Chronic stable angina risk stratification: Difference between revisions

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{{SI}}
__NOTOC__
{{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}}
 
'''Associate Editor-in-Chief:''' Smita Kohli, M.D.
 
{{EH}}
 
 
'''Click [[Chronic stable angina|''here'']] for the Chronic stable angina main page'''
 


==Overview==
==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>


The average mortality in patients with stable angina ranges from 1-3%. However, there is a wide variability in the prognosis and
==Risk Stratification==
hence it is important to risk stratify every patient. Risk stratification is based on 4 types of patient characteristics. 
===Risk Stratification Based on Different Factors===
* Left ventricular function, which is the strongest predictor of long term survival
====Anatomic Factors====
* Extent of atherosclerosis in the coronary arteries
*[[Left ventricular function]], indicated as the strongest predictor of long term survival
* Evidence of a recent coronary plaque rupture
*Extent of [[atherosclerosis]] in the [[coronary artery|coronary arteries]] (single vessel disease vs [[multivessel coronary artery disease|multivessel disease]])
* Overall health and presence of other co-morbidities.
*Evidence of a recent [[coronary artery|coronary]] [[plaque rupture]] ([[acute coronary syndrome]])
 
*Overall health and presence of other [[comorbidity|co-morbidities]]
An initial scoring system was proposed by the Framingham Heart Study group to predict 10 year risk for [[CAD]] based on patient's age, sex, total cholesterol, presence of hypertension and history of smoking and diabetes. Presence of other peripheral vascular diseases is also used to risk stratify the patients.
==Risk Stratification of Chronic Stable Angina==
 
===ECG/Chest X-ray in asymptomatic patients===
 
Presence of [[ECG]] abnormalities at rest puts the patient at higher risk than those with normal resting [[ECG]]. [[ECG]] abnormalities may be present in the form of LVH by ECG criteria, persistent ST-T wave inversions in V1-V3, Q waves in multiple leads or R wave in V1, bundle branch blocks and atrial or ventricular arrythmias.
Presence of cardiomegaly or pulmonary vascular congestion on Ches X-ray are also associated with poor prognosis.
 
===Importance of assessing Left Ventricular function===
 
Indications for assessing LV function are not only limited to patients with evidence of heart failure or valvular dysfunction but also includes patients with documented [[MI]] or [[ECG]] showing Q waves(suggestive of old MI). A resting or exercise LV ejection fraction of less than 35% is associated with significant higher mortality than a normal EF. [[Echocardiography]] is the best initial tool for obtaining an estimate of the LV function, both systolic and diastolic. In addition to this, it will also provide information about associated valvular dysfunction and pulmonary artery pressures. This information can in turn be used to select or modify the treatment regimen for the patient.
 
==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>==
{{cquote|
===Class I===
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)''
 
2. [[Echocardiography]] in patients with a [[systolic murmur]] suggesting [[mitral regurgitation]] to assess its severity and etiology. ''(Level of Evidence: C)''
 
3. [[Echocardiography]] or RNA in patients with complex [[ventricular arrhythmia]]s to assess [[LV function]]. ''(Level of Evidence: B)''
 
===Class III===
1. Routine periodic reassessment of stable patients for whom no new change in therapy is contemplated. ''(Level of Evidence: C)''
 
2. Patients with a normal [[ECG]], no history of [[MI]], and no symptoms or signs suggestive of [[heart failure]]. ''(Level of Evidence: B)''}}
 
 
===Exercise testing for Risk Stratification and Prognosis===
 
==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>==
{{cquote|
===Class I===
1. Patients undergoing initial evaluation. (Exceptions are listed below in classes IIb and III.) ''(Level of Evidence: B)''
 
2. Patients after a significant change in cardiac symptoms. ''(Level of Evidence: C)''
 
===Class IIb===
1. Patients with the following [[ECG]] abnormalities:
:a. Preexcitation ([[Wolff-Parkinson-White syndrome|Wolff-Parkinson-White]]) syndrome. ''(Level of Evidence: B)''
:b. Electronically paced ventricular rhythm. ''(Level of Evidence: B)''
:c. More than 1 mm of rest ST depression. ''(Level of Evidence: B)''
:d. Complete [[left bundle-branch block]]. ''(Level of Evidence: B)''
 
