Chronic stable angina risk stratification
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Cafer Zorkun, M.D., Ph.D. [2]
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Overview
The average mortality in patients with stable angina ranges from 1-3%. However, there is a wide variability in the prognosis and hence it is important to do risk stratification for every patient. Risk stratification is based on 4 types of patient characteristics.
- Left ventricular function, which is the strongest predictor of long term survival
- Extent of atherosclerosis in the coronary arteries
- Evidence of a recent coronary plaque rupture
- Overall health and presence of other co-morbidities.
An initial scoring system was proposed by the Framingham Heart Study group to predict 10 year risk forCAD based on patient's age, sex, total cholesterol, presence of hypertension and history of smoking and diabetes. Presence of other peripheral vascular diseases is also used to risk stratify the patients.
Risk Stratification of Chronic Stable Angina
ECG/Chest X-ray in aysmptomatic patients
Presence of ECG abnormalities at rest puts the patient at higher risk than those with normal resting ECG. ECG abnormalities may be present in the form of LVH by ECG criteria, persistent ST-T wave inversions in V1-V3, Q waves in multiple leads or R wave in V1, bundle branch blocks and atrial or ventricular arrythmias. Presence of cardiomegaly or pulmonary vascular congestion on Ches X-ray are also associated with poor prognosis.
Importance of assessing Left Ventricular function
Indications for assessing LV function are not only limited to patients with evidence of heart failure or valvular dysfunction but also includes patients with documented MI or ECG showing Q waves(suggestive of old MI). A resting or exercise LV ejection fraction of less than 35% is associated with significant higher mortality than a normal EF. Echocardiography is the best initial tool for obtaining an estimate of the LV function, both systolic and diastolic. In addition to this, it will also provide information about associated valvular dysfunction and pulmonary artery pressures. This information can in turn be used to select or modify the treatment regimen for the patient.
ACC / AHA Guidelines- Measurement of Rest LV Function by Echocardiography or Radionuclide Angiography (DO NOT EDIT)[1]
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Class I1. Echocardiography or radionuclide angiography (RNA) in patients with a history of prior MI, pathological Q waves, or symptoms or signs suggestive of heart failure to assess LV function. (Level of Evidence: B) 2. Echocardiography in patients with a systolic murmur suggesting mitral regurgitation to assess its severity and etiology. (Level of Evidence: C) 3. Echocardiography or RNA in patients with complex ventricular arrhythmias to assess LV function. (Level of Evidence: B) Class III1. Routine periodic reassessment of stable patients for whom no new change in therapy is contemplated. (Level of Evidence: C) 2. Patients with a normal ECG, no history of MI, and no symptoms or signs suggestive of heart failure. (Level of Evidence: B) |
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Exercise testing for Risk Stratification and Prognosis
ACC / AHA Guidelines- Risk Assessment and Prognosis in Patients With an Intermediate or High Probability of CAD (DO NOT EDIT)[1]
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Class I1. Patients undergoing initial evaluation. (Exceptions are listed below in classes IIb and III.) (Level of Evidence: B) 2. Patients after a significant change in cardiac symptoms. (Level of Evidence: C) Class IIb1. Patients with the following ECG abnormalities:
2. Patients who have undergone cardiac catheterization to identify ischemia in the distribution of a coronary lesion of borderline severity. (Level of Evidence: C) 3. Postrevascularization patients who have a significant change in anginal pattern suggesting ischemia. (Level of Evidence: C) Class III1. Patients with severe comorbidity likely to limit life expectancy or prevent revascularization. (Level of Evidence: C) |
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ACC / AHA Guidelines- Cardiac Stress Imaging for Risk Stratification of Patients With Chronic Stable Angina Who Are Able to Exercise (DO NOT EDIT)[1]
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Class I1. Exercise myocardial perfusion imaging or exercise echocardiography to identify the extent, severity, and location of ischemia in patients who do not have left bundle-branch block or an electronically paced ventricular rhythm and have either an abnormal rest ECG or are using digoxin. (Level of Evidence: B) 2. Dipyridamole or adenosine myocardial perfusion imaging in patients with left bundle-branch block or electronically paced ventricular rhythm. (Level of Evidence: B) 3. Exercise myocardial perfusion imaging or exercise echocardiography to assess the functional significance of coronary lesions (if not already known) in planning PTCA. (Level of Evidence: B) Class IIb1. Exercise or dobutamine echocardiography in patients with left bundle-branch block. (Level of Evidence: C) 2. Exercise, dipyridamole, adenosine myocardial perfusion imaging, or exercise or dobutamine echocardiography as the initial test in patients who have a normal rest ECG and are not taking digoxin. (Level of Evidence: B) Class III1. Exercise myocardial perfusion imaging in patients with left bundle-branch block. (Level of Evidence: C) 2. Exercise, dipyridamole, adenosine myocardial perfusion imaging, or exercise or dobutamine echocardiography in patients with severe comorbidity likely to limit life expectation or prevent revascularization. (Level of Evidence: C) |
