Chronic stable angina patient follow-up: Difference between revisions

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(/* 1999 ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina (DO NOT EDIT) Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999) ACC/AHA/ACP-ASIM guidelines for the management of patient...)
 
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{{Chronic stable angina}}
{{Chronic stable angina}}


{{CMG}} '''Associate Editor-In-Chief:''' {{CZ}}  
{{CMG}} '''Associate Editor-In-Chief:''' {{CZ}}; {{AA}}


==Overview==
==Overview==
Ongoing follow-up of the patient with chronic stable angina is necessary to monitor symptoms and to optimize antianginal therapy. It is generally recommended that these patients be evaluated every 4-6 months during first year of diagnosis / initiation of therapy and annually thereafter.  Based upon clinical judgement, if the patient is poorly responsive to therapy, if the episodes are severe or frequent, or if the patient is fragile with multiple co-morbidities, they may need to be seen more frequently.  
Ongoing follow-up of the patient with chronic stable angina is necessary to monitor symptoms and to optimize antianginal therapy. It is generally recommended that these patients be evaluated every 4-6 months during first year of diagnosis/initiation of therapy and annually thereafter.  Based upon clinical judgement, if the patient is poorly responsive to therapy, if the episodes are severe or frequent, or if the patient is fragile with multiple co-morbidities, they may need to be seen more frequently. During a follow-up visit, the patient should be asked about the frequency and severity of their anginal symptoms, their level of exercise capacity, whether they have been able to modify his/her risk factors, how well they are tolerating and complying with the therapy and whether he/she has developed new illnesses or co-morbidities.


During a follow-up visit, the patient should be asked about the frequency and severity of their anginal symptoms, their level of exercise capacity, whether they have been able to modify his/her risk factors, how well they are tolerating and complying with the therapy and whether he/she has developed new illnesses or co-morbidities.
==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><ref name="pmid12570960">{{cite journal| author=Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS et al.| title=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). | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 1 | pages= 159-68 | pmid=12570960 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12570960  }} </ref>==


Guidelines for obtaining imaging studies during follow-up visits are listed below:
===Patient Follow-Up, Monitoring of Symptoms and Antianginal Therapy(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><ref name="pmid12570960">{{cite journal| author=Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS et al.| title=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). | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 1 | pages= 159-68 | pmid=12570960 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12570960  }} </ref>===
====Clinical Evaluation, Echocardiography During Routine, Periodic Follow-Up====


==ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina (DO NOT EDIT)<ref name="pmid12570960">{{cite journal| author=Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS et al.| title=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). | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 1 | pages= 159-68 | pmid=12570960 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12570960  }} </ref>==
{|class="wikitable"
 
|-
===Echocardiography, Treadmill Exercise Testing, Stress Imaging Studies, and Coronary Angiography During                          Patient Follow-Up                        (DO NOT EDIT)<ref name="pmid12570960">{{cite journal| author=Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS et al.| title=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). | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 1 | pages= 159-68 | pmid=12570960 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12570960  }} </ref>===
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Patients with SIHD should receive periodic follow-up, at least annually, that includes all of the following:
a. Assessment of symptoms and clinical function;
b. Surveillance for complications of SIHD, including heart failure and arrhythmias;.
c. Monitoring of cardiac risk factors; and
d. Assessment of the adequacy of and adherence to recommended lifestyle changes and medical therapy. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|}


{|class="wikitable"
{|class="wikitable"
|-
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' Assessment of LV ejection fraction and segmental wall motion by echocardiography or radionuclide imaging is recommended in patients with new or worsening heart failure or evidence of intervening MI by history or ECG. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' [[Chest x-ray]] for patients with evidence of new or worsening [[congestive heart failure]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Periodic screening for important comorbidities that are prevalent in patients with SIHD, including diabetes mellitus, depression, and chronic kidney disease might be reasonable. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Assessment of [[LV ejection fraction]] and segmental wall motion in patients with new or worsening [[congestive heart failure]] or evidence of intervening [[MI]] by history or [[ECG]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' A resting 12-lead ECG at 1-year or longer intervals between studies in patients with stable symptoms might be reasonable.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|}
{|class="wikitable"
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' [[Echocardiography]] for evidence of new or worsening [[valvular heart disease]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
| colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' [[Treadmill exercise test]] for patients without prior [[revascularization]] who have a significant change in clinical status, are able to exercise, and do not have any of the [[ECG]] abnormalities listed below in number 5. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
| bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' Measurement of LV function with a technology such as echocardiography or radionuclide imaging is not recommended for routine periodic reassessment of patients who have not had a change in clinical status or who are at low risk of adverse cardiovascular events ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
 
====Noninvasive Testing in Known SIHD====
'''Follow-Up Noninvasive Testing in Patients With Known SIHD: New, Recurrent, or Worsening Symptoms Not Consistent With Unstable Angina'''
 