2. Patients who have undergone [[cardiac catheterization]] to identify [[ischemia]] in the distribution of a coronary lesion of borderline severity. ''(Level of Evidence: C)''
 
3. [[Revascularization|Postrevascularization]] patients who have a significant change in anginal pattern suggesting [[ischemia]]. ''(Level of Evidence: C)''
 
===Class III===
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>==
{{cquote|
===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)''
 
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)''
 
===Class IIb===
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)''
 
===Class III===
1. Exercise myocardial perfusion imaging in patients with left [[bundle-branch block]]. ''(Level of Evidence: C)''
 
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)''}}
 
 
==ACC / AHA Guidelines- Cardiac Stress Imaging as the Initial Test for Risk Stratification of Patients With Chronic Stable Angina Who Are Unable 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>==
{{cquote|
===Class I===
1. [[Dipyridamole]] or [[adenosine]] myocardial perfusion imaging or [[dobutamine]] [[echocardiography]] to identify the extent, severity, and location of [[ischemia]] in patients who do not have [[left bundle-branch block]] or electronically paced ventricular rhythm. ''(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)''


3. [[Dipyridamole]] or [[adenosine]] myocardial perfusion imaging or [[dobutamine]] [[echocardiography]] to assess the functional significance of coronary lesions (if not already known) in planning [[PTCA]]. ''(Level of Evidence: B)''
====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:
*Patient's age and sex
*Total [[cholesterol]]  
*Presence of [[hypertension]]  
*History of [[smoking]] and [[diabetes]]  
*Presence of other [[peripheral vascular diseases]]


===Class IIb===
For a full discussion on individual risk stratifying topics, visit the microchapters below:
1. [[Dobutamine]] [[echocardiography]] in patients with [[left bundle-branch block]]. ''(Level of Evidence: C)''


===Class III===
*'''[[Chronic stable angina risk stratification electrocardiogram/chest x-ray|Electrocardiogram/chest X-ray]]'''
1. [[Dipyridamole]] or [[adenosine]] myocardial perfusion imaging or [[dobutamine]] [[echocardiography]] in patients with severe [[comorbidity]] likely to limit life expectation or prevent [[revascularization]]. ''(Level of Evidence: C)''}}
*'''[[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]]'''


==ACC / AHA Guidelines- Coronary Angiography and Left Ventriculography (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>==
*Exercise testing for Risk Stratification and Prognosis:
{{cquote|
:*'''[[Chronic stable angina risk assessment in patients with an intermediate or high probability of coronary artery disease|Exercise treadmill test]]'''
===Class I===
:*'''[[Chronic stable angina risk stratification cardiac stress imaging in patients who are able to exercise|In patients who are able to exercise]]'''
1. Patients with disabling (Canadian Cardiovascular Society (CCS) classes III and IV) chronic stable angina despite medical therapy. ''(Level of Evidence: B)''
:*'''[[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 high-risk criteria on noninvasive testing regardless of anginal severity. ''(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]].


3. Patients with [[angina]] who have survived [[sudden cardiac death]] or serious [[ventricular arrhythmia]]. ''(Level of Evidence: B)''
===Risk Stratification of Chronic Stable Angina in Symptomatic Patients===
The next step after establishing the clinical probability of [[angina]] is to assess the risk of underlying [[coronary artery disease]] based on initial [[Chronic stable angina risk stratification electrocardiogram/chest x-ray|rest ECG]] and the patients ability to [[Chronic stable angina risk assessment in patients with an intermediate or high probability of coronary artery disease|exercise]].
*If the [[Chronic stable angina risk stratification electrocardiogram/chest x-ray|rest ECG]] is abnormal, the next step is to conduct a [[Chronic stable angina risk stratification cardiac stress imaging in patients who are able to exercise|stress imaging test]].
*If the patient is unable to exercise then a [[Chronic stable angina risk stratification cardiac stress imaging in patients who are unable to exercise|pharmacological stress test]] is used to stratify the risk underlying the [[atherosclerosis|atherosclerotic state]].
*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]].


