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(/* ESC Guidelines- Revascularization to improve prognosis in patients with stable angina (DO NOT EDIT){{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 pe...)
 
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__NOTOC__
__NOTOC__
{{Chronic stable angina}}
{{Chronic stable angina}}
{{CMG}}
{{CMG}}; '''Associate Editor-In-Chief:''' [[Lakshmi Gopalakrishnan]], M.B.B.S.


==Overview==
==Overview==
Reduced LV function, number and location of stenoses, workload in METs calculated using Duke score are the strongest predictors of survival in patients with chronic stable angina.
Reduced LV function, number and location of stenoses, workload in METs calculated using Duke score are the strongest predictors of survival in patients with chronic stable angina.


==Mortality Index==
==Prognosis==
*The estimated annual mortality rate in patients with chronic stable angina ranges from '''0.9% - 1.4%''' <ref name="pmid8682134">Rehnqvist N, Hjemdahl P, Billing E, Björkander I, Eriksson SV, Forslund L et al. (1996) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=8682134 Effects of metoprolol vs verapamil in patients with stable angina pectoris. The Angina Prognosis Study in Stockholm (APSIS)] ''Eur Heart J'' 17 (1):76-81. PMID: [http://pubmed.gov/8682134 8682134]</ref> <ref name="pmid14522473">Henderson RA, Pocock SJ, Clayton TC, Knight R, Fox KA, Julian DG et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=14522473 Seven-year outcome in the RITA-2 trial: coronary angioplasty versus medical therapy.] ''J Am Coll Cardiol'' 42 (7):1161-70. PMID: [http://pubmed.gov/14522473 14522473]</ref> <ref name="pmid1360557">Juul-Möller S, Edvardsson N, Jahnmatz B, Rosén A, Sørensen S, Omblus R (1992) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=1360557 Double-blind trial of aspirin in primary prevention of myocardial infarction in patients with stable chronic angina pectoris. The Swedish Angina Pectoris Aspirin Trial (SAPAT) Group.] ''Lancet'' 340 (8833):1421-5. PMID: [http://pubmed.gov/1360557 1360557]</ref> with an annual incidence of non-fatal [[MI]] between '''0.5%'''<ref name="pmid14657064">Pepine CJ, Handberg EM, Cooper-DeHoff RM, Marks RG, Kowey P, Messerli FH et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=14657064 A calcium antagonist vs a non-calcium antagonist hypertension treatment strategy for patients with coronary artery disease. The International Verapamil-Trandolapril Study (INVEST): a randomized controlled trial.] ''JAMA'' 290 (21):2805-16. [http://dx.doi.org/10.1001/jama.290.21.2805 DOI:10.1001/jama.290.21.2805] PMID: [http://pubmed.gov/14657064 14657064]</ref> and '''2.6%'''<ref name="pmid8682138">Fox KM, Mulcahy D, Findlay I, Ford I, Dargie HJ (1996) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=8682138 The Total Ischaemic Burden European Trial (TIBET). Effects of atenolol, nifedipine SR and their combination on the exercise test and the total ischaemic burden in 608 patients with stable angina. The TIBET Study Group.] ''Eur Heart J'' 17 (1):96-103. PMID: [http://pubmed.gov/8682138 8682138]</ref>.
===Mortality===
*The estimated annual mortality rate in patients with chronic stable angina ranges from 0.9% - 1.4%<ref name="pmid8682134">Rehnqvist N, Hjemdahl P, Billing E, Björkander I, Eriksson SV, Forslund L et al. (1996) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=8682134 Effects of metoprolol vs verapamil in patients with stable angina pectoris. The Angina Prognosis Study in Stockholm (APSIS)] ''Eur Heart J'' 17 (1):76-81. PMID: [http://pubmed.gov/8682134 8682134]</ref><ref name="pmid14522473">Henderson RA, Pocock SJ, Clayton TC, Knight R, Fox KA, Julian DG et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=14522473 Seven-year outcome in the RITA-2 trial: coronary angioplasty versus medical therapy.] ''J Am Coll Cardiol'' 42 (7):1161-70. PMID: [http://pubmed.gov/14522473 14522473]</ref><ref name="pmid1360557">Juul-Möller S, Edvardsson N, Jahnmatz B, Rosén A, Sørensen S, Omblus R (1992) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=1360557 Double-blind trial of aspirin in primary prevention of myocardial infarction in patients with stable chronic angina pectoris. The Swedish Angina Pectoris Aspirin Trial (SAPAT) Group.] ''Lancet'' 340 (8833):1421-5. PMID: [http://pubmed.gov/1360557 1360557]</ref> with an annual incidence of non-fatal [[MI]] between 0.5%<ref name="pmid14657064">Pepine CJ, Handberg EM, Cooper-DeHoff RM, Marks RG, Kowey P, Messerli FH et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=14657064 A calcium antagonist vs a non-calcium antagonist hypertension treatment strategy for patients with coronary artery disease. The International Verapamil-Trandolapril Study (INVEST): a randomized controlled trial.] ''JAMA'' 290 (21):2805-16. [http://dx.doi.org/10.1001/jama.290.21.2805 DOI:10.1001/jama.290.21.2805] PMID: [http://pubmed.gov/14657064 14657064]</ref> and 2.6%.<ref name="pmid8682138">Fox KM, Mulcahy D, Findlay I, Ford I, Dargie HJ (1996) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=8682138 The Total Ischaemic Burden European Trial (TIBET). Effects of atenolol, nifedipine SR and their combination on the exercise test and the total ischaemic burden in 608 patients with stable angina. The TIBET Study Group.] ''Eur Heart J'' 17 (1):96-103. PMID: [http://pubmed.gov/8682138 8682138]</ref>


