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| {{SI}}
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| {{WikiDoc Cardiology Network Infobox}}
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| {{CMG}}; {{CZ}}
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| {{JFS}} | | {{Chronic stable angina}} |
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| {{EH}} | | '''Editor-In-Chief:''' [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com] Phone:617-632-7753; '''Associate Editor(s)-In-Chief:''' {{CZ}}; [[John Fani Srour, M.D.]]; [[WikiDoc Scholars#WikiDoc Scholars with Distinction|Jinhui Wu, M.D.]]; [[Lakshmi Gopalakrishnan|Lakshmi Gopalakrishnan. M.B.B.S.]] |
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| ==Overview of the management of the patient with chronic stable angina== | | ==Overview== |
| | Treatment of chronic stable angina aims at minimizing symptoms, reducing recurrent [[ischemia]], improving the quality of life and improving [[Chronic stable angina prognosis|prognosis]] by preventing [[MI]] and death. Treatment options include [[Chronic stable angina secondary prevention|lifestyle modification]], [[Chronic stable angina medical therapy|pharmacotherapy]] and [[Chronic stable angina revascularization|revascularization]] that help in slowing the disease progression, preserving the endothelial function and preventing [[thrombosis]]. |
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| ===Identification and treatment of exacerbating conditions===
| | Patients with [[CAD|single-vessel CAD]] may be started on initial [[Chronic stable angina medical therapy|pharmacologic therapy]] and if non-responsive or symptomatic despite on therapy, [[Chronic stable angina revascularization percutaneous coronary intervention|PCI]] may be a preferred alternative. |
| While chronic stable angina may be due to underlying [[atherosclerosis]], other factors may either precipitate or exacerbate angina. Indentification and management of these conditions may reduce the frequency and intesity of anginal episodes. These conditions include [[anemia]], uncontrolled [[hypertension]], thyroid disorders ([[thyrotoxicosis]]), heart rhythm abnormalities ([[tachyarrhythmias]]), decompensated [[congestive heart failure]] and concomitant [[valvular heart disease]].
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| ===Risk factor modification===
| | Patients with [[CAD|double-vessel CAD]] and with [[EF|normal LV function]] may be started on initial [[Chronic stable angina medical therapy|medical management]] and in non-responders, [[Chronic stable angina revascularization percutaneous coronary intervention|PCI]] may be considered. However, the decision of [[Chronic stable angina revascularization percutaneous coronary intervention|PCI]] versus [[Chronic stable angina revascularization coronary artery bypass grafting|CABG]] depends on the coronary anatomy, [[EF|LV function]] and the need for complete revascularization. |
| Initiate risk factor modification, promote for regular physical exercise (all patients should be encouraged to obtain 30 to 60 minutes/day of regular aerobic activity), low fat diet, and lifestyle modification.
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| ===Pharmacotherapy===
| | Patients with [[CAD|triple-vessel CAD]] or [[left main]] [[CAD|disease]] or reduced [[EF|left ventricular function]], [[Chronic stable angina revascularization coronary artery bypass grafting|CABG]] is the mainstay of management. However, in cases of mild symptoms or preserved [[EF|LVEF]] in patients with triple-vessel disease, initial [[Chronic stable angina medical therapy|pharmacologic therapy]] or [[Chronic stable angina revascularization percutaneous coronary intervention|PCI]] may be tried. |
| First line therapy in the patient with chronic stable angina includes [[aspirin]] to minimize the risk of thrombosis superimposed on the chronic fixed obstruction and [[beta blockade]] to reduce [[heart rate]] and myocardial oxygen demands, as well as reduce the risk of [[fatal arrhythmias]] should [[plaque rupture]] occur. Strong consideration should be given to initiaion of [[ACE inhibition]] as potential disease modifying therapy.
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| Evaluate fasting lipid profile and initiate proper lipid lowering drug therapy when necessary. Ideally start with HMG-CoA reductase inhibitor to reduce LDL cholesterol level below 100 mg/dl (<70 mg/dl in high risk patients).
| | ==Treatment== |
| | ===Precipitating Factors=== |
| | *While chronic stable angina may be due to underlying [[atherosclerosis]], other factors may either precipitate or exacerbate angina. |
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| Use sublingual [[nitroglycerin]] for alleviation of symptoms.
| | *Identification and management of these conditions may reduce the frequency and intensity of anginal episodes. These conditions include: |
| | :*[[Anemia]], |
| | :*[[Hypertension|Uncontrolled hypertension]], |
| | :*Thyroid disorders ([[thyrotoxicosis]]), |
| | :*Heart rhythm abnormalities ([[tachyarrhythmias]]), |
| | :*[[congestive heart failure|Decompensated congestive heart failure]] and |
| | :*[[valvular heart disease|Concomitant valvular heart disease]]. |
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| If angina episodes occur >2-3 times in a week, consider to add a calcium antagonist drug or a long acting nitrate. Regardless of severity and frequency of anginal symptoms adding Ca antagonists and/or long lasting nitrates to main treatment regimen may helpful to reduce blood pressure and therefore treat ventricular function abnormalities.
| | ===Risk Factor Modification=== |
| | *Initiation of intensive modification of risk factors is an urgent and essential part of the main therapy in chronic stable angina. |
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| Consider adding the third one if angina persists despite of two anti anginal drugs.
| | *Initiate risk factor modification, promote regular physical exercise (all patients should be encouraged to obtain 30 to 60 minutes/day of regular aerobic activity), low fat diet, and lifestyle modification. |
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| Coronary angiography is indicated in patients with refractory symptoms or ischemia despite administration of optimal medical therapy. It should also be carried out in "high-risk" patients with non invasive test results, and in those with special occupations or sedentary life styles that require a more aggressive approach.
| | *You can read in greater detail about each of the risk factor modification topics below: |
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| ==The treatment essentials==
| | :'''[[Chronic stable angina treatment smoking cessation|Smoking Cessation]] | [[Chronic stable angina treatment weight management|Weight Management]] | [[Chronic stable angina treatment physical activity|Physical Activity]] | [[Chronic stable angina treatment lipid management|Lipid Management]] | [[Chronic stable angina treatment blood pressure control|BP Control]] | [[Chronic stable angina treatment diabetes control|Diabetes Control]] | [[Chronic stable angina treatment ACC/AHA guidelines for cardiovascular risk factor reduction|ACC/AHA Guidelines for Cardiovascular Risk Factor Reduction]]''' |
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| Alphabet of chronic stable angina management: elements listed below are the most important components of stable angina management. | | ===The Treatment Essentials=== |
| | Alphabet of chronic stable angina management: Elements listed below are the most important components of stable angina management. |
| | *'''A:''' [[Aspirin]] use |
| | *'''A:''' Anti anginal therapy |
| | *'''B:''' [[Beta blocker]] use |
| | *'''B:''' [[Blood pressure]] control |
| | *'''C:''' Cholesterol lowering therapy |
| | *'''C:''' Cigarette smoking cessation |
| | *'''D:''' [[Diabetes Mellitus]] control |
| | *'''D:''' Diet |
| | *'''E:''' Exercise |
| | *'''E:''' Education |
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| *A=[[Aspirin]] use
| | ===Pharmacotherapy=== |
| *A=Anti anginal therapy
| | *The role of pharmacotherapy in the management of chronic stable angina is to reduce the severity and frequency of symptoms and to provide a bettered overall prognosis. |
| *B=[[Beta blocker]] use
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| *B=[[Blood pressure]] control
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| *C=Cholesterol lowering therapy
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| *C=Cigarette smoking cessation
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| *D=[[Diabetes Mellitus]] control
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| *D=Diet
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| *E=Exercise | |
| *E=Education
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| ==Lifestyle modifications==
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| Initiation of intensive modification is urgent and an essential part of the main therapy
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| *Smoking cessation
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| This is one of the main parts of chronic stable angina pectoris management. Smoking cessation and avoidance of exposure to environmental tobacco smoke at work and home is recommended. Follow-up, referral to special programs, and/or pharmacotherapy (including nicotine replacement) is recommended, as is a stepwise strategy for smoking cessation (Ask, Advise, Assess, Assist, Arrange).
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| The cardiovascular effects of nicotine, such as increases in heart rate with small rises in blood pressure, have provoked some concerns about the use of NRT in patients with coronary artery disease. However, nicotine patches have been used successfully in heart disease patients without any adverse effects. Similarly, it is suggested that nicotine replacement therapy may be initiated as early as 2–3 days after acute myocardial infarction and that it may be used in all patients with stable angina pectoris and cardiac arrhythmias.
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| *Limit alcohol intake to 2 drinks per day for men and 1 drink per day for women.
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| *Limit sodium intake to 6 grams per day
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| *Lose weight, if overweight:
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| Body Mass Index = BMI and waist circumference should be assessed regularly. On each patient visit, it is useful to consistently encourage weight maintenance/reduction through an appropriate balance of physical activity, caloric intake, and formal behavioral programs when indicated to achieve and maintain a BMI between 18.5 and 24.9 kg/m2.