4. Patients with [[angina]] and symptoms and signs of [[congestive heart failure]]. ''(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==


5. Patients with clinical characteristics that indicate a high likelihood of severe [[CAD]]. ''(Level of Evidence: C)''
{| class="wikitable" style="width: 80%; text-align: justify;"
|-
| '''Noninvasive Risk Stratification'''
|-
| '''High risk (>3% annual death or MI)'''
'''1.''' Severe resting LV dysfunction (LVEF <35%) not readily explained by noncoronary causes


===Class IIa===
'''2.''' Resting perfusion abnormalities ≥10% of the myocardium in patients without prior history or evidence of MI
1. Patients with significant [[LV dysfunction]] (ejection fraction <45%), CCS class I or II angina, and demonstrable [[ischemia]] but less than high-risk criteria on noninvasive testing. ''(Level of Evidence: C)''


2. Patients with inadequate prognostic information after noninvasive testing. ''(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 IIb===
'''4.''' Severe stress-induced LV dysfunction (peak exercise LVEF <45% or drop in LVEF with stress ≥10%)
1. Patients with CCS class I or II [[angina]], preserved [[LV function]] (ejection fraction >45%), and less than high-risk criteria on noninvasive testing. ''(Level of Evidence: C)''


===Class III===
'''5.''' Stress-induced perfusion abnormalities encumbering ≥10% myocardium or stress segmental scores indicating multiple vascular territories with
1. Patients with CCS class I or II [[angina]] who respond to medical therapy and have no evidence of [[ischemia]] on noninvasive testing. ''(Level of Evidence: C)''
abnormalities


2. Patients who prefer to avoid [[revascularization]]. ''(Level of Evidence: C)''}}
'''6.''' Stress-induced LV dilation


===Asymptomatic patients===
'''7.''' Inducible wall motion abnormality (involving >2 segments or 2 coronary beds)


==ACC / AHA Guidelines- Noninvasive Testing for the Diagnosis of Obstructive CAD and Risk Stratification 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>==
'''8.''' Wall motion abnormality developing at low dose of dobutamine (≤ 10 mg/kg/min) or at a low heart rate (<120 beats/min)
{{cquote|
===Class IIb===
1. Exercise [[ECG]] testing without an imaging modality in asymptomatic patients with possible [[myocardial ischemia]] on [[ambulatory ECG]] ([[AECG]]) monitoring or with severe [[coronary calcification]] on [[EBCT]] in the absence of one of the following [[ECG]] abnormalities:
:a. Preexcitation ([[Wolff-Parkinson-White syndrome|Wolff-Parkinson-White]]) syndrome ''(Level of Evidence: C)''
:b. Electronically paced ventricular rhythm ''(Level of Evidence: C)''
:c. More than 1 mm of ST depression at rest ''(Level of Evidence: C)''
:d. Complete [[left bundle-branch block]]. ''(Level of Evidence: C)''


2. Exercise perfusion imaging or exercise [[echocardiography]] in asymptomatic patients with possible [[myocardial ischemia]] on [[AECG]] monitoring or with severe [[coronary calcification]] on [[EBCT]] who are able to exercise and have one of the following baseline [[ECG]] abnormalities:
'''9.''' CAC score >400 Agatston units
:a. Preexcitation ([[Wolff-Parkinson-White syndrome|Wolff-Parkinson-White]]) syndrome ''(Level of Evidence: C)''
:b. More than 1 mm of ST depression at rest. ''(Level of Evidence: C)''


