one of the still running Crystal Palace railroad station now, another station is the gateway to the parade country, today all of the riders can still see its Italian manner mosaic roof. Finally, Among the exhibits, about every Victorian’s coevals left are surprising for the visitants, there are included clayware, porcelain field, Fe mills, steam cock, hydraulic, aroma, pianos, houses, plunging cogwheel, guns, barometers, Textiles and pyrotechnics etc. On the other manus, The Crystal Palace was have a batch other jobs to impact modern-day design and develop the edifice. First, in the points of the stuffs, the traditional Earth, wood, brick, rock was replaced by Fe and glass. Although is non of the first to used Fe as a edifice stuff, nevertheless, used the Fe prefabricated frame was unprecedented. Its effects unfastened to intuition since it is a unprecedented instance, they can non hold a successful instance to back up they when they are develop the edifice. Second, in footings of building, traditional brick and rock stack engineering is rivet, sleeve and screw adjustments, fasteners replaced as the house as a machine to put in. It is an insecure pattern as the Crystal Palace has around 3-story edifice and chiefly points of the stuffs were a Fe and glass, the Crystal Palace have a batch of visitants to see, so the construction of the edifice must be really safety. Finally, In November 1936 the Crystal Palace was tragically destroyed in a dramatic fire. the Crystal Palace was made by Fe and glass which are constructing stuffs. When the visible radiation from the Sun is direct exposure on the Crystal Palace, it will originate a fire and the Fe is non to have a high temperature, it is easy to go distorted. The consequence is the fire will distribute so fast. However, Royal Exhibition Building in Melbourne, Australia Expo once more inherited the London Crystal Palace manner. The difference is chiefly due to Crystal Palace is non a lasting edifice, the chief stuffs were Fe and glass, all set up was for the convenience and short-run used, was non a long-run used and was non a 1 of the Exhibition Building. World Expo and a figure of metropoliss in Europe after several decennaries of old ages, many of the marquee type edifices are modeled on glass frame construction by Crystal Palace. Royal Exhibition Building is a lasting edifice with solid walls and roof. Until today, the Royal Exhibition Building is still standing in the Riccarton Park Melbourne. A hundred old ages ago, doing it progressively intriguing Victorian’s elegance. In all of the edifices in Melbourne, its influence comparable to stabilizer. In June 2004, Royal Exhibition Building was included in the World Heritage List of the United Nations, Australia has become the lone ranked as the universe s cultural heritage edifices. The Crystal Palace in London had merely provided a locale for the Expo exhibits show, but has become the first World Expo of the most successful plants and exhibits, it non merely witnessed to the infinite glorification of the Victorian epoch has besides become a symbol of the universe expounding. Today, the modern metropolis edifice is really fast, nevertheless, if we can careful to inquiry, we can detect many of today s edifice stuffs and methods are within from the impact of the Crystal Palace, Although The Crystal Palace was a historical edifices, yet in a different signifier altering Joseph Paxton s originative thoughts. In this sense, the Crystal Palace is still alive in our side, and will hanker continue. .ud3f55bd67f589ce9e7d299f8f863832d , .ud3f55bd67f589ce9e7d299f8f863832d .postImageUrl , .ud3f55bd67f589ce9e7d299f8f863832d .centered-text-area { min-height: 80px; position: relative; } .ud3f55bd67f589ce9e7d299f8f863832d , .ud3f55bd67f589ce9e7d299f8f863832d:hover , .ud3f55bd 67f589ce9e7d299f8f863832d:visited , .ud3f55bd67f589ce9e7d299f8f863832d:active { border:0!important; } .ud3f55bd67f589ce9e7d299f8f863832d .clearfix:after { content: ""; display: table; clear: both; } .ud3f55bd67f589ce9e7d299f8f863832d { display: block; transition: background-color 250ms; webkit-transition: background-color 250ms; width: 100%; opacity: 1; transition: opacity 250ms; webkit-transition: opacity 250ms; background-color: #95A5A6; } .ud3f55bd67f589ce9e7d299f8f863832d:active , .ud3f55bd67f589ce9e7d299f8f863832d:hover { opacity: 1; transition: opacity 250ms; webkit-transition: opacity 250ms; background-color: #2C3E50; } .ud3f55bd67f589ce9e7d299f8f863832d .centered-text-area { width: 100%; position: relative; } .ud3f55bd67f589ce9e7d299f8f863832d .ctaText { border-bottom: 0 solid #fff; color: #2980B9; font-size: 16px; font-weight: bold; margin: 0; padding: 0; text-decoration: underline; } .ud3f55bd67f589ce9e7d299f8f863832d .postTitle { color: #FFFFFF; font-size: 