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| If waist circumference is ≥35 inches (89 cm) in women or ≥40 inches (102 cm) in men, it is beneficial to initiate lifestyle changes and consider treatment strategies for metabolic syndrome as indicated. Some male patients can develop multiple metabolic risk factors when the waist circumference is only marginally increased (e.g., 37 to 40 inches [94 to 102 cm]). Such persons may have a strong genetic contribution to [[insulin resistance]]. They should benefit from changes in life habits, similarly to men with categorical increases in waist circumference.
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| The initial goal of weight loss therapy should be to gradually reduce body weight by approximately 10% from baseline. With success, further weight loss can be attempted if indicated through further assessment.
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| *Increase physical activity within the patient’s limitation:
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| Physical activity of 30 to 60 minutes, 7 days per week (minimum 5 days per week) is recommended. All patients should be encouraged to obtain 30 to 60 minutes of moderate-intensity aerobic activity, such as brisk walking, on most, preferably all, days of the week, supplemented by an increase in daily activities (such as walking breaks at work, gardening or household work). The patient’s risk should be assessed with a physical activity history. Where appropriate, an exercise test is useful to guide the exercise prescription.
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| Medically supervised programs (cardiac rehabilitation) are recommended for at-risk patients (e.g., recent acute coronary syndrome or revascularization, heart failure). Expanding physical activity to include resistance training on 2 days per week may be reasonable.
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| *Suggest changes and modifications in diet
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| :* Encourage a high intake of fruits and vegetables (5 to 9 servings/day).
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| :* Suggest to eat grain products, with an emphasis on whole grains (≥6 servings/day).
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| :* Suggest to eat at least 2 servings of fish per week
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| :* Limit total fat intake to <30% and saturated fat to <7% of energy.
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| Replace dietary saturated fats and trans fatty acids with monounsaturated and polyunsaturated fats (including foods rich in omega-3 fatty acids).
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| Food sources of omega-3 fatty acids include fatty fish (such as salmon), flaxseed and flaxseed oil, soybean oil, canola oil, and nuts.
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| :*Limit amounts of dairy products to 2 to 4 servings of low fat or fat free items per day.
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| *Anger management
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| Consider and advice to control stress and use relaxation techniques. Many believe that relaxation techniques help alleviate feelings of stress, which is often a contributing factor to heart disease, and relieve chest pain. Such practices might include the use of meditation, progressive muscle relaxation, breathing exercises, yoga, self-hypnosis, or biofeedback
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| *Control other concomitant disorders such as diabetes mellitus, hypertension, kidney diseases and anemia:
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| :*Diabetes management should include lifestyle modification and measures to achieve HbA1c in normal range.
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| :*Recommended blood pressure should be ≤140 mmHg or ≤130/80 mmHg for patients with diabetes mellitus and chronic kidney disease. For hypertensive patients with well established coronary artery disease, it is useful to add blood pressure medication as tolerated, treating initially with beta blockers and/or ACE inhibitors, with addition of other drugs as needed to achieve target blood pressure.
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| ==Drug therapy==
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| ===Angiotensin Converting Enzyme Inhibitors (ACEI) and Renin Angiotensin Aldosterone System Blockers (RAAS Blockers)===
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| Angiotensin Converting Enzyme (ACE) inhibitors should be started and continued indefinitely in all patients with left ventricular ejection fraction (LV EF) ≤40% and in those with hypertension, diabetes mellitus or chronic kidney disease (CKD) unless contraindicated (Class II Evidence Level A recommendation)
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| ACE inhibitors should be started and continued indefinitely in patients who are not at lower risk unless contraindicated (lower risk defined as patients with normal LVEF and whom cardiovascular risk factors are well controlled and coronary revascularization has been performed) (Class I Evidence Level B recommendation)
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| It is reasonable to use ACE inhibitors among lower risk patients with mildly reduced or normal LV EF if their cardiovascular risk factors are well controlled and coronary revascularization has been performed (Class IIa Evidence Level B recommendation)
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| Angiotensin receptor blockers (ARB) are recommended for patients who have hypertension, have indications for but are intolerant of ACE inhibitors, have heart failure, or have had a myocardial infarction with LV EF ≤40% (Class I Evidence Level A recommendation).
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| Angiotensin receptor blockers may be considered in combination with ACE inhibitors for heart failure due to left ventricular systolic dysfunction (Class II b Evidence Level B recommendation)
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| Aldosterone blockade is recommended for use in post myocardial infarction patients without significant kidney dysfunction or hyperkalemia who are already receiving therapeutic doses of an ACE inhibitor and a beta blocker, have a LV EF ≤40% and have either diabetes mellitus or heart failure (Class I Evidence Level A recommendation)
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| ===Beta Blockers===
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| It is beneficial to start and continue beta blocker drug therapy indefinitely in all patients who have had myocardial infarction, acute coronary syndrome (ACS) or left ventricular dysfunction with or without heart failure symptoms, unless contraindicated (Class I Evidence Level A recommendation).
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| In general, beta blocking drugs decrease heart rate, blood pressure, and contractility and, as a result, reduce myocardial oxygen consumption.
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| A slowing of heart rate is associated with an increased left ventricular perfusion time. Exercise induced increases in heart rate and blood pressure are also blunted. In patients with stable angina, beta adrenergic blocking agents increase exercise duration and the time to the onset of angina and of ST segment depression, although the double product threshold (heart rate multiplied by blood pressure) at which ischemia occurs remains unchanged.
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| Beta blocking agents with beta selectivity (such as metoprolol and atenolol) are preferable in patients with mild asthma, chronic obstructive pulmonary disease (COPD), insulin dependent diabetes mellitus (IDDM) or intermittent claudication. However, with increased doses of beta blockers, selectivity is lost and both types of beta receptors are blocked.
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| The major side effects of beta blocker therapy include fatigue, impaired exercise tolerance, depression, insomnia, nightmares, and worsening claudication and bronchospasm.
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| Severe bradycardia, episodes of second or third degree atrioventricular (AV) blocks, poorly controlled left ventricular failure, severe depression of left ventricular function, and severe peripheral vascular disease are contraindications to the use of beta blockers. Beta blockers may increase the blood sugar level and impair insulin sensitivity, particularly when used concurrently with diuretics. They may decrease the reaction to hypoglycemia in patients with insulin dependent diabetes mellitus (IDDM) and may exert unfavorable effects on the blood lipid profile with an increase in triglycerides and reduction in high density lipoprotein (HDL-C). However, the clinical significance of these adverse changes in the lipid profile with beta blockers has not yet been defined.
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| The effective dose of any beta blocker drug varies considerably from patient to patient. For an effective treatment; resting heart rate should be reduced to between 45 and 60 bpm (beats per minute) and heart rate should be below 90 beats per minute during moderate exercise, such as climbing two stairs at a normal pace.
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| If administration of beta blockers induces symptomatic heart failure, they should be discontinued or the dose reduced. For maintenance therapy of stable angina, beta blocking drugs with a relatively long half-life are preferable. The sudden withdrawal of beta blocker therapy may result in worsening of angina (rebound effect) and precipitation of acute ischemic episodes; it is preferable to taper these medications gradually over 2 to 3 weeks.
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| ===Calcium Channel Blockers===
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| Calcium antagonists consist of three subclasses as dihydropyridines (e.g., nifedipine), phenylalkylamines (e.g., verapamil), and the modified benzothiazepines (e.g., diltiazem).
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| These agents are used as second line therapy when beta blockers are genuinely contraindicated. Several trials have shown that verapamil is as effective as beta-blockers in the control of angina, but this agent does not prolong life. Verapamil is a more effective anti anginal agent than diltiazem or dihydropyridines (DHPs) and is considered a first choice, but the drug must be used with caution and must not be combined with a beta blocker.
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| Calcium Channel Blockers reduce the transmembrane flux of calcium via slow calcium channels. The dihydropyridines, for example, nifedipine, exert a greater inhibitory effect on vascular smooth muscle than on the myocardium. Thus, the major therapeutic effect can be expected to be peripheral or coronary vasodilation. These agents, however, also exert a negative inotropic effect and therefore can produce myocardial depression, which is less pronounced with amlodipine and nisoldipine. The peripheral vasodilation caused by the dihydropyridines also can cause reflex adrenergic activation, tachycardia, and stimulation of the rennin-angiotensin system. These agents increase coronary blood flow owing to vasodilation of both conductance and resistance coronary vessels. Intermittent adrenergic activation with short-acting dihydropyridines has been implicated as the mechanism for the potentially adverse cardiovascular effects.
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| The non-dihydropyridine calcium channel blockers such as verapamil and diltiazem cause slowing of the sinus node and hence may potentiate the bradycardia of beta blockers. However, they are less potent peripheral vasodilators than the dihydropyridines and less likely to cause hypotension, flushing, and dizziness.
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| Epicardial coronary artery spasm is effectively relieved and prevented by calcium channel blockers, so that these are the agents of choice (along with nitrates) for the treatment of vasospastic angina. Some patients with coronary spasm may require a combination of two calcium channel blockers to achieve efficacy. With some calcium channel blockers, such as verapamil and diltiazem, heart rate may also decrease, associated with a reduced myocardial oxygen requirement. In patients with mixed, walk through, postprandial, and late nocturnal angina, in which increased coronary vascular tone appears to contribute to the pathogenesis of the ischemia, the use of calcium channel blockers may be of benefit, particularly when nitrate therapy alone is inadequate.