3. [[Adenosine]] or [[dipyridamole]] myocardial perfusion imaging in patients with severe [[coronary calcification]] on [[EBCT]] but with one of the following baseline [[ECG]] abnormalities:
'''10.''' Multivessel obstructive CAD (≥70% stenosis) or left main stenosis (≥50% stenosis) on CCTA
:a. Electronically paced ventricular rhythm ''(Level of Evidence: C)''
|-
:b. [[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


4. [[Adenosine]] or [[dipyridamole]] myocardial perfusion imaging or [[dobutamine]] [[echocardiography]] in patients with possible [[myocardial ischemia]] on [[AECG]] monitoring or with [[coronary calcification]] on [[EBCT]] who are unable to exercise. ''(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


5. Exercise [[myocardial perfusion]] imaging or exercise [[echocardiography]] after exercise [[ECG]] testing in asymptomatic patients with an intermediate-risk or high-risk Duke treadmill score. ''(Level of Evidence: C)''
'''3.''' ≥1 mm of ST-segment depression occurring with exertional symptoms


6. [[Adenosine]] or [[dipyridamole]] myocardial perfusion imaging or [[dobutamine]] [[echocardiography]] after exercise [[ECG]] testing in asymptomatic patients with an inadequate exercise [[ECG]]. ''(Level of Evidence: C)''
'''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


===Class III===
'''5.''' Small wall motion abnormality involving 1 to 2 segments and only 1 coronary bed
1. Exercise [[ECG]] testing without an imaging modality in asymptomatic patients with possible [[myocardial ischemia]] on [[AECG]] monitoring or with [[coronary calcification]] on [[EBCT]] but with the baseline [[ECG]] abnormalities listed under Class IIb1 above. ''(Level of Evidence: B)''


2. Exercise [[ECG]] testing without an imaging modality in asymptomatic patients with an established diagnosis of [[CAD]] owing to prior [[MI]] or [[coronary angiography]]; however, testing can assess functional capacity and prognosis. ''(Level of Evidence: B)''
'''6.''' CAC score 100 to 399 Agatston units


3. Exercise or [[dobutamine]] [[echocardiography]] in asymptomatic patients with [[left bundle-branch block]]. ''(Level of Evidence: C)''
'''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


4. [[Adenosine]] or [[dipyridamole]] myocardial perfusion imaging or [[dobutamine]] [[echocardiography]] in asymptomatic patients who are able to exercise and who do not have [[left bundle-branch block]] or electronically paced ventricular rhythm. ''(Level of Evidence: C)''
'''2.''' Normal or small myocardial perfusion defect at rest or with stress encumbering <5% of the myocardium*


5. Exercise myocardial perfusion imaging, exercise [[echocardiography]], [[adenosine]] or [[dipyridamole]] myocardial perfusion imaging, or [[dobutamine]] [[echocardiography]] after exercise [[ECG]] testing in asymptomatic patients with a low-risk Duke treadmill score. ''(Level of Evidence: C)''}}
'''3.''' Normal stress or no change of limited resting wall motion abnormalities during stress


==ACC / AHA Guidelines- Coronary Angiography for Risk Stratification 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>==
'''4.''' CAC score <100 Agaston units
{{cquote|
5. No coronary stenosis >50% on CCTA
===Class IIa===
|-
1. Patients with high-risk criteria that suggest [[ischemia]] on noninvasive testing. ''(Level of Evidence: C)''
|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.
 
|}
===Class IIb===
===Guidelines for Risk Stratification of Chronic Stable Angina ===
1. Patients with inadequate prognostic information after noninvasive testing. ''(Level of Evidence: C)''
Visit the microchapters below:
 
*'''[[Chronic stable angina risk stratification in asymptomatic patients by noninvasive testing|Risk Stratification by Noninvasive Testing]]'''
===Class III===
*'''[[Chronic stable angina risk stratification by coronary angiography|Risk Stratification by Coronary Angiography]]'''
1. Patients who prefer to avoid [[revascularization]]. ''(Level of Evidence: C)''}}
 
==See Also==
*[[The Living Guidelines: Chronic Stable Angina Pectoris | The Chronic Stable Angina Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines]]
 
==Sources==
*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>
 
*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>


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

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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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