*The '''Framingham Heart Study''' <ref name="pmid5058341">Kannel WB, Feinleib M (1972) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=5058341 Natural history of angina pectoris in the Framingham study. Prognosis and survival.] ''Am J Cardiol'' 29 (2):154-63. PMID: [http://pubmed.gov/5058341 5058341]</ref> <ref name="pmid8252666">Murabito JM, Evans JC, Larson MG, Levy D (1993) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=8252666 Prognosis after the onset of coronary heart disease. An investigation of differences in outcome between the sexes according to initial coronary disease presentation.] ''Circulation'' 88 (6):2548-55. PMID: [http://pubmed.gov/8252666 8252666]</ref> revealed the 2-year incidence rates of nonfatal [[MI]] and [[coronary heart disease]] death for men and women who initially presented with stable angina was 14.3% and 5.5% in men, and 6.2 and 3.8% in women, respectively.  
*The Framingham Heart Study<ref name="pmid5058341">Kannel WB, Feinleib M (1972) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=5058341 Natural history of angina pectoris in the Framingham study. Prognosis and survival.] ''Am J Cardiol'' 29 (2):154-63. PMID: [http://pubmed.gov/5058341 5058341]</ref><ref name="pmid8252666">Murabito JM, Evans JC, Larson MG, Levy D (1993) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=8252666 Prognosis after the onset of coronary heart disease. An investigation of differences in outcome between the sexes according to initial coronary disease presentation.] ''Circulation'' 88 (6):2548-55. PMID: [http://pubmed.gov/8252666 8252666]</ref> revealed the 2-year incidence rates of non-fatal [[MI]] and [[coronary heart disease]] death for men and women who initially presented with stable angina was 14.3% MI and 5.5% CAD death in men, and 6.2% MI and 3.8% CAD death in women.


*'''Relative Risk based on anginal characteristics in elderly associated with no comorbidities:''' <ref name="pmid8609316">Califf RM, Armstrong PW, Carver JR, D'Agostino RB, Strauss WE (1996) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=8609316 27th Bethesda Conference: matching the intensity of risk factor management with the hazard for coronary disease events. Task Force 5. Stratification of patients into high, medium and low risk subgroups for purposes of risk factor management.] ''J Am Coll Cardiol'' 27 (5):1007-19. PMID: [http://pubmed.gov/8609316 8609316]</ref>
*Relative risk based on anginal characteristics in elderly associated with no comorbidities:<ref name="pmid8609316">Califf RM, Armstrong PW, Carver JR, D'Agostino RB, Strauss WE (1996) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=8609316 27th Bethesda Conference: matching the intensity of risk factor management with the hazard for coronary disease events. Task Force 5. Stratification of patients into high, medium and low risk subgroups for purposes of risk factor management.] ''J Am Coll Cardiol'' 27 (5):1007-19. PMID: [http://pubmed.gov/8609316 8609316]</ref>
 