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| In patients with stable exertional angina, calcium channel blockers improve exercise tolerance (longer time to the onset of angina and to ST segment depression) during treadmill exercise tests. The mechanism of these beneficial effects is primarily decreased myocardial oxygen consumption. Calcium channel blockers and beta-adrenergic blocking drugs in combination can produce synergistic beneficial effects in patients with stable angina pectoris.
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| Controversy exists for the use of calcium channel blockers for the long term treatment of stable exertional angina, since the short acting, immediate release dihydropyridines, such as nifedipine, may increase the risk of myocardial infarction and mortality.
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| Worsening congestive heart failure and increased mortality has also been observed with diltiazem in postinfarction patients with depressed left ventricular ejection fraction.
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| However, second generation vasoselective dihydropyridine derivative calcium channel blockers, such as amlodipine and felodipine, are well tolerated by patients with left ventricular dysfunction and even overt clinical heart failure, and no increase in the risk of mortality has been described. Furthermore, vasoselective long acting dihydropyridines (such as amlodipine) and extended release (nifedipine) and slow release (verapamil and diltiazem) have all been shown to reduce frequency and symptoms of angina.
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| Thus, if necessary, these agents can be used for treatment of stable exertional angina. The new T channel types of calcium blockers are also effective in controlling hypertension and angina. They appear to possess little negative inotropic effect and produce little or no edema or constipation.
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| The general side effects of calcium channel blockers are constipation, peripheral edema, dizziness, flushing and occasionally, headache. With dihydropyridines, a reflex tachycardia may produce palpitation. With diltiazem and verapamil, sinus bradycardia and different grades of atrioventricular blocks may occur. Verapamil may cause constipation. In choosing a particular calcium channel blocker in a given patient, the hemodynamic profile should be considered. Dihydropyridines are preferable in the presence of sinus bradycardia, sinus node dysfunction, or atrioventricular block, particularly when the blood pressure is not adequately controlled. Diltiazem or verapamil is preferable in patients with relative tachycardia.
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| Amlodipine has minimal negative inotropic effects and can be combined with a beta blocker in patients with EF> 35%. Although beta-blockers may be used in patients with EF <30%, the combination of a beta-blocker with diltiazem or dihydropyridine should be avoided in patients with EF <40%. Verapamil and, to a lesser extent, diltiazem, when added to a beta-blocker, may cause conduction disturbances or HF, and the verapamil combination is considered unsafe.
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| Calcium antagonists have also been postulated to have anti atherosclerotic properties. The Prospective Randomized Evaluation of the Vascular Effect of Norvasc Trial (PREVENT) did demonstrate slowing of atherosclerotic progression in carotid but not in the coronary vasculatures.
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| Given to patients prior to undergoing PTCA, amlodipine was shown to reduce major cardiovascular end points (death, MI, CABG, repeat PCI) in the Coronary Angioplasty Amlodipine Restenosis Study (CAPARES).
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| ===Antiplatelet Agents/Anticoagulants===
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| Aspirin inhibits cyclo oxygenase and the subsequent suppression of thromboxane A2, the key moderator of irreversible platelet aggregation. Aspirin is a potent anti platelet agent and has been shown to improve survival and to prevent infarction in patients with unstable angina or after myocardial infarction. A 75-mg dose has been shown to be effective and causes less gastrointestinal bleeding than the commonly prescribed 325 mg dose.
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| Meta-analysis of 140,000 patients from the Antiplatelet Trialists’ Collaboration showed that aspirin (75-325 mg/day) reduced the rate of subsequent myocardial infarction, stroke, and death in patients with history of angina pectoris, myocardial infarction, CABG, and stroke. In the Swedish Angina Pectoris Aspirin Trial (SAPAT), aspirin (75 mg/day) in conjunction with the beta blocker sotalol conferred an additional 34% reduction in acute myocardial infarction and sudden death among men and women with chronic stable angina. Aspirin also improves endothelial function and, when used in high dose (300 mg/day), has been shown to reduce circulating levels of C-reactive protein. Therefore, it should be started at 75 to 162 mg/day and continued indefinitely in all patients with chronic stable angina pectoris, unless contraindicated (Class I Evidence Level A recommendation). This dosing range appears to have comparable efficacy for secondary prevention compared to dosing at 160-325 mg/day and also reduces bleeding risk.
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| If aspirin use is contraindicated, clopidogrel is advisable. Clopidogrel has been shown to have favorable effects on cardiovascular events, equal to those of aspirin,
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| Use of warfarin in conjunction with aspirin and/or clopidogrel is associated with an increased risk of bleeding and should be monitored closely (Class I Evidence Level B recommendation).
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| In the Clopidogrel Versus Aspirin in Patients at Risk of Ischemic Events (CAPRIE) trial, randomized comparison between clopidogrel and aspirin showed that clopidogrel resulted in 8.7% relative risk reduction of vascular death, ischemic stroke, or myocardial infarction among patients with established atherosclerotic vascular disease. In the latest Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management, and Avoidance (CHARISMA) trial, dual anti platelet therapy with clopidogrel + aspirin was not significantly more effective compared to aspirin alone in reducing the rate of myocardial infarction, stroke, or cardiovascular death in patients with established vascular disease or at high risk for developing vascular disease.
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| ===Nitroglycerin and Long Acting Nitrates===
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| Nitroglycerin and other nitrates are endothelium independent vasodilators that produce their beneficial effects both by decreasing myocardial oxygen requirements and by improving myocardial perfusion.
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| It has been postulated that nitrates, after entering the vessel wall, are converted to nitric oxide (NO), which stimulates guanylate cyclase to produce cyclic guanosine mono phosphate (cGMP), the substance that is responsible for vasodilation.
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| Nitrates dilate large coronary arteries and collateral vessels, relieve coronary vasospasm, and decrease the degree of coronary artery stenosis produced by an eccentric atherosclerotic plaque. Nitrates, therefore, have the potential to improve myocardial perfusion by coronary vasodilatation, by decreasing the degree of epicardial coronary artery stenosis, and by increasing collateral blood flow to the ischemic myocardium. Nitrates also decrease myocardial oxygen requirements by decreasing intra cardiac volumes consequent to reduced venous return resulting from peripheral venous dilatation and by reducing arterial pressure. These beneficial effects may be offset partly by a reflex increase in heart rate, which can be prevented by simultaneous beta adrenergic blockade.
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| Nitrates are effective for the management of various clinical subsets of stable angina pectoris. In patients with [[exertional angina]], nitrates improve exercise tolerance, the time to the onset of angina, and ST segment depression during the treadmill exercise test.
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| In patients with vasospastic angina, nitrates relax the smooth muscles of the epicardial coronary arteries and thereby relieve coronary artery spasm. In patients with mixed angina and postprandial angina, nitrates reduce myocardial oxygen demand and promote coronary vasodilation.
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| A variety of nitrate preparations are currently available. The onset of action of sublingual nitroglycerin tablets or nitroglycerin spray is within 1 to 3 minutes, making these the preferred agents for the acute relief of effort or rest angina.
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| The patient should be instructed that active nitroglycerin will cause some tingling under the tongue, and that if this does not occur, the efficacy of their nitroglycerine tablets may be expired. Nitroglycerin is also very useful for prophylaxis when used several minutes before planned exertion. However, its short duration of action (20 to 30 min) makes it less practical for long-term prevention of ischemia in patients with stable angina.
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| For angina prophylaxis, long acting nitrate preparations such as isosorbide dinitrate, mono nitrates, transdermal nitroglycerin patches, and nitroglycerin paste are preferable. However, the major clinical problem for long term nitrate therapy is nitrate tolerance. ”’The most reliable method for the prevention of nitrate tolerance is to ensure a nitrate free period of approximately 10 hours, usually including sleeping hours, in patients with effort angina’”. Isosorbide dinitrate should not be used more frequently than three times a day, or a transdermal patch more often than every 12 hours.
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| The most common side effect of nitrate therapy is a throbbing headache, which tends to decrease with continued use. Although postural dizziness and weakness occur in some patients, frank syncope due to hypotension is relatively uncommon. Nitrates do not worsen glaucoma, once thought to be a contraindication to their use, and they can be used safely in the presence of increased intraocular pressure.
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| ===Antilipids===
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| If baseline LDL-Cholesterol is ≥100 mg/dL, LDL lowering drug therapy should be initiated in addition to therapeutic lifestyle changes. When LDL lowering medications are used in high risk or moderately high risk persons, it is recommended that intensity of therapy be sufficient to achieve a 30% to 40% reduction in LDL-Cholesterol levels.
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| If baseline LDL-C is 70 to 100 mg/dL, it is reasonable to treat LDL-C to <70 mg/dL. If on-treatment LDL-C is ≥100 mg/dL, LDL lowering drug therapy should be intensified.
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| If Triglycerides are 200-499 mg/dL, the sum of non–HDL-Cholesterol levels should be <130 mg/dL. Moreover this, further reduction of non–HDL Cholesterol to <100 mg/dL is reasonable, if Triglycerides are ≥200 to 499 mg/dL.
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| Therapeutic options to reduce non–HDL-C are: ’’’Niacin”’ can be useful as a therapeutic option to reduce non–HDL-C (after LDL-C lowering therapy) or ’’’Fibrate”’ therapy as a therapeutic option can be useful to reduce non–HDL-C (after starting to LDL-C–lowering therapy).