16px; font-weig ht: 600; margin: 0; padding: 0; width: 100%; } .ud3f55bd67f589ce9e7d299f8f863832d .ctaButton { background-color: #7F8C8D!important; color: #2980B9; border: none; border-radius: 3px; box-shadow: none; font-size: 14px; font-weight: bold; line-height: 26px; moz-border-radius: 3px; text-align: center; text-decoration: none; text-shadow: none; width: 80px; min-height: 80px; background: url(https://artscolumbia.org/wp-content/plugins/intelly-related-posts/assets/images/simple-arrow.png)no-repeat; position: absolute; right: 0; top: 0; } .ud3f55bd67f589ce9e7d299f8f863832d:hover .ctaButton { background-color: #34495E!important; } .ud3f55bd67f589ce9e7d299f8f863832d .centered-text { display: table; height: 80px; padding-left: 18px; top: 0; } .ud3f55bd67f589ce9e7d299f8f863832d .ud3f55bd67f589ce9e7d299f8f863832d-content { display: table-cell; margin: 0; padding: 0; padding-right: 108px; position: relative; vertical-align: middle; width: 100%; } .ud3f55bd67f589ce9e7d299f8f863832d:after { content: ""; display: block; clear: both; } READ: Atomic Bomb Essay

The ABCs of APR Everything You Need to Know

The ABCs of APR Everything You Need to Know SAT / ACT Prep Online Guides and Tips When you look at a loan or credit card offer, you’ll see the term â€Å"APR,† or annual percentage rate, popping up all over the place. What is APR, exactly, and why is it important when taking out a loan or choosing a credit card? This guide will tell you everything you need to know about annual percentage rate and how you can use it to understand the annual costs of a loan or credit line. To start, let’s establish a working definition of APR. What Is APR? What is APR? What does APR stand for? APR stands for annual percentage rate, and it tells you the total amount of interest and fees you’ll pay each year on borrowed money. It’s a more comprehensive value than interest rate, and it’s meant to help you compare loans and credit cards on a standardized basis. APR is presented as a percentage of the total amount borrowed, or the principal. That being said, APR works differently on loans than it does on credit cards. Let’s take a closer look at both, starting with loans. How Does APR Work on Loans and Mortgages? On a loan or mortgage, APR tells you to the total amount of interest and fees you’ll pay each year. The types of fees depend on the type of loan. On a personal loan, for instance, a common additional fee is an origination fee. On a home loan, the main additional fee is closing costs. If your loan or mortgage doesn’t have any fees, then the APR will equal the annual interest rate. Let’s say you borrow $100,000 at a 5% interest rate on a 30-year fixed rate mortgage. You pay $1,000 in closing costs. Your APR, then, is 5.1% (interest rate + closing costs, as a percentage of the principal). You would pay $5.10 each year for every $100 you borrowed. APR includes closing costs, so it’s a more realistic representation of your long-term costs than the annual interest rate is. Because of the Truth in Lending Act of 1968, lenders must calculate loan APR in the same way. This consistency allows you to compare offers and clearly see your long-terms costs. APR gives customers a quick and easy way to compare the terms of loans or mortgages on an apples-to-apples basis. By knowing the APR, you can use an APR calculator to calculate your monthly payments and figure out how much you’ll end up paying in fees and interests. Usually, a lower APR means you’ll spend less money over the long term. To see why, consider the example of a $200,000 mortgage below with two loan APRs that differ by just a few percentage points. Thanks to the 1968 Truth in Lending Act, all lenders must calculate APR in the same way. Examples of APR on a 30-Year Mortgage Let’s consider two scenarios using a $200,000 mortgage. In the first scenario, you get a 5.5% APR on a 30-year mortgage. In the second, you manage to get just a 5.2% APR over 30 years. By comparing the two rates, you can see how much money you save in the long run with an APR that’s only slightly lower than another one. Scenario 1: $200k Mortgage With a 5.5% APR Using Bankrate’s APR calculator, let’s consider a $200,000 mortgage over a 30-year term with a 5.5% APR. To pay off this mortgage over 30 years, you’d have a monthly payment of $1,135.58. After 30 years, you’d end up paying a total of $408,807. Since you initially took out $200,000, this means you’d end up paying $208,807 in interest and other fees. Scenario 2: $200k Mortgage With a 5.2% APR What if your APR was a bit lower, say 5.2%? How much would you save in the long run? With a 5.2% APR on a $200,000 loan, you’d pay $1,098.22 a month for 30 years for a total of $395,361. Your additional costs would add up to $195,361 - a large amount, but significantly lower than the