{| border="1" align="center" style="background:lightskyblue"
{| border="1" align="center" style="background:lightblue"
|-
| bgcolor="CornFlowerBlue" |'''Characteristic'''
| bgcolor="CornFlowerBlue" |'''1-yr Mortality Rate''' (%)
|-
|-
| Characteristic
| Non anginal pain
| Non anginal pain
| 0.4
|-
| Atypical angina
| Atypical angina
| 0.8
|-
| Stable angina
| Stable angina
| 1.3
|-
| Progressive
| Progressive
| 1.5
|-
| Unstable
| Unstable
|-
| 1-yr Mortality Rate (%)
| 0.4
| 0.8
| 1.3
| 1.5
| 1.7
| 1.7
|}
|}


==Factors that affect Long Term Prognosis in patients with Chronic Stable Angina==
===Factors that Affect Long Term Prognosis in Patients with Chronic Stable Angina===


*'''Reduced LV function''' (reduced [[ejection fraction]]; [[LV hypertrophy]]) remains the strongest predictor of survival in patients with chronic stable angina. <ref name="pmid8609316">Califf RM, Armstrong PW, Carver JR, D'Agostino RB, Strauss WE (1996) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=8609316 27th Bethesda Conference: matching the intensity of risk factor management with the hazard for coronary disease events. Task Force 5. Stratification of patients into high, medium and low risk subgroups for purposes of risk factor management.] ''J Am Coll Cardiol'' 27 (5):1007-19. PMID: [http://pubmed.gov/8609316 8609316]</ref>
*Reduced LV function (reduced [[ejection fraction]]; [[LV hypertrophy]]) remains the strongest predictor of survival in patients with chronic stable angina.<ref name="pmid8609316">Califf RM, Armstrong PW, Carver JR, D'Agostino RB, Strauss WE (1996) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=8609316 27th Bethesda Conference: matching the intensity of risk factor management with the hazard for coronary disease events. Task Force 5. Stratification of patients into high, medium and low risk subgroups for purposes of risk factor management.] ''J Am Coll Cardiol'' 27 (5):1007-19. PMID: [http://pubmed.gov/8609316 8609316]</ref>


*'''Number of stenoses''' (patients with three-vessel disease have a higher mortality rate in comparison to patients with single vessel disease).
*Location of stenosis (proximal stenosis involving the [[left main]] and proximal [[left anterior descending artery]] ([[LAD]]), are associated with poor outcomes and increased risk of ischemic events).


:*[[CAD]] Prognostic index: <ref name="pmid8609316">Califf RM, Armstrong PW, Carver JR, D'Agostino RB, Strauss WE (1996) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=8609316 27th Bethesda Conference: matching the intensity of risk factor management with the hazard for coronary disease events. Task Force 5. Stratification of patients into high, medium and low risk subgroups for purposes of risk factor management.] ''J Am Coll Cardiol'' 27 (5):1007-19. PMID: [http://pubmed.gov/8609316 8609316]</ref>
*Number of stenoses (patients with three-vessel disease have a higher mortality rate in comparison to patients with single vessel disease).


{| border="1" align="center" style="background:lightblue"
<center>'''Table 1:Coronary Artery Disease Prognostic Index<ref name="pmid8609316">Califf RM, Armstrong PW, Carver JR, D'Agostino RB, Strauss WE (1996)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=8609316 27th Bethesda Conference: matching the intensity of risk factor management with the hazard for coronary disease events. Task Force 5. Stratification of patients into high, medium and low risk subgroups for purposes of risk factor management.] ''J Am Coll Cardiol'' 27 (5):1007-19. PMID: [http://pubmed.gov/8609316 8609316]</ref>'''
{| border="1" align="center" style="background:lightskyblue"
|-
|-
| Extent of CAD
| bgcolor="CornFlowerBlue" |'''Extent of CAD'''
| Prognostic Weight (0-100)
| bgcolor="CornFlowerBlue" |'''Prognostic Weight''' (0-100)
| 5-year Mortality Rate (%) (assuming medical treatment only)
| bgcolor="CornFlowerBlue" |'''5-year Mortality Rate''' (%)  
|- rowspan="2" |
|
|
| ''(assuming medical treatment only)''
|-
|-
| 1-vessel disease, 75%
| 1-vessel disease, 75%
Line 91: Line 100:
| 74
| 74
| 41
| 41
|}
|}</center>


*Associated risk factors<ref name="pmid16415069">Daly CA, De Stavola B, Sendon JL, Tavazzi L, Boersma E, Clemens F et al. (2006) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16415069 Predicting prognosis in stable angina--results from the Euro heart survey of stable angina: prospective observational study.] ''BMJ'' 332 (7536):262-7. [http://dx.doi.org/10.1136/bmj.38695.605440.AE DOI:10.1136/bmj.38695.605440.AE] PMID: [http://pubmed.gov/16415069 16415069]</ref> that contribute to poor outcomes are:
:*[[Smoking]]
:*[[Diabetes mellitus]]
:*[[Hypertension]]
:*[[Hypercholesterolemia]]
:*Low [[HDL]]-C.


