Chronic stable angina exercise electrocardiography: Difference between revisions

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__NOTOC__
{{Chronic stable angina}}
{{Chronic stable angina}}
'''Editor-In-Chief:''' [[C. Michael Gibson, M.S., M.D.]] [mailto:mgibson@perfuse.org] Phone:617-632-7753; '''Associate Editor(s)-In-Chief:''' {{CZ}}; Smita Kohli, M.D.; [[Lakshmi Gopalakrishnan|Lakshmi Gopalakrishnan, M.B.B.S.]]
'''Editor-In-Chief:''' [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com]; '''Associate Editor(s)-In-Chief:''' {{CZ}}; Smita Kohli, M.D.; [[Lakshmi Gopalakrishnan|Lakshmi Gopalakrishnan, M.B.B.S.]]; {{AA}}


==Overview==
==Overview==
In patients with chronic stable angina, exercise ECG is more sensitive and specific to identify inducible ischemia and to diagnose [[coronary artery disease]].<ref name="pmid11075788">Ashley EA, Myers J, Froelicher V (2000) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11075788 Exercise testing in clinical medicine.] ''Lancet'' 356 (9241):1592-7. [http://dx.doi.org/10.1016/S0140-6736(00)03138-X DOI:10.1016/S0140-6736(00)03138-X] PMID: [http://pubmed.gov/11075788 11075788]</ref> ECG abnormalities associated with [[MI]] include: down sloping of ST-segment depression or elevation, accompanying angina that occurs at a low workload during early stages of exercise and persistent for more than 3-minutes after exercise. The reliability of diagnosis is shown to improve with the evaluation of ST changes in relation to heart rate.<ref name="pmid6127094">Elamin MS, Boyle R, Kardash MM, Smith DR, Stoker JB, Whitaker W et al. (1982) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=6127094 Accurate detection of coronary heart disease by new exercise test.] ''Br Heart J'' 48 (4):311-20. PMID: [http://pubmed.gov/6127094 6127094]</ref> Bruce protocol or treadmill ''(expressed in terms of METs)'' or bicycle ergometer ''(expressed in terms of watts)'' are used to detect [[MI]]. Exercise ECG test must be terminated on the achievement of maximal predicted heart rate and/or if the patient becomes symptomatic or develops pain with significant ST-segment changes. Exercise ECG test also provides prognostic stratification to evaluate the response to medical therapy or revascularization.<ref name="pmid1875969">Mark DB, Shaw L, Harrell FE, Hlatky MA, Lee KL, Bengtson JR et al. (1991) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=1875969 Prognostic value of a treadmill exercise score in outpatients with suspected coronary artery disease.] ''N Engl J Med'' 325 (12):849-53. [http://dx.doi.org/10.1056/NEJM199109193251204 DOI:10.1056/NEJM199109193251204] PMID: [http://pubmed.gov/1875969 1875969]</ref>
In patients with chronic stable angina, exercise ECG is more sensitive and specific to identify inducible ischemia and to diagnose [[coronary artery disease]].<ref name="pmid11075788">Ashley EA, Myers J, Froelicher V (2000) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11075788 Exercise testing in clinical medicine.] ''Lancet'' 356 (9241):1592-7. [http://dx.doi.org/10.1016/S0140-6736(00)03138-X DOI:10.1016/S0140-6736(00)03138-X] PMID: [http://pubmed.gov/11075788 11075788]</ref> ECG abnormalities associated with [[MI]] include: down sloping of ST-segment depression or elevation, accompanying angina that occurs at a low workload during early stages of exercise and persistent for more than 3-minutes after exercise. The reliability of diagnosis is shown to improve with the evaluation of ST changes in relation to heart rate.<ref name="pmid6127094">Elamin MS, Boyle R, Kardash MM, Smith DR, Stoker JB, Whitaker W et al. (1982) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=6127094 Accurate detection of coronary heart disease by new exercise test.] ''Br Heart J'' 48 (4):311-20. PMID: [http://pubmed.gov/6127094 6127094]</ref> Bruce protocol or treadmill (expressed in terms of METs) or bicycle ergometer (expressed in terms of watts) are used to detect [[MI]]. Exercise ECG test must be terminated on the achievement of maximal predicted heart rate and/or if the patient becomes symptomatic or develops pain with significant ST-segment changes. Exercise ECG test also provides prognostic stratification to evaluate the response to medical therapy or revascularization.<ref name="pmid1875969">Mark DB, Shaw L, Harrell FE, Hlatky MA, Lee KL, Bengtson JR et al. (1991) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=1875969 Prognostic value of a treadmill exercise score in outpatients with suspected coronary artery disease.] ''N Engl J Med'' 325 (12):849-53. [http://dx.doi.org/10.1056/NEJM199109193251204 DOI:10.1056/NEJM199109193251204] PMID: [http://pubmed.gov/1875969 1875969]</ref>