costs incurred with a 5.5% APR. You would pay $13,446 less on a $200k, 30-year mortgage with a 5.2% APR than you would with a 5.5% APR. As you can see, getting a mortgage with a slightly lower APR can save you a significant amount of money in the long run. When you're shopping for a mortgage, you should compare offers to get the best deal. Now that you have a sense of how APR works on a loan or mortgage, let’s look closer at how annual percentage rates work on credit cards. When you're choosing a 30-year mortgage, remember that a difference of just one or two percentage points in an APR can make a big difference in your long-term costs. How Does APR Work on Credit Cards? When you look at a credit card, you’ll see several APRs. Credit cards have different APR for different types of transactions, like one for making purchases and another for transferring cash. For most people, the APR related to making purchases is the most important rate. On credit cards, APRs don’t typically include additional fees related to cash advances or late payments. Rather, they reflect the daily periodic rate, or the interest that’s calculated on your account each and every day, over the entire year. If you want to know your daily periodic rate, then you can simply take the APR and divide it by 365. How do credit cards come up with APR? They use the U.S. prime rate and then add their own margin. For instance, the prime rate could be 5% and the issuer could charge a 12% margin. The APR, then, would be 17%. APR on a credit card could stay the same from year to year, or it could fluctuate along with the U.S. prime rate. APRs that change are called floating or variable APRs. Your APR may also depend on your creditworthiness, as you’ll see in the example below. People with higher credit scores get a lower APR, and people with lower credit scores get a higher APR. Credit card companies may also offer promotional APRs when you open a new account. You could get 0% APR on purchases for the first year. After that promotional period, the APR would return to the normal rate. While you’ll see a lot of promotions regarding APR from credit card companies, you should keep in mind that APR may not matter. In fact, it shouldn’t even be a factor for many people. Read on to learn why. Are you making a purchase? Transferring cash? A credit card usually has several APRs, one for each kind of transaction. APR on Credit Cards: Does It Matter? If you pay off your full credit card balance every month, then you will never have to pay interest. For all intents and purposes, your APR is always 0%. To use a credit card responsibly, you should always pay off your full balance every month. Credit card interest rates are high, and carrying a balance is one of the quickest ways to get into debt. If you’re spending more than you can afford to pay off within the month, then you need to step back, make a budget, and take steps to control your personal finances. If you’re using a credit card well, then the promotional and regular APR offers should not matter. Instead, you can choose a credit card based on other perks, like cash back and travel points. Speaking of travel rewards, let’s look at one of the best cards for travel points, the Chase Sapphire card, to get a sense of its various APR structures. If you pay off your full credit card balance every month, then your purchase APR will be 0%. Example of APR on the Chase Sapphire Preferred Credit Card Here are the various APRs on the Chase Sapphire Preferred credit card, as borrowed from its website. Notice how it offers a range of rates, based on your â€Å"creditworthiness.† The first is the one that applies to credit card purchases, while the others have to do with other transactions. INTEREST RATES AND INTEREST CHARGES Purchase Annual Percentage Rate (APR) 16.24% to 23.24%, based on your creditworthiness. These APRs will vary with the market based on the Prime Rate. Balance Transfer APR 16.24% to 23.24%, based on your creditworthiness. These APRs will vary with the market based on the Prime Rate. Cash Advance APR 25.24%. This APR will vary with the market based on the Prime Rate. Overdraft Advance APR 25.24%. This APR will vary with the market based on the Prime Rate. How does Chase Sapphire calculate its credit card APR rates? It uses the U.S. prime rate as of December 22, 2015, which was set at 3.5%. According to Chase, â€Å"We add 12.74% to 19.74% to the Prime Rate to determine the Purchase/Balance Transfer APR...We add 21.74% to the Prime Rate to determine the Cash Advance/Overdraft Advance APR.