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| If Triglycerides are ≥500 mg/dL, therapeutic options to lower the Triglycerides to reduce the risk of pancreatitis are fibrate or niacin; these should be initiated before LDL-Choesterol lowering therapy. The goal is to achieve non–HDL-C <130 mg/dL if possible.
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| If LDL-Cholesterol <70 mg/dL is the chosen target, consider drug titration to achieve this level to minimize side effects and cost of therapy. When LDL-Cholesterol level of <70 mg/dL is not achievable because of high baseline LDL-Cholesterol levels, it is generally possible to achieve reductions of >50% in LDL-Cholesterol levels by either statins or any other LDL-Cholesterol –lowering drug combinations. Treatment with anti lipid drug combinations is beneficial for patients on lipid lowering therapy who are unable to achieve LDL-Cholesterol <100 mg/dL.
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| ===Choices among Pharmacologic Agents for Angina===
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| In patients with stable exertional angina, beta blocker therapy is the preferred as an initial treatment. These agents reduce or prevent ischemia with a single daily dose and their known long term prognostic benefit may also be generalized to other patients with ischemic heart disease. All patients should also be given nitroglycerin and instructions about its therapeutic and prophylactic use.
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| Calcium channel blockers are not preferred initial therapy for the management of patients with stable exertional angina. In patients with special circumstances or concomitant diseases, specific medications, or combinations of medications are preferable. For most patients, however, the initial therapy should consist of use of beta-adrenergic blocking agents, and nitrates should be added if the response to beta blocker therapy is inadequate. Calcium channel blockers should be considered in patients who cannot tolerate beta blockers or nitrates or who respond inadequately to these drugs. Extended release nifedipine, second generation vasoselective calcium channel blockers, and extended-release verapamil or diltiazem are the calcium blockers of choice.
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| ==Revascularization==
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| ===Introduction===
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| The goals of treatment of stable [[angina]] are to reduce symptoms, delay the progression of [[atherosclerosis]], and prevent cardiovascular events. This is usually established with medical therapy with revascularization used only in selected patients. The main indications for revascularization therapy (PCI or CABG) in stable angina are:
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| * Patients with symptoms uncontrolled with optimal medical therapy (see above).
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| The definition of an inadequate response to medical therapy is fairly wide and depends on the patient’s lifestyle, occupation, and expectations. At one extreme are patients who are limited by angina pectoris despite optimal drug treatment and lifestyle modifications, including achievement of optimal weight and cessation of smoking (see above). At the other end of the range are patients who consider medical therapy to have failed if control of angina pectoris requires higher doses of anti-anginal medications that cause side effects.
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| * Patients who would have a survival benefit from revascularization (PCI or CABG).
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| This depends on the location, severity, and number of lesions; the presence or absence of left ventricular dysfunction is an important factor as well.
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| 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:
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| * Disabling anginal symptoms (Canadian Cardiovascular Society [CCS] classes III and IV) despite medical therapy.
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| * 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]]).
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| * Survivors of sudden cardiac death or serious ventricular [[arrhythmia]].
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| * Symptoms and signs of heart failure.
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| * Clinical features that suggest that the patient has a high likelihood of severe coronary artery disease.
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| 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.
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| There are currently two well-established revascularization approaches to treatment of chronic stable angina caused by coronary [[atherosclerosis]]. Since the introduction of [[bypass]] surgery in 1967 and percutaneous transluminal coronary [[angioplasty]] [PTCA] in 1977, it has become clear that both strategies can contribute to the effective treatment of patients with chronic stable angina and both 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 performed for many lesions including more complex ones.
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| ===Complications of percutaneous coronary intervention===
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| Ideal candidates for PTCA/PCI are under 75 years of age, with single-vessel, single-lesion CAD, without a history of diabetes. Lesions that are best for these procedures are short (<10 mm), concentric, discrete, and readily accessible. The risk of morbidity and mortality from the procedure is increased, particularly in patients with long (>20 mm), tortuous, irregular, angulated, calcified, severely stenotic (>90% stenosis) lesions and when more than one such lesion is present in an artery. Other important factors include operator volume and the presence or absence of on site cardiovascular surgeon. The 2005 ACC/AHA/SCAI guidelines for percutaneous coronary intervention made recommendations about hospital and operator volume and the importance of onsite cardiac surgery for both elective and primary PCI. The improvements in devices, the use of stents, and aggressive antiplatelet therapy have significantly reduced the incidence of major procedural complications of PCI over the past 2 decades despite the increasing complexity of cases.
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|
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| Primary success of coronary interventions is generally defined as an absolute increase of 20 percentage points in luminal diameter and a final diameter obstruction less than 30%. Such angiographic success can be anticipated in more than 90% of properly selected patients.
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| The major complications of PTCA/PCI include coronary artery dissection and acute closure, intramural hematoma, coronary artery perforation, and occlusion of branch vessels:
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| Dissections are found in up to 50 percent of patients immediately after PTCA. Intimal tears or dissections following PTCA have been arbitrarily divided into types A to F.
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| • Type A — Luminal haziness
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| • Type B — Linear dissection
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| • Type C — Extraluminal contrast staining
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| • Type D — Spiral dissection
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| • Type E — Dissection with reduced flow
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| • Type F — Dissection with total occlusion
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| These problems are now much less frequent since stent placement is performed in most percutaneous coronary procedures.
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| Abrupt closure is most often due to arterial dissection and is manifested as acute ischemic chest pain and ECG changes. The incidence of abrupt closure with conventional balloon angioplasty (PTCA) is approximately 5% and is associated with a 10-fold increase in mortality to about 1 percent and nonfatal MI. The frequency of this complication, however, has now been greatly reduced by pretreatment with the platelet glycoprotein IIb/IIIa receptor blockers and by the insertion of an intracoronary stent. If stenting does not restore adequate flow, emergency CABG can be performed.
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| Coronary artery intramural hematoma is defined as an accumulation of blood within the medial space displacing the internal elastic membrane inward and the external elastic membrane outward, with or without identifiable entry and exit points. It is identified in 6.7 percent of procedures by intravascular ultrasound (IVUS).
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| Coronary artery perforation in the stent era is a rare but potentially disastrous complication.
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| Downstream embolization of thrombus or plaque contents with microvascular obstruction is common after PCI and occlusion of side branches has been reported in up to 19 percent of cases in which a stent was placed across a major side branch.
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|
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| Stent thrombosis is catastrophic complication that usually leads to death or ST segment elevation MI. It is therefore a medical emergency. Stent thrombosis can occur acutely (during or soon after the PCI), subacutely (within 30 days after stent placement), or as a complication. Late stent thrombosis is associated with the cessation of aspirin or clopidogrel therapy. On the other hand, very late stent thrombosis, occurring after one year, is associated with drug-eluting stents.
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| Restenosis is the result of arterial damage with subsequent neointimal tissue proliferation. It is usually defined as a greater than 50% diameter stenosis. The incidence of angiographic restenosis is approximately 30% to 40% after PTCA. Intracoronary stents reduce the rate of angiographic and clinical restenosis and post-procedural myocardial infarction compared to percutaneous transluminal coronary angioplasty (PTCA) alone. Trials have demonstrated that the sirolimus and paclitaxel drug-eluting stents markedly reduced the incidence of in-stent restenosis and the rate of target lesion revascularization compared to bare metal stents. As a result, stents are currently utilized in nearly all percutaneous coronary interventions. However, the benefits of drug-eluting stents on restenosis must be weighed against rates of stent thrombosis, which often leads to death or MI, if dual antiplatelet therapy is prematurely discontinued. Restenosis occurs more frequently in diabetics, smaller arteries, among total occlusions, and in left anterior descending arteries, particularly proximal lesions. Since not all angiographic restenosis results in recurrent symptoms, the rates of clinical restenosis are lower than these angiographic estimates. Recurrent sever angina occurs in approximately half of the patients who develop angiographic restenosis and usually responds to stenting. In symptomatic patients with BMS restenosis, a repeat stenting using a DES is usually recommended. In symptomatic patients with intracoronary DES restenosis, there are insufficient data to suggest any specific treatment.
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|
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| ===Clinical trials: PTCA/PCI versus medical treatment in the management of stable angina pectoris:===
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| There are important limitations concerning the applicability of the results of older trials and even newer trials to the current clinical practice.
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| In early trials of percutaneous intervention versus medical therapy, the majority of patients underwent coronary angioplasty alone without stenting. For example, the benefits of PTCA have been compared to medical therapy in single vessel disease in the randomized Veterans Affairs Angioplasty Compared to Medicine (ACME) trial. PTCA resulted in a reduction in anginal symptoms compared to medical therapy (50% angina free versus 24% at one month), however, while the benefit of PTCA was still significant at 6 months, the magnitude of this benefit was reduced (64% angina free versus 45%). Patients treated with PTCA also had an improvement of 2.1 3.1 minutes in exercise duration which was significantly greater than the 0.5 2.2 minutes experienced in the medical therapy group.
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| Other older trials compared PTCA to both limited (AVERT trial) and optimal medical interventions (RITA-2 and MASS II). The findings of these trials were that patients undergoing PTCA had similar rates of death and myocardial infarction as those on medical therapy and were less likely to have angina during the first few years.