'''''Patients able to exercise'''''
{|class="wikitable" style="width:80%"
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''5.''' Stress imaging procedures for patients without prior [[revascularization]] who have a significant change in clinical status and are unable to exercise or have 1 of the following [[ECG]] abnormalities: <nowiki>"</nowiki>
|colspan="1" style="text-align:center; background:LightGreen"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''a.''' Preexcitation ([[Wolff-Parkinson-White syndrome|Wolff-Parkinson-White]]) syndrome. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Standard exercise ECG testing is recommended in patients with known SIHD who have new or worsening symptoms not consistent with UA and who have a) at least moderate physical functioning and no disabling comorbidity and b) an interpretable ECG ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|}
{|class="wikitable" style="width:80%"
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''b.''' Electronically paced ventricular rhythm. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''c.''' More than 1 mm of rest ST depression. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Exercise with nuclear MPI or echocardiography is reasonable in patients with known SIHD who have new or worsening symptoms not consistent with UA and who have a) at least moderate physical functioning and no disabling comorbidity, b) previously required imaging with exercise stress, or c) known multivessel disease or high risk for multivessel disease ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|}
{|class="wikitable" style="width:80%"
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''d.'''Complete [[left bundle-branch block]].  ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|colspan="1" style="text-align:center; background:LightCoral"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''6.''' Stress imaging procedures for patients who have a significant change in clinical status and required a stress imaging procedure on their initial evaluation because of equivocal or intermediate-risk treadmill results. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
| bgcolor="Lightcoral"|<nowiki>"</nowiki>'''1.''' Pharmacological stress imaging with nuclear MPI, echocardiography, or CMR is not recommended in patients with known SIHD who have new or worsening symptoms not consistent with UA and who are capable of at least moderate physical functioning or have no disabling comorbidity (. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|}
 
'''''Patients unable to exercise'''''
{|class="wikitable" style="width:80%"
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''7.'''  Stress imaging procedures for patients with prior [[revascularization]] who have a significant change in clinical status. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''  <nowiki>"</nowiki>
|colspan="1" style="text-align:center; background:LightGreen"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''8.''' [[Coronary angiography]] in patients with marked limitation of ordinary activity (CCS class III) despite maximal medical therapy. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Pharmacological stress imaging with nuclear MPI or echocardiography is recommended in patients with known SIHD who have new or worsening symptoms not consistent with UA and who are incapable of at least moderate physical functioning or have disabling comorbidity. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|}
|}


{|class="wikitable"
|-
|colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Pharmacological stress imaging with CMR is reasonable in patients with known SIHD who have new or worsening symptoms not consistent with UA and who are incapable of at least moderate physical functioning or have disabling comorbidity ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|}
{|class="wikitable"
{|class="wikitable"
|-
|-
|colspan="1" style="text-align:center; background:LightCoral"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit)
|colspan="1" style="text-align:center; background:LightCoral"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit)
|-
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' [[Echocardiography]] or radionuclide imaging for assessment of [[LV ejection fraction]] and segmental wall motion in patients with a normal [[ECG]], no history of [[MI]], and no evidence of [[congestive heart failure]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' Standard exercise ECG testing should not be performed in patients with known SIHD who have new or worsening symptoms not consistent with UA and who a) are incapable of at least moderate physical functioning or have disabling comorbidity or b) have an uninterpretable ECG''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
 
====Irrespective of the ability to exercise====
{|class="wikitable"
|-
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''2.''' Repeat [[treadmill exercise testing]] in <3 years in patients who have no change in clinical status and an estimated annual mortality <1% on their initial evaluation as demonstrated by 1 of the following: <nowiki>"</nowiki>
|colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]  
|-
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''a.''' Low-risk Duke treadmill score (without imaging). ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' CCTA for assessment of patency of CABG or of coronary stents 3 mm or larger in diameter might be reasonable in patients with known SIHD who have new or worsening symptoms not consistent with UA, irrespective of ability to exercise ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|-
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''b.''' Low-risk Duke treadmill score with negative imaging. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' CCTA might be reasonable in patients with known SIHD who have new or worsening symptoms not consistent with UA, irrespective of ability to exercise, in the absence of known moderate or severe calcification or if the CCTA is intended to assess coronary stents less than 3 mm in diameter ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|}
{|class="wikitable"
|-
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''c.''' Normal [[LV function]] and a normal [[coronary angiogram]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|colspan="1" style="text-align:center; background:LightCoral"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]
|-
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''d.''' Normal [[LV function]] and insignificant [[CAD]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' CCTA should not be performed for assessment of native coronary arteries with known moderate or severe calcification or with coronary stents less than 3mm in diameter in patients with known SIHD who have new or worsening symptoms not consistent with UA, irrespective of ability to exercise. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|}
 