† As with many other lenders, Chase sets its own margin and adds this margin to the prime rate. Then, it assigns APRs based on the creditworthiness of each individual. Again, credit card APR might not come into play if you pay your balance off in full from month to month. It’s still important to know what you’re signing up for, though, just so you understand the costs that you can incur from using a credit card. In closing, let’s go over the key points you need to remember about APR, including what it is and how you can use it to decide between loans, mortgages, or credit cards. Some credit cards have a floating APR that fluctuate along with the prime rate. APR: Just the Basics APR, or annual percentage rate, works a little differently on loans than it does on credit cards. A loan APR tells you what percentage of your loan or mortgage you’ll be paying in interest and other fees each year. Because it incorporates costs beyond interest, APR is a more inclusive rate than interest rate. If there are no additional costs, then the loan APR will be the same as the annual interest rate. Since all lenders must calculate APR in the same way, APR helps consumers compare loan and mortgage offers on a standardized basis. In most cases, you’ll save money by getting the lowest APR you can. If you’re comparing credit card offers, remember that the â€Å"purchase APR† is likely the most relevant piece of data. Ideally, you won’t be paying any interest on your credit card. If you always pay off your monthly balances in full, then you can choose a credit card based on its rewards and points structure rather than on its various APRs. Whenever you’re taking out a loan or opening a card, make sure to read the ins and outs of any contract before you sign it. By looking at APR, you can gain a clear understanding of your long-term costs. What's Next? Which credit card is best for you? Check out our personal spending quiz to find the best credit card for your habits. Do you want to take a more proactive approach to managing your finances? Check out our 7-step guide for taking control of your personal finances. Are you starting to think about investing in the stock market? Check out our full guide to figure out what kind of investor you are and learn how to invest in the stock market.

Starting a Street Team

Starting a Street Team Every writers dream is to find as many readers as possible, but finding readers takes valuable time away from writing. The idea having an army of readers working to promote your book sounds too good to be true. But, is it? You can develop your own street team to grow your readership. But how? This is what I learned from my first street-team: Start a closed Facebook group for your street team. Use this group to promote your book before its release and during the first week. They in turn share on their own social pages. Send an invite to as many of your most active followers/fans as possible to join the private group. We like thinking we are on the inside of something. It is fun to connect with other readers who really like the authors work. Update the street team on the progress of the release, give date and goals, i.e., 100 verified reviews on Amazon in the first week, etc. Â  They are going to buy/read anyways, you are just asking them to do it quickly. I read the last book in one day (release date) and had my review posted on the second day. Encourage them to ask friends and associates to read/review as a favor, etc., share the goal of 100 reviews needed for a favored author. The idea is that people flock to a blockbuster movie, and this is no different, plus they get the enjoyment of reading! Books are always better than movies. Provide your input/commentary on posts Encourage one person to take the lead. They will keep the group on target without you having to do everything. Â  A short Good morning post to the group each morning acts as a reminder to the others to reach out in some way. Consider giving your galley copies to the group to read and post reviews on Amazon, Barnes Noble, Goodreads, Facebook, Twitter, and more. They can pass them on to other reader/reviewers to help your pre-and post-release numbers. Let your publisher know if your street team members belong to NetGalley so they can download a copy of your book to read and review. Post frequently to the street team group leading up to the book release (one month before the release through the end of the first week) to give encouragement/praise. Encourage them to post photos, advertisements, and promotional ideas on their private social pages, too. Add any of the other things you have already been doing to promotebut make the group the first audience for your ideas, etc. It is a fluid group that will adapt to any ideas you share. Marketing our work is the hardest part of being an author, but it is not impossible. Using a street team will make that much easier. You will make a few new friends and connect with more readers who love your work. Isnt that our goal, after all, expanding our readership?