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| More recent literature provides comparison between the use of stents and medical management, however, there is few data examining the extensive use of drug eluting stents and current extensive antithrombotic regimens (clopidogrel and GP IIb/IIIa inhibitors). In the most recent trial, COURAGE, drug-eluting stents were used in only 15 percent of patients. However, the COURAGE trial has the data most applicable to current practice. In this study 2287 patients were randomized to either aggressive medical therapy alone or aggressive medical therapy plus PCI with bare metal stenting. Patients were required to have both objective evidence of ischemia and significant CHD in a least one vessel; 87 percent were symptomatic and 58 percent had Canadian Cardiovascular Society [CCS] class II or III angina. Patients were excluded if they had CCS class IV angina, ≥50 percent left main disease, a markedly positive treadmill test (significant ST segment depressions and/or a hypotensive response during stage I of the Bruce protocol), an LVEF less than 30 percent, or coronary lesions deemed unsuitable for PCI. All patients received optimal medical therapy with beta blockers, calcium channel blockers, nitrates, antiplatelet therapy (either aspirin or clopidogrel), and aggressive lipid-lowering therapy with statin (attained median LDL-cholesterol was 72 mg/dL at five years). Exercise was recommended to achieve further improvements in the lipid profile when necessary. The results were published at a median follow-up of 4.6 years. There was no significant difference between the two treatment strategies for the primary end point of death from any cause and non-fatal MI. There was no significant difference in the rates of hospitalization for ACS. Patients in the PCI group underwent significantly fewer subsequent revascularization procedures (21 versus 33 percent, HR 0.60, 95% CI 0.51-71).
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| The issue of whether patients who receive PCI plus optimal medical therapy have a better quality of life and less angina than those who receive optimal medical therapy was addressed in COURAGE as well:
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| At baseline, 22 percent of patients were free of angina. At three months, significantly more patients who received PCI were angina free (53 versus 42 percent), but at 36 months there was no significant difference (59 versus 56 percent).
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| Patients in both groups showed significant improvements from baseline values in various measures of quality of life. The percent of patients with clinically significant improvement in parameters such as physical limitation, angina stability, angina frequency, and overall quality of life was significantly higher in the PCI group by the sixth months. However, there was no significant difference in these rates at 36 months.
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| The results of COURAGE demonstrate that PCI with bare metal stents plus optimal medical therapy and initial, optimal medical therapy with revascularization as necessary are comparable strategies.
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| ===Indications for CABG===
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| CABG is carried out to prolong life or improve its quality (see above). Prolongation of life has been shown in patients with more than 50% luminal diameter stenosis of the left main coronary artery and in those with impaired left ventricular function (left ventricular ejection fraction <40%) and critical, >70% stenosis in all three major coronary arteries or in two arteries, one of which is the proximal left anterior descending artery. The presence of a high-risk result on a noninvasive test also increases the benefit of surgery. Patients with severe left ventricular dysfunction obtain a survival benefit from CABG if the myocardium with impaired contractile function is viable (hibernating myocardium) rather than necrotic.
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| The stenotic arteries are bypassed with an internal mammary (arterial) or saphenous vein graft. Arterial grafts have excellent long-term patency rates (90% at 10 years), whereas saphenous vein grafts show accelerated atherosclerosis with approximately 50% patency at 10 years. The use of internal mammary artery grafts is associated with a 27% reduction in 15-year mortality compared with saphenous vein grafts. The left internal mammary artery is most favorable to a graft to the left anterior descending coronary artery and the right internal mammary artery is most applicable to graft to the right coronary artery. Patients who require more than two grafts generally receive a combination of arterial and venous grafts. Minimally invasive CABG via a smaller thoractomy incision or a thorascopic approach reduces the morbidity and hospital length-of-stay.
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| The operative mortality of CABG is about 2%. The steady improvements in perioperative care have been offset by the progressively sicker patients who are referred for this procedure. Angina pectoris is relieved in more than 90% of patients who undergo CABG. The recurrence of angina is due to graft stenosis or progression of disease in nongrafted vessels.
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| ===Clinical trials: coronary artery bypass surgery versus medical treatment in the management of stable angina pectoris:===
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| It is well established that CABG provides more symptoms relief and survival benefits in some patients with chronic stable angina. However, the long term benefit of CABG is limited by the progression of atherosclerosis in other unbypassed vessels and stenosis of the graft itself. The CASS Trial (Coronary Artery Surgery Study) showed that more patients remained symptom-free after CABG compared to medical therapy at one year (66 versus 30 percent) and five years (63 versus 38 percent). However, by 10 years, this difference had disappeared (47 versus 42 percent). Trials from the 1970's showed that CABG offered no significant overall mortality benefits compared to medical therapy. However, several trials established the survival benefits in selected patients:
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| *Left main coronary artery stenosis or left main equivalent disease (defined as severe (≥70 percent) proximal left anterior descending and proximal left circumflex disease):
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| The Veterans Administration Cooperative Study compared a strategy of initial CABG versus deferred CABG: there was a substantial survival advantage patients assigned to initial CABG at two years (93 versus 71 percent) and at 11 years, but not at 18 years. The benefit was greatest in high-risk patients with >75 percent left main stenosis and/or left ventricular dysfunction. The CASS registry demonstrated similar results. Yusuf S et al published an overview of 10-year results from randomized trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration. They found that the relative risk reduction for death provided by CABG over medical therapy alone was greater at five years for left main disease than for three vessel or one or two vessel disease (odds ratio 0.32 versus 0.58 and 0.77); the absolute survival benefit from CABG among those with left main disease was 19.3 months.
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| PCI for left main coronary artery stenosis: PCI has been performed in patients with angina and left main disease who are considered inoperable, at high risk for CABG, or with prior CABG and one patent graft to either the left anterior descending or circumflex artery ("protected" left main).
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| *Multivessel coronary disease and left ventricular dysfunction:
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| Reduced left ventricular function is an important determinant of prognosis in patients with stable angina and is an indication for revascularization. CABG may improve survival in patients with left ventricular dysfunction and hibernating myocardium; therefore, myocardial viability should be assessed prior to recommending CABG in patients with multivessel coronary disease and left ventricular dysfunction. CASS registry showed that survival at seven years was improved with CABG compared to medical treatment (88 versus 65 percent) in patients with an LVEF between 35 and 49 percent and had three vessel disease. No benefit from CABG could be identified in patients with one or two vessel disease.
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| ===Clinical trials: Bypass surgery versus percutaneous intervention in the management of stable angina pectoris:===
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| ====Limitations of the clinical trials====
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| Multiple trials have compared the strategy of initial PTCA with initial CABG for treatment of CAD. These large randomized trials were published in the mid-1990s. The findings from these studies constitute the primary source of data upon which clinical decision making has been made.
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|
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| # The patients entered into these trials are poorly reflective of the general population (numerous patients were excluded and most included patients had preserved left ventricular function and focal atherosclerotic coronary disease).
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| # The initial trials are probably not relevant to current practice because of the lack of use of [[stents]] (especially drug eluting stents or DES) during PCI or of [[internal mammary artery]] rather than saphenous vein [[grafts]] during CABG. In addition, current [[antithrombotic]] regimens (eg, [[clopidogrel]] and glycoprotein IIb/IIIa inhibitors) were not employed during PCI.
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| ====Percutaneous intervention versus CABG for isolated LAD disease====
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| There is great evidence that CABG of the LAD using an arterial conduit is associated with improved survival compared to medical therapy, especially if the LAD lesion is severe or associated with multi-vessel disease and/or left ventricular dysfunction. The internal mammary artery grafts are preferred because of the increases in long-term patency and survival compared to venous grafts. On the other hand, medical therapy can be considered for patients with isolated LAD disease with minimal evidence of ischemia on stress testing. In regards to percutaneous interventions on the LAD (usually PTCA with stent), this can be performed with a great success and low risk of complications in proximal LAD disease. However, surgical [[revascularization]] should be considered in more complex lesions such as ostial location, particularly with involvement of the distal left main, adjacent circumflex ostial disease, or complex bifurcation lesions involving a dominant first diagonal branch. Despite this low incidence of major complications with stenting of the proximal lesion, the need for revascularization is still lower with CABG than with stenting. This was illustrated in the SIMA trial (Stent versus Internal Mammary Artery grafting):
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| *SIMA trial: The SIMA trial involved 123 patients with a proximal, isolated LAD stenosis, and compared stenting using bare-metal stent (BMS) to CABG using an internal mammary artery. At 10 years, the incidence of death and myocardial infarction was identical; only the need for additional revascularization was significantly higher in the stent group. It is remarkable that no patients randomized to CABG required a second revascularization of the LAD.
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| The restenosis rate after PCI is likely to decrease with the increased use of drug-eluting stents(DES). In fact, clinical trials of sirolimus-eluting stents (SES) and paclitaxel-eluting stents (PES) have demonstrated a marked reduction in the incidence of restenosis in trials evaluating patients with both single and multivessel coronary disease:
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| *The RAVEL trial (A Randomized Comparison of a Sirolimus-Eluting Stent With a Standard Stent for Coronary Revascularization) is the first controlled trial of a coronary drug-eluting stent. The The 5-year rate of target lesion revascularization (TLR) associated with SES was significantly lower than that with BMS.