===Noninvasive Testing in Known SIHD===
{|class="wikitable" style="width:80%"
|-
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''3.''' Stress imaging procedures for patients who have no change in clinical status and a normal rest [[ECG]], are not taking [[digoxin]], are able to exercise, and did not require a stress imaging procedure on their initial evaluation because of equivocal or intermediate-risk treadmill results. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
| colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''4.''' Repeat [[coronary angiography]] in patients with no change in clinical status, no change on repeat exercise testing or stress imaging, and insignificant [[CAD]] on initial evaluation. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Nuclear MPI, echocardiography, or CMR with either exercise or pharmacological stress can be useful for follow-up assessment at 2-year or longer intervals in patients with SIHD with prior evidence of silent ischemia or who are at high risk for a recurrent
cardiac event and a) are unable to exercise to an adequate workload, b) have an uninterpretable ECG, or c) have a history of incomplete coronary revascularization. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|}
|}


{|class="wikitable"
{|class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|-
| colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Standard exercise ECG testing performed at 1-year or longer intervals might be considered for follow-up assessment in patients with SIHD who have had prior evidence of silent ischemia or are at high risk for a recurrent cardiac event and are able to exercise to an
adequate workload and have an interpretable ECG ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|-
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Annual treadmill exercise testing in patients who have no change in clinical status, can exercise, have none of the [[ECG]] abnormalities listed in number 5 above, and have an estimated annual mortality of >1%. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' In patients who have no new or worsening symptoms or no prior evidence of silent ischemia and are not at high risk for a recurrent cardiac event, the usefulness of annual surveillance exercise ECG testing is not well established. (Level of Evidence: C)''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|}
|}
==2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina (DO NOT EDIT) <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>==
=== Influenza Vaccination (DO NOT EDIT) <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>===


{|class="wikitable"
{|class="wikitable"
|-
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| colspan="1" style="text-align:center; background:LightCoral"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' An annual influenza vaccination is recommended for patients with cardiovascular disease.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' Nuclear MPI, echocardiography, or CMR, with either exercise or pharmacological stress or CCTA, is not recommended for follow-up assessment in patients with SIHD, if performed more frequently than at a) 5-year intervals after CABG or b) 2-year intervals after PCI ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|}
|}
==Related Chapters==
*[[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="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>
*The ACC/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. PMID: [http://pubmed.gov/12515758 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="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://dx.doi.org/10.1161/CIRCULATIONAHA.107.187930 DOI:10.1161/CIRCULATIONAHA.107.187930] PMID: [http://pubmed.gov/17998462 17998462]</ref>


==References==
==References==
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Latest revision as of 22:00, 1 November 2016

Chronic stable angina Microchapters

Acute Coronary Syndrome Main Page

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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)
Spinal Cord Stimulation (SCS)
Enhanced External Counter Pulsation (EECP)
ACC/AHA Guidelines for Alternative Therapies in patients with Refractory Angina

Discharge Care

Patient Follow-Up
Rehabilitation

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 patient follow-up On the Web

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to Hospitals Treating Chronic stable angina patient follow-up

Risk calculators and risk factors for Chronic stable angina patient follow-up

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Aysha Anwar, M.B.B.S[3]

Overview

Ongoing follow-up of the patient with chronic stable angina is necessary to monitor symptoms and to optimize antianginal therapy. It is generally recommended that these patients be evaluated every 4-6 months during first year of diagnosis/initiation of therapy and annually thereafter. Based upon clinical judgement, if the patient is poorly responsive to therapy, if the episodes are severe or frequent, or if the patient is fragile with multiple co-morbidities, they may need to be seen more frequently. During a follow-up visit, the patient should be asked about the frequency and severity of their anginal symptoms, their level of exercise capacity, whether they have been able to modify his/her risk factors, how well they are tolerating and complying with the therapy and whether he/she has developed new illnesses or co-morbidities.

ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina (DO NOT EDIT)[1][2]

Patient Follow-Up, Monitoring of Symptoms and Antianginal Therapy(DO NOT EDIT)[1][2]

Clinical Evaluation, Echocardiography During Routine, Periodic Follow-Up

Class I
"1. Patients with SIHD should receive periodic follow-up, at least annually, that includes all of the following:

a. Assessment of symptoms and clinical function; b. Surveillance for complications of SIHD, including heart failure and arrhythmias;. c. Monitoring of cardiac risk factors; and d. Assessment of the adequacy of and adherence to recommended lifestyle changes and medical therapy. (Level of Evidence: C) "

