Chronic stable angina revascularization: Difference between revisions

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__NOTOC__
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{{Chronic stable angina}}
{{Chronic stable angina}}
'''Editors-In-Chief:''' [[C. Michael Gibson, M.S., M.D.]] [mailto:mgibson@perfuse.org] Phone:617-632-7753; {{CZ}}; '''Associate Editors-In-Chief:''' [[John Fani Srour, M.D.]];  Smita Kohli, M.D.
'''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]]; {{AKK}}


==Overview==
==Overview==
The goal of treatment for chronic stable angina is: to reduce symptoms, delay the progression of [[atherosclerosis]], and prevent cardiovascular events. To achieve this, medical therapy with revascularization may be used in applicable patients. The main indication for revascularization therapy (PCI or CABG), in chronic stable angina, are:
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.
* Patients with symptoms uncontrolled by optimal medical therapy (see [[Chronic stable angina treatment#Pharmacotherapy|Pharmacotherapy]] and [[Chronic stable angina treatment#Lifestyle modifications|Lifestyle modifications]] for stable angina).  
::The definition of inadequate response to 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.
* 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.
::There is evidence and/or general agreement that coronary [[angiography]] should be performed to risk stratify patients with chronic stable angina in the following settings:
::* Disabling anginal symptoms (Canadian Cardiovascular Society [[CCS]] classes III and IV) despite medical therapy.  
::* High-risk criteria on noninvasive testing independent of the severity of [[angina]] (The amount and distribution of viable but jeopardized left ventricular myocardium and the percentage of irreversibly scarred [[myocardium]]).  
::* 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.
:On the other hand, [[angiography]] is not recommended for patients with CCS class I or II angina that responds to medical therapy and, on noninvasive testing, shows no evidence of ischemia.


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==
===Indications for Revascularization Therapy===
====Increase Survival====
*Increased survival following revascularization depends on the location, severity, and number of lesions; the presence or absence of left ventricular dysfunction is an important factor as well. Therefore, revascularization is recommended in the following situations:
** 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
*Patients who would also have a survival benefit from revascularization (PCI or CABG) are survivors 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="Qaseem">Qaseem A, Fihn SD, Dallas P, et al. Management of patients with stable ischemic heart disease: Executive summary of a clinical practice guideline from the American College of Physicians, American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med 2012. </ref>


==Revascularization approaches for the treatment of stable angina==
====Relief of Symptoms Refractory to Medical Therapy====
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.
* 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="Qaseem">Qaseem A, Fihn SD, Dallas P, et al. Management of patients with stable ischemic heart disease: Executive summary of a clinical practice guideline from the American College of Physicians, American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med 2012. </ref>
*The definition of inadequate response to [[Chronic stable angina treatment#Pharmacotherapy|medical therapy]] can be fairly broad and depends 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]].
** Patients having symptoms and signs of [[heart failure]].
** Patients having clinical features that suggest high likelihood of severe [[coronary artery disease]].


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


==See Also==
* 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>
*[[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==
==Revascularization: Further Readings==
*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>
==ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/ STS 2017 Appropriate Use Criteria for Coronary Revascularization in Patients With Stable Ischemic Heart Disease==


*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>
==Revascularization to Improve Survival Compared With Medical Therapy (DO NOT EDIT)==


*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>
{| class="wikitable" style="width: 80%; text-align: justify;"
! style="width:12%" | '''Anatomic Setting'''
! style="width:80%" | ''' COR'''
! style="width:8%" | '''LOE'''
|-
| colspan="3" | '''UPLM or complex CAD'''
|-
| CABG and PCI || bgcolor="LightGreen" | I—Heart Team approach recommended || bgcolor="LightBlue" | C
|-
| CABG and PCI || bgcolor="LemonChiffon" | IIa—Calculation of STS and SYNTAX scores || bgcolor="LightBlue" | B 
|-
| colspan="3" | '''UPLM'''
|-
| CABG || bgcolor="LightGreen" | I || bgcolor="LightBlue" | B
|-
| PCI || bgcolor="LemonChiffon" | IIa - For SIHD when both of the following are present: 
'''1)''' Anatomic conditions associated with a low risk of PCI procedural complications and a high likelihood of good long-term outcome (e.g., a low SYNTAX score of ≤ 22, ostial or trunk left main CAD)  '''2)''' Clinical characteristics that predict a significantly increased risk of adverse surgical outcomes (e.g., STS-predicted risk of operative mortality ≥ 5%)
| bgcolor="LightBlue" | B 
|-
| PCI || bgcolor="LemonChiffon" | IIa—For UA/NSTEMI if not a CABG candidate || bgcolor="LightBlue" | B
|-
| PCI || bgcolor="LemonChiffon" | IIa—For STEMI when distal coronary flow is TIMI flow grade <3 and PCI can be performed more rapidly and safely than CABG || bgcolor="LightBlue" | C
|-
| PCI || bgcolor="LemonChiffon" | IIb—For SIHD when both of the following are present:1) Anatomic conditions associated with a low to intermediate risk of PCI procedural complications and an intermediate to high likelihood of good long-term outcome (e.g., low-intermediate SYNTAX score of <33, bifurcation left main CAD) 2) Clinical characteristics that predict an increased risk of adverse surgical outcomes (e.g., moderate—severe COPD, disability from prior stroke, or prior cardiac surgery; STS-predicted operative mortality >2%) || bgcolor="LightBlue" | B
|-
| PCI || bgcolor="LightCoral" | III: Harm—For SIHD in patients (versus performing CABG) with unfavorable anatomy for PCI and who are good candidates for CABG || bgcolor="LightBlue" | B
|-
| colspan="3" | '''3-vessel disease with or without proximal LAD artery disease'''
|-
| CABG || bgcolor="LightGreen" | I || bgcolor="LightBlue" | B
|-
| || bgcolor="LemonChiffon" | IIa—It is reasonable to choose CABG over PCI in patients with complex 3-vessel CAD (e.g., SYNTAX score >22) who are good candidates for CABG. || bgcolor="LightBlue" | B
|-
| PCI || bgcolor="LemonChiffon" | IIb—Of uncertain benefit || bgcolor="LightBlue" | B
|-
| colspan="3" | '''2-vessel disease with proximal LAD artery disease'''
|-
| CABG || bgcolor="LightGreen" | I || bgcolor="LightBlue" | B
|-
| PCI || bgcolor="LemonChiffon" | IIb—Of uncertain benefit || bgcolor="LightBlue" | B
|-
| colspan="3" | '''2-vessel disease without proximal LAD artery disease'''
|-
| CABG || bgcolor="LemonChiffon" | IIa—With extensive ischemia || bgcolor="LightBlue" | B
|-
| CABG || bgcolor="LemonChiffon" | IIb—Of uncertain benefit without extensive ischemia || bgcolor="LightBlue" | C
|-
| CABG || bgcolor="LemonChiffon" | IIb—Of uncertain benefit || bgcolor="LightBlue" | B
|-
| colspan="3" |'''1-vessel proximal LAD artery disease'''
|-
| CABG || bgcolor="LemonChiffon" | IIa—With LIMA for long-term benefit || bgcolor="LightBlue" | B
|-
| PCI || bgcolor="LemonChiffon" | IIb—With LIMA for long-term benefit || bgcolor="LightBlue" | B
|-
| || 1-vessel proximal LAD artery disease ||
|-
| CABG || bgcolor="LightCoral" | III: Harm || bgcolor="LightBlue" | B
|-
| PCI || bgcolor="LightCoral" | III: Harm || bgcolor="LightBlue" | B
|-
| colspan="2" | '''LV dysfunction'''||
|-
| CABG || bgcolor="LemonChiffon" | IIa—EF 35% to 50% || bgcolor="LightBlue" | B
|-
| CABG || bgcolor="LemonChiffon" | IIb—EF <35% without significant left main CAD || bgcolor="LightBlue" | B
|-
| PCI || Insufficient data ||
|-
| colspan="3" |'''Survivors of sudden cardiac death with presumed ischemia-mediated VT'''
|-
| CABG || bgcolor="LightGreen" | I || bgcolor="LightBlue" | B
|-
| PCI || bgcolor="LightGreen" | I || bgcolor="LightBlue" | C
|-
| colspan="3" | '''No anatomic or physiological criteria for revascularization'''
|-
| CABG || bgcolor="LightCoral" | III: Harm || bgcolor="LightBlue" | B
|-
| PCI || bgcolor="LightCoral" | III: Harm || bgcolor="LightBlue" | B
|-
| colspan="3" |'''CABG''' indicates coronary artery bypass graft; '''CAD''', coronary artery disease; '''COPD''', chronic obstructive pulmonary disease; '''COR''', class of recommendation; '''EF''', ejection fraction; '''LAD''', left anterior descending; '''LIMA''', left internal mammary artery; '''LOE''', level of evidence; '''LV''', left ventricular; '''N/A''', not available; '''PCI''', percutaneous coronary intervention; '''SIHD''', stable ischemic heart disease; '''STEMI''', ST-elevation myocardial infarction; '''STS''', Society of Thoracic Surgeons; '''SYNTAX''', Synergy between Percutaneous Coronary Intervention with '''TAXUS''' and Cardiac Surgery; '''TIMI''', Thrombolysis In Myocardial Infarction; '''UA/NSTEMI''', unstable angina/non–ST-elevation myocardial infarction; '''UPLM''', unprotected left main disease; and VT, ventricular tachycardia.
|}
 