===Duke Score (Exercise Treadmill Test)<ref name="pmid19384658">Johnson GG, Decker WW, Lobl JK, Laudon DA, Hess JJ, Lohse CM et al. (2008) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19384658 Risk stratification of patients in an emergency department chest pain unit: prognostic value of exercise treadmill testing using the Duke score.] ''Int J Emerg Med'' 1 (2):91-5. [http://dx.doi.org/10.1007/s12245-008-0031-5 DOI:10.1007/s12245-008-0031-5] PMID: [http://pubmed.gov/19384658 19384658]</ref>===


*'''Location of stenosis''' (proximal stenosis involving the left main and proximal LAD, are associated with poor outcomes and increased risk of ischemic events).
*Workload in [[METs]] assessed using the DUKE Score is an important factor in estimating the prognosis of patients with chronic stable angina.


*Associated '''risk factors''' <ref name="pmid16415069">Daly CA, De Stavola B, Sendon JL, Tavazzi L, Boersma E, Clemens F et al. (2006) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16415069 Predicting prognosis in stable angina--results from the Euro heart survey of stable angina: prospective observational study.] ''BMJ'' 332 (7536):262-7. [http://dx.doi.org/10.1136/bmj.38695.605440.AE DOI:10.1136/bmj.38695.605440.AE] PMID: [http://pubmed.gov/16415069 16415069]</ref> that contribute to poor outcomes are:
*Duke score = [(exercise duration in minutes) - (5 x [[ST segment deviation]] in millimeters) - (4 x treadmill angina index)]
:*Smoking,
:*[[Diabetes mellitus]],
:*[[Hypertension]],
:*[[Hypercholesterolemia]],
:*Low [[HDL]]-C.


==Duke Score (Exercise Treadmill Test)<ref name="pmid19384658">Johnson GG, Decker WW, Lobl JK, Laudon DA, Hess JJ, Lohse CM et al. (2008) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19384658 Risk stratification of patients in an emergency department chest pain unit: prognostic value of exercise treadmill testing using the Duke score.] ''Int J Emerg Med'' 1 (2):91-5. [http://dx.doi.org/10.1007/s12245-008-0031-5 DOI:10.1007/s12245-008-0031-5] PMID: [http://pubmed.gov/19384658 19384658]</ref>==
*Angina index:
:*0 for no angina,  
:*1 for angina, and
:*2 if angina is the reason for stopping the test.  


*'''Workload in METs''' assessed using the DUKE Score is an important factor in estimating the prognosis of patients with chronic stable angina.
{| border="1" align="center" style="background:lightskyblue"
 
*'''Duke score = [(exercise duration in minutes) - (5 x [[ST segment deviation]] in millimeters) - (4 x treadmill angina index)]'''
 
{| border="1" align="center" style="background:lightblue"
|-
|-
| Risk (DTS)
| bgcolor="CornFlowerBlue" |'''CAD risk probability (DTS)'''
| 4-year survival
| bgcolor="CornFlowerBlue" |'''4-year survival'''
| Annual mortality
| bgcolor="CornFlowerBlue" |'''Annual mortality'''
|-
|-
| LOW (>5)
| Low probability (more than 5 DTS)
| 99%
| 99%
| 0.25%
| 0.25%
|-
|-
| MODERATE (-10 to 4)
| Moderate probability (-10 to 4 DTS)
| 95%
| 95%
| 1.25%
| 1.25%
|-
|-
| HIGH (< -10)
| High probability (less than -10 DTS)
| 79%
| 79%
| 5%
| 5%
|}
|}


==ESC Recommendations for pharmacological therapy to improve prognosis in patients with stable angina (DO NOT EDIT)<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>==
''For more information about prognosis of excercise stress testing, click [[Exercise stress testing#Prognosis|here]].''
{{cquote|
===Class I===
'''1.''' [[Aspirin]] 75 mg daily in all patients without specific contraindications (i.e. active GI bleeding, aspirin allergy, or previous aspirin intolerance). ''(Level of Evidence: A)''


