Chronic stable angina risk stratification: Difference between revisions

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{{Chronic stable angina}}
{{Chronic stable angina}}
{{CMG}}; '''Associate Editor(s)-in-Chief:''' {{CZ}}; Smita Kohli, M.D.; [[Lakshmi Gopalakrishnan]], M.B.B.S.
{{CMG}}; '''Associate Editor(s)-in-Chief:''' {{CZ}}; Smita Kohli, M.D.; [[Lakshmi Gopalakrishnan]], M.B.B.S. ;{{AKK}}


==Overview==
==Overview==
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====Clinical Factors====
====Clinical Factors====
An initial scoring system was proposed by the ''Framingham Heart Study group'' to predict 10 year risk for patients with CAD based upon:
An initial scoring system was proposed by the Framingham Heart Study group to predict 10 year risk for patients with CAD based upon:
*Patient's age and sex  
*Patient's age and sex  
*Total [[cholesterol]]  
*Total [[cholesterol]]  
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*History of [[smoking]] and [[diabetes]]  
*History of [[smoking]] and [[diabetes]]  
*Presence of other [[peripheral vascular diseases]]
*Presence of other [[peripheral vascular diseases]]
For a full discussion on individual risk stratifying topics, visit the microchapters below:
*'''[[Chronic stable angina risk stratification electrocardiogram/chest x-ray|Electrocardiogram/chest X-ray]]'''
*'''[[Chronic stable angina risk stratification rest left ventricular function|Assessment of resting LV function]]'''
*'''[[Chronic stable angina risk stratification coronary angiography|Coronary angiography and left ventriculography]]'''
*Exercise testing for Risk Stratification and Prognosis:
:*'''[[Chronic stable angina risk assessment in patients with an intermediate or high probability of coronary artery disease|Exercise treadmill test]]'''
:*'''[[Chronic stable angina risk stratification cardiac stress imaging in patients who are able to exercise|In patients who are able to exercise]]'''
:*'''[[Chronic stable angina risk stratification cardiac stress imaging in patients who are unable to exercise|In patients who are unable to exercise]]'''


===Risk Stratification Categories and Appropriate Management===
===Risk Stratification Categories and Appropriate Management===
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===Risk Stratification of Chronic Stable Angina in Symptomatic Patients===
===Risk Stratification of Chronic Stable Angina in Symptomatic Patients===
*The next step after establishing the clinical probability of [[angina]] is to assess the risk of underlying [[coronary artery disease]] based on initial [[Chronic stable angina risk stratification electrocardiogram/chest x-ray|rest ECG]] and the patients ability to [[Chronic stable angina risk assessment in patients with an intermediate or high probability of coronary artery disease|exercise]].
The next step after establishing the clinical probability of [[angina]] is to assess the risk of underlying [[coronary artery disease]] based on initial [[Chronic stable angina risk stratification electrocardiogram/chest x-ray|rest ECG]] and the patients ability to [[Chronic stable angina risk assessment in patients with an intermediate or high probability of coronary artery disease|exercise]].
:*If the [[Chronic stable angina risk stratification electrocardiogram/chest x-ray|rest ECG]] is abnormal, the next step is to conduct a [[Chronic stable angina risk stratification cardiac stress imaging in patients who are able to exercise|stress imaging test]].
*If the [[Chronic stable angina risk stratification electrocardiogram/chest x-ray|rest ECG]] is abnormal, the next step is to conduct a [[Chronic stable angina risk stratification cardiac stress imaging in patients who are able to exercise|stress imaging test]].
:*If the patient is unable to exercise then a [[Chronic stable angina risk stratification cardiac stress imaging in patients who are unable to exercise|pharmacological stress test]] is used to stratify the risk underlying the [[atherosclerosis|atherosclerotic state]].
*If the patient is unable to exercise then a [[Chronic stable angina risk stratification cardiac stress imaging in patients who are unable to exercise|pharmacological stress test]] is used to stratify the risk underlying the [[atherosclerosis|atherosclerotic state]].
:*For patients with [[ Canadian Cardiovascular Society#C.C.S. Class III|CCS class III or IV]] [[angina]], patients with poor [[LVEF]] or non responsive to medical therapy there may be some benefit to performing [[Chronic stable angina risk stratification coronary angiography|coronary angiography]].
*For patients with [[ Canadian Cardiovascular Society#C.C.S. Class III|CCS class III or IV]] [[angina]], patients with poor [[LVEF]] or non responsive to medical therapy there may be some benefit to performing [[Chronic stable angina risk stratification coronary angiography|coronary angiography]].
 
==ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/ STS 2017 Appropriate Use Criteria for Coronary Revascularization in Patients With Stable Ischemic Heart Disease==
 
{| class="wikitable" style="width: 80%; text-align: justify;"
|-
| '''Noninvasive Risk Stratification'''
|-
| '''High risk (>3% annual death or MI)'''
'''1.''' Severe resting LV dysfunction (LVEF <35%) not readily explained by noncoronary causes
 
'''2.''' Resting perfusion abnormalities ≥10% of the myocardium in patients without prior history or evidence of MI
 
'''3.''' Stress ECG findings including ≥2 mm of ST-segment depression at low workload or persisting into recovery, exercise-induced ST-segment elevation, or
exercise-induced VT/VF
 
'''4.''' Severe stress-induced LV dysfunction (peak exercise LVEF <45% or drop in LVEF with stress ≥10%)
 
'''5.''' Stress-induced perfusion abnormalities encumbering ≥10% myocardium or stress segmental scores indicating multiple vascular territories with
abnormalities
 
'''6.''' Stress-induced LV dilation
 
'''7.''' Inducible wall motion abnormality (involving >2 segments or 2 coronary beds)
 
'''8.''' Wall motion abnormality developing at low dose of dobutamine (≤ 10 mg/kg/min) or at a low heart rate (<120 beats/min)
 
'''9.''' CAC score >400 Agatston units
 
'''10.''' Multivessel obstructive CAD (≥70% stenosis) or left main stenosis (≥50% stenosis) on CCTA
|-
| '''Intermediate risk (1% to 3% annual death or MI)'''
'''1.''' Mild/moderate resting LV dysfunction (LVEF 35% to 49%) not readily explained by noncoronary causes
 
'''2'''. Resting perfusion abnormalities in 5% to 9.9% of the myocardium in patients without a history or prior evidence of MI


====For a Full Discussion on Individual Risk Stratifying Topics, Visit the Microchapters Below====
'''3.''' ≥1 mm of ST-segment depression occurring with exertional symptoms
'''[[Chronic stable angina risk stratification electrocardiogram/chest x-ray|Electrocardiogram/chest X-ray]] | [[Chronic stable angina risk stratification rest left ventricular function|Assessment of resting LV function]] | [[Chronic stable angina risk stratification coronary angiography|Coronary angiography and left ventriculography]]'''


Exercise testing for Risk Stratification and Prognosis: '''[[Chronic stable angina risk assessment in patients with an intermediate or high probability of coronary artery disease|Exercise treadmill test]] | [[Chronic stable angina risk stratification cardiac stress imaging in patients who are able to exercise|In patients who are able to exercise]] | [[Chronic stable angina risk stratification cardiac stress imaging in patients who are unable to exercise|In patients who are unable to exercise]]'''
'''4.''' Stress-induced perfusion abnormalities encumbering 5% to 9.9% of the myocardium or stress segmental scores (in multiple segments) indicating 1 vascular territory with abnormalities but without LV dilation


===Guidelines for Risk Stratification of Chronic Stable Angina in Asymptomatic Patients===
'''5.''' Small wall motion abnormality involving 1 to 2 segments and only 1 coronary bed
'''[[Chronic stable angina risk stratification in asymptomatic patients by noninvasive testing|Risk Stratification by Noninvasive Testing]] | [[Chronic stable angina risk stratification in asymptomatic patients by coronary angiography|Coronary Angiography in Asymptomatic Patients]]'''