==Indications==
==Exercise Electrocardiography==
===Indications===
An exercise [[ECG]] is more useful than the [[Chronic stable angina electrocardiography|resting ECG]] in detecting [[myocardial ischemia]] and evaluating the cause of [[chest pain]].  
An exercise [[ECG]] is more useful than the [[Chronic stable angina electrocardiography|resting ECG]] in detecting [[myocardial ischemia]] and evaluating the cause of [[chest pain]].  


==Diagnostic criteria==
===Diagnostic Criteria===
'''ST-segment changes''' suggestive of [[coronary artery disease]] include:
ST-segment changes suggestive of [[coronary artery disease]] include:
*Down sloping or horizontal [[ST segment depression|ST segment depressions]] are highly suggestive of myocardial ischemia, particularly when:
*Down sloping or horizontal [[ST segment depression|ST segment depressions]] are highly suggestive of myocardial ischemia, particularly when:
:*It occurs at a low workload,  
:*It occurs at a low workload,  
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*In converse, up-sloping [[ST segment|ST segments]] are much less specific indicators of [[coronary artery disease]].
*In converse, up-sloping [[ST segment|ST segments]] are much less specific indicators of [[coronary artery disease]].


==Sensitivity and Specificity==
===Sensitivity and Specificity===
*Exercise electrocardiography has a '''sensitivity of approximately 70%''' for detecting [[coronary artery disease]].
*Exercise electrocardiography has a sensitivity of approximately 70% for detecting [[coronary artery disease]].
*Exercise electrocardiography has a '''specificity of approximately 75%''' for excluding [[coronary artery disease]].  
*Exercise electrocardiography has a specificity of approximately 75% for excluding [[coronary artery disease]].  
*To assess the probability of [[coronary artery disease]] in an individual patient, the exercise ECG result must be integrated with the clinical presentation.
*To assess the probability of [[coronary artery disease]] in an individual patient, the exercise ECG result must be integrated with the clinical presentation.


*Conditions that increase the probability of exercise [[ECG]] yielding '''false positive''' results are:
*Conditions that increase the probability of exercise [[ECG]] yielding false positive results are:
:*An abnormal [[Chronic stable angina electrocardiography|resting ECG]] associated with [[left ventricular hypertrophy]], intraventricular conduction abnormalities, pre-excitation syndromes (Long Ganong Lewine Syndrome = LGL, [[Wolf-Parkinson-White syndrome]] = WPW and Mahaim type), electrolyte imbalance or therapy with [[digitalis]]
:*An abnormal [[Chronic stable angina electrocardiography|resting ECG]] associated with [[left ventricular hypertrophy]], intraventricular conduction abnormalities, pre-excitation syndromes (Long Ganong Lewine Syndrome = LGL, [[Wolf-Parkinson-White syndrome]] = WPW and Mahaim type), electrolyte imbalance or therapy with [[digitalis]]
:*In women, the lower prior probability of [[CAD]] is associated with more false positive results on [[ECG]].
:*In women, the lower prior probability of [[CAD]] is associated with more false positive results on [[ECG]].


*On the other hand, a fall in systolic pressure of 10 mmHg or more during exercise or the appearance of a murmur of [[mitral regurgitation]] during exercise increases the probability that, an abnormal stress ECG is a '''true positive''' test result.
*On the other hand, a fall in systolic pressure of 10 mm Hg or more during exercise or the appearance of a murmur of [[mitral regurgitation]] during exercise increases the probability that, an abnormal stress ECG is a true positive test result.


==Treadmill exercise test==
===Treadmill Exercise Test===
*[[Treadmill exercise]] test is more preferable to [[bicycle exercise test]] (or ergometer) for detecting [[myocardial ischemia]].  
*[[Treadmill exercise]] test is more preferable to [[bicycle exercise test]] (or ergometer) for detecting [[myocardial ischemia]].  