== One Vessel Disease==
 
{| class="wikitable" style="width: 80%; text-align: justify;"
 
! colspan="9" style="width:52%" | '''Appropriate Use Score (1-9)'''
|-
|'''One-Vessel Disease''' || colspan="2" | '''Asymptomatic'''  || colspan="6" | '''Ischemic Symptoms'''
|-
|One-Vessel Disease || colspan="2" |Not on AA Therapy or With AA Therapy|| colspan="2" | Not on AA Therapy|| colspan="2" | On 1 AA Drug (BB Preferred)|| colspan="2" | On ≥2 AA Drugs
|-
|Indication ||PCI || CABG ||PCI || CABG ||PCI ||CABG ||PCI || CABG
|-
| colspan="9" | '''No Proximal LAD or Proximal Left Dominant LCX Involvement'''
|-
| Low-risk findings on noninvasive testing || bgcolor="LightCoral" | R (2) || bgcolor="LightCoral" | R (1) || bgcolor="LightCoral" | R (3) || bgcolor="LightCoral" | R (2) || bgcolor="LemonChiffon" | M (4) || bgcolor="LightCoral" | R (3) || bgcolor="LightGreen" | A (7) || bgcolor="LemonChiffon" | M (5)
|-
| Intermediate- or high-risk findings on noninvasive testing || bgcolor="LemonChiffon" | M (4) || bgcolor="LightCoral" | R (3) || bgcolor="LemonChiffon" | M (5) || bgcolor="LemonChiffon" | M (4) || bgcolor="LemonChiffon" | M (6) || bgcolor="LemonChiffon" | M (4) || bgcolor="LightGreen" | A (8) || bgcolor="LemonChiffon" | M (6)
|-
| No stress test performed or, if performed, results are indeterminate - FFR ≤0.80 || bgcolor="LemonChiffon" | M (4) || bgcolor="LightCoral" | R (2) || bgcolor="LemonChiffon" | M (5) || bgcolor="LightCoral" | R (3) || bgcolor="LemonChiffon" | M (6) || bgcolor="LemonChiffon" | M (4) || bgcolor="LightGreen" | A (8) || bgcolor="LemonChiffon" | M (6)
|-
| colspan="9" | '''Proximal LAD or Proximal Left Dominant LCX Involvement Present'''
|-
| Low-risk findings on noninvasive testing || bgcolor="LemonChiffon" | M (4) || bgcolor="LightCoral" | R (3) || bgcolor="LemonChiffon" | M (4) || bgcolor="LemonChiffon" | M (4) || bgcolor="LemonChiffon" | M (5) || bgcolor="LemonChiffon" | M (5) || bgcolor="LightGreen" | A (7) || bgcolor="LightGreen" | A (7)
|-
| Intermediate- or high-risk findings on noninvasive testing || bgcolor="LemonChiffon" | M (5) || bgcolor="LemonChiffon" | M (5) || bgcolor="LemonChiffon" | M (6) || bgcolor="LemonChiffon" | M (6) || bgcolor="LightGreen" | A (7) || bgcolor="LightGreen" | A (7) || bgcolor="LightGreen" | A (8) || bgcolor="LightGreen" | A (8)
|-
| No stress test performed or, if performed, results are indeterminate - FFR ≤0.80 || bgcolor="LemonChiffon" | M (5) || bgcolor="LemonChiffon" | M (5) || bgcolor="LemonChiffon" | M (6) || bgcolor="LemonChiffon" | M (6) || bgcolor="LemonChiffon" | M (6) || bgcolor="LemonChiffon" | M (6) || bgcolor="LightGreen" | A (8) || bgcolor="LightGreen" | A (7)
|-
| colspan="9" | A indicates appropriate; AA, antianginal; BB, beta blockers; CABG, coronary artery bypass graft; FFR, fractional flow reserve; iFR, instant wave-free ratio; LAD, left anterior descending coronary artery; LCX, left circumflex artery; M, may be appropriate; PCI, percutaneous coronary intervention; and R, rarely appropriate. A separate, independent rating panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate for the clinical scenario presented. Scores of 1 to 3 indicate that revascularization is considered rarely appropriate for the clinical scenario, whereas scores in the mid-range of 4 to 6 indicate that coronary revascularization may be appropriate for the clinical scenario.
|}
 
==Two-Vessel Disease==
 
{| class="wikitable" style="width: 80%; text-align: justify;"
 