Critically assess the importance of solar variability, volcanic Essay

Critically assess the importance of solar variability, volcanic eruptions and greenhouse gas concentrations as climate forcing f - Essay Example Climate change is brought about by many factors. These include circulation of the oceanic processes, solar variations, volcanic eruptions, plate tectonic activities and human factors. Studies to determine the level of climate change is done using observation and theorems. Factors that affect climate are called climate forcings (Yang et al,2000) .They are internal and external climate forcings; these forcings affect some parts of the environment faster or slower depending on the position of the given atmospheric location. The ocean is known to respond slowly to climate forcings. Forcings are either internal or external depending on the genesis of the process (Valet, 2003). Internal forcings include natural processes within the atmosphere like volcanic eruptions, tectonic plate movements, variations in solar radiations and concentration of greenhouse gas effects (Geel et al., 1999). External forcings are human activities that lead to the emission of dangerous gases into the atmosphere. There also are climate change feedbacks which are elements that act in three ways to climatic forcings (Orr, 1999). It can be sudden, where there occurs a sudden cooling effect occasioned by a high presence of volcanic ash in the atmosphere which will reflect sunlight and heat. It can be gradual, in this case, the water bodies become warm slowly; and then overflow. The third possibility is a combination of both fast and slow reactions, in such a situation a sudden cooling of ice is experienced in the Arctic Ocean followed by a sudden meltdown of the ocean ice (Grootes and Stuiver, 1997). Currently, we are in a period between two ice ages, and if there are no other influences, another ice age will occur in a time scale of thousands of years. The rate of global temperature change linked to astronomical forcing is approximated to be in the order of a few tenths of a degree Celsius per thousand years (Washington et al., 2001). Solar Variations Information on solar changes is obtained f rom cosmogenic radionuclide records. The variables used in this study illustrate how changes over periods of time have influenced the climatic conditions of given geographical regulates and the production of carbon dioxide. (Svensmark and Friis-Christensen, 1997). High powered galactic cosmic rays induce a reactivity series of nuclear reactions that produce cosmogenic radionuclide in the atmosphere. When elements carrying high energy hit oxygen and nitrogen in the atmosphere, Be (beryllium) is formed. Further reactions of this element with nitrogen form slow neutrons. The sun regulates the intensity of the galactic cosmic rays (GCR) that reaches the earth’s surface and in this way, affects the production of radionuclides in the atmosphere. After Be is formed, it combines with aerosols and hangs in the atmosphere for one to two years (Mc Hargue and Damon, 1997). Disparities in 10Be records between Antarctica and Greenland during 1950 AD have led to differing conclusions regard ing solar activity in this period (Lean, 1991). According to Greenland records, there was low 10 Be production after 1950 AD but in the Antarctic records, the trend is opposite. These 11-year averages of sunspot data and the neutron monitor show

Cultural Studies Essay Example | Topics and Well Written Essays - 5500 words

Cultural Studies - Essay Example From the essay it is clear images, sounds and various types of spectacles form the foundation of media culture and in turn influence our everyday life closely. It dominates the leisure time of individuals, influences political opinions, social behavior and provides materials out of which people create their identity. Different types of media resources like radio, television and films particular focus over the materials that emphasis over the aspects of gender discrimination on sexual grounds. At the same time the ideas of being successful or unsuccessful, powerful or powerless are also determined by the media. As the report declares media is also one of the major sources for providing the indications with the help of which an individual identifies his class, ethnicity, race, nationality and a concept of us and them. It is through such prevailing influence media not only determines culture but also outlook of the world. In the context of determining right or wrong act, morality and immorality, the role of media is undeniable. At the same time it is media culture which determines what is good and what is bad, positive and negative, moral or immoral. The various issues portrayed by the media helps in constructing various symbols, myths which in turn constitutes a common culture for the larger part of the population. It should be noted that it is the various materials of the media which gives an individual the basis to locate himself within a technically advanced capitalist society and which in turn gives rise to a new type of global culture.

