Chronic stable angina risk stratification: Difference between revisions

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


{{EH}}
==Overview==
The average [[mortality]] in patients with stable angina ranges from 1-3%. However, the [[prognosis]] varies widely depending on various factors such as: the duration and severity of [[symptom]]s, [[Chronic stable angina risk stratification electrocardiogram/chest x-ray|resting ECG abnormalities]], [[Chronic stable angina risk stratification based upon rest left ventricular function|abnormal left ventricular function]] and associated [[comorbidity|comorbidities]].<ref name="pmid16415069">Daly CA, De Stavola B, Sendon JL, Tavazzi L, Boersma E, Clemens F et al. (2006) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16415069 Predicting prognosis in stable angina--results from the Euro heart survey of stable angina: prospective observational study.] ''BMJ'' 332 (7536):262-7. [http://dx.doi.org/10.1136/bmj.38695.605440.AE DOI:10.1136/bmj.38695.605440.AE] PMID: [http://pubmed.gov/16415069 16415069]</ref>


==Risk Stratification of Chronic Stable Angina==
==Risk Stratification==
===Risk Stratification Based on Different Factors===
====Anatomic Factors====
*[[Left ventricular function]], indicated as the strongest predictor of long term survival
*Extent of [[atherosclerosis]] in the [[coronary artery|coronary arteries]] (single vessel disease vs [[multivessel coronary artery disease|multivessel disease]])
*Evidence of a recent [[coronary artery|coronary]] [[plaque rupture]] ([[acute coronary syndrome]])
*Overall health and presence of other [[comorbidity|co-morbidities]]


==ACC / AHA Guidelines- Measurement of Rest LV Function by Echocardiography or Radionuclide Angiography (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>==
====Clinical Factors====
{{cquote|
An initial scoring system was proposed by the Framingham Heart Study group to predict 10 year risk for patients with CAD based upon:
===Class I===
*Patient's age and sex
1. [[Echocardiography]] or [[radionuclide angiography]] (RNA) in patients with a history of prior [[MI]], pathological Q waves, or symptoms or signs suggestive of [[heart failure]] to assess [[LV function]]. ''(Level of Evidence: B)''
*Total [[cholesterol]]  
*Presence of [[hypertension]]  
*History of [[smoking]] and [[diabetes]]  
*Presence of other [[peripheral vascular diseases]]


2. [[Echocardiography]] in patients with a [[systolic murmur]] suggesting [[mitral regurgitation]] to assess its severity and etiology. ''(Level of Evidence: C)''
For a full discussion on individual risk stratifying topics, visit the microchapters below:


3. [[Echocardiography]] or RNA in patients with complex [[ventricular arrhythmia]]s to assess [[LV function]]. ''(Level of Evidence: B)''
*'''[[Chronic stable angina risk stratification electrocardiogram/chest x-ray|Electrocardiogram/chest X-ray]]'''
*'''[[Chronic stable angina risk stratification rest left ventricular function|Assessment of resting LV function]]'''
*'''[[Chronic stable angina risk stratification coronary angiography|Coronary angiography and left ventriculography]]'''


===Class III===
*Exercise testing for Risk Stratification and Prognosis:
1. Routine periodic reassessment of stable patients for whom no new change in therapy is contemplated. ''(Level of Evidence: C)''
:*'''[[Chronic stable angina risk assessment in patients with an intermediate or high probability of coronary artery disease|Exercise treadmill test]]'''
:*'''[[Chronic stable angina risk stratification cardiac stress imaging in patients who are able to exercise|In patients who are able to exercise]]'''
:*'''[[Chronic stable angina risk stratification cardiac stress imaging in patients who are unable to exercise|In patients who are unable to exercise]]'''


2. Patients with a normal [[ECG]], no history of [[MI]], and no symptoms or signs suggestive of [[heart failure]]. ''(Level of Evidence: B)''}}
===Risk Stratification Categories and Appropriate Management===
*Patients at low risk have an annual [[mortality rate]] of less than 1% and can be managed medically.
*Patients at intermediate risk have an annual [[mortality rate]] of 1%–3% and may require additional imaging studies such as [[Chronic stable angina risk stratification cardiac stress imaging in patients who are able to exercise|exercise imaging]] for further risk assessment.
*Patients at high risk have an annual [[mortality rate]] of more than 3% and require [[Chronic stable angina risk stratification coronary angiography|coronary angiography]].