! colspan="9" style="width:52%" | '''Appropriate Use Score (1-9)'''
|-
|'''Two-Vessel Disease''' || colspan="2" | '''Asymptomatic'''  || colspan="6" | '''Ischemic Symptoms'''
|-
|Two-Vessel Disease || colspan="2" |Not on AA Therapy or With AA Therapy|| colspan="2" | Not on AA Therapy|| colspan="2" | On 1 AA Drug (BB Preferred)|| colspan="2" | On ≥2 AA Drugs
|-
|Indication ||PCI || CABG ||PCI || CABG ||PCI ||CABG ||PCI || CABG
|-
| colspan="9" | No Proximal LAD Involvement
|-
| Low-risk findings on noninvasive testing || bgcolor="LightCoral" | R (3) || bgcolor="LightCoral" | R (2) || bgcolor="LemonChiffon" | M (4) || bgcolor="LightCoral" | R (3) || bgcolor="LemonChiffon" | M (5) || bgcolor="LemonChiffon" | M (4) || bgcolor="LightGreen" | A (7) || bgcolor="LemonChiffon" | M (6)
|-
| Intermediate- or high-risk findings on noninvasive testing || bgcolor="LemonChiffon" | M (5) || bgcolor="LemonChiffon" | M (4) || bgcolor="LemonChiffon" | M (6) || bgcolor="LemonChiffon" | M (5) || bgcolor="LemonChiffon" | M (6) || bgcolor="LemonChiffon" | M (4) || bgcolor="LightGreen" | A (7) || bgcolor="LemonChiffon" | M (6)
|-
| No stress test performed or, if performed, results are indeterminate - FFR ≤0.80 in both vessels || bgcolor="LemonChiffon" | M (5) || bgcolor="LemonChiffon" | M (4) || bgcolor="LemonChiffon" | M (6) || bgcolor="LemonChiffon" | M (4) || bgcolor="LightGreen" | A (7) || bgcolor="LemonChiffon" | M (5) || bgcolor="LightGreen" | A (8) || bgcolor="LightGreen" | A (8)
|-
| colspan="9" | '''Proximal LAD Involvement and No Diabetes Present'''
|-
| Low-risk findings on noninvasive testing || bgcolor="LemonChiffon" | M (4) || bgcolor="LemonChiffon" | M (4)  || bgcolor="LemonChiffon" | M (5) || bgcolor="LemonChiffon" | M (5) || bgcolor="LemonChiffon" | M (6) || bgcolor="LemonChiffon" | M (6) || bgcolor="LightGreen" | A (7) || bgcolor="LightGreen" | A (7)
|-
| Intermediate- or high-risk findings on noninvasive testing || bgcolor="LemonChiffon" | M (6) || bgcolor="LemonChiffon" | M (6)  || bgcolor="LightGreen" | A (7)  || bgcolor="LightGreen" | A (7)  || bgcolor="LightGreen" | A (7) || bgcolor="LightGreen" | A (7)  || bgcolor="LightGreen" | A (8) || bgcolor="LightGreen" | A (8)
|-
| No stress test performed or, if performed, results are indeterminate - FFR ≤0.80 in both vessels || bgcolor="LemonChiffon" | M (6) || bgcolor="LemonChiffon" | M (6) || bgcolor="LemonChiffon" | M (6) || bgcolor="LemonChiffon" | M (6) || bgcolor="LightGreen" | A (7) || bgcolor="LightGreen" | A (7) || bgcolor="LightGreen" | A (8) || bgcolor="LightGreen" | A (8)
|-
| colspan="9" | '''Proximal LAD Involvement With Diabetes Present'''
|-
| Low-risk findings on noninvasive testing || bgcolor="LemonChiffon" | M (4) || bgcolor="LemonChiffon" | M (5)  || bgcolor="LemonChiffon" | M (4) || bgcolor="LemonChiffon" | M (6) || bgcolor="LemonChiffon" | M (6) || bgcolor="LightGreen" | A (7) || bgcolor="LightGreen" | A (7) || bgcolor="LightGreen" | A (8)
|-
| Intermediate- or high-risk findings on noninvasive testing || bgcolor="LemonChiffon" | M (5) || bgcolor="LightGreen" | A (7)  || bgcolor="LemonChiffon" | M (6) || bgcolor="LightGreen" | A (7)  || bgcolor="LightGreen" | A (7) || bgcolor="LightGreen" | A (8)  || bgcolor="LightGreen" | A (8) || bgcolor="LightGreen" | A (9)
|-
| No stress test performed or, if performed, results are indeterminate - FFR ≤0.80 in both vessels || bgcolor="LemonChiffon" | M (5) || bgcolor="LemonChiffon" | M (6) || bgcolor="LemonChiffon" | M (6) || bgcolor="LightGreen" | A (7) || bgcolor="LightGreen" | A (7) || bgcolor="LightGreen" | A (8) || bgcolor="LightGreen" | A (7) || bgcolor="LightGreen" | A (8)
|-
| colspan="9" | A indicates appropriate; AA, antianginal; BB, beta blockers; CABG, coronary artery bypass graft; FFR, fractional flow reserve; iFR, instant wave-free ratio; LAD, left anterior descending coronary artery; M, may be appropriate; PCI, percutaneous coronary intervention; and R, rarely appropriate. A separate, independent rating panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate for the clinical scenario presented. Scores of 1 to 3 indicate that revascularization is considered rarely appropriate for the clinical scenario, whereas scores in the mid-range of 4 to 6 indicate that coronary revascularization may be appropriate for the clinical scenario.
|}
 
==Three-Vessel Disease==
 
{| class="wikitable" style="width: 80%; text-align: justify;"
 
! colspan="9" style="width:52%" | '''Appropriate Use Score (1-9)'''
|-
|'''Three-Vessel Disease''' || colspan="2" | '''Asymptomatic'''  || colspan="6" | '''Ischemic Symptoms'''
|-
|Three-Vessel Disease || colspan="2" |Not on AA Therapy or With AA Therapy|| colspan="2" | Not on AA Therapy|| colspan="2" | On 1 AA Drug (BB Preferred)|| colspan="2" | On ≥2 AA Drugs
|-
|Indication ||PCI || CABG ||PCI || CABG ||PCI ||CABG ||PCI || CABG
|-
| colspan="9" | '''Low Disease Complexity (e.g., Focal Stenoses, SYNTAX ≤22)'''
|-
| Low-risk findings on noninvasive testing || bgcolor="LemonChiffon" | M (4) || bgcolor="LemonChiffon" | M (5) || bgcolor="LemonChiffon" | M (5) || bgcolor="LemonChiffon" | M (6) || bgcolor="LemonChiffon" | M (6) || bgcolor="LemonChiffon" | M (6) || bgcolor="LightGreen" | A (7) || bgcolor="LightGreen" | A (7)
|-
| Intermediate- or high-risk findings on noninvasive testing - No diabetes || bgcolor="LemonChiffon" | M (6) || bgcolor="LightGreen" | A (7) || bgcolor="LightGreen" | A (7) || bgcolor="LightGreen" | A (7) || bgcolor="LightGreen" | A (7) || bgcolor="LightGreen" | A (8) || bgcolor="LightGreen" | A (8) || bgcolor="LightGreen" | A (8)
|-
| Low-risk findings on non-invasive testing - Diabetes present || bgcolor="LemonChiffon" | M (4) || bgcolor="LemonChiffon" | M (6) || bgcolor="LemonChiffon" | M (5) || bgcolor="LemonChiffon" | M (6) || bgcolor="LightGreen" | A (6) || bgcolor="LightGreen" | A (7) || bgcolor="LightGreen" | A (7) || bgcolor="LightGreen" | A (8)
|-
| Intermediate- or high-risk findings on noninvasive testing - Diabetes present|| bgcolor="LemonChiffon" | M (6) || bgcolor="LightGreen" | A (7) || bgcolor="LemonChiffon" | M (6) || bgcolor="LightGreen" | A (8) || bgcolor="LightGreen" | A (7) || bgcolor="LightGreen" | A (8) || bgcolor="LightGreen" | A (7) || bgcolor="LightGreen" | A (9)
|-
| colspan="9" | '''Intermediate or High Disease Complexity (e.g. Multiple Features of Complexity as Noted Previously, SYNTAX >22)'''
|-
| Low-risk findings on noninvasive testing - No diabetes || bgcolor="LemonChiffon" | M (4) || bgcolor="LemonChiffon" | M (6) || bgcolor="LemonChiffon" | M (4) || bgcolor="LightGreen" | A (7) || bgcolor="LemonChiffon" | M (5)  || bgcolor="LightGreen" | A (7) || bgcolor="LemonChiffon" | M (6) || bgcolor="LightGreen" | A (8)
|-
| Intermediate- or high-risk findings on noninvasive testing - No diabetes || bgcolor="LemonChiffon" | M (5) || bgcolor="LightGreen" | A (7) || bgcolor="LemonChiffon" | M (6) || bgcolor="LightGreen" | A (7) || bgcolor="LemonChiffon" | M (6)  || bgcolor="LightGreen" | A (8) || bgcolor="LemonChiffon" | M (6) || bgcolor="LightGreen" | A (9)
|-
|Low-risk findings on noninvasive testing - Diabetes present || bgcolor="LemonChiffon" | M (4) || bgcolor="LightGreen" | A (7) || bgcolor="LemonChiffon" | M (4) || bgcolor="LightGreen" | A (7) || bgcolor="LemonChiffon" | M (5)  || bgcolor="LightGreen" | A (8) || bgcolor="LemonChiffon" | M (6) || bgcolor="LightGreen" | A (9)
|-
|Intermediate- or high-risk findings on noninvasive testing - Diabetes present || bgcolor="LemonChiffon" | M (4) || bgcolor="LightGreen" | A (8) || bgcolor="LemonChiffon" | M (5) || bgcolor="LightGreen" | A (8) || bgcolor="LemonChiffon" | M (5)  || bgcolor="LightGreen" | A (8) || bgcolor="LemonChiffon" | M (6) || bgcolor="LightGreen" | A (9)
|-
| colspan="9" | A indicates appropriate; AA, antianginal; BB, beta blockers; CABG, coronary artery bypass graft; M, may be appropriate; PCI, percutaneous coronary intervention; and SYNTAX, Synergy between PCI with Taxus and Cardiac Surgery trial. A separate, independent rating panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate for the clinical scenario presented. Scores of 1 to 3 indicate that revascularization is considered rarely appropriate for the clinical scenario, whereas scores in the mid-range of 4 to 6 indicate that coronary revascularization may be appropriate for the clinical scenario.
|}
 
