View source for Chronic stable angina revascularization

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{{Chronic stable angina}}
'''Editors-In-Chief:''' [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com] Phone:617-632-7753; {{CZ}}; '''Associate Editors-In-Chief:''' [[John Fani Srour, M.D.]];  Smita Kohli, M.D.; [[User:Rim Halaby|Rim Halaby]]

==Overview==
The goal of the treatment of [[chronic stable angina]] is to reduce the symptoms, delay the progression of [[atherosclerosis]], and prevent cardiovascular events. In order to achieve these goals, lifestyle modifications and medical therapy are the '''first line treatment'''. Revascularization is done to increase survival in specific conditions where the stenosis of the coronary arteries is anatomically and functionally significant and the symptoms are refractory to medical therapy. There are currently two well-established revascularization approaches for the treatment of chronic stable angina caused by coronary [[atherosclerosis]]: [[CABG]] and [[PCI]]. Since the introduction of [[bypass|coronary artery bypass surgery]] in 1967 and [[angioplasty|percutaneous transluminal coronary angioplasty (PTCA)]] in 1977, research has supported the effective usage of both strategies for treatment of patients with chronic stable angina. However, as with any treatment method, both methodologies have weaknesses. The choice between PCI and CABG is based upon anatomy and other factors such as left ventricular function and the presence or absence of [[diabetes]]. In general, PTCA is reserved for single or some cases of two vessel disease, while CABG is reserved for patients with two or three vessel disease or left main disease. With the availability of drug-eluting [[stents]], PCI is increasingly being performed for many lesions including more complex ones.

==Revascularization Therapy==
===Indications for Revascularization Therapy===
====Increase Survival====
Patients who would have a survival benefit from revascularization (PCI or CABG): 
*This depends on the location, severity, and number of lesions; the presence or absence of left ventricular dysfunction is an important factor as well.
** More than '''50%''' stenosis of the '''left main coronary''':
***[[CABG]] is indicated
***[[PCI]] is not indicated when patients are good candidates for CABG or when the anatomy is not favorable.
** More than '''70%''' stenosis of '''three major coronary artery''' or '''proximal left anterior descending artery''':
***[[CABG]] is indicated
*Survivals of sudden cardiac death secondary to ischemia induced tachycardia, where ischemia is caused by more than '''70%''' stenosis of a '''major coronary artery''':
**[[CABG]] or [[PCI]] are indicated.<ref name="pmid23121323">{{cite journal| author=Farkouh ME, Domanski M, Sleeper LA, Siami FS, Dangas G, Mack M et al.| title=Strategies for Multivessel Revascularization in Patients with Diabetes. | journal=N Engl J Med | year= 2012 | volume=  | issue=  | pages=  | pmid=23121323 | doi=10.1056/NEJMoa1211585 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23121323  }} </ref>

====Relief of Symptoms Refractory to medical Therapy====
* Coronary [[angiography]] should be performed in the following settings:
** More than 70% stenosis of a non left main artery or more than 50% stenosis of left main artery
***[[CABG]] or [[PCI]] are indicated.<ref name="pmid23121323">{{cite journal| author=Farkouh ME, Domanski M, Sleeper LA, Siami FS, Dangas G, Mack M et al.| title=Strategies for Multivessel Revascularization in Patients with Diabetes. | journal=N Engl J Med | year= 2012 | volume=  | issue=  | pages=  | pmid=23121323 | doi=10.1056/NEJMoa1211585 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23121323  }} </ref>
*The definition of inadequate response to [[Chronic stable angina treatment#Pharmacotherapy|medical therapy]] can be fairly broad and depend largely on the patient's lifestyle, occupation and expectations:
**At one extreme are patients who are limited by angina pectoris despite optimal drug treatments and lifestyle modifications, including achievement of optimal weight and cessation of smoking.
**At the other end are patients in whom we can consider medical therapy to have failed if control of [[angina pectoris]] requires higher doses of anti-anginal medications that cause side effects.
*The following patients should also be considered:
** Survivors of sudden cardiac death or serious ventricular [[arrhythmia]]. 
** Symptoms and signs of [[heart failure]]. 
** Clinical features that suggest that the patient has a high likelihood of severe [[coronary artery disease]].

===Considerations===
* [[PCI]] should not be done in patients that will not be compliant with dual antiplatelet therapies.

* Patients with diabetes and advanced three-vessel coronary artery disease have shown lower mortality and myocardial infarction rates and higher risk of strokes when undergoing [[CABG]] compared to [[PCI]] with drug eluting stents.<ref name="pmid23121323">{{cite journal| author=Farkouh ME, Domanski M, Sleeper LA, Siami FS, Dangas G, Mack M et al.| title=Strategies for Multivessel Revascularization in Patients with Diabetes. | journal=N Engl J Med | year= 2012 | volume=  | issue=  | pages=  | pmid=23121323 | doi=10.1056/NEJMoa1211585 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23121323  }} </ref>

==Revascularization: Further Readings==
You can read in greater detail about specific revascularization approaches for the treatment of chronic stable angina by clicking on the link below for that topic.

[[Chronic stable angina revascularization percutaneous coronary intervention(PCI)|PCI]] | [[Chronic stable angina revascularization coronary artery bypass grafting(CABG)|CABG]] | [[Chronic stable angina percutaneous coronary intervention versus coronary artery bypass grafting|PCI vs CABG]] | [[Chronic stable angina ACC/AHA guidelines for revascularization|ACC/AHA Guidelines for Revascularization]]

==See Also==
*[[The Living Guidelines: Chronic Stable Angina Pectoris | The Chronic Stable Angina Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines]]

==Guidelines Resources==
*The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina <ref name="pmid10351980">Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10351980 ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina).] ''Circulation'' 99 (21):2829-48. PMID: [http://pubmed.gov/10351980 10351980]</ref>

*The ACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina <ref name="pmid12515758">Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12515758 ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina).] ''Circulation'' 107 (1):149-58. PMID: [http://pubmed.gov/12515758 12515758]</ref>

*The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina <ref name="pmid17998462">Fraker TD, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J et al. (2007) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=17998462 2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina.] ''Circulation'' 116 (23):2762-72. [http://dx.doi.org/10.1161/CIRCULATIONAHA.107.187930 DOI:10.1161/CIRCULATIONAHA.107.187930] PMID: [http://pubmed.gov/17998462 17998462]</ref>

==References==
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