Class IIa
"2. Assessment of LV ejection fraction and segmental wall motion by echocardiography or radionuclide imaging is recommended in patients with new or worsening heart failure or evidence of intervening MI by history or ECG. (Level of Evidence: C) "
Class IIb
"1. Periodic screening for important comorbidities that are prevalent in patients with SIHD, including diabetes mellitus, depression, and chronic kidney disease might be reasonable. (Level of Evidence: C) "
"2. A resting 12-lead ECG at 1-year or longer intervals between studies in patients with stable symptoms might be reasonable.(Level of Evidence: C) "
Class III
"1. Measurement of LV function with a technology such as echocardiography or radionuclide imaging is not recommended for routine periodic reassessment of patients who have not had a change in clinical status or who are at low risk of adverse cardiovascular events (Level of Evidence: C)"

Noninvasive Testing in Known SIHD

Follow-Up Noninvasive Testing in Patients With Known SIHD: New, Recurrent, or Worsening Symptoms Not Consistent With Unstable Angina

Patients able to exercise

Class I
"1. Standard exercise ECG testing is recommended in patients with known SIHD who have new or worsening symptoms not consistent with UA and who have a) at least moderate physical functioning and no disabling comorbidity and b) an interpretable ECG (Level of Evidence: B) "
Class IIa
"1. Exercise with nuclear MPI or echocardiography is reasonable in patients with known SIHD who have new or worsening symptoms not consistent with UA and who have a) at least moderate physical functioning and no disabling comorbidity, b) previously required imaging with exercise stress, or c) known multivessel disease or high risk for multivessel disease (Level of Evidence: B) "
Class III
"1. Pharmacological stress imaging with nuclear MPI, echocardiography, or CMR is not recommended in patients with known SIHD who have new or worsening symptoms not consistent with UA and who are capable of at least moderate physical functioning or have no disabling comorbidity (. (Level of Evidence: C) "

Patients unable to exercise

Class I
"1. Pharmacological stress imaging with nuclear MPI or echocardiography is recommended in patients with known SIHD who have new or worsening symptoms not consistent with UA and who are incapable of at least moderate physical functioning or have disabling comorbidity. (Level of Evidence: B) "
Class IIa
"1. Pharmacological stress imaging with CMR is reasonable in patients with known SIHD who have new or worsening symptoms not consistent with UA and who are incapable of at least moderate physical functioning or have disabling comorbidity (Level of Evidence: B) "
Class III (No Benefit)
"1. Standard exercise ECG testing should not be performed in patients with known SIHD who have new or worsening symptoms not consistent with UA and who a) are incapable of at least moderate physical functioning or have disabling comorbidity or b) have an uninterpretable ECG(Level of Evidence: C)"

Irrespective of the ability to exercise

Class IIb
"1. CCTA for assessment of patency of CABG or of coronary stents 3 mm or larger in diameter might be reasonable in patients with known SIHD who have new or worsening symptoms not consistent with UA, irrespective of ability to exercise (Level of Evidence: B) "
"2. CCTA might be reasonable in patients with known SIHD who have new or worsening symptoms not consistent with UA, irrespective of ability to exercise, in the absence of known moderate or severe calcification or if the CCTA is intended to assess coronary stents less than 3 mm in diameter (Level of Evidence: B) "
Class III
"1. CCTA should not be performed for assessment of native coronary arteries with known moderate or severe calcification or with coronary stents less than 3mm in diameter in patients with known SIHD who have new or worsening symptoms not consistent with UA, irrespective of ability to exercise. (Level of Evidence: B) "

Noninvasive Testing in Known SIHD

Class IIa
"1. Nuclear MPI, echocardiography, or CMR with either exercise or pharmacological stress can be useful for follow-up assessment at 2-year or longer intervals in patients with SIHD with prior evidence of silent ischemia or who are at high risk for a recurrent

cardiac event and a) are unable to exercise to an adequate workload, b) have an uninterpretable ECG, or c) have a history of incomplete coronary revascularization. (Level of Evidence: C) "

Class IIa
"1. Standard exercise ECG testing performed at 1-year or longer intervals might be considered for follow-up assessment in patients with SIHD who have had prior evidence of silent ischemia or are at high risk for a recurrent cardiac event and are able to exercise to an

adequate workload and have an interpretable ECG (Level of Evidence: C) "

"2. In patients who have no new or worsening symptoms or no prior evidence of silent ischemia and are not at high risk for a recurrent cardiac event, the usefulness of annual surveillance exercise ECG testing is not well established. (Level of Evidence: C)(Level of Evidence: C) "
Class III
"1. Nuclear MPI, echocardiography, or CMR, with either exercise or pharmacological stress or CCTA, is not recommended for follow-up assessment in patients with SIHD, if performed more frequently than at a) 5-year intervals after CABG or b) 2-year intervals after PCI (Level of Evidence: C) "

References

  1. ↑ 1.0 1.1 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.
  2. ↑ 2.0 2.1 Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS; et al. (2003). "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)". J Am Coll Cardiol. 41 (1): 159–68. PMID 12570960.

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