==Left Main Coronary Artery Stenosis==
 
{| class="wikitable" style="width: 80%; text-align: justify;"
 
! colspan="9" style="width:52%" | '''Appropriate Use Score (1-9)'''
|-
|'''Left Main Disease''' || colspan="2" | '''Asymptomatic'''  || colspan="6" | '''Ischemic Symptoms'''
|-
| Left Main Disease || colspan="2" |Not on AA Therapy or With AA Therapy|| colspan="2" | Not on AA Therapy|| colspan="2" | On 1 AA Drug (BB Preferred)|| colspan="2" | On ≥2 AA Drugs
|-
|Indication ||PCI || CABG ||PCI || CABG ||PCI ||CABG ||PCI || CABG
|-
| Isolated LMCA disease - Ostial or midshaft stenosis || bgcolor="LemonChiffon" | M (6) || bgcolor="LightGreen" | A (8) || bgcolor="LightGreen" | A (7) || bgcolor="LightGreen" | A (8) || bgcolor="LightGreen" | A (7) || bgcolor="LightGreen" | A (9) || bgcolor="LightGreen" | A (7) || bgcolor="LightGreen" | A (9)
|-
| Isolated LMCA disease - Bifurcation involvement || bgcolor="LemonChiffon" | M (5) || bgcolor="LightGreen" | A (8) || bgcolor="LemonChiffon" | M (5) || bgcolor="LightGreen" | A (8) || bgcolor="LemonChiffon" | M (5) || bgcolor="LightGreen" | A (9) || bgcolor="LemonChiffon" | M (6) || bgcolor="LightGreen" | A (9)
|-
|LMCA disease - Ostial or mid shaft stenosis - Concurrent multi vessel disease - Low disease burden (e.g., 1–2 additional focal stenoses, SYNTAX score ≤22) || bgcolor="LemonChiffon" | M (6) || bgcolor="LightGreen" | A (8) || bgcolor="LemonChiffon" | M (6) || bgcolor="LightGreen" | A (9) || bgcolor="LightGreen" | A (7) || bgcolor="LightGreen" | A (9) || bgcolor="LightGreen" | A (7) || bgcolor="LightGreen" | A (9)
|-
|Ostial or mid shaft stenosis - Concurrent multi vessel disease - Intermediate or high disease burden (e.g., 1–2 additional bifurcation stenosis, long stenoses, SYNTAX score >22) || bgcolor="LemonChiffon" | M (4) || bgcolor="LightGreen" | A (9) || bgcolor="LemonChiffon" | M (4) || bgcolor="LightGreen" | A (9) || bgcolor="LemonChiffon" | M (4) || bgcolor="LightGreen" | A (9) || bgcolor="LemonChiffon" | M (4) || bgcolor="LightGreen" | A (9)
|-
|Ostial or mid shaft stenosis - Concurrent multi vessel disease - Intermediate or high disease burden (e.g., 1–2 additional bifurcation stenosis, long stenoses, SYNTAX score >22) || bgcolor="LemonChiffon" | M (4) || bgcolor="LightGreen" | A (9) || bgcolor="LemonChiffon" | M (4) || bgcolor="LightGreen" | A (9) || bgcolor="LemonChiffon" | M (4) || bgcolor="LightGreen" | A (9) || bgcolor="LemonChiffon" | M (4) || bgcolor="LightGreen" | A (9)
|-
|LMCA disease - Bifurcation involvement - Low disease burden in other vessels (e.g., 1–2 additional focal stenosis, SYNTAX score ≤22) || bgcolor="LemonChiffon" | M (4) || bgcolor="LightGreen" | A (8) || bgcolor="LemonChiffon" | M (5) || bgcolor="LightGreen" | A (8) || bgcolor="LemonChiffon" | M (5) || bgcolor="LightGreen" | A (9) || bgcolor="LemonChiffon" | M (6) || bgcolor="LightGreen" | A (9)
|-
|LMCA disease - Bifurcation involvement - Intermediate or high disease burden in other vessels (e.g., 1–2 additional bifurcation stenosis, long stenoses, SYNTAX score >22) || bgcolor="LightCoral" | R (3) || bgcolor="LightGreen" | A (8) || bgcolor="LightCoral" | R (3) || bgcolor="LightGreen" | A (9) || bgcolor="LightCoral" | R (3) || bgcolor="LightGreen" | A (9) || bgcolor="LightCoral" | R (3) || bgcolor="LightGreen" | A (9)
|-
| colspan="9" | A indicates appropriate; AA, antianginal; BB, beta blockers; CABG, coronary artery bypass graft; LMCA, left main coronary artery; M, may be appropriate; PCI, percutaneous coronary intervention; R, rarely appropriate; and SYNTAX, Synergy between PCI with Taxus and Cardiac Surgery trial. A separate, independent rating panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate for the clinical scenario presented. Scores of 1 to 3 indicate that revascularization is considered rarely appropriate for the clinical scenario, whereas scores in the mid-range of 4 to 6 indicate that coronary revascularization may be appropriate for the clinical scenario.
|}
 
==IMA to LAD Patent and Without Significant Stenoses==
 
{| class="wikitable" style="width: 80%; text-align: justify;"
 