'''2.''' [[Statin]] therapy for all patients with [[coronary artery disease]]. ''(Level of Evidence: A)''
==ESC Guidelines- Pharmacological therapy to improve prognosis in patients with stable angina (DO NOT EDIT)<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>==


'''3.''' [[ACE-inhibitor]] therapy in patients with coincident indications for ACE-inhibition, such as [[hypertension]], [[heart failure]], [[LV dysfunction]], prior [[MI]] with LV dysfunction, or [[diabetes]]. ''(Level of Evidence: A)''
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[European society of cardiology#Classes of Recommendation|Class I]]


'''4.''' Oral [[beta-blocker]] therapy in patients post-[[MI]] or with [[heart failure]]. ''(level of evidence: A)''
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' [[Chronic stable angina treatment aspirin|Aspirin]] 75 mg daily in all patients without specific contraindications (i.e. active GI bleeding, aspirin allergy, or previous aspirin intolerance). ''([[European society of cardiology#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' [[Chronic stable angina treatment anti-lipid agents|Statin therapy]] for all patients with [[coronary artery disease]]. ''([[European society of cardiology#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' [[Chronic stable angina treatment angiotensin converting enzyme inhibitors (ACEI) and renin angiotensin aldosterone system blockers (RAAS blockers)|ACE-inhibitor therapy]] in patients with coincident indications for ACE-inhibition, such as [[hypertension]], [[heart failure]], [[LV dysfunction]], prior [[MI]] with LV dysfunction, or [[diabetes]]. ''([[European society of cardiology#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' [[Chronic stable angina treatment beta blockers|Oral beta-blocker therapy]] in patients post-[[MI]] or with [[heart failure]]. ''([[European society of cardiology#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|}


===Class IIa===
{|class="wikitable"
'''1.''' [[ACE-inhibitor]] therapy in all patients with [[angina]] and proven [[coronary artery disease]]. ''(level of evidence: B)''
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[European society of cardiology#Classes of Recommendations|Class IIa]]


'''2.''' [[Clopidogrel]] as an alternative antiplatelet agent in patients with stable angina who cannot take [[aspirin]] (e.g. aspirin allergic. ''(level of evidence: B)''
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' [[Chronic stable angina treatment angiotensin converting enzyme inhibitors (ACEI) and renin angiotensin aldosterone system blockers (RAAS blockers)|ACE-inhibitor therapy]] in all patients with [[Chronic stable angina definition|angina]] and proven [[coronary artery disease]]. ''([[European society of cardiology#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' [[Chronic stable angina treatment clopidogrel|Clopidogrel]] as an alternative antiplatelet agent in patients with stable angina who cannot take [[Chronic stable angina treatment aspirin|aspirin]] (e.g. aspirin allergic). ''([[European society of cardiology#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' High dose [[Chronic stable angina treatment anti-lipid agents|statin therapy]] in high-risk (0.2% annual CV mortality) patients with proven [[coronary artery disease]]. ''([[European society of cardiology#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}


'''3.''' High dose [[statin]] therapy in high-risk (0.2% annual CV mortality) patients with proven [[coronary artery disease]]. ''(level of evidence: B)''
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[European society of cardiology#Classes of Recommendations|Class IIa]]


===Class IIb===
|-
'''1.''' [[Fibrate]] therapy in patients with low [[HDL]] and high [[triglycerides]] who have [[diabetes]] or the [[metabolic syndrome]]. ''(level of evidence: B)''
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' [[Chronic stable angina treatment anti-lipid agents|Fibrate therapy]] in patients with [[HDL|low HDL]] and [[triglycerides|high triglycerides]] who have [[diabetes]] or the [[metabolic syndrome]]. ''([[European society of cardiology#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' [[Chronic stable angina treatment anti-lipid agents|Fibrate]] or [[nicotinic acid]] as adjunctive therapy to [[Chronic stable angina treatment anti-lipid agents|statin]] in patients with [[HDL|low HDL]] and [[triglycerides|high triglycerides]] at high risk (0.2% annual CV mortality). ''([[European society of cardiology#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}


'''2.''' [[Fibrate]] or [[nicotinic acid]] as adjunctive therapy to [[statin]] in patients with low [[HDL]] and high [[triglycerides]] at high
==ESC Guidelines- Revascularization to improve prognosis in patients with stable angina (DO NOT EDIT)<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>==
risk (0.2% annual CV mortality). ''(level of evidence: C)''}}