==ACC / AHA Guidelines- Risk Assessment and Prognosis in Patients With an Intermediate or High Probability of CAD (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>==
===Risk Stratification of Chronic Stable Angina in Symptomatic Patients===
{{cquote|
The next step after establishing the clinical probability of [[angina]] is to assess the risk of underlying [[coronary artery disease]] based on initial [[Chronic stable angina risk stratification electrocardiogram/chest x-ray|rest ECG]] and the patients ability to [[Chronic stable angina risk assessment in patients with an intermediate or high probability of coronary artery disease|exercise]].
===Class I===
*If the [[Chronic stable angina risk stratification electrocardiogram/chest x-ray|rest ECG]] is abnormal, the next step is to conduct a [[Chronic stable angina risk stratification cardiac stress imaging in patients who are able to exercise|stress imaging test]].
1. Patients undergoing initial evaluation. (Exceptions are listed below in classes IIb and III.) ''(Level of Evidence: B)''
*If the patient is unable to exercise then a [[Chronic stable angina risk stratification cardiac stress imaging in patients who are unable to exercise|pharmacological stress test]] is used to stratify the risk underlying the [[atherosclerosis|atherosclerotic state]].
*For patients with [[ Canadian Cardiovascular Society#C.C.S. Class III|CCS class III or IV]] [[angina]], patients with poor [[LVEF]] or non responsive to medical therapy there may be some benefit to performing [[Chronic stable angina risk stratification coronary angiography|coronary angiography]].


2. Patients after a significant change in cardiac symptoms. ''(Level of Evidence: C)''
==ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/ STS 2017 Appropriate Use Criteria for Coronary Revascularization in Patients With Stable Ischemic Heart Disease==


===Class IIb===
{| class="wikitable" style="width: 80%; text-align: justify;"
1. Patients with the following [[ECG]] abnormalities:
|-  
:a. Preexcitation ([[Wolff-Parkinson-White syndrome|Wolff-Parkinson-White]]) syndrome. ''(Level of Evidence: B)''
| '''Noninvasive Risk Stratification'''
:b. Electronically paced ventricular rhythm. ''(Level of Evidence: B)''
|-
:c. More than 1 mm of rest ST depression. ''(Level of Evidence: B)''
| '''High risk (>3% annual death or MI)'''
:d. Complete [[left bundle-branch block]]. ''(Level of Evidence: B)''
'''1.''' Severe resting LV dysfunction (LVEF <35%) not readily explained by noncoronary causes


2. Patients who have undergone [[cardiac catheterization]] to identify [[ischemia]] in the distribution of a coronary lesion of borderline severity. ''(Level of Evidence: C)''
'''2.''' Resting perfusion abnormalities ≥10% of the myocardium in patients without prior history or evidence of MI


3. [[Revascularization|Postrevascularization]] patients who have a significant change in anginal pattern suggesting [[ischemia]]. ''(Level of Evidence: C)''
'''3.''' Stress ECG findings including ≥2 mm of ST-segment depression at low workload or persisting into recovery, exercise-induced ST-segment elevation, or
exercise-induced VT/VF


===Class III===
'''4.''' Severe stress-induced LV dysfunction (peak exercise LVEF <45% or drop in LVEF with stress ≥10%)
1. Patients with severe [[comorbidity]] likely to limit life expectancy or prevent [[revascularization]]. ''(Level of Evidence: C)''}}


==ACC / AHA Guidelines- Cardiac Stress Imaging for Risk Stratification of Patients With Chronic Stable Angina Who Are Able to Exercise (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>==
'''5.''' Stress-induced perfusion abnormalities encumbering ≥10% myocardium or stress segmental scores indicating multiple vascular territories with
{{cquote|
abnormalities
===Class I===
1. Exercise myocardial perfusion imaging or exercise [[echocardiography]] to identify the extent, severity, and location of [[ischemia]] in patients who do not have [[left bundle-branch block]] or an electronically paced ventricular rhythm and have either an abnormal rest [[ECG]] or are using [[digoxin]]. ''(Level of Evidence: B)''


2. [[Dipyridamole]] or [[adenosine]] myocardial perfusion imaging in patients with [[left bundle-branch block]] or electronically paced ventricular rhythm. ''(Level of Evidence: B)''
'''6.''' Stress-induced LV dilation


3. Exercise myocardial perfusion imaging or exercise [[echocardiography]] to assess the functional significance of coronary lesions (if not already known) in planning [[PTCA]]. ''(Level of Evidence: B)''
'''7.''' Inducible wall motion abnormality (involving >2 segments or 2 coronary beds)


===Class IIb===
'''8.''' Wall motion abnormality developing at low dose of dobutamine (≤ 10 mg/kg/min) or at a low heart rate (<120 beats/min)
1. Exercise or [[dobutamine]] [[echocardiography]] in patients with [[left bundle-branch block]]. ''(Level of Evidence: C)''


2. Exercise, [[dipyridamole]], [[adenosine]] myocardial perfusion imaging, or exercise or [[dobutamine]] [[echocardiography]] as the initial test in patients who have a normal rest [[ECG]] and are not taking [[digoxin]]. ''(Level of Evidence: B)''
'''9.''' CAC score >400 Agatston units


