Chronic stable angina revascularization: Difference between revisions
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***[[CABG]] is indicated | ***[[CABG]] is indicated | ||
*Patients who would also have a survival benefit from revascularization (PCI or CABG) are survivors of sudden cardiac death secondary to ischemia induced tachycardia, where ischemia is caused by more than '''70%''' stenosis of a '''major coronary artery''': | *Patients who would also have a survival benefit from revascularization (PCI or CABG) are survivors of sudden cardiac death secondary to ischemia induced tachycardia, where ischemia is caused by more than '''70%''' stenosis of a '''major coronary artery''': | ||
**[[CABG]] or [[PCI]] are indicated.<ref name=" | **[[CABG]] or [[PCI]] are indicated.<ref name="Qaseem">Qaseem A, Fihn SD, Dallas P, et al. Management of patients with stable ischemic heart disease: Executive summary of a clinical practice guideline from the American College of Physicians, American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med 2012. </ref> | ||
====Relief of Symptoms Refractory to medical Therapy==== | ====Relief of Symptoms Refractory to medical Therapy==== | ||
* Coronary [[angiography]] should be performed in the following settings: | * Coronary [[angiography]] should be performed in the following settings: | ||
** More than 70% stenosis of a non left main artery or more than 50% stenosis of left main artery | ** More than 70% stenosis of a non left main artery or more than 50% stenosis of left main artery | ||
***[[CABG]] or [[PCI]] are indicated.<ref name=" | ***[[CABG]] or [[PCI]] are indicated.<ref name="Qaseem">Qaseem A, Fihn SD, Dallas P, et al. Management of patients with stable ischemic heart disease: Executive summary of a clinical practice guideline from the American College of Physicians, American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med 2012. </ref> | ||
*The definition of inadequate response to [[Chronic stable angina treatment#Pharmacotherapy|medical therapy]] can be fairly broad and depends largely on the patient's lifestyle, occupation and expectations: | *The definition of inadequate response to [[Chronic stable angina treatment#Pharmacotherapy|medical therapy]] can be fairly broad and depends largely on the patient's lifestyle, occupation and expectations: | ||
**At one extreme are patients who are limited by angina pectoris despite optimal drug treatments and lifestyle modifications, including achievement of optimal weight and cessation of smoking. | **At one extreme are patients who are limited by angina pectoris despite optimal drug treatments and lifestyle modifications, including achievement of optimal weight and cessation of smoking. | ||
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* [[PCI]] should not be done in patients that will not be compliant with dual antiplatelet therapies. | * [[PCI]] should not be done in patients that will not be compliant with dual antiplatelet therapies. | ||
* Patients with diabetes and advanced three-vessel coronary artery disease have shown lower mortality and myocardial infarction rates and higher risk of strokes when undergoing [[CABG]] compared to [[PCI]] with drug eluting stents.<ref name=" | * Patients with diabetes and advanced three-vessel coronary artery disease have shown lower mortality and myocardial infarction rates and higher risk of strokes when undergoing [[CABG]] compared to [[PCI]] with drug eluting stents.<ref name="Qaseem">Qaseem A, Fihn SD, Dallas P, et al. Management of patients with stable ischemic heart disease: Executive summary of a clinical practice guideline from the American College of Physicians, American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med 2012. </ref> | ||
==Revascularization: Further Readings== | ==Revascularization: Further Readings== | ||
Revision as of 04:51, 21 November 2012
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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 revascularization On the Web | ||
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to Hospitals Treating Chronic stable angina revascularization | ||
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Risk calculators and risk factors for Chronic stable angina revascularization | ||
Editors-In-Chief: C. Michael Gibson, M.S., M.D. [1] Phone:617-632-7753; Cafer Zorkun, M.D., Ph.D. [2]; Associate Editors-In-Chief: John Fani Srour, M.D.; Smita Kohli, M.D.; Rim Halaby
Overview
The goal of the treatment of chronic stable angina is to reduce the symptoms, delay the progression of atherosclerosis, and prevent cardiovascular events. In order to achieve these goals, lifestyle modifications and medical therapy are the first line treatment. Revascularization is done to increase survival in specific conditions where the stenosis of the coronary arteries is anatomically and functionally significant and the symptoms are refractory to medical therapy. There are currently two well-established revascularization approaches for the treatment of chronic stable angina caused by coronary atherosclerosis: CABG and PCI. Since the introduction of coronary artery bypass surgery in 1967 and percutaneous transluminal coronary angioplasty (PTCA) in 1977, research has supported the effective usage of both strategies for treatment of patients with chronic stable angina. However, as with any treatment method, both methodologies have weaknesses. The choice between PCI and CABG is based upon anatomy and other factors such as left ventricular function and the presence or absence of diabetes. In general, PTCA is reserved for single or some cases of two vessel disease, while CABG is reserved for patients with two or three vessel disease or left main disease. With the availability of drug-eluting stents, PCI is increasingly being performed for many lesions including more complex ones.
Revascularization Therapy
Indications for Revascularization Therapy
Increase Survival
- Increased survival following revascularization depends on the location, severity, and number of lesions; the presence or absence of left ventricular dysfunction is an important factor as well:
- Patients who would also have a survival benefit from revascularization (PCI or CABG) are survivors of sudden cardiac death secondary to ischemia induced tachycardia, where ischemia is caused by more than 70% stenosis of a major coronary artery:
Relief of Symptoms Refractory to medical Therapy
- Coronary angiography should be performed in the following settings:
- The definition of inadequate response to medical therapy can be fairly broad and depends largely on the patient's lifestyle, occupation and expectations:
- At one extreme are patients who are limited by angina pectoris despite optimal drug treatments and lifestyle modifications, including achievement of optimal weight and cessation of smoking.
- At the other end are patients in whom we can consider medical therapy to have failed if control of angina pectoris requires higher doses of anti-anginal medications that cause side effects.
- The following patients should also be considered:
- Survivors of sudden cardiac death or serious ventricular arrhythmia.
- Patients having symptoms and signs of heart failure.
- Patients having clinical features that suggest high likelihood of severe coronary artery disease.
Considerations
- PCI should not be done in patients that will not be compliant with dual antiplatelet therapies.
- Patients with diabetes and advanced three-vessel coronary artery disease have shown lower mortality and myocardial infarction rates and higher risk of strokes when undergoing CABG compared to PCI with drug eluting stents.[1]
Revascularization: Further Readings
You can read in greater detail about specific revascularization approaches for the treatment of chronic stable angina by clicking on the link below for that topic.
PCI | CABG | PCI vs CABG | ACC/AHA Guidelines for Revascularization
See Also
Guidelines Resources
- The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina [2]
- The ACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina [3]
- The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina [4]
References
- ↑ 1.0 1.1 1.2 Qaseem A, Fihn SD, Dallas P, et al. Management of patients with stable ischemic heart disease: Executive summary of a clinical practice guideline from the American College of Physicians, American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med 2012.
- ↑ Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999) 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: 10351980
- ↑ 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). Circulation 107 (1):149-58. PMID: 12515758
- ↑ Fraker TD, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J et al. (2007) 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. DOI:10.1161/CIRCULATIONAHA.107.187930 PMID: 17998462