==ESC Recommendations for revascularization to improve prognosis in patients with stable angina (DO NOT EDIT)<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>==
{|class="wikitable"
{{cquote|
|-
===Class I===
| colspan="1" style="text-align:center; background:LightGreen"|[[European society of cardiology#Classes of Recommendations|Class I]]
'''1.''' [[CABG]] for significant left main [[CAD]] or its equivalent (i.e. severe stenosis of ostial/proximal segment of left descending and circumflex coronary arteries). ''(level of evidence: A)''


'''2.''' [[CABG]] for significant proximal stenosis of three major vessels, particularly in those patients with abnormal LV function or with early or extensive reversible [[ischaemia]] on functional testing. ''(level of evidence: A)''
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' [[Chronic stable angina revascularization coronary artery bypass grafting(CABG)|CABG]] for significant left main [[CAD]] or its equivalent (i.e. severe stenosis of ostial/proximal segment of left descending and circumflex coronary arteries). ''([[European society of cardiology#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' [[Chronic stable angina revascularization coronary artery bypass grafting(CABG)|CABG]] for significant proximal stenosis of three major vessels, particularly in those patients with abnormal LV function or with early or extensive reversible [[ischaemia]] on functional testing. ''([[European society of cardiology#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' [[Chronic stable angina revascularization coronary artery bypass grafting(CABG)|CABG]] for one- or two-vessel disease with high-grade stenosis of [[LAD|proximal LAD]] with reversible [[ischaemia]] on non-invasive testing.  ''([[European society of cardiology#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' [[Chronic stable angina revascularization coronary artery bypass grafting(CABG)|CABG]] for significant disease with impaired LV function and viability demonstrated by non-invasive testing. ''([[European society of cardiology#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}


'''3.''' [[CABG]] for one- or two-vessel disease with high-grade stenosis of proximal [[LAD]] with reversible [[ischaemia]] on non-invasive testing.  ''(level of evidence: A)''
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[European society of cardiology#Classes of Recommendations|Class IIa]]


'''4.''' [[CABG]] for significant disease with impaired LV function and viability demonstrated by non-invasive testing. ''(level of evidence: B)''
|-
 
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' [[Chronic stable angina revascularization coronary artery bypass grafting(CABG)|CABG]] for one- or two-vessel [[CAD]] without significant [[LAD|proximal LAD]] stenosis in patients who have survived [[sudden cardiac death]] or sustained [[ventricular tachycardia]]. ''([[European society of cardiology#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
===Class IIa===
|-
'''1.''' [[CABG]] for one- or two-vessel [[CAD]] without significant proximal LAD stenosis in patients who have survived [[sudden cardiac death]] or sustained [[ventricular tachycardia]]. ''(level of evidence: B)''
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' [[Chronic stable angina revascularization coronary artery bypass grafting(CABG)|CABG]] for significant three-vessel disease in [[diabetics]] with reversible [[ischaemia]] on functional testing. ''([[European society of cardiology#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
 
|-
'''2.''' [[CABG]] for significant three-vessel disease in [[diabetics]] with reversible [[ischaemia]] on functional testing. ''(level of evidence: C)''
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' [[Chronic stable angina revascularization percutaneous coronary intervention(PCI)|PCI]] or [[Chronic stable angina revascularization coronary artery bypass grafting(CABG)|CABG]] for patients with reversible [[ischaemia]] on functional testing and evidence of frequent episodes of [[ischaemia]] during daily activities. ''([[European society of cardiology#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
 
|}
'''3.''' [[PCI]] or [[CABG]] for patients with reversible [[ischaemia]] on functional testing and evidence of frequent episodes of [[ischaemia]] during daily activities. ''(level of evidence: C)''}}
 
==Vote on and Suggest Revisions to the Current Guidelines==
*[[The Living Guidelines: Chronic Stable Angina Pectoris | The Chronic Stable Angina Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines]]
 
==Sources==
*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=url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16735367 [http://www.escardio.org/guidelines-surveys/esc-guidelines/GuidelinesDocuments/guidelines-angina-FT.pdf]}} </ref>
 
*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. [http://circ.ahajournals.org/content/99/21/2829.full.pdf] PMID: [http://pubmed.gov/10351980 10351980]</ref>
 
*TheACC/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.[http://content.onlinejacc.org/cgi/reprint/41/1/159.pdf] 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://content.onlinejacc.org/cgi/reprint/50/23/2264.pdf] PMID: [http://pubmed.gov/17998462 17998462]</ref>


==References==
==References==
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Latest revision as of 19:04, 29 January 2013

Chronic stable angina Microchapters

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Differentiating Chronic Stable Angina from Acute Coronary Syndromes

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Chronic stable angina prognosis On the Web

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Risk calculators and risk factors for Chronic stable angina prognosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S.