==Vote on and Suggest Revisions to the Current Guidelines==
'''6.''' CAC score 100 to 399 Agatston units
*[[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==
'''7.''' One vessel CAD with ≥70% stenosis or moderate CAD stenosis (50% to 69% stenosis) in ≥2 arteries on CCTA
*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>
|-  
|'''Low risk (<1% annual death or MI)'''
'''1.''' Low-risk treadmill score (score ≥5) or no new ST segment changes or exercise-induced chest pain symptoms; when achieving maximal levels of exercise


*Guidelines on the management of stable angina pectoris: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology <ref name="pmid16735367">{{cite journal| author=Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F et al.| title=Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. | journal=Eur Heart J | year= 2006 | volume= 27 | issue= 11 | pages= 1341-81 | pmid=16735367 | doi=10.1093/eurheartj/ehl001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16735367  }} </ref>
'''2.''' Normal or small myocardial perfusion defect at rest or with stress encumbering <5% of the myocardium*


*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>
'''3.''' Normal stress or no change of limited resting wall motion abnormalities during stress


*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>
'''4.''' CAC score <100 Agaston units
5. No coronary stenosis >50% on CCTA
|-
|CAC indicates coronary artery calcium; CAD, coronary artery disease; CCTA, coronary computed tomography angiography; LV, left ventricular; LVEF, left ventricular ejection fraction; and MI, myocardial infarction.
|}
===Guidelines for Risk Stratification of Chronic Stable Angina ===
Visit the microchapters below:
*'''[[Chronic stable angina risk stratification in asymptomatic patients by noninvasive testing|Risk Stratification by Noninvasive Testing]]'''
*'''[[Chronic stable angina risk stratification by coronary angiography|Risk Stratification by Coronary Angiography]]'''


==References==
==References==
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Latest revision as of 18:28, 28 October 2017

Chronic stable angina Microchapters

Acute Coronary Syndrome Main Page

Home

Patient Information

Overview

Historical Perspective

Classification

Classic
Chronic Stable Angina
Atypical
Walk through Angina
Mixed Angina
Nocturnal Angina
Postprandial Angina
Cardiac Syndrome X
Vasospastic Angina

Differentiating Chronic Stable Angina from Acute Coronary Syndromes

Pathophysiology

Epidemiology and Demographics

Risk Stratification

Pretest Probability of CAD in a Patient with Angina

Prognosis

Diagnosis

History and Symptoms

Physical Examination

Test Selection Guideline for the Individual Basis

Laboratory Findings

Electrocardiogram

Exercise ECG

Chest X Ray

Myocardial Perfusion Scintigraphy with Pharmacologic Stress

Myocardial Perfusion Scintigraphy with Thallium

Echocardiography

Exercise Echocardiography

Computed coronary tomography angiography(CCTA)

Positron Emission Tomography

Ambulatory ST Segment Monitoring

Electron Beam Tomography

Cardiac Magnetic Resonance Imaging

Coronary Angiography

Treatment

Medical Therapy

Revascularization

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CABG
Hybrid Coronary Revascularization

Alternative Therapies for Refractory Angina

Transmyocardial Revascularization (TMR)
Spinal Cord Stimulation (SCS)
Enhanced External Counter Pulsation (EECP)
ACC/AHA Guidelines for Alternative Therapies in patients with Refractory Angina

Discharge Care

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Guidelines for Asymptomatic Patients

Noninvasive Testing in Asymptomatic Patients
Risk Stratification by Coronary Angiography
Pharmacotherapy to Prevent MI and Death in Asymptomatic Patients

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Case #1

Chronic stable angina risk stratification On the Web

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Risk calculators and risk factors for Chronic stable angina risk stratification

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Smita Kohli, M.D.; Lakshmi Gopalakrishnan, M.B.B.S. ;Arzu Kalayci, M.D. [3]