! colspan="9" style="width:52%" | '''Appropriate Use Score (1-9)'''
|-
|'''IMA to LAD Patent and Without Significant Stenoses''' || colspan="2" | '''Asymptomatic'''  || colspan="6" | '''Ischemic Symptoms'''
|-
| || colspan="2" |Not on AA Therapy or With AA Therapy|| colspan="2" | Not on AA Therapy|| colspan="2" | On 1 AA Drug (BB Preferred)|| colspan="2" | On ≥2 AA Drugs
|-
|Indication ||PCI || CABG ||PCI || CABG ||PCI ||CABG ||PCI || CABG
|-
| colspan="9" | '''Stenosis Supplying 1 Territory Disease (Bypass Graft or Native Artery) to Territory Other Than Anterior'''
|-
| Low-risk findings on noninvasive testing || bgcolor="LightCoral" | R (3) || bgcolor="LightCoral" | R (1) || bgcolor="LightCoral" | R (3) || bgcolor="LightCoral" | R (2) || bgcolor="LemonChiffon" | M (6) || bgcolor="LightCoral" | R (3) || bgcolor="LightGreen" | A (7) || bgcolor="LemonChiffon" | M (4)
|-
| Intermediate- or high-risk findings on noninvasive testing || bgcolor="LemonChiffon" | M (5) || bgcolor="LightCoral" | R (3) || bgcolor="LemonChiffon" | M (5)                  || bgcolor="LightCoral" | R (3)
| bgcolor="LightGreen" | A (7) || bgcolor="LemonChiffon" | M (4) || bgcolor="LightGreen" | A (8) || bgcolor="LemonChiffon" | M (5)
|-
| No stress test performed or, if performed, the results are indeterminate - FFR of stenosis ≤0.80 || bgcolor="LemonChiffon" | M (4) || bgcolor="LightCoral" | R (3) || bgcolor="LemonChiffon" | M (4) || bgcolor="LightCoral" | R (3) || bgcolor="LemonChiffon" | M (6) || bgcolor="LemonChiffon" | M (4) || bgcolor="LightGreen" | A (8) || bgcolor="LemonChiffon" | M (5)
|-
| colspan="9" | '''Stenoses Supplying 2 Territories (Bypass Graft or Native Artery, Either 2 Separate Vessels or Sequential Graft Supplying 2 Territories) Not Including Anterior Territory'''
|-
| Low-risk findings on noninvasive testing || bgcolor="LightCoral" | R (3) || bgcolor="LightCoral" | R (2) || bgcolor="LemonChiffon" | M (4) || bgcolor="LightCoral" | R (3) || bgcolor="LemonChiffon" | M (6) || bgcolor="LightCoral" | R (3) || bgcolor="LightGreen" | A (7) || bgcolor="LemonChiffon" | M (5)
|-
| Intermediate- or high-risk findings on noninvasive testing || bgcolor="LemonChiffon" | M (5) || bgcolor="LightCoral" | R (3) || bgcolor="LemonChiffon" | M (5)                  || bgcolor="LemonChiffon" | M (4) || bgcolor="LightGreen" | A (7) || bgcolor="LemonChiffon" | M (5) || bgcolor="LightGreen" | A (8) || bgcolor="LemonChiffon" | M (6)
|-
| colspan="9" | A indicates appropriate; AA, Antianginal; BB, beta blockers; CABG, coronary artery bypass graft; FFR, fractional flow reserve; iFR, instant wave-free ratio; IMA, internal mammary artery; LAD, left anterior descending coronary artery; M, may be appropriate; PCI, percutaneous coronary intervention; and R, rarely appropriate. A separate, independent rating panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate for the clinical scenario presented. Scores of 1 to 3 indicate that revascularization is considered rarely appropriate for the clinical scenario, whereas scores in the mid-range of 4 to 6 indicate that coronary revascularization may be appropriate for the clinical scenario.
|}
 
==IMA to LAD Not Patent==
 
{| class="wikitable" style="width: 80%; text-align: justify;"
 
! colspan="9" style="width:52%" | '''Appropriate Use Score (1-9)'''
|-
|'''IMA to LAD Not Patent''' || colspan="2" | '''Asymptomatic'''  || colspan="6" | '''Ischemic Symptoms'''
|-
| || colspan="2" |Not on AA Therapy or With AA Therapy|| colspan="2" | Not on AA Therapy|| colspan="2" | On 1 AA Drug (BB Preferred)|| colspan="2" | On ≥2 AA Drugs
|-
|Indication ||PCI || CABG ||PCI || CABG ||PCI ||CABG ||PCI || CABG
|-
| colspan="9" | '''Stenosis Supplying 1-Territory Disease (Bypass Graft or Native Artery)–Anterior (LAD) Territory'''
|-
| Low-risk findings on noninvasive testing|| bgcolor="LemonChiffon" | M (4) || bgcolor="LightCoral" | R (3) || bgcolor="LemonChiffon" | M (5) || bgcolor="LightCoral" | R (3)    || bgcolor="LemonChiffon" | M (6) || bgcolor="LemonChiffon" | M (4) || bgcolor="LightGreen" | A (7) || bgcolor="LemonChiffon" | M (5)
|-
| Intermediate- or high-risk findings on noninvasive testing || bgcolor="LemonChiffon" | M (6) || bgcolor="LemonChiffon" | M (4) || bgcolor="LemonChiffon" | M (6)                || bgcolor="LemonChiffon" | M (4) || bgcolor="LightGreen" | A (7) || bgcolor="LemonChiffon" | M (5) || bgcolor="LightGreen" | A (8) || bgcolor="LemonChiffon" | M (6)
|-
| No stress test performed or, if performed, the results are indeterminate - FFR of stenosis ≤0.80 || bgcolor="LemonChiffon" | M (5) || bgcolor="LemonChiffon" | M (4) || bgcolor="LemonChiffon" | M (6) || bgcolor="LemonChiffon" | M (4) || bgcolor="LightGreen" | A (7) || bgcolor="LemonChiffon" | M (5) || bgcolor="LightGreen" | A (7) || bgcolor="LemonChiffon" | M (6)
|-
| colspan="9" | '''Stenoses Supplying 2 Territories (Bypass Graft or Native Artery, Either 2 Separate Vessels or Sequential Graft Supplying 2 Territories) LAD Plus Other Territory'''
|-
| Low-risk findings on noninvasive testing|| bgcolor="LemonChiffon" | M (5) || bgcolor="LemonChiffon" | M (4) || bgcolor="LemonChiffon" | M (6) || bgcolor="LemonChiffon" | M (4)    || bgcolor="LightGreen" | A (7) || bgcolor="LemonChiffon" | M (5) || bgcolor="LightGreen" | A (7) || bgcolor="LemonChiffon" | M (6)
|-
| Intermediate- or high-risk findings on noninvasive testing || bgcolor="LemonChiffon" | M (6) || bgcolor="LemonChiffon" | M (5) || bgcolor="LightGreen" | A (7)                || bgcolor="LemonChiffon" | M (6) || bgcolor="LightGreen" | A (7) || bgcolor="LightGreen" | A (7) || bgcolor="LightGreen" | A (8) || bgcolor="LightGreen" | A (8)
|-
| colspan="9" | '''Stenoses Supplying 3 Territories (Bypass Graft or Native Arteries, Separate Vessels, Sequential Grafts, or Combination Thereof) LAD Plus 2 Other Territories'''
|-
| Low-risk findings on noninvasive testing|| bgcolor="LemonChiffon" | M (5) || bgcolor="LemonChiffon" | M (5) || bgcolor="LemonChiffon" | M (6) || bgcolor="LemonChiffon" | M (5)    || bgcolor="LemonChiffon" | M (6) || bgcolor="LemonChiffon" | M (6) || bgcolor="LightGreen" | A (7) || bgcolor="LightGreen" | A (7)
|-
| Intermediate- or high-risk findings on noninvasive testing || bgcolor="LightGreen" | A (7) || bgcolor="LightGreen" | A (7) || bgcolor="LightGreen" | A (7)                || bgcolor="LightGreen" | A (7) || bgcolor="LightGreen" | A (7) || bgcolor="LightGreen" | A (7) || bgcolor="LightGreen" | A (8) || bgcolor="LightGreen" | A (8)
|-
| colspan="9" | A indicates appropriate; AA, Antianginal; BB, beta blockers; CABG, coronary artery bypass graft; FFR, fractional flow reserve; iFR, instant wave-free ratio; IMA, internal mammary artery; LAD, left anterior descending coronary artery; M, may be appropriate; PCI, percutaneous coronary intervention; and R, rarely appropriate. A separate, independent rating panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate for the clinical scenario presented. Scores of 1 to 3 indicate that revascularization is considered rarely appropriate for the clinical scenario, whereas scores in the mid-range of 4 to 6 indicate that coronary revascularization may be appropriate for the clinical scenario.
|}
 