Overview

Reduced LV function, number and location of stenoses, workload in METs calculated using Duke score are the strongest predictors of survival in patients with chronic stable angina.

Prognosis

Mortality

  • The estimated annual mortality rate in patients with chronic stable angina ranges from 0.9% - 1.4%[1][2][3] with an annual incidence of non-fatal MI between 0.5%[4] and 2.6%.[5]
  • The Framingham Heart Study[6][7] revealed the 2-year incidence rates of non-fatal MI and coronary heart disease death for men and women who initially presented with stable angina was 14.3% MI and 5.5% CAD death in men, and 6.2% MI and 3.8% CAD death in women.
  • Relative risk based on anginal characteristics in elderly associated with no comorbidities:[8]
Characteristic 1-yr Mortality Rate (%)
Non anginal pain 0.4
Atypical angina 0.8
Stable angina 1.3
Progressive 1.5
Unstable 1.7

Factors that Affect Long Term Prognosis in Patients with Chronic Stable Angina

  • Number of stenoses (patients with three-vessel disease have a higher mortality rate in comparison to patients with single vessel disease).
Table 1:Coronary Artery Disease Prognostic Index[8]
Extent of CAD Prognostic Weight (0-100) 5-year Mortality Rate (%)
(assuming medical treatment only)
1-vessel disease, 75% 23 7
>1-vessel disease, 50-74% 23 7
1-vessel disease, ≥ 95% 32 9
2-vessel disease 37 12
2-vessel disease, both ≥ 95% 42 14
1-vessel disease, ≥ 95% proximal LAD 48 17
2-vessel disease, ≥ 95% LAD 48 17
2-vessel disease, ≥ 95% proximal LAD 56 21
3-vessel disease 56 21
3-vessel disease, ≥ 95% in at least 1 63 27
3-vessel disease, 75% proximal LAD 67 33
3-vessel disease, ≥ 95% proximal LAD 74 41
  • Associated risk factors[9] that contribute to poor outcomes are:

Duke Score (Exercise Treadmill Test)[10]

  • Workload in METs assessed using the DUKE Score is an important factor in estimating the prognosis of patients with chronic stable angina.
  • Duke score = [(exercise duration in minutes) - (5 x ST segment deviation in millimeters) - (4 x treadmill angina index)]
  • Angina index:
  • 0 for no angina,
  • 1 for angina, and
  • 2 if angina is the reason for stopping the test.
CAD risk probability (DTS) 4-year survival Annual mortality
Low probability (more than 5 DTS) 99% 0.25%
Moderate probability (-10 to 4 DTS) 95% 1.25%
High probability (less than -10 DTS) 79% 5%

For more information about prognosis of excercise stress testing, click here.

ESC Guidelines- Pharmacological therapy to improve prognosis in patients with stable angina (DO NOT EDIT)[11]

Class I
"1. Aspirin 75 mg daily in all patients without specific contraindications (i.e. active GI bleeding, aspirin allergy, or previous aspirin intolerance). (Level of Evidence: A)"
"2. Statin therapy for all patients with coronary artery disease. (Level of Evidence: A)"
"3. ACE-inhibitor therapy in patients with coincident indications for ACE-inhibition, such as hypertension, heart failure, LV dysfunction, prior MI with LV dysfunction, or diabetes. (Level of Evidence: A)"
"4. Oral beta-blocker therapy in patients post-MI or with heart failure. (Level of Evidence: A)"
Class IIa
"1. ACE-inhibitor therapy in all patients with angina and proven coronary artery disease. (Level of Evidence: B)"
"2. Clopidogrel as an alternative antiplatelet agent in patients with stable angina who cannot take aspirin (e.g. aspirin allergic). (Level of Evidence: B)"
"3. High dose statin therapy in high-risk (0.2% annual CV mortality) patients with proven coronary artery disease. (Level of Evidence: B)"
Class IIa
"1. Fibrate therapy in patients with low HDL and high triglycerides who have diabetes or the metabolic syndrome. (Level of Evidence: B)"
"2. Fibrate or nicotinic acid as adjunctive therapy to statin in patients with low HDL and high triglycerides at high risk (0.2% annual CV mortality). (Level of Evidence: C)"

ESC Guidelines- Revascularization to improve prognosis in patients with stable angina (DO NOT EDIT)[11]