*In patients who cannot perform treadmill exercise, [[Chronic stable angina perfusion scintigraphy with pharmacologic stress|pharmacologic stress scintigraphy]] or [[Chronic stable angina echocardiography|echocardiography]] is preferable to upper body arm exercise.  
*In patients who cannot perform treadmill exercise, [[Chronic stable angina perfusion scintigraphy with pharmacologic stress|pharmacologic stress scintigraphy]] or [[Chronic stable angina echocardiography|echocardiography]] is preferable to upper body arm exercise.  


*Variables of the Treadmill Exercise Test which indicate the '''high risk''' are:
*Variables of the Treadmill Exercise Test which indicate the high risk are:
:*Short exercise duration less than 5 METs,  
:*Short exercise duration less than 5 METs,  
:*Significant [[ST segment depression]] (magnitude ≥2 mm, starts at exercise stage I or II, duration of exercise test is <5 minutes and ≥5 leads with ST changes,  
:*Significant [[ST segment depression]] (magnitude ≥2 mm, starts at exercise stage I or II, duration of exercise test is <5 minutes and ≥5 leads with ST changes,  
:*Significant changes in [[blood pressure]]: low peak systolic blood pressure (<130 mm Hg), significant decrease in systolic blood pressure during the test (below the resting standing blood pressure),  
:*Significant changes in [[blood pressure]]: low peak systolic blood pressure (<130 mm Hg), significant decrease in systolic blood pressure during the test (below the resting standing blood pressure),  
:*Inability to attain to the target [[heart rate]],  
:*Inability to attain to the target [[heart rate]],  
:*Presence of exercise [[induced angina]],  
:*Presence of exercise induced angina,  
:*Presence of frequent [[ventricular ectopy]] (e.g. couplets or tachycardia) at low workload.
:*Presence of frequent [[ventricular ectopy]] (e.g. couplets or tachycardia) at low workload.


[[Image:Stress_ECG.jpg|500px|center]]
[[Image:Stress_ECG.jpg|500px|center]]


''For more information on exercise EKG during exercise stress testing, click [[Exercise stress testing#Exercise EKG|here]].''


==ACC / AHA Guidelines- Exercise ECG for Diagnosis (DO NOT EDIT) <ref name="pmid10351980">Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10351980 ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina).] ''Circulation'' 99 (21):2829-48. PMID: [http://pubmed.gov/10351980 10351980]</ref>==
==ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina (DO NOT EDIT)<ref name="pmid23166210">{{cite journal| author=Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP et al.| title=2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. | journal=Circulation | year= 2012 | volume= 126 | issue= 25 | pages= 3097-137 | pmid=23166210 | doi=10.1161/CIR.0b013e3182776f83 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23166210  }} </ref>==
{{cquote|
===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]===
'''1.''' Patients with an [[Chronic stable angina assessing the pretest probability of coronary artery disease|intermediate pretest probability]] of [[CAD]] based on age, gender, and symptoms, including those with complete [[right bundle-branch block]] or less than 1 mm of rest [[ST depression]] (exceptions are listed below in [[ACC AHA guidelines classification scheme#Classification of Recommendations|classes II]] and [[ACC AHA guidelines classification scheme#Classification of Recommendations|III]]). ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''


===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]===
===Stress Testing and Advanced Imaging for Initial Diagnosis in Patients With Suspected SIHD Who Require Noninvasive Testing<ref name="pmid23166210">{{cite journal| author=Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP et al.| title=2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. | journal=Circulation | year= 2012 | volume= 126 | issue= 25 | pages= 3097-137 | pmid=23166210 | doi=10.1161/CIR.0b013e3182776f83 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23166210  }} </ref>(DO NOT EDIT)===
'''1.''' Patients with suspected [[vasospastic angina]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''


===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]===
'''Patients able to exercise'''
'''1.''' Patients with a [[Chronic stable angina assessing the pretest probability of coronary artery disease|high pretest probability]] of [[CAD]] by age, gender, and symptoms. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''


'''2.''' Patients with a [[Chronic stable angina assessing the pretest probability of coronary artery disease|low pretest probability]] of [[CAD]] by age, gender, and symptoms. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]


'''3.''' Patients taking [[digoxin]] with [[Chronic stable angina electrocardiography|ECG baseline]] ST segment depression less than 1 mm. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Standard exercise ECG testing is recommended for patients with an intermediate pretest probability of IHD who have an interpretable ECG and at least moderate physical functioning or no disabling comorbidity''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>