==2014 Focused update of 2012 AHA guidelines for the management of chronic stable angina<ref name="pmid25077860">{{cite journal| author=Fihn SD, Blankenship JC, Alexander KP, Bittl JA, Byrne JG, Fletcher BJ et al.| title=2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. | journal=J Am Coll Cardiol | year= 2014 | volume= 64 | issue= 18 | pages= 1929-49 | pmid=25077860 | doi=10.1016/j.jacc.2014.07.017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25077860  }} </ref><ref name="pmid23166210">{{cite journal| author=Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP et al.| title=2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. | journal=Circulation | year= 2012 | volume= 126 | issue= 25 | pages= 3097-137 | pmid=23166210 | doi=10.1161/CIR.0b013e3182776f83 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23166210  }} </ref>==
===Heart Team Approach Revascularization Guidelines<ref name="pmid25077860">{{cite journal| author=Fihn SD, Blankenship JC, Alexander KP, Bittl JA, Byrne JG, Fletcher BJ et al.| title=2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. | journal=J Am Coll Cardiol | year= 2014 | volume= 64 | issue= 18 | pages= 1929-49 | pmid=25077860 | doi=10.1016/j.jacc.2014.07.017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25077860  }} </ref><ref name="pmid23166210">{{cite journal| author=Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP et al.| title=2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. | journal=Circulation | year= 2012 | volume= 126 | issue= 25 | pages= 3097-137 | pmid=23166210 | doi=10.1161/CIR.0b013e3182776f83 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23166210  }} </ref>===
{|class="wikitable" style="width:80%"
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' A Heart Team approach to revascularization is recommended in patients with diabetes mellitus and complex multivessel CAD<nowiki>"</nowiki>''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:C ]])'' <nowiki>"</nowiki>
|}
{|class="wikitable" style="width:80%"
|-
|colspan="1" style="text-align:center; background:Lemonchiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="Lemonchiffon"|<nowiki>"</nowiki>'''1.''' Calculation of the STS and SYNTAX scores is reasonable in patients with unprotected left main and complex CAD <nowiki>"</nowiki>''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B ]])'' <nowiki>"</nowiki>
|}
 
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]]'''
*'''[[Chronic stable angina revascularization coronary artery bypass grafting|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]]'''


==References==
==References==
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[[Category:Up-To-Date cardiology]]

Latest revision as of 18:22, 28 October 2017

Chronic stable angina Microchapters

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Risk calculators and risk factors for Chronic stable angina revascularization

Editors-In-Chief: C. Michael Gibson, M.S., M.D. [1] Phone:617-632-7753; Cafer Zorkun, M.D., Ph.D. [2]; Associate Editors-In-Chief: John Fani Srour, M.D.; Smita Kohli, M.D.; Rim Halaby; Arzu Kalayci, M.D. [3]

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 coronary artery bypass surgery in 1967 and 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

Indications for Revascularization Therapy

Increase Survival

  • Increased survival following revascularization depends on the location, severity, and number of lesions; the presence or absence of left ventricular dysfunction is an important factor as well. Therefore, revascularization is recommended in the following situations:
    • 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:
  • Patients who would also have a survival benefit from revascularization (PCI or CABG) are survivors of sudden cardiac death secondary to ischemia induced tachycardia, where ischemia is caused by more than 70% stenosis of a major coronary artery:

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
  • The definition of inadequate response to medical therapy can be fairly broad and depends 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:

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.[2]

Revascularization: Further Readings

ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/ STS 2017 Appropriate Use Criteria for Coronary Revascularization in Patients With Stable Ischemic Heart Disease

Revascularization to Improve Survival Compared With Medical Therapy (DO NOT EDIT)

Anatomic Setting COR LOE
UPLM or complex CAD
CABG and PCI I—Heart Team approach recommended C
CABG and PCI IIa—Calculation of STS and SYNTAX scores B
UPLM
CABG I B
PCI IIa - For SIHD when both of the following are present:

1) Anatomic conditions associated with a low risk of PCI procedural complications and a high likelihood of good long-term outcome (e.g., a low SYNTAX score of ≤ 22, ostial or trunk left main CAD) 2) Clinical characteristics that predict a significantly increased risk of adverse surgical outcomes (e.g., STS-predicted risk of operative mortality ≥ 5%)

B
PCI IIa—For UA/NSTEMI if not a CABG candidate B
PCI IIa—For STEMI when distal coronary flow is TIMI flow grade <3 and PCI can be performed more rapidly and safely than CABG C
PCI IIb—For SIHD when both of the following are present:1) Anatomic conditions associated with a low to intermediate risk of PCI procedural complications and an intermediate to high likelihood of good long-term outcome (e.g., low-intermediate SYNTAX score of <33, bifurcation left main CAD) 2) Clinical characteristics that predict an increased risk of adverse surgical outcomes (e.g., moderate—severe COPD, disability from prior stroke, or prior cardiac surgery; STS-predicted operative mortality >2%) B
PCI III: Harm—For SIHD in patients (versus performing CABG) with unfavorable anatomy for PCI and who are good candidates for CABG B
3-vessel disease with or without proximal LAD artery disease
CABG I B
IIa—It is reasonable to choose CABG over PCI in patients with complex 3-vessel CAD (e.g., SYNTAX score >22) who are good candidates for CABG. B
PCI IIb—Of uncertain benefit B
2-vessel disease with proximal LAD artery disease
CABG I B
PCI IIb—Of uncertain benefit B
2-vessel disease without proximal LAD artery disease
CABG IIa—With extensive ischemia B
CABG IIb—Of uncertain benefit without extensive ischemia C
CABG IIb—Of uncertain benefit B
1-vessel proximal LAD artery disease
CABG IIa—With LIMA for long-term benefit B
PCI IIb—With LIMA for long-term benefit B
1-vessel proximal LAD artery disease
CABG III: Harm B
PCI III: Harm B
LV dysfunction
CABG IIa—EF 35% to 50% B
CABG IIb—EF <35% without significant left main CAD B
PCI Insufficient data
Survivors of sudden cardiac death with presumed ischemia-mediated VT
CABG I B
PCI I C
No anatomic or physiological criteria for revascularization
CABG III: Harm B
PCI III: Harm B
CABG indicates coronary artery bypass graft; CAD, coronary artery disease; COPD, chronic obstructive pulmonary disease; COR, class of recommendation; EF, ejection fraction; LAD, left anterior descending; LIMA, left internal mammary artery; LOE, level of evidence; LV, left ventricular; N/A, not available; PCI, percutaneous coronary intervention; SIHD, stable ischemic heart disease; STEMI, ST-elevation myocardial infarction; STS, Society of Thoracic Surgeons; SYNTAX, Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery; TIMI, Thrombolysis In Myocardial Infarction; UA/NSTEMI, unstable angina/non–ST-elevation myocardial infarction; UPLM, unprotected left main disease; and VT, ventricular tachycardia.