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| *The role of drug-eluting stents in patients with LAD disease was evaluated in a post hoc analysis of data from the SIRIUS trial. Of 1101 patients enrolled in the original study, 459 had an LAD stenosis. All patients were randomly assigned to either a sirolimus-eluting stent or a bare metal stent. At eight months, the incidence of angiographic LAD restenosis was significantly lower among patients treated with a sirolimus-eluting stent (2 versus 42 percent). At one year, the incidence of major adverse events (death, MI, or target lesion revascularization) was also significantly reduced (10 versus 25 percent).
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| *Paclitaxel stent (PES): In 536 randomized patients with an LAD lesion in the TAXUS IV trial, at one year, the Paclitaxel stent was associated with significant reductions in target vessel revascularization (7.9 versus 18.6 percent) and the need for CABG (2.6 versus 6.3 percent).
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| *TAXi trial compared both types of drug-eluting stents: These stents were associated with very low rates of target lesion revascularization (1 and 3 percent at seven months). The three-year follow-up study, the TAXi-LATE trial, showed no difference in mortality of all causes in the PES and the SES groups (3% vs. 7%, P=0.98) or in major adverse cardiac event free survival (89% vs. 83%, P=0.28). Four stent thromboses were observed, two in the PES group (205 and 788 days) and two in the SES group (210 and 772 days).
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| Drug-eluting stents also appear to improve outcomes in patients with lesions at the origins of the LAD. This was illustrated in a study comparing sirolimus stents in 68 consecutive patients with such lesions to 77 patients treated with bare metal stents during the preceding two years. Positioning of the sirolimus stent into the distal left main trunk was required in one-third of patients for complete lesion coverage. The sirolimus stent was associated with significant reductions in angiographic restenosis at six months (5 versus 32 percent with bare metal stents) and target vessel revascularization at one year (0 versus 17 percent).
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| ====Percutaneous intervention (PTCA/PCI) versus CABG for multivessel disease====
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| The two U.S. trials of PTCA versus CABG are the multicenter Bypass Angioplasty Revascularization Investigation (BARI) trial and the single-center Emory Angioplasty Surgery Trial (EAST).
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| In both trials, a majority of patients had two- rather than three-vessel disease and normal LV function. In the BARI trial, 37% of patients had a proximal LAD lesion. In the EAST trial, more than 70% of patients had proximal LAD lesions. The results of both these trials at an approximately seven to eight-year follow-up interval have shown that early and late survival rates have been equivalent for the PTCA and CABG groups. In the BARI trial, the subgroup of patients with treated diabetes had a significantly better survival rate with CABG. That survival advantage for CABG was focused in the group of diabetic patients with multiple severe lesions. In the EAST trial, persons with diabetes had an equivalent survival rate with CABG or PTCA at five years, after which the curves began to diverge but failed to reach a statistically significant difference at eight years (surgical survival 75.5%, PTCA 60.1%; p = 0.23). In both trials, the biggest differences in late outcomes were the need for repeat revascularization procedures and symptom status. In both BARI and EAST, 54% of PTCA patients underwent subsequent revascularization procedures during the five-year follow-up versus 8% of the BARI CABG group and 13% of the EAST CABG group. In addition, the rate of freedom from angina was better in the CABG group in both EAST and BARI, and fewer patients in the CABG groups needed to take anti-anginal medications.
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| Non U.S. trials:
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| *RITA trial: The Randomized Intervention Treatment of Angina (RITA) trial was the first of the large scale trials to be published, involving 1011 patients from the United Kingdom. The long-term outcome of patients in the RITA trial (median follow up of 6.5 years) showed that the rates of death or nonfatal infarction for PTCA or CABG were the same (17 versus 16 percent). Angina was consistently higher in the PTCA group, 26 percent of whom required CABG, and 19 percent of whom required another PTCA. Repeat revascularization was usually performed within the first year, while the reintervention rate was 4 percent per year after the first three years.
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| *GABI trial: The German Angioplasty Bypass Surgery Investigation showed that both bypass surgery and angioplasty were equally effective in relieving angina at one year. This was associated with an increased rate of periprocedural morbidity with bypass surgery but more reinterventions with angioplasty.
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| *CABRI trial: The Europe-based multicenter Coronary Angioplasty versus Bypass Revascularization Investigation (CABRI) compared CABG to PTCA in 1054 patients. There was a similar mortality rate in the two groups at one year. However, patients assigned to PTCA required more repeat procedures and had a higher incidence of clinically significant angina. Restenosis after PTCA only partially accounted for this difference; of greater importance was the higher likelihood of residual disease after PTCA compared with CABG.
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| Stenting versus CABG for multivessel disease:
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| The introduction of stents has resulted in a significant reduction of restenosis and of target vessel revascularization. 2 trials address this question: The ARTS and the SoS. However, these 2 trials did use bare metal stents and not the drug-eluting stents that further reduce the risk of restenosis. In addition, only few patients were treated with GP IIb/IIa inhibitors.
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| Bare metal stents
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| 1205 patients were included in the ARTS 1 trial and were randomized to undergo bare metal stent implantation or bypass surgery. There was no difference in mortality (2.5 versus 2.8 percent at one year, 3.7 versus 4.6 percent at three years, 8.0 versus 7.6 percent at five years) or the rate of the combined end point of death, MI, or stroke for stented patients compared to those undergoing CABG. There was, however, a significant increase in the need for repeat revascularization with stenting (21 versus 4 percent at one year, 27 versus 7 percent at three years, and 30 versus 9 percent at five years). Diabetics and those with incomplete revascularization had the worse outcomes.
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| The Medicine, Angioplasty, or Surgery Study for Multivessel Coronary Artery Disease (MASS II), the Argentine Randomized Study of Coronary Angioplasty with Stenting versus Coronary Bypass Surgery in Patients with Multiple Vessel Disease (ERACI-II) and the Angina with Extremely Serious Operative Mortality Evaluation (AWESOME) showed similar survival rates but higher revascularization rates among patients with bare-metal stents at 5 years. Others (the Stent or Surgery trial; SoS) have shown a significant long-term survival advantage with surgery.
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| SoS trial: This trial included 988 patients between 1996 and 1999. At a median follow-up of two years, PCI was associated with a significantly higher rate of repeat revascularization (21 versus 6 percent) with CABG. At six years, mortality was significantly higher in the PCI group (10.9 versus 6.8; hazard ratio 1.66, 95% CI 1.08 to 2.55. Of note, there was a large number of death related to cancer in the stenting group.
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| Meta-analyses: Three meta-analyses published in 1995, 2007, and 2008 showed no significant difference between the PCI and CABG in all-cause mortality or cardiac death at one to five years, although angioplasty for multivessel disease was associated with a significant increase in mortality compared to CABG at five and eight years in a subgroup analysis.
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| Drug eluting stents:
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| Data from randomized, controlled trials of drug-eluting stents as compared with bare-metal stents have shown significant reductions in the rate of repeat intervention, with similar rates of death and myocardial infarction. Studies comparing PCI involving drug-eluting stents with CABG have generally been smaller and nonrandomized.
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| Sirolimus-eluting stents (SES):
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| In ARTS II study, the CABG-control group was a historical group from the ARTS I trial. As a result, conclusions should be made with caution. This trial demonstrated lower rates of revascularization and major adverse cardiac and cerebrovascular events (MACCE) with SES compared with BMS, as well as a higher rate of revascularization with equivalent MACCE to CABG at one year.
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| Paclitaxel-eluting stents (PES):
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| The Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX): The SYNTAX trial is a prospective, clinical trial conducted in 85 sites that randomly assigned 1800 patients with three-vessel or left main coronary artery disease to undergo CABG or PCI (in a 1:1 ratio). A noninferiority comparison of the two groups was performed for the primary end point — a major adverse cardiac or cerebrovascular event (i.e., death from any cause, stroke, myocardial infarction, or repeat revascularization) during the 12-month period after randomization. The trial showed that the rates of major adverse cardiac or cerebrovascular events at 12 months were significantly higher in the PCI group (17.8%, vs. 12.4% for CABG; P=0.002), in large part because of an increased rate of repeat revascularization (13.5% vs. 5.9%, P<0.001); as a result, the criterion for noninferiority was not met. The study concluded that CABG remains the standard of care for patients with three-vessel or left main coronary artery disease.
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| A randomized trial is under way — the Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM) study — that specifically compares drug-eluting stents with bypass surgery in patients with diabetes who have multivessel disease.
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| ==Non-pharmacological anti anginal applications==
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| ===Transmyocardial Revascularization (TMR)===
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| Transmyocardial Revascularization is an alternative, and invasive therapy for refractory angina. It effects;
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| ====Sympathetic denervation====
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| ====Angiogenesis====
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| ===Spinal Cord Stimulation(SCS)===
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| SCS uses an implanted device with an electrode tip that extends into the dorsal epidural space, usually at the C7-T1 level. In patients with refractory angina not amenable to coronary revascularization, spinal cord stimulation using specific electrodes inserted into the epidural space uses neuromodulation to reduce painful stimulus.
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| Several observational studies have reported success rates of up to 80% in decreasing anginal frequency and severity. This method is proposed for patients with chronic stable angina refractory to medical, catheter intervention, and surgical therapy (more data are still needed and therefore, spinal cord stimulation should be only considered when other treatment options have failed).