Loft Living Essay Example for Free

Loft Living Essay My dictionary defines loft as a room or place used for storing things. (Oxford’s learner’s advanced. 2009 edition) Loft places have become a fashionable lifestyle choice in London. As a result the design of lofty interiors, their accessories and associated urban lifestyle have become iconic images of cool London or cool urban living. In this essay I will explore loft living as a lifestyle, its history, and reasons for its growing popularity plus tips on how to exploit the unique qualities it offers. Once thought of as strictly for artists and bohemian types, loft living is now a sought after lifestyle accessory. Previously, starving artists had to sleep in their studio lofts to avoid paying rent, but now loft living is one of the most sought after type of housing for most people. Loft living has its origin in Manhattan area of New York, but today a look at any downtown area across many cities reveals a trend that is gaining popularity. In London, loft living gained widespread use in the nineties. â€Å"In London, the loft boom is owed much to someone who was the furthest thing from cool- Margret Thatcher. In her government’s misguided attempt to boost the pockets of property owners, camouflaged as an attempt for urban regeneration, the use of Class Order of 198 was passed. Basically, this attempt to simplify planning meant that office and industrial property were classified as one, giving landlords the opportunity to change rents on inner city workshops and light industrial units. †(Richard, 2010) Most businesses especially in Clerkenwell area was affected as tenants were forced to move rather than pay the exorbitant rents. But with the onset of recession, most industrial buildings became vacant and in an attempt to regeneration, the Islington council changed use of the buildings to residential use. 1. The oxford learners dictionary, 2009 2. Richard Artus, 2010. The history of loft living. www. urbanspaces. com 2 It is now common to find loft apartments, usually in renovated factories or other commercial structures: the appeal for living in open spaces is growing day by day. â€Å"Loft living is no longer just meant for starving artists who could not afford to live elsewhere, today loft lifestyle is a much desired trendy way to live. Particularly hip among upwardly mobile young adults, typical lofts are generally located in urban centers which offer easy access to shopping, dining, and all things that are happening now. And along with being in the middle of the action, loft living offers a very specific lifestyle. Today while many lofts are housed in turn-of-the-the-century industrial buildings in metro cities like London, New York Chicago and Los Angeles, quite a few are actually built from scratch. It seems like the desire to this unique and contemporary way of living has caught on in areas where the number of available buildings has been depleted† (Deborah, Jun 29 2010) There are other factors that are contributing to the growth of the trend. Many lofts are situated in downtown areas, which mean greater access to many social amenities, shorter commutes and the joy of living in rejuvenated neighborhoods. Additionally, lofts can be customized according to the owner’s tastes: the space can be partitioned to incorporate several rooms as per the owner’s requirements. Many of today’s newer loft developments are being built without proper adherence to the original industrial feel-usually to save costs , but most offer other amenities for comfort and convenience. A typical loft utilizes large open space and so presents unique challenges. However, one should utilize the unique qualities offered by loft living. 3. Deborah s. Hildebrand Jun 29 2010. Choosing Loft Living as a Lifestyle. www. sute101. com 3 When buying or renting a loft, there are a number of things that one should bear in mind. Location is one of them. It should, ideally, be near a major thoroughfare, in a quiet place and yet accessible to social amenities such as hospital and schools. A potential buyer should also review, as in newer lofts, the integrity of the developer, builder or agent. The other thing is whether the package has any hidden costs. Loft living has its challenges though, and most of the challenges arise in design. Designing the interior decor for instance may present a challenge to many people. This is due to the fact that most lofts were not intended to be residential in the first place. Rebecca Tanqueray and Oviana Fielding in their book Loft: Living in space, says, â€Å"coming up with a lofty notion is one thing, coming home to a lofty apartment is another. Big plans converting big spaces need practical and artful solutions to manage all that scale, all that space and all those industrial-strength problems. Adaptive re-use in residential design may call for revising user assumptions and adaptations to such unusual spaces. †(Victoria Carlson, 1999) Most of the loft design in the area feature exposed brick walls, and support columns and vintage wooden flooring. Given that they were designed to be warehouses, they have high ceiling. And it is not uncommon to see duct work, beams rafters and pipes for an industrial edge. The lofts I visited use a certain measure of open plan living in which most of the living spaces flow into each other. This is different from what I am used to at home where rooms are separate and in some instances, a distance from each other. 