'''4.''' Patients with ECG criteria for [[LV hypertrophy]] and less than 1 mm of [[Chronic stable angina electrocardiography|baseline ST segment depression]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
|}


===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]===
{|class="wikitable"
'''1.''' Patients with the following [[Chronic stable angina electrocardiography|baseline ECG]] abnormalities:
|-
:a. Preexcitation ([[Wolff-Parkinson-White syndrome]]). ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
:b. Electronically paced ventricular rhythm. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
:c. More than 1 mm of rest [[ST depression]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
:d. Complete [[left bundle-branch block]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''


'''2.''' Patients with an established diagnosis of [[CAD]] due to prior [[MI]] or [[Chronic stable angina coronary angiography|coronary angiography]]; however, testing can assess functional capacity and [[Chronic stable angina prognosis|prognosis]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''}}
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' For patients with a low pretest probability of obstructive IHD who do require testing, standard exercise ECG testing can be useful, provided the patient has an interpretable ECG and at least moderate physical functioning or no disabling comorbidity. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>


==ESC Guidelines- Exercise ECG for Initial diagnostic assessment of angina (DO NOT EDIT) <ref name="pmid16735367">{{cite journal| author=Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F et al.| title=Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. | journal=Eur Heart J | year= 2006 | volume= 27 | issue= 11 | pages= 1341-81 | pmid=16735367 | doi=10.1093/eurheartj/ehl001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16735367  }} </ref>==
|}
{{cquote|
===[[European society of cardiology#Classes of Recommendations|Class I]]===
'''1.''' Patients with symptoms of [[Chronic stable angina definition|angina]] and [[Chronic stable angina assessing the pretest probability of coronary artery disease|intermediate pre-test probability]] of [[coronary artery disease]] based on age, gender, and symptoms, unless unable to exercise or displays [[ECG]] changes which make ECG non-evaluable. ''([[European society of cardiology#Level of Evidence|Level of Evidence: B]])''


===[[European society of cardiology#Classes of Recommendations|Class IIb]]===
'''Patients unable to exercise'''
'''1.''' Patients with more than 1 mm [[ST-depression]] on [[Chronic stable angina electrocardiography|resting ECG]] or taking [[digoxin]]. ''([[European society of cardiology#Level of Evidence|Level of Evidence: B]])''
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:Lightcoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]


'''2.''' In patients with [[Chronic stable angina assessing the pretest probability of coronary artery disease|low pre-test probability]] (less than 10% probability) of [[CAD|coronary disease]] based on age, gender, and symptoms. ''([[European society of cardiology#Level of Evidence|Level of Evidence: B]])''}}
|-
| bgcolor="Lightcoral"|<nowiki>"</nowiki>'''1.''' Standard exercise ECG testing is not recommended for patients who have an uninterpretable ECG or are incapable of at least moderate physical functioning or have disabling comorbidity. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>


==ESC Guidelines- Exercise ECG for Routine re-assessment in patients with chronic stable angina (DO NOT EDIT)<ref name="pmid16735367">{{cite journal| author=Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F et al.| title=Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. | journal=Eur Heart J | year= 2006 | volume= 27 | issue= 11 | pages= 1341-81 | pmid=16735367 | doi=10.1093/eurheartj/ehl001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16735367  }} </ref>==
|}
{{cquote|
===[[European society of cardiology#Classes of Recommendations|Class IIb]]===
'''1.''' Routine periodic exercise ECG in the absence of clinical change. ''([[European society of cardiology#Level of Evidence|Level of Evidence: C]])''}}


==Related Chapter==
==ESC Guidelines- Exercise ECG for Initial Diagnostic Assessment of Angina (DO NOT EDIT)<ref name="pmid16735367">{{cite journal| author=Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F et al.| title=Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. | journal=Eur Heart J | year= 2006 | volume= 27 | issue= 11 | pages= 1341-81 | pmid=16735367 | doi=10.1093/eurheartj/ehl001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16735367  }} </ref>==
*[[Exercise stress testing#Exercise EKG|Exercise EKG]]


==Vote on and Suggest Revisions to the Current Guidelines==
{|class="wikitable"
*[[The Living Guidelines: Chronic Stable Angina Pectoris | The Chronic Stable Angina Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines]]
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[European society of cardiology#Classes of Recommendations|Class I]]