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| *Decreases neurotransmission of painful stimuli
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| *Increases release of endogenous opiates
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| *Redistributes myocardial blood flow to ischemic areas
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| ===Enhanced External Counter Pulsation (EECP)===
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| Enhanced external counter pulsation (EECP) is another alternative therapy for refractory angina. Most data are from observational studies, which have reported improvement in exercise tolerance and reduction in anginal frequency as well as nitroglycerin use among patients treated with EECP.
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| EECP has been postulated to decrease myocardial oxygen demand, enhance myocardial collateral flow via increased transmyocardial pressure, and improve endothelial function. The therapy is usually administered over 7 weeks consisting of 35 one hour treatments. Possible placebo effect associated with EECP has not been addressed in many studies, which have not included sham controls.
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| EECP uses three paired pneumatic cuffs that are applied to the lower extremities. The cuffs are sequentially inflated then deflated.
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| *Increases endothelial function
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| *Promotes coronary collateral formation
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| *Decreases peripheral vascular resistance
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| *Increases ventricular function
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| *Placebo effect
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|
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| ==Therapies no longer recommended in the treatment of chronic stable angina pectoris==
| | *In patients with chronic stable angina, immediate symptomatic relief is achieved with [[Chronic stable angina nitrate therapy|short-acting sublingual nitrates]] and long term relief of symptoms is achieved with [[Chronic stable angina beta blocker therapy|beta blockers]], [[Chronic stable angina treatment calcium channel blockers|calcium channel blockers]] and [[Chronic stable angina nitrate therapy|long-acting nitrates]]. |
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| ===Estrogen Replacement Therapy (ERT)===
| | *Drugs that improve quality of life and are associated with better prognosis include: [[Chronic stable angina treatment aspirin|low dose aspirin]], [[Chronic stable angina treatment angiotensin converting enzyme inhibitors (ACEI) and renin angiotensin aldosterone system blockers (RAAS blockers)|ACEIs]], [[Chronic stable angina beta blocker therapy|beta-blockers]]. |
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| Randomized, controlled secondary prevention trials like the Heart and Estrogen / Progestin Replacement Study (HERS), HERS-II and the Women’s Health Initiative (WHI) have suggested that hormone replacement therapy does not reduce cardiovascular events or mortality in patients with stable angina pectoris. Therefore current recommendations and practice guidelines do not support the use of hormone replacement therapy to reduce the risk of heart disease.
| | *You can read in greater detail about each of the pharmacotherapies for chronic stable angina below by clicking on the link for that topic: |
| | :*'''[[Chronic stable angina medical therapy|Overview]]''' |
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| ===Antioxidants===
| | :*Antiplatelet agents: '''[[Chronic stable angina treatment aspirin|Aspirin]] | [[Chronic stable angina treatment dipyridamole|Dipyridamole]] | [[Chronic stable angina treatment clopidogrel|Clopidogrel]]''' |
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| The Heart Protection Study Collaborative Group enrolled more than 20,000 patients with established atherosclerotic vascular disease or diabetes mellitus and conclusively demonstrated no reduction in all cause mortality, MI, or other vascular events with the regimen of vitamin C, vitamin E, and beta carotene.
| | :*Antianginal agents: '''[[Chronic stable angina nitrate therapy|Nitrates]] | [[Chronic stable angina beta blocker therapy|Beta Blockers]] | [[Chronic stable angina treatment calcium channel blockers|Calcium Channel Blockers]] | [[Chronic stable angina treatment potassium channel openers|Potassium Channel Openers]] | [[Chronic stable angina newer antianginal agents|Newer Anti-anginal Agents]]''' |
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| ===Chelation therapy===
| | :*'''[[Chronic stable angina treatment angiotensin converting enzyme inhibitors (ACEI) and renin angiotensin aldosterone system blockers (RAAS blockers)|ACEI/RAAS Blockers]]''' |
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| Intravenous infusion of ethylene diamine tetra acetic acid (EDTA) is not recommended for the treatment of chronic angina or arteriosclerotic cardiovascular disease and may be harmful because of its potential to cause hypocalcaemia.
| | :*'''[[Chronic stable angina treatment anti-lipid agents|Anti-lipid Agents]]''' |
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| ==ACC / AHA Guidelines- Pharmacotherapy to Prevent MI and Death and Reduce Symptoms (DO NOT EDIT)<ref name="Gibbons1"> Gibbons RJ, Chatterjee K, Daley J, et al. 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. 1999; 99: 2829–2848. PMID 10351980</ref>==
| | :*'''[[Chronic stable angina guidelines for pharmacotherapy to improve prognosis and reduce symptoms|Guidelines for Pharmacotherapy to Improve Prognosis and Reduce Symptoms]]''' |
| {{cquote|
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| ===Class I===
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| 1. [[Aspirin]] in the absence of contraindications. ''(Level of Evidence: A)''
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| 2. [[Beta-blockers]] as initial therapy in the absence of contraindications in patients with prior [[MI]]. ''(Level of Evidence: A)''
| | ===Revascularization=== |
| | *[[Revascularization]] is only used for select patients specially those who have uncontrolled symptoms with optimal medical therapy. |
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| 3. [[Beta-blockers]] as initial therapy in the absence of contraindications in patients without prior [[MI]]. ''(Level of Evidence: B)''
| | *This can be achieved with either percutaneous coronary intervention ([[PCI]]) with stent placement or [[coronary artery bypass surgery]]. |
| | :*In general, [[PCI]] is reserved for single or some cases of two vessel disease, and |
| | :*[[CABG]] is reserved for patients with two or three vessel disease or left main disease. |
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| 4. [[Calcium antagonists]] (short-acting [[dihydropyridine calcium antagonist]]s should be avoided) and/or long-acting [[nitrate]]s as initial therapy when [[beta-blockers]] are contraindicated. ''(Level of Evidence: B)''
| | *With the availability of drug-eluting stents, [[PCI]] is increasingly being performed for many lesions including more complex ones. |
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| 5. [[Calcium antagonists]] (short-acting [[dihydropyridine calcium antagonist]]s should be avoided) and/or long-acting [[nitrate]]s in combination with [[beta-blockers]] when initial treatment with [[beta-blockers]] is not successful. ''(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. |
| | :'''[[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]]''' |
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| 6. [[Calcium antagonists]] (short-acting [[dihydropyridine calcium antagonist]]s should be avoided) and/or long-acting [[nitrate]]s as a substitute for [[beta-blockers]] if initial treatment with [[beta-blockers]] leads to unacceptable side effects. ''(Level of Evidence: C)''
| | ===Alternative Therapies for Refractory Angina=== |
| | You can read in greater detail about each of the alternative therapies for refractory angina below by clicking on the link for that topic: |
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| 7. Sublingual [[nitroglycerin]] or nitroglycerin spray for the immediate relief of [[angina]]. ''(Level of Evidence: C)''
| | *'''[[Chronic stable angina transmyocardial revascularization(TMR)|Transmyocardial Revascularization]]''' |
| | | *'''[[Chronic stable angina spinal cord stimulation(SCS)|Spinal Cord Stimulation]]''' |
| 8. Lipid-lowering therapy in patients with documented or suspected [[CAD]] and [[LDL cholesterol]] >130 mg/dL with a target [[LDL]] of <100 mg/dL. ''(Level of Evidence: A)''
| | *'''[[Chronic stable angina enhanced external counter pulsation(EECP)|Enhanced External Counter Pulsation (EECP)]]''' |
| | | *'''[[Chronic stable angina ACC/AHA guidelines for alternative therapies in patients with refractory angina|ACC/AHA Guidelines for Alternative Therapies in Patients with Refractory Angina]]''' |
| ===Class IIa===
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| 1. [[Clopidogrel]] when [[aspirin]] is absolutely contraindicated. ''(Level of Evidence: B)''
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| 2. Long-acting nondihydropyridine [[calcium antagonists]] (short-acting [[dihydropyridine calcium antagonist]]s should be avoided) instead of [[beta-blockers]] as initial therapy. ''(Level of Evidence: B)''
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| 3. Lipid-lowering therapy in patients with documented or suspected [[CAD]] and [[LDL cholesterol]] 100 to 129 mg/dL, with a target [[LDL]] of 100 mg/dL. ''(Level of Evidence: B)''
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| ===Class IIb===
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| 1. Low-intensity anticoagulation with [[warfarin]] in addition to [[aspirin]]. ''(Level of Evidence: B)''
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| ===Class III===
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| 1. [[Dipyridamole]]. ''(Level of Evidence: B)''
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| 2. [[Chelation therapy]]. ''(Level of Evidence: B)''}}
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| ==ACC / AHA Guidelines- Pharmacotherapy to Prevent MI and Death in Asymptomatic Patients (DO NOT EDIT)<ref name="Gibbons2">Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, Ferguson TB Jr, Fihn SD, Fraker TD Jr, Gardin JM, O'Rourke RA, Pasternak RC, Williams SV, Gibbons RJ, Alpert JS, Antman EM, Hiratzka LF, Fuster V, Faxon DP, Gregoratos G, Jacobs AK, Smith SC Jr; American College of Cardiology; American Heart Association Task Force on Practice Guidelines. Committee on the Management of Patients With Chronic Stable Angina. 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. 2003 Jan 7; 107 (1): 149-58. PMID 12515758 </ref>==
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| {{cquote|
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| ===Class I===