4. Victoria Carlson, 1999. Review of the book, Loft: Living in space by Rebecca tanqueray and Oviana Fielding 4 Living in a loft should provide the same feeling as living in a condominium or a normal house. But there are several things that one should incorporate into the design, decor and the floor plan to create a homely mood. To begin, one needs to create a positive impression at the entry. Apart from introducing the house mood the entry area serves as catch-all for mail, bags, umbrellas, shoes and rain jackets. This problem may be alleviated by constructing a storage area. Once you have created space, it is easier to decorate the rest of the loft. A small rug placed at the entry will protect the rest of the house from dusty, wet or muddy shoes. In addition to that, family members or guests may want to check their appearance as the move in or out of the loft. So, the next piece of furniture that may be considered in the entry area is a mirror, hang over a table or narrow shelf. Alternatively, one may want to place to stop and wear shoes, so a small bench or love seat, depending on the available space, can also work in the new loft entry. After choosing the furniture and the flooring for the entry, one can think about whether to light this area separately. A small central pendant light fixture or a spotlight will create drama and a warm feel as will a table lamp. Finally, personalize the entry by including accessories like a wall painting, dried and fresh flowers, and holiday souvenirs. Decorating the loft interior may pose challenges as one needs to create an overall impression of cohesion while maintaining a suitable separate atmosphere for each area. If you have to paint the walls, choose colors that complement the general outlook of the interior. 5 Due to thee open nature of most lofts, one should put a touch of personality, and relate the same to its surrounding. For instance, prints of food works best in living, dining area and the kitchen. Some children find wall masks very scary and their preferences should also be taken into account. Avoid disturbingly provocative art in bedrooms or studies. Artwork should be framed to coordinate with the loft decor. Always select a frame that complements your decor style and the colors you have used in the loft. Where possible, use similar frames and mats for objects that will be displayed together. The loft interior plan too should incorporate a functional and comfortable floor plan with places for entertainment, working and storage. These individual living areas can then be defined with room dividers, rugs and furniture. Room division can be in form of sliding or folding screens and frosted glass panels. Another way of to establish subtle transition is the use of raised platforms. Furniture arrangement can be problematic if traffic flows between the open spaces is not carefully planned. Different activities can overlap. For instance, it ca be difficult to conduct a conversation in the living area wile the children play noisily in the dining room. Part of the charm of loft living is that it allows a family to connect to each other and their guests informally. For example, a meal can be prepared while guests wait by the dining table taking their pre-dinner drinks. When decorating, one should think of the loft as a one entity instead of creating a different personality and themes for every room or living area. This creates cohesion and simplifies your decor choices. One should use similar or complementary decorative finishes throughout, linking 6 any two sections that open up into each other with similar paint, wall paper or using the same curtains. Also keep the flooring similar to visually expand the space. Proper loft planning should also be extended to furniture arrangement. The first step in creating an ideal furniture arrangement is choosing a focal point which might be an architectural detail such as a fire place. Since most lofts do not come with a fireplace built in, you can have one built. In an area with no discernable focal point, you can create one. This can be the wall facing you when you once you enter the room or the entertainment unit in a family room or area. The next step is to arrange your furniture around the focal point. In the living area, for instance, the sofa should ideally face the focal point or be arranged around it to underscore its importance. After placing the biggest furniture item, lace the items that relate to it next. This could be coffee tables or side tables. Place all other items in a manner that enhances the living experience. For example, the TV might look great in a corner but can it be viewed from the main sofa? Is there somewhere to place a cup of tea as one watch TV? As one place the furniture, one has to bear in mind how occupants will use the room. Is there enough space between