Chronic stable angina test selection guideline for the individual basis
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Editor-in-Chief: C. Michael Gibson, M.S.,M.D. [1] Phone:617-632-7753; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Smita Kohli, M.D.
Overview
Criteria for test selection hinges largely on the current disease state of the individual patient and subsequent level of fitness for testing. Potential diagnostic testing modalities include: exercise ECG, ECG at rest, exercise echocardiography, echocardiography at rest, and stress scintigraphy.
Test Selection Guidelines for the Individual Basis
- The exercise electrocardiography is the test of choice in patients with typical exertional angina with a normal resting ECG who are able to exercise.
- Even when the exercise ECG is not deemed clinically necessary to establish the diagnosis of coronary artery disease (CAD), it can be helpful in assessing CAD severity.
- If evidence for ischemia (by ECG or by perfusion scintigraphy or echocardiography) is detected during the first stage of exercise, the incidence of three-vessel disease or left main coronary artery stenosis is greater than compared to cases more exercise is required to provoke a positive test.
- Exercise electrocardiography in patients with suspected or established stable angina pectoris can be a useful tool in determining usage of nonpharmacologic and pharmacologic therapeutic interventions.
- In patients with stable angina pectoris, mixed angina, postprandial angina, walk through angina, or patients without prior myocardial infarction, the exercise ECG can be an adequate means to assess the presence and severity of myocardial ischemia.
- The diagnosis of metabolic syndrome is established by the presence of typical anginal discomfort that is accompanied by ischemic changes on exercise ECG (or exercise or stress scintigraphy) with subsequent demonstration of the absence of critical coronary artery obstruction on coronary arteriography.
- In women with typical angina, exercise ECG can be an adequate testing means. However, due to a higher incidence of false positive test results in stress ECG in women, exercise perfusion scintigraphy or exercise echocardiography should also be considered as a reasonable testing alternative, often with fewer specificity issues.
- Exercise perfusion scintigraphy should be considered as the test of choice when stress ECGs are uninterpretable, as in patients with (BBB) bundle branch block, interventricular conduction defects, left ventricular hypertrophy with baseline ST segment or T-wave abnormalities, pre-excitation syndromes or ST segment changes owing to electrolyte imbalance or digitalis therapy. In these cases, stress perfusion scintigraphy can be a more accurate method than the stress electrocardiography to determine the extent and distribution of ischemia.
- In patients who are classified as unable to exercise, adenosine or dipyridamole perfusion scintigraphy and dobutamine echocardiography are the preferred noninvasive tests to assess the presence and extent of myocardial ischemia. These methods are also recommended in patients with a blunted heart rate response as a result of antianginal therapy.
- In patients with moderate or severe chronic obstructive pulmonary airway diseases and poor exercise tolerance, dobutamine echocardiography is the preferred diagnostic test instead of adenosine or dipyridamole perfusion scintigraphy.
- Not all noninvasive or invasive tests available for the diagnosis of coronary artery disease and myocardial ischemia are applicable to all clinical subsets of patients with stable angina.
- For patients with stable exertional angina, mixed angina, postprandial angina, walk through angina, and nocturnal angina within 1 to 2 hours after the rest, it is desirable to select tests that are likely to induce myocardial ischemia by increasing myocardial oxygen requirements. In these patients, exercise ECG, exercise or stress perfusion scintigraphy and exercise echocardiography are designed to provoke ischemia.
- In patients with stable angina pectoris, particularly those with documented prior myocardial infarction, an assessment of left ventricular systolic function is necessary for selection of an appropriate therapy method. In this group of patients, assessment for myocardial ischemia and ventricular function can be performed by the combination of a test for ischemia; exercise ECG and a LV function test (i.e., echocardiography at rest), or echocardiography both, at rest and during exercise.