| |
| 1. [[Aspirin]] in the absence of contraindication in patients with prior [[MI]]. ''(Level of Evidence: A)''
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| 2. [[Beta-blockers]] as initial therapy in the absence of contraindications in patients with prior [[MI]]. ''(Level of Evidence: B)''
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| 3. Lipid-lowering therapy in patients with documented [[CAD]] and [[LDL cholesterol]] greater than 130 mg/dL, with a target [[LDL]] of less than 100 mg/dL. ''(Level of Evidence: A)''
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| 4. [[ACE inhibitor]] in patients with [[CAD]] who also have [[diabetes]] and/or [[left ventricular systolic dysfunction]]. ''(Level of Evidence: A)''
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| ===Class IIa===
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| 1. [[Aspirin]] in the absence of contraindications in patients without prior [[MI]]. ''(Level of Evidence: B)''
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| | |
| 2. [[Beta-blockers]] as initial therapy in the absence of contraindications in patients without prior [[MI]]. ''(Level of Evidence: C)''
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| 3. Lipid-lowering therapy in patients with documented [[CAD]] and [[LDL cholesterol]] 100 to 129 mg/dL, with a target [[LDL]] of 100 mg/dL. ''(Level of Evidence: C)''
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| 4. [[ACE inhibitor]] in all patients with [[CAD]] or other [[vascular disease]]. ''(Level of Evidence: B)''}}
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| ==ACC / AHA Guidelines- Revascularization for Chronic Stable Angina (DO NOT EDIT)<ref name="Gibbons1"> Gibbons RJ, Chatterjee K, Daley J, et al. 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. 1999; 99: 2829–2848. PMID 10351980</ref>==
| |
| {{cquote|
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| ===Class I===
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| 1. [[CABG]] for patients with significant [[left main]] coronary disease. ''(Level of Evidence: A)''
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| 2. [[CABG]] for patients with 3-vessel disease. The survival benefit is greater in patients with abnormal [[LV function]] (ejection fraction <50%). ''(Level of Evidence: A)''
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| 3. [[CABG]] for patients with 2-vessel disease with significant proximal [[left anterior descending artery|left anterior descending]] [[CAD]] and either abnormal [[LV function]] (ejection fraction <50%) or demonstrable [[ischemia]] on noninvasive testing. ''(Level of Evidence: A)''
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| 4. [[PTCA]] for patients with 2- or 3-vessel disease with significant proximal [[left anterior descending artery|left anterior descending]] [[CAD]], who have anatomy suitable for catheter-based therapy, normal [[LV function]], and who do not have treated [[diabetes]]. ''(Level of Evidence: B)''
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| 5. [[PTCA]] or [[CABG]] for patients with 1- or 2-vessel [[CAD]] without significant proximal [[left anterior descending artery|left anterior descending]] [[CAD]] but with a large area of viable [[myocardium]] and high-risk criteria on noninvasive testing. ''(Level of Evidence: B)''
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| 6. [[CABG]] for patients with 1- or 2-vessel [[CAD]] without significant proximal [[left anterior descending artery|left anterior descending]] [[CAD]] who have survived [[sudden cardiac death]] or sustained [[ventricular tachycardia]]. ''(Level of Evidence: C)''
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| 7. In patients with prior [[PTCA]], [[CABG]] or [[PTCA]] for recurrent [[stenosis]] associated with a large area of viable [[myocardium]] and/or high-risk criteria on noninvasive testing. ''(Level of Evidence: C)''
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| 8. [[PTCA]] or [[CABG]] for patients who have not been successfully treated by medical therapy and can undergo [[revascularization]] with acceptable risk. ''(Level of Evidence: B)''
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| ===Class IIa===
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| 1. Repeat [[CABG]] for patients with multiple [[saphenous vein graft]] stenoses, especially when there is significant [[stenosis]] of a graft supplying the [[left anterior descending coronary artery]]. [[PTCA]] may be appropriate for focal [[saphenous vein graft]] lesions or multiple stenoses in poor candidates for reoperative surgery. ''(Level of Evidence: C)''
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| 2. [[PTCA]] or [[CABG]] for patients with 1- or 2-vessel [[CAD]] without significant proximal [[left anterior descending artery|left anterior descending]] [[CAD]] but with a moderate area of viable [[myocardium]] and demonstrable [[ischemia]] on noninvasive testing. ''(Level of Evidence: B)''
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| 3. [[PTCA]] or [[CABG]] for patients with 1-vessel disease with significant proximal [[left anterior descending artery|left anterior descending]] [[CAD]]. ''(Level of Evidence: B)''
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| ===Class IIb===
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| 1. Compared with [[CABG]], [[PTCA]] for patients with 3- or 2-vessel disease with significant proximal [[left anterior descending artery|left anterior descending]] [[CAD]] who have anatomy suitable for catheter-based therapy and who have treated [[diabetes]] or abnormal [[LV function]]. ''(Level of Evidence: B)''
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| 2. [[PTCA]] for patients with significant [[left main coronary artery|left main coronary]] disease who are not candidates for [[CABG]]. ''(Level of Evidence: C)''
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| 3. [[PTCA]] for patients with 1- or 2-vessel [[CAD]] without significant proximal [[left anterior descending artery|left anterior descending]] [[CAD]] who have survived [[sudden cardiac death]] or sustained [[ventricular tachycardia]]. ''(Level of Evidence: C)''
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| ===Class III===
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| 1. [[PTCA]] or [[CABG]] for patients with 1- or 2-vessel [[CAD]] without significant [[left anterior descending artery|left anterior descending]] [[CAD]] who
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| :a. Have mild symptoms that are unlikely due to [[myocardial ischemia]] or have not received an adequate trial of medical therapy and
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| ::1) Have only a small area of viable [[myocardium]] or
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| ::2) Have no demonstrable [[ischemia]] on noninvasive testing. ''(Level of Evidence: C)''
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| 2. [[PTCA]] or [[CABG]] for patients with borderline coronary stenoses (50% to 60% diameter in locations other than the [[left main]]) and no demonstrable [[ischemia]] on noninvasive testing. ''(Level of Evidence: C)''
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| | |
| 3. [[PTCA]] or [[CABG]] for patients with insignificant coronary [[stenosis]] (<50% diameter). ''(Level of Evidence: C)''
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| 4. [[PTCA]] in patients with significant [[left main]] [[CAD]] who are candidates for [[CABG]]. ''(Level of Evidence: B)''}}
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| ==ACC / AHA Guidelines- Alternative Therapies for Chronic Stable Angina in Patients Refractory to Medical Therapy Who Are Not Candidates for Percutaneous Intervention or Revascularization (DO NOT EDIT)<ref name="Gibbons2">Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, Ferguson TB Jr, Fihn SD, Fraker TD Jr, Gardin JM, O'Rourke RA, Pasternak RC, Williams SV, Gibbons RJ, Alpert JS, Antman EM, Hiratzka LF, Fuster V, Faxon DP, Gregoratos G, Jacobs AK, Smith SC Jr; American College of Cardiology; American Heart Association Task Force on Practice Guidelines. Committee on the Management of Patients With Chronic Stable Angina. 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. 2003 Jan 7; 107 (1): 149-58. PMID 12515758 </ref>==
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| {{cquote|
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| ===Class IIa===
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| 1. Surgical laser [[transmyocardial revascularization]] ([[TMR]]). ''(Level of Evidence: A)''
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| ===Class IIb===
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| 1. [[Enhanced external counterpulsation]] ([[EECP]]). ''(Level of Evidence: B)''
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| 2. [[Spinal cord stimulation]] ([[SCS]]). ''(Level of Evidence: B)''}}
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| ==See Also==
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| *[[The Living Guidelines: Chronic Stable Angina Pectoris | The Chronic Stable Angina Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines]]
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| ==Sources==
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| *The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina <ref name="Gibbons1"> Gibbons RJ, Chatterjee K, Daley J, et al. 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. 1999; 99: 2829–2848. PMID 10351980</ref>
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| *The ACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina <ref name="Gibbons2">Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, Ferguson TB Jr, Fihn SD, Fraker TD Jr, Gardin JM, O'Rourke RA, Pasternak RC, Williams SV, Gibbons RJ, Alpert JS, Antman EM, Hiratzka LF, Fuster V, Faxon DP, Gregoratos G, Jacobs AK, Smith SC Jr; American College of Cardiology; American Heart Association Task Force on Practice Guidelines. Committee on the Management of Patients With Chronic Stable Angina. 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. 2003 Jan 7; 107 (1): 149-58. PMID 12515758 </ref>
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| *The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina <ref name="Fraker"> Fraker TD Jr, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, Ferguson TB Jr, Gardin JM, O'Rourke RA, Williams SV, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Buller CE, Creager MA, Ettinger SM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Page RL, Riegel B, Tarkington LG, Yancy CW; American College of Cardiology; American Heart Association; American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group. 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. 2007 Dec 4; 116 (23): 2762-72. Epub 2007 Nov 12. PMID 17998462 </ref>
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| ==References== | | ==References== |
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