the furniture items to allow for someone to sit down comfortably and stretch their legs without touching another person or a piece of furniture? More often than not the issue of space is very important, as most lofts have large spaces. The most common mistake people make when furnishing a loft is having too much furniture in 7 screens, they separate two areas but ensure that the two sections of the room are not claustrophobic. How one arranges the furniture and electronic equipment and how much of it you include can make or break the vision of the beautiful living space one might be trying to achieve. The best furniture placement maximizes on your current space instead of limiting it, it allows for smooth traffic flows in and out of the individual spaces and enhances the living experiences.. By making complementary furniture choices, your furniture sits well in both rooms, For instance, one should use chairs that can double up as extra seating in the living room area. One should avoid using too much furniture and opt instead for multifunctional furniture. For example a rectangular or oval table can be elongated or folded into a small unit for a dining table. When not in use as a dining table, it can act as a console. Since most loft spaces are huge open spaces, making individual spaces becomes inevitable. One option for physically creating some privacy while still maintaining spaciousness is the use of folding screens. When placed between a dining area and living room, or living room and bedroom, it can hide the mess of one area. Decorative room screens divide the room without cutting out the light, and come in a variety of materials including wood and wrought iron. If hand carved or well crafted, they can be a visual statement in the area. See through shelving units are good room dividers as they also provide additional storage and attractive display opportunities. 8 Another form of shelving is a low wall of kitchen base units that divide the room only up to waist level. Some shelving can either be permanent or free-standing. The least way of dividing a living area is by arranging the furniture so that it forms a natural barrier. However it is important to ensure that the back of whichever furniture piece is used is presentable. Another factor that one should consider is weather. Most lofts were built for other purposes other than residential, so it is very important to consider the issue of weather in the interior design. For instance the general needs during the cold, dark months are warmth, comfort, security and indoor stimulation. The loft may become inhabitable through the cold or the hot season. So the interior should incorporate designs that would cater for cold as well as the hot seasons. Due to the big nature of most lofts spaces, conditioning the rooms may prove to be a challenge. So, when shopping for things like furniture, it important to bear in mind that some pieces retain heat while others lose it easily. Generally, the less solid a piece is and the less fabric it has, for example wicker, rattan and bamboo, the faster it will lose heat. However, chunkier heavily upholstered chairs help in retaining heat. Also recliners keep you warmer by keeping your feet off the floor. Regardless of how cold it is, one can still make the full use of the natural light, afforded by the loft’s big windows, and heat as well as use some artificial heat sources from fireplaces or heaters. In the cold months if you have sheer curtains it is advisable to replace them with heavy window draperies to keep out cold draft of air and retain heat indoors ,artificial light fixtures too, will help in creating feelings of warmth and comfort. Glass, stainless steel and plastic, look and feel very cold because they are smooth, textured surfaces on the other hand trap pockets of air and add warmth. So, where possible, bring in textured materials and items. 9 For throws and cushion covers, choose from fleece, wool or cashmere and drape one across the arm of a chair or over the back of a sofa, or at the foot of a bed. Marble or tile flooring will definitely be colder in such weather. A wooden floor is much warmer. However, for softness underfoot and insulation from the cold turn to carpet in your living room and bedrooms. To provide further luxurious comfort, ensure that the carpet is lined with under-felt, in addition, provide area rugs for passageways, thick bath mats and bedside rugs. Loft living may or not be viable and significant solutions to the housing solution to the housing problem facing many city planners and designers, but the trend is opening new frontiers and creating many opportunities-we simply cannot afford to ignore it. The challenge, however is to make this former warehouses, churches and sawmills into habitable and most importantly, comfortable homes. Works cited: 1. The oxford learners dictionary, 2009 2. Richa Deborah s. Hildebrand Jun 29 2010. Choosing Loft Living as a Lifestyle. www. sute101. com 3. Richard Artus, 2010. The history of loft living. www. urbanspaces. com 4. Victoria Carlson, 1999. Review of the book, Loft: Living in space by Rebecca tanqueray and Oviana Fielding