One Vessel Disease

Appropriate Use Score (1-9)
One-Vessel Disease Asymptomatic Ischemic Symptoms
One-Vessel Disease Not on AA Therapy or With AA Therapy Not on AA Therapy On 1 AA Drug (BB Preferred) On ≥2 AA Drugs
Indication PCI CABG PCI CABG PCI CABG PCI CABG
No Proximal LAD or Proximal Left Dominant LCX Involvement
Low-risk findings on noninvasive testing R (2) R (1) R (3) R (2) M (4) R (3) A (7) M (5)
Intermediate- or high-risk findings on noninvasive testing M (4) R (3) M (5) M (4) M (6) M (4) A (8) M (6)
No stress test performed or, if performed, results are indeterminate - FFR ≤0.80 M (4) R (2) M (5) R (3) M (6) M (4) A (8) M (6)
Proximal LAD or Proximal Left Dominant LCX Involvement Present
Low-risk findings on noninvasive testing M (4) R (3) M (4) M (4) M (5) M (5) A (7) A (7)
Intermediate- or high-risk findings on noninvasive testing M (5) M (5) M (6) M (6) A (7) A (7) A (8) A (8)
No stress test performed or, if performed, results are indeterminate - FFR ≤0.80 M (5) M (5) M (6) M (6) M (6) M (6) A (8) A (7)
A indicates appropriate; AA, antianginal; BB, beta blockers; CABG, coronary artery bypass graft; FFR, fractional flow reserve; iFR, instant wave-free ratio; LAD, left anterior descending coronary artery; LCX, left circumflex artery; M, may be appropriate; PCI, percutaneous coronary intervention; and R, rarely appropriate. A separate, independent rating panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate for the clinical scenario presented. Scores of 1 to 3 indicate that revascularization is considered rarely appropriate for the clinical scenario, whereas scores in the mid-range of 4 to 6 indicate that coronary revascularization may be appropriate for the clinical scenario.

Two-Vessel Disease

Appropriate Use Score (1-9)
Two-Vessel Disease Asymptomatic Ischemic Symptoms
Two-Vessel Disease Not on AA Therapy or With AA Therapy Not on AA Therapy On 1 AA Drug (BB Preferred) On ≥2 AA Drugs
Indication PCI CABG PCI CABG PCI CABG PCI CABG
No Proximal LAD Involvement
Low-risk findings on noninvasive testing R (3) R (2) M (4) R (3) M (5) M (4) A (7) M (6)
Intermediate- or high-risk findings on noninvasive testing M (5) M (4) M (6) M (5) M (6) M (4) A (7) M (6)
No stress test performed or, if performed, results are indeterminate - FFR ≤0.80 in both vessels M (5) M (4) M (6) M (4) A (7) M (5) A (8) A (8)
Proximal LAD Involvement and No Diabetes Present
Low-risk findings on noninvasive testing M (4) M (4) M (5) M (5) M (6) M (6) A (7) A (7)
Intermediate- or high-risk findings on noninvasive testing M (6) M (6) A (7) A (7) A (7) A (7) A (8) A (8)
No stress test performed or, if performed, results are indeterminate - FFR ≤0.80 in both vessels M (6) M (6) M (6) M (6) A (7) A (7) A (8) A (8)
Proximal LAD Involvement With Diabetes Present
Low-risk findings on noninvasive testing M (4) M (5) M (4) M (6) M (6) A (7) A (7) A (8)
Intermediate- or high-risk findings on noninvasive testing M (5) A (7) M (6) A (7) A (7) A (8) A (8) A (9)
No stress test performed or, if performed, results are indeterminate - FFR ≤0.80 in both vessels M (5) M (6) M (6) A (7) A (7) A (8) A (7) A (8)
A indicates appropriate; AA, antianginal; BB, beta blockers; CABG, coronary artery bypass graft; FFR, fractional flow reserve; iFR, instant wave-free ratio; LAD, left anterior descending coronary artery; M, may be appropriate; PCI, percutaneous coronary intervention; and R, rarely appropriate. A separate, independent rating panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate for the clinical scenario presented. Scores of 1 to 3 indicate that revascularization is considered rarely appropriate for the clinical scenario, whereas scores in the mid-range of 4 to 6 indicate that coronary revascularization may be appropriate for the clinical scenario.

Three-Vessel Disease

Appropriate Use Score (1-9)
Three-Vessel Disease Asymptomatic Ischemic Symptoms
Three-Vessel Disease Not on AA Therapy or With AA Therapy Not on AA Therapy On 1 AA Drug (BB Preferred) On ≥2 AA Drugs
Indication PCI CABG PCI CABG PCI CABG PCI CABG
Low Disease Complexity (e.g., Focal Stenoses, SYNTAX ≤22)
Low-risk findings on noninvasive testing M (4) M (5) M (5) M (6) M (6) M (6) A (7) A (7)
Intermediate- or high-risk findings on noninvasive testing - No diabetes M (6) A (7) A (7) A (7) A (7) A (8) A (8) A (8)
Low-risk findings on non-invasive testing - Diabetes present M (4) M (6) M (5) M (6) A (6) A (7) A (7) A (8)
Intermediate- or high-risk findings on noninvasive testing - Diabetes present M (6) A (7) M (6) A (8) A (7) A (8) A (7) A (9)
Intermediate or High Disease Complexity (e.g. Multiple Features of Complexity as Noted Previously, SYNTAX >22)
Low-risk findings on noninvasive testing - No diabetes M (4) M (6) M (4) A (7) M (5) A (7) M (6) A (8)
Intermediate- or high-risk findings on noninvasive testing - No diabetes M (5) A (7) M (6) A (7) M (6) A (8) M (6) A (9)
Low-risk findings on noninvasive testing - Diabetes present M (4) A (7) M (4) A (7) M (5) A (8) M (6) A (9)
Intermediate- or high-risk findings on noninvasive testing - Diabetes present M (4) A (8) M (5) A (8) M (5) A (8) M (6) A (9)
A indicates appropriate; AA, antianginal; BB, beta blockers; CABG, coronary artery bypass graft; M, may be appropriate; PCI, percutaneous coronary intervention; and SYNTAX, Synergy between PCI with Taxus and Cardiac Surgery trial. A separate, independent rating panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate for the clinical scenario presented. Scores of 1 to 3 indicate that revascularization is considered rarely appropriate for the clinical scenario, whereas scores in the mid-range of 4 to 6 indicate that coronary revascularization may be appropriate for the clinical scenario.

