Chronic stable angina risk stratification: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{Chronic stable angina}} | {{Chronic stable angina}} | ||
{{CMG}}; '''Associate | {{CMG}}; '''Associate Editor(s)-in-Chief:''' {{CZ}}; Smita Kohli, M.D.; [[Lakshmi Gopalakrishnan]], M.B.B.S. ;{{AKK}} | ||
==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> | |||
* | ==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]] | |||
====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]] | |||
For a full discussion on individual risk stratifying topics, visit the microchapters below: | |||
: | |||
*'''[[Chronic stable angina risk stratification electrocardiogram/chest x-ray|Electrocardiogram/chest X-ray]]''' | |||
*'''[[Chronic stable angina risk stratification rest left ventricular function|Assessment of resting LV function]]''' | |||
*'''[[Chronic stable angina risk stratification coronary angiography|Coronary angiography and left ventriculography]]''' | |||
*Exercise testing for Risk Stratification and Prognosis: | |||
:*'''[[Chronic stable angina risk assessment in patients with an intermediate or high probability of coronary artery disease|Exercise treadmill test]]''' | |||
*Exercise testing for Risk Stratification and Prognosis: | :*'''[[Chronic stable angina risk stratification cardiac stress imaging in patients who are able to exercise|In patients who are able to exercise]]''' | ||
:*'''[[Chronic stable angina risk stratification cardiac stress imaging in patients who are unable to exercise|In patients who are unable to exercise]]''' | |||
==Risk Stratification | ===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]]. | |||
*[[Chronic stable angina risk stratification in | ===Risk Stratification of Chronic Stable Angina in Symptomatic Patients=== | ||
*[[Chronic stable angina risk stratification in | 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]]. | |||
== | ==ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/ STS 2017 Appropriate Use Criteria for Coronary Revascularization in Patients With Stable Ischemic Heart Disease== | ||
{| class="wikitable" style="width: 80%; text-align: justify;" | |||
|- | |||
| '''Noninvasive Risk Stratification''' | |||
|- | |||
| '''High risk (>3% annual death or MI)''' | |||
'''1.''' Severe resting LV dysfunction (LVEF <35%) not readily explained by noncoronary causes | |||
'''2.''' Resting perfusion abnormalities ≥10% of the myocardium in patients without prior history or evidence of MI | |||
'''3.''' Stress ECG findings including ≥2 mm of ST-segment depression at low workload or persisting into recovery, exercise-induced ST-segment elevation, or | |||
exercise-induced VT/VF | |||
'''4.''' Severe stress-induced LV dysfunction (peak exercise LVEF <45% or drop in LVEF with stress ≥10%) | |||
'''5.''' Stress-induced perfusion abnormalities encumbering ≥10% myocardium or stress segmental scores indicating multiple vascular territories with | |||
abnormalities | |||
'''6.''' Stress-induced LV dilation | |||
'''7.''' Inducible wall motion abnormality (involving >2 segments or 2 coronary beds) | |||
'''8.''' Wall motion abnormality developing at low dose of dobutamine (≤ 10 mg/kg/min) or at a low heart rate (<120 beats/min) | |||
'''9.''' CAC score >400 Agatston units | |||
'''10.''' Multivessel obstructive CAD (≥70% stenosis) or left main stenosis (≥50% stenosis) on CCTA | |||
|- | |||
| '''Intermediate risk (1% to 3% annual death or MI)''' | |||
'''1.''' Mild/moderate resting LV dysfunction (LVEF 35% to 49%) not readily explained by noncoronary causes | |||
'''2'''. Resting perfusion abnormalities in 5% to 9.9% of the myocardium in patients without a history or prior evidence of MI | |||
'''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: | |||
*'''[[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}} | ||
{{WikiDoc Help Menu}} | {{WikiDoc Help Menu}} | ||
{{WikiDoc Sources}} | {{WikiDoc Sources}} | ||
[[Category:Disease]] | |||
[[Category:Ischemic heart diseases]] | |||
[[Category:Cardiology]] | |||
[[Category:Emergency medicine]] | |||
[[Category:Intensive care medicine]] | |||
[[Category:Up-To-Date]] | |||
[[Category:Up-To-Date cardiology]] | |||
Latest revision as of 18:28, 28 October 2017
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Chronic stable angina Microchapters | ||
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Classification | ||
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Differentiating Chronic Stable Angina from Acute Coronary Syndromes | ||
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Diagnosis | ||
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Alternative Therapies for Refractory Angina | ||
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Discharge Care | ||
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Guidelines for Asymptomatic Patients | ||
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Case Studies | ||
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Chronic stable angina risk stratification On the Web | ||
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to Hospitals Treating Chronic stable angina risk stratification | ||
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Risk calculators and risk factors for Chronic stable angina risk stratification | ||
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Smita Kohli, M.D.; Lakshmi Gopalakrishnan, M.B.B.S. ;Arzu Kalayci, M.D. [3]
Overview
The average mortality in patients with stable angina ranges from 1-3%. However, the prognosis varies widely depending on various factors such as: the duration and severity of symptoms, resting ECG abnormalities, abnormal left ventricular function and associated comorbidities.[1]
Risk Stratification
Risk Stratification Based on Different Factors
Anatomic Factors
- Left ventricular function, indicated as the strongest predictor of long term survival
- Extent of atherosclerosis in the coronary arteries (single vessel disease vs multivessel disease)
- Evidence of a recent coronary plaque rupture (acute coronary syndrome)
- Overall health and presence of other co-morbidities
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
For a full discussion on individual risk stratifying topics, visit the microchapters below:
- Electrocardiogram/chest X-ray
- Assessment of resting LV function
- Coronary angiography and left ventriculography
- Exercise testing for Risk Stratification and Prognosis:
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 exercise imaging for further risk assessment.
- Patients at high risk have an annual mortality rate of more than 3% and require coronary angiography.
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.
- If the rest ECG is abnormal, the next step is to conduct a stress imaging test.
- If the patient is unable to exercise then a pharmacological stress test is used to stratify the risk underlying the atherosclerotic state.
- For patients with CCS class III or IV angina, patients with poor LVEF or non responsive to medical therapy there may be some benefit to performing coronary angiography.
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
- ↑ 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