Class I
"1. CABG for significant left main CAD or its equivalent (i.e. severe stenosis of ostial/proximal segment of left descending and circumflex coronary arteries). (Level of Evidence: A)"
"2. CABG for significant proximal stenosis of three major vessels, particularly in those patients with abnormal LV function or with early or extensive reversible ischaemia on functional testing. (Level of Evidence: A)"
"3. CABG for one- or two-vessel disease with high-grade stenosis of proximal LAD with reversible ischaemia on non-invasive testing. (Level of Evidence: A)"
"4. CABG for significant disease with impaired LV function and viability demonstrated by non-invasive testing. (Level of Evidence: B)"
Class IIa
"1. CABG for one- or two-vessel CAD without significant proximal LAD stenosis in patients who have survived sudden cardiac death or sustained ventricular tachycardia. (Level of Evidence: B)"
"2. CABG for significant three-vessel disease in diabetics with reversible ischaemia on functional testing. (Level of Evidence: C)"
"3. PCI or CABG for patients with reversible ischaemia on functional testing and evidence of frequent episodes of ischaemia during daily activities. (Level of Evidence: C)"

References

  1. ↑ Rehnqvist N, Hjemdahl P, Billing E, Björkander I, Eriksson SV, Forslund L et al. (1996) Effects of metoprolol vs verapamil in patients with stable angina pectoris. The Angina Prognosis Study in Stockholm (APSIS) Eur Heart J 17 (1):76-81. PMID: 8682134
  2. ↑ Henderson RA, Pocock SJ, Clayton TC, Knight R, Fox KA, Julian DG et al. (2003) Seven-year outcome in the RITA-2 trial: coronary angioplasty versus medical therapy. J Am Coll Cardiol 42 (7):1161-70. PMID: 14522473
  3. ↑ Juul-Möller S, Edvardsson N, Jahnmatz B, Rosén A, Sørensen S, Omblus R (1992) Double-blind trial of aspirin in primary prevention of myocardial infarction in patients with stable chronic angina pectoris. The Swedish Angina Pectoris Aspirin Trial (SAPAT) Group. Lancet 340 (8833):1421-5. PMID: 1360557
  4. ↑ Pepine CJ, Handberg EM, Cooper-DeHoff RM, Marks RG, Kowey P, Messerli FH et al. (2003) A calcium antagonist vs a non-calcium antagonist hypertension treatment strategy for patients with coronary artery disease. The International Verapamil-Trandolapril Study (INVEST): a randomized controlled trial. JAMA 290 (21):2805-16. DOI:10.1001/jama.290.21.2805 PMID: 14657064
  5. ↑ Fox KM, Mulcahy D, Findlay I, Ford I, Dargie HJ (1996) The Total Ischaemic Burden European Trial (TIBET). Effects of atenolol, nifedipine SR and their combination on the exercise test and the total ischaemic burden in 608 patients with stable angina. The TIBET Study Group. Eur Heart J 17 (1):96-103. PMID: 8682138
  6. ↑ Kannel WB, Feinleib M (1972) Natural history of angina pectoris in the Framingham study. Prognosis and survival. Am J Cardiol 29 (2):154-63. PMID: 5058341
  7. ↑ Murabito JM, Evans JC, Larson MG, Levy D (1993) Prognosis after the onset of coronary heart disease. An investigation of differences in outcome between the sexes according to initial coronary disease presentation. Circulation 88 (6):2548-55. PMID: 8252666
  8. ↑ 8.0 8.1 8.2 Califf RM, Armstrong PW, Carver JR, D'Agostino RB, Strauss WE (1996) 27th Bethesda Conference: matching the intensity of risk factor management with the hazard for coronary disease events. Task Force 5. Stratification of patients into high, medium and low risk subgroups for purposes of risk factor management. J Am Coll Cardiol 27 (5):1007-19. PMID: 8609316
  9. ↑ 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
  10. ↑ Johnson GG, Decker WW, Lobl JK, Laudon DA, Hess JJ, Lohse CM et al. (2008) Risk stratification of patients in an emergency department chest pain unit: prognostic value of exercise treadmill testing using the Duke score. Int J Emerg Med 1 (2):91-5. DOI:10.1007/s12245-008-0031-5 PMID: 19384658
  11. ↑ 11.0 11.1 Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F; et al. (2006). "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". Eur Heart J. 27 (11): 1341–81. doi:10.1093/eurheartj/ehl001. PMID 16735367.

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