==Guideline Resources==
|-
*The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina <ref name="pmid10351980">Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10351980 ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina).] ''Circulation'' 99 (21):2829-48. [http://circ.ahajournals.org/content/99/21/2829.full.pdf] PMID: [http://pubmed.gov/10351980 10351980]</ref>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Patients with symptoms of [[Chronic stable angina definition|angina]] and [[Chronic stable angina assessing the pretest probability of coronary artery disease|intermediate pre-test probability]] of [[coronary artery disease]] based on age, gender, and symptoms, unless unable to exercise or displays [[ECG]] changes which make ECG non-evaluable. ''([[European society of cardiology#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}


*Guidelines on the management of stable angina pectoris: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology <ref name="pmid16735367">{{cite journal| author=Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F et al.| title=Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. | journal=Eur Heart J | year= 2006 | volume= 27 | issue= 11 | pages= 1341-81 | pmid=16735367 | doi=10.1093/eurheartj/ehl001 | pmc= |url=url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16735367 [http://www.escardio.org/guidelines-surveys/esc-guidelines/GuidelinesDocuments/guidelines-angina-FT.pdf]}} </ref>
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[European society of cardiology#Classes of Recommendations|Class IIb]]


*TheACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina <ref name="pmid12515758">Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12515758 ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina).] ''Circulation'' 107 (1):149-58.[http://content.onlinejacc.org/cgi/reprint/41/1/159.pdf] PMID: [http://pubmed.gov/12515758 12515758]</ref>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Patients with more than 1 mm [[ST-depression]] on [[Chronic stable angina electrocardiography|resting ECG]] or taking [[digoxin]]. ''([[European society of cardiology#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' In patients with [[Chronic stable angina assessing the pretest probability of coronary artery disease|low pre-test probability]] (less than 10% probability) of [[CAD|coronary disease]] based on age, gender, and symptoms. ''([[European society of cardiology#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}


*The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina <ref name="pmid17998462">Fraker TD, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J et al. (2007)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=17998462 2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina.] ''Circulation'' 116 (23):2762-72.[http://content.onlinejacc.org/cgi/reprint/50/23/2264.pdf] PMID: [http://pubmed.gov/17998462 17998462]</ref>
==ESC Guidelines- Exercise ECG for Routine Re-assessment in Patients with Chronic Stable Angina (DO NOT EDIT)<ref name="pmid16735367">{{cite journal| author=Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F et al.| title=Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. | journal=Eur Heart J | year= 2006 | volume= 27 | issue= 11 | pages= 1341-81 | pmid=16735367 | doi=10.1093/eurheartj/ehl001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16735367  }} </ref>==
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[European society of cardiology#Classes of Recommendations|Class IIb]]
 
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Routine periodic exercise ECG in the absence of clinical change. ''([[European society of cardiology#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}


==References==
==References==
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Latest revision as of 20:10, 28 October 2016

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Differentiating Chronic Stable Angina from Acute Coronary Syndromes

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Chronic stable angina exercise electrocardiography On the Web

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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.; Aysha Anwar, M.B.B.S[3]

Overview

In patients with chronic stable angina, exercise ECG is more sensitive and specific to identify inducible ischemia and to diagnose coronary artery disease.[1] ECG abnormalities associated with MI include: down sloping of ST-segment depression or elevation, accompanying angina that occurs at a low workload during early stages of exercise and persistent for more than 3-minutes after exercise. The reliability of diagnosis is shown to improve with the evaluation of ST changes in relation to heart rate.[2] Bruce protocol or treadmill (expressed in terms of METs) or bicycle ergometer (expressed in terms of watts) are used to detect MI. Exercise ECG test must be terminated on the achievement of maximal predicted heart rate and/or if the patient becomes symptomatic or develops pain with significant ST-segment changes. Exercise ECG test also provides prognostic stratification to evaluate the response to medical therapy or revascularization.[3]

Exercise Electrocardiography

Indications

An exercise ECG is more useful than the resting ECG in detecting myocardial ischemia and evaluating the cause of chest pain.

Diagnostic Criteria

ST-segment changes suggestive of coronary artery disease include:

  • Down sloping or horizontal ST segment depressions are highly suggestive of myocardial ischemia, particularly when:
  • It occurs at a low workload,
  • It occurs during early stages of exercise,
  • It persists for more than 3 minutes after exercise, or
  • It is accompanied by chest discomfort that is compatible with angina.