===Class III===
'''10.''' Multivessel obstructive CAD (≥70% stenosis) or left main stenosis (≥50% stenosis) on CCTA
1. Exercise myocardial perfusion imaging in patients with left [[bundle-branch block]]. ''(Level of Evidence: C)''
|-  
| '''Intermediate risk (1% to 3% annual death or MI)'''
'''1.''' Mild/moderate resting LV dysfunction (LVEF 35% to 49%) not readily explained by noncoronary causes


2. Exercise, [[dipyridamole]], [[adenosine]] myocardial perfusion imaging, or exercise or [[dobutamine]] [[echocardiography]] in patients with severe [[comorbidity]] likely to limit life expectation or prevent [[revascularization]]. ''(Level of Evidence: C)''}}
'''2'''. Resting perfusion abnormalities in 5% to 9.9% of the myocardium in patients without a history or prior evidence of MI


==See Also==
'''3.''' ≥1 mm of ST-segment depression occurring with exertional symptoms
*[[The Living Guidelines: Chronic Stable Angina Pectoris | The Chronic Stable Angina Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines]]


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


*TheACC/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>
'''5.''' Small wall motion abnormality involving 1 to 2 segments and only 1 coronary bed


*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>
'''6.''' CAC score 100 to 399 Agatston units
 
'''7.''' One vessel CAD with ≥70% stenosis or moderate CAD stenosis (50% to 69% stenosis) in ≥2 arteries on CCTA
|-
|'''Low risk (<1% annual death or MI)'''
'''1.''' Low-risk treadmill score (score ≥5) or no new ST segment changes or exercise-induced chest pain symptoms; when achieving maximal levels of exercise
 
'''2.''' Normal or small myocardial perfusion defect at rest or with stress encumbering <5% of the myocardium*
 
'''3.''' Normal stress or no change of limited resting wall motion abnormalities during stress
 
'''4.''' CAC score <100 Agaston units
5. No coronary stenosis >50% on CCTA
|-
|CAC indicates coronary artery calcium; CAD, coronary artery disease; CCTA, coronary computed tomography angiography; LV, left ventricular; LVEF, left ventricular ejection fraction; and MI, myocardial infarction.
|}
===Guidelines for Risk Stratification of Chronic Stable Angina ===
Visit the microchapters below:
*'''[[Chronic stable angina risk stratification in asymptomatic patients by noninvasive testing|Risk Stratification by Noninvasive Testing]]'''
*'''[[Chronic stable angina risk stratification by coronary angiography|Risk Stratification by Coronary Angiography]]'''


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
{{Circulatory system pathology}}
{{SIB}}
[[Category:Cardiology]]


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Latest revision as of 18:28, 28 October 2017

Chronic stable angina Microchapters

Acute Coronary Syndrome Main Page

Home

Patient Information

Overview

Historical Perspective

Classification

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

Differentiating Chronic Stable Angina from Acute Coronary Syndromes

Pathophysiology

Epidemiology and Demographics

Risk Stratification

Pretest Probability of CAD in a Patient with Angina

Prognosis

Diagnosis

History and Symptoms

Physical Examination

Test Selection Guideline for the Individual Basis

Laboratory Findings

Electrocardiogram

Exercise ECG

Chest X Ray

Myocardial Perfusion Scintigraphy with Pharmacologic Stress

Myocardial Perfusion Scintigraphy with Thallium

Echocardiography

Exercise Echocardiography

Computed coronary tomography angiography(CCTA)

Positron Emission Tomography

Ambulatory ST Segment Monitoring

Electron Beam Tomography

Cardiac Magnetic Resonance Imaging

Coronary Angiography

Treatment

Medical Therapy

Revascularization

PCI
CABG
Hybrid Coronary Revascularization

Alternative Therapies for Refractory Angina

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

Discharge Care

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Secondary Prevention

Guidelines for Asymptomatic Patients

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

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Case #1

Chronic stable angina risk stratification On the Web

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CDC onChronic stable angina risk stratification

Chronic stable angina risk stratification in the news

Blogs on Chronic stable angina risk stratification

to Hospitals Treating Chronic stable angina risk stratification

Risk calculators and risk factors for Chronic stable angina risk stratification

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

Overview

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

Risk Stratification

Risk Stratification Based on Different Factors

Anatomic Factors

Clinical Factors

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

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

  • Exercise testing for Risk Stratification and Prognosis:

Risk Stratification Categories and Appropriate Management

Risk Stratification of Chronic Stable Angina in Symptomatic Patients

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

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

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

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

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

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

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

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

6. Stress-induced LV dilation

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

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

9. CAC score >400 Agatston units

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

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

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

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

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

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

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

6. CAC score 100 to 399 Agatston units

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

Low risk (<1% annual death or MI)

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

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

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

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

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

Guidelines for Risk Stratification of Chronic Stable Angina

Visit the microchapters below:

References

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


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