Overview

The average mortality in patients with stable angina ranges from 1-3%. However, the prognosis varies widely depending on various factors such as: the duration and severity of symptoms, resting ECG abnormalities, abnormal left ventricular function and associated comorbidities.[1]

Risk Stratification

Risk Stratification Based on Different Factors

Anatomic Factors

Clinical Factors

An initial scoring system was proposed by the Framingham Heart Study group to predict 10 year risk for patients with CAD based upon:

For a full discussion on individual risk stratifying topics, visit the microchapters below:

  • Exercise testing for Risk Stratification and Prognosis:

Risk Stratification Categories and Appropriate Management

Risk Stratification of Chronic Stable Angina in Symptomatic Patients

The next step after establishing the clinical probability of angina is to assess the risk of underlying coronary artery disease based on initial rest ECG and the patients ability to exercise.

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

Noninvasive Risk Stratification
High risk (>3% annual death or MI)

1. Severe resting LV dysfunction (LVEF <35%) not readily explained by noncoronary causes

2. Resting perfusion abnormalities ≥10% of the myocardium in patients without prior history or evidence of MI

3. Stress ECG findings including ≥2 mm of ST-segment depression at low workload or persisting into recovery, exercise-induced ST-segment elevation, or exercise-induced VT/VF

4. Severe stress-induced LV dysfunction (peak exercise LVEF <45% or drop in LVEF with stress ≥10%)

5. Stress-induced perfusion abnormalities encumbering ≥10% myocardium or stress segmental scores indicating multiple vascular territories with abnormalities

6. Stress-induced LV dilation

7. Inducible wall motion abnormality (involving >2 segments or 2 coronary beds)

8. Wall motion abnormality developing at low dose of dobutamine (≤ 10 mg/kg/min) or at a low heart rate (<120 beats/min)

9. CAC score >400 Agatston units

10. Multivessel obstructive CAD (≥70% stenosis) or left main stenosis (≥50% stenosis) on CCTA

Intermediate risk (1% to 3% annual death or MI)

1. Mild/moderate resting LV dysfunction (LVEF 35% to 49%) not readily explained by noncoronary causes

2. Resting perfusion abnormalities in 5% to 9.9% of the myocardium in patients without a history or prior evidence of MI

3. ≥1 mm of ST-segment depression occurring with exertional symptoms

4. Stress-induced perfusion abnormalities encumbering 5% to 9.9% of the myocardium or stress segmental scores (in multiple segments) indicating 1 vascular territory with abnormalities but without LV dilation

5. Small wall motion abnormality involving 1 to 2 segments and only 1 coronary bed

6. CAC score 100 to 399 Agatston units

7. One vessel CAD with ≥70% stenosis or moderate CAD stenosis (50% to 69% stenosis) in ≥2 arteries on CCTA

Low risk (<1% annual death or MI)

1. Low-risk treadmill score (score ≥5) or no new ST segment changes or exercise-induced chest pain symptoms; when achieving maximal levels of exercise

2. Normal or small myocardial perfusion defect at rest or with stress encumbering <5% of the myocardium*

3. Normal stress or no change of limited resting wall motion abnormalities during stress

4. CAC score <100 Agaston units 5. No coronary stenosis >50% on CCTA

CAC indicates coronary artery calcium; CAD, coronary artery disease; CCTA, coronary computed tomography angiography; LV, left ventricular; LVEF, left ventricular ejection fraction; and MI, myocardial infarction.

Guidelines for Risk Stratification of Chronic Stable Angina

Visit the microchapters below:

References

  1. ↑ Daly CA, De Stavola B, Sendon JL, Tavazzi L, Boersma E, Clemens F et al. (2006) Predicting prognosis in stable angina--results from the Euro heart survey of stable angina: prospective observational study. BMJ 332 (7536):262-7. DOI:10.1136/bmj.38695.605440.AE PMID: 16415069


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