Sensitivity and Specificity

  • Exercise electrocardiography has a sensitivity of approximately 70% for detecting coronary artery disease.
  • Exercise electrocardiography has a specificity of approximately 75% for excluding coronary artery disease.
  • To assess the probability of coronary artery disease in an individual patient, the exercise ECG result must be integrated with the clinical presentation.
  • Conditions that increase the probability of exercise ECG yielding false positive results are:
  • On the other hand, a fall in systolic pressure of 10 mm Hg or more during exercise or the appearance of a murmur of mitral regurgitation during exercise increases the probability that, an abnormal stress ECG is a true positive test result.

Treadmill Exercise Test

  • Variables of the Treadmill Exercise Test which indicate the high risk are:
  • Short exercise duration less than 5 METs,
  • Significant ST segment depression (magnitude ≥2 mm, starts at exercise stage I or II, duration of exercise test is <5 minutes and ≥5 leads with ST changes,
  • Significant changes in blood pressure: low peak systolic blood pressure (<130 mm Hg), significant decrease in systolic blood pressure during the test (below the resting standing blood pressure),
  • Inability to attain to the target heart rate,
  • Presence of exercise induced angina,
  • Presence of frequent ventricular ectopy (e.g. couplets or tachycardia) at low workload.

For more information on exercise EKG during exercise stress testing, click here.

ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina (DO NOT EDIT)[4]

Stress Testing and Advanced Imaging for Initial Diagnosis in Patients With Suspected SIHD Who Require Noninvasive Testing[4](DO NOT EDIT)

Patients able to exercise

Class I
"1. Standard exercise ECG testing is recommended for patients with an intermediate pretest probability of IHD who have an interpretable ECG and at least moderate physical functioning or no disabling comorbidity(Level of Evidence: A)"
Class IIa
"1. For patients with a low pretest probability of obstructive IHD who do require testing, standard exercise ECG testing can be useful, provided the patient has an interpretable ECG and at least moderate physical functioning or no disabling comorbidity. (Level of Evidence: C)"

Patients unable to exercise

Class III
"1. Standard exercise ECG testing is not recommended for patients who have an uninterpretable ECG or are incapable of at least moderate physical functioning or have disabling comorbidity. (Level of Evidence: C)"

ESC Guidelines- Exercise ECG for Initial Diagnostic Assessment of Angina (DO NOT EDIT)[5]

Class I
"1. Patients with symptoms of angina and intermediate pre-test probability of coronary artery disease based on age, gender, and symptoms, unless unable to exercise or displays ECG changes which make ECG non-evaluable. (Level of Evidence: B)"
Class IIb
"1. Patients with more than 1 mm ST-depression on resting ECG or taking digoxin. (Level of Evidence: B)"
"1. In patients with low pre-test probability (less than 10% probability) of coronary disease based on age, gender, and symptoms. (Level of Evidence: B)"

ESC Guidelines- Exercise ECG for Routine Re-assessment in Patients with Chronic Stable Angina (DO NOT EDIT)[5]

Class IIb
"1. Routine periodic exercise ECG in the absence of clinical change. (Level of Evidence: C)"

References

  1. ↑ Ashley EA, Myers J, Froelicher V (2000) Exercise testing in clinical medicine. Lancet 356 (9241):1592-7. DOI:10.1016/S0140-6736(00)03138-X PMID: 11075788
  2. ↑ Elamin MS, Boyle R, Kardash MM, Smith DR, Stoker JB, Whitaker W et al. (1982) Accurate detection of coronary heart disease by new exercise test. Br Heart J 48 (4):311-20. PMID: 6127094
  3. ↑ Mark DB, Shaw L, Harrell FE, Hlatky MA, Lee KL, Bengtson JR et al. (1991) Prognostic value of a treadmill exercise score in outpatients with suspected coronary artery disease. N Engl J Med 325 (12):849-53. DOI:10.1056/NEJM199109193251204 PMID: 1875969
  4. ↑ 4.0 4.1 Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP; et al. (2012). "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 126 (25): 3097–137. doi:10.1161/CIR.0b013e3182776f83. PMID 23166210.
  5. ↑ 5.0 5.1 Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F; et al. (2006). "Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology". Eur Heart J. 27 (11): 1341–81. doi:10.1093/eurheartj/ehl001. PMID 16735367.

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