Left Main Coronary Artery Stenosis

Appropriate Use Score (1-9)
Left Main Disease Asymptomatic Ischemic Symptoms
Left Main Disease Not on AA Therapy or With AA Therapy Not on AA Therapy On 1 AA Drug (BB Preferred) On ≥2 AA Drugs
Indication PCI CABG PCI CABG PCI CABG PCI CABG
Isolated LMCA disease - Ostial or midshaft stenosis M (6) A (8) A (7) A (8) A (7) A (9) A (7) A (9)
Isolated LMCA disease - Bifurcation involvement M (5) A (8) M (5) A (8) M (5) A (9) M (6) A (9)
LMCA disease - Ostial or mid shaft stenosis - Concurrent multi vessel disease - Low disease burden (e.g., 1–2 additional focal stenoses, SYNTAX score ≤22) M (6) A (8) M (6) A (9) A (7) A (9) A (7) A (9)
Ostial or mid shaft stenosis - Concurrent multi vessel disease - Intermediate or high disease burden (e.g., 1–2 additional bifurcation stenosis, long stenoses, SYNTAX score >22) M (4) A (9) M (4) A (9) M (4) A (9) M (4) A (9)
Ostial or mid shaft stenosis - Concurrent multi vessel disease - Intermediate or high disease burden (e.g., 1–2 additional bifurcation stenosis, long stenoses, SYNTAX score >22) M (4) A (9) M (4) A (9) M (4) A (9) M (4) A (9)
LMCA disease - Bifurcation involvement - Low disease burden in other vessels (e.g., 1–2 additional focal stenosis, SYNTAX score ≤22) M (4) A (8) M (5) A (8) M (5) A (9) M (6) A (9)
LMCA disease - Bifurcation involvement - Intermediate or high disease burden in other vessels (e.g., 1–2 additional bifurcation stenosis, long stenoses, SYNTAX score >22) R (3) A (8) R (3) A (9) R (3) A (9) R (3) A (9)
A indicates appropriate; AA, antianginal; BB, beta blockers; CABG, coronary artery bypass graft; LMCA, left main coronary artery; M, may be appropriate; PCI, percutaneous coronary intervention; R, rarely appropriate; and SYNTAX, Synergy between PCI with Taxus and Cardiac Surgery trial. A separate, independent rating panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate for the clinical scenario presented. Scores of 1 to 3 indicate that revascularization is considered rarely appropriate for the clinical scenario, whereas scores in the mid-range of 4 to 6 indicate that coronary revascularization may be appropriate for the clinical scenario.

IMA to LAD Patent and Without Significant Stenoses

Appropriate Use Score (1-9)
IMA to LAD Patent and Without Significant Stenoses Asymptomatic Ischemic Symptoms
Not on AA Therapy or With AA Therapy Not on AA Therapy On 1 AA Drug (BB Preferred) On ≥2 AA Drugs
Indication PCI CABG PCI CABG PCI CABG PCI CABG
Stenosis Supplying 1 Territory Disease (Bypass Graft or Native Artery) to Territory Other Than Anterior
Low-risk findings on noninvasive testing R (3) R (1) R (3) R (2) M (6) R (3) A (7) M (4)
Intermediate- or high-risk findings on noninvasive testing M (5) R (3) M (5) R (3) A (7) M (4) A (8) M (5)
No stress test performed or, if performed, the results are indeterminate - FFR of stenosis ≤0.80 M (4) R (3) M (4) R (3) M (6) M (4) A (8) M (5)
Stenoses Supplying 2 Territories (Bypass Graft or Native Artery, Either 2 Separate Vessels or Sequential Graft Supplying 2 Territories) Not Including Anterior Territory
Low-risk findings on noninvasive testing R (3) R (2) M (4) R (3) M (6) R (3) A (7) M (5)
Intermediate- or high-risk findings on noninvasive testing M (5) R (3) M (5) M (4) A (7) M (5) A (8) M (6)
A indicates appropriate; AA, Antianginal; BB, beta blockers; CABG, coronary artery bypass graft; FFR, fractional flow reserve; iFR, instant wave-free ratio; IMA, internal mammary artery; LAD, left anterior descending coronary artery; M, may be appropriate; PCI, percutaneous coronary intervention; and R, rarely appropriate. A separate, independent rating panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate for the clinical scenario presented. Scores of 1 to 3 indicate that revascularization is considered rarely appropriate for the clinical scenario, whereas scores in the mid-range of 4 to 6 indicate that coronary revascularization may be appropriate for the clinical scenario.

IMA to LAD Not Patent

Appropriate Use Score (1-9)
IMA to LAD Not Patent Asymptomatic Ischemic Symptoms
Not on AA Therapy or With AA Therapy Not on AA Therapy On 1 AA Drug (BB Preferred) On ≥2 AA Drugs
Indication PCI CABG PCI CABG PCI CABG PCI CABG
Stenosis Supplying 1-Territory Disease (Bypass Graft or Native Artery)–Anterior (LAD) Territory
Low-risk findings on noninvasive testing M (4) R (3) M (5) R (3) M (6) M (4) A (7) M (5)
Intermediate- or high-risk findings on noninvasive testing M (6) M (4) M (6) M (4) A (7) M (5) A (8) M (6)
No stress test performed or, if performed, the results are indeterminate - FFR of stenosis ≤0.80 M (5) M (4) M (6) M (4) A (7) M (5) A (7) M (6)
Stenoses Supplying 2 Territories (Bypass Graft or Native Artery, Either 2 Separate Vessels or Sequential Graft Supplying 2 Territories) LAD Plus Other Territory
Low-risk findings on noninvasive testing M (5) M (4) M (6) M (4) A (7) M (5) A (7) M (6)
Intermediate- or high-risk findings on noninvasive testing M (6) M (5) A (7) M (6) A (7) A (7) A (8) A (8)
Stenoses Supplying 3 Territories (Bypass Graft or Native Arteries, Separate Vessels, Sequential Grafts, or Combination Thereof) LAD Plus 2 Other Territories
Low-risk findings on noninvasive testing M (5) M (5) M (6) M (5) M (6) M (6) A (7) A (7)
Intermediate- or high-risk findings on noninvasive testing A (7) A (7) A (7) A (7) A (7) A (7) A (8) A (8)
A indicates appropriate; AA, Antianginal; BB, beta blockers; CABG, coronary artery bypass graft; FFR, fractional flow reserve; iFR, instant wave-free ratio; IMA, internal mammary artery; LAD, left anterior descending coronary artery; M, may be appropriate; PCI, percutaneous coronary intervention; and R, rarely appropriate. A separate, independent rating panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate for the clinical scenario presented. Scores of 1 to 3 indicate that revascularization is considered rarely appropriate for the clinical scenario, whereas scores in the mid-range of 4 to 6 indicate that coronary revascularization may be appropriate for the clinical scenario.

2014 Focused update of 2012 AHA guidelines for the management of chronic stable angina[3][4]

Heart Team Approach Revascularization Guidelines[3][4]

Class I
"1. A Heart Team approach to revascularization is recommended in patients with diabetes mellitus and complex multivessel CAD"(Level of Evidence:C ) "
Class I
"1. Calculation of the STS and SYNTAX scores is reasonable in patients with unprotected left main and complex CAD "(Level of Evidence:B ) "

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:

References

  1. ↑ 1.0 1.1 Qaseem A, Fihn SD, Dallas P, et al. Management of patients with stable ischemic heart disease: Executive summary of a clinical practice guideline from the American College of Physicians, American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med 2012.
  2. ↑ Farkouh ME, Domanski M, Sleeper LA, Siami FS, Dangas G, Mack M; et al. (2012). "Strategies for Multivessel Revascularization in Patients with Diabetes". N Engl J Med. doi:10.1056/NEJMoa1211585. PMID 23121323.
  3. ↑ 3.0 3.1 Fihn SD, Blankenship JC, Alexander KP, Bittl JA, Byrne JG, Fletcher BJ; et al. (2014). "2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". J Am Coll Cardiol. 64 (18): 1929–49. doi:10.1016/j.jacc.2014.07.017. PMID 25077860.
  4. ↑ 4.0 4.1 Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP; et al. (2012). "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 126 (25): 3097–137. doi:10.1161/CIR.0b013e3182776f83. PMID 23166210.

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