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ACC / AHA Guidelines- Cardiac Stress Imaging as the Initial Test for Risk Stratification of Patients With Chronic Stable Angina Who Are Unable to Exercise (DO NOT EDIT)[1]
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Class I1. Dipyridamole or adenosine myocardial perfusion imaging or dobutamine echocardiography to identify the extent, severity, and location of ischemia in patients who do not have left bundle-branch block or electronically paced ventricular rhythm. (Level of Evidence: B) 2. Dipyridamole or adenosine myocardial perfusion imaging in patients with left bundle-branch block or electronically paced ventricular rhythm. (Level of Evidence: B) 3. Dipyridamole or adenosine myocardial perfusion imaging or dobutamine echocardiography to assess the functional significance of coronary lesions (if not already known) in planning PTCA. (Level of Evidence: B) Class IIb1. Dobutamine echocardiography in patients with left bundle-branch block. (Level of Evidence: C) Class III1. Dipyridamole or adenosine myocardial perfusion imaging or dobutamine echocardiography in patients with severe comorbidity likely to limit life expectation or prevent revascularization. (Level of Evidence: C) |
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ACC / AHA Guidelines- Coronary Angiography and Left Ventriculography (DO NOT EDIT)[1]
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Class I1. Patients with disabling (Canadian Cardiovascular Society (CCS) classes III and IV) chronic stable angina despite medical therapy. (Level of Evidence: B) 2. Patients with high-risk criteria on noninvasive testing regardless of anginal severity. (Level of Evidence: B) 3. Patients with angina who have survived sudden cardiac death or serious ventricular arrhythmia. (Level of Evidence: B) 4. Patients with angina and symptoms and signs of congestive heart failure. (Level of Evidence: C) 5. Patients with clinical characteristics that indicate a high likelihood of severe CAD. (Level of Evidence: C) Class IIa1. Patients with significant LV dysfunction (ejection fraction <45%), CCS class I or II angina, and demonstrable ischemia but less than high-risk criteria on noninvasive testing. (Level of Evidence: C) 2. Patients with inadequate prognostic information after noninvasive testing. (Level of Evidence: C) Class IIb1. Patients with CCS class I or II angina, preserved LV function (ejection fraction >45%), and less than high-risk criteria on noninvasive testing. (Level of Evidence: C) Class III1. Patients with CCS class I or II angina who respond to medical therapy and have no evidence of ischemia on noninvasive testing. (Level of Evidence: C) 2. Patients who prefer to avoid revascularization. (Level of Evidence: C) |
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ACC / AHA Guidelines- Noninvasive Testing for the Diagnosis of Obstructive CAD and Risk Stratification in Asymptomatic Patients (DO NOT EDIT)[2]
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Class IIb1. Exercise ECG testing without an imaging modality in asymptomatic patients with possible myocardial ischemia on ambulatory ECG (AECG) monitoring or with severe coronary calcification on EBCT in the absence of one of the following ECG abnormalities:
d. Complete left bundle-branch block. (Level of Evidence: C) 2. Exercise perfusion imaging or exercise echocardiography in asymptomatic patients with possible myocardial ischemia on AECG monitoring or with severe coronary calcification on EBCT who are able to exercise and have one of the following baseline ECG abnormalities:
3. Adenosine or dipyridamole myocardial perfusion imaging in patients with severe coronary calcification on EBCT but with one of the following baseline ECG abnormalities:
4. Adenosine or dipyridamole myocardial perfusion imaging or dobutamine echocardiography in patients with possible myocardial ischemia on AECG monitoring or with coronary calcification on EBCT who are unable to exercise. (Level of Evidence: C) 5. Exercise myocardial perfusion imaging or exercise echocardiography after exercise ECG testing in asymptomatic patients with an intermediate-risk or high-risk Duke treadmill score. (Level of Evidence: C) 6. Adenosine or dipyridamole myocardial perfusion imaging or dobutamine echocardiography after exercise ECG testing in asymptomatic patients with an inadequate exercise ECG. (Level of Evidence: C) Class III1. Exercise ECG testing without an imaging modality in asymptomatic patients with possible myocardial ischemia on AECG monitoring or with coronary calcification on EBCT but with the baseline ECG abnormalities listed under Class IIb1 above. (Level of Evidence: B) 2. Exercise ECG testing without an imaging modality in asymptomatic patients with an established diagnosis of CAD owing to prior MI or coronary angiography; however, testing can assess functional capacity and prognosis. (Level of Evidence: B) 3. Exercise or dobutamine echocardiography in asymptomatic patients with left bundle-branch block. (Level of Evidence: C) 4. Adenosine or dipyridamole myocardial perfusion imaging or dobutamine echocardiography in asymptomatic patients who are able to exercise and who do not have left bundle-branch block or electronically paced ventricular rhythm. (Level of Evidence: C) 5. Exercise myocardial perfusion imaging, exercise echocardiography, adenosine or dipyridamole myocardial perfusion imaging, or dobutamine echocardiography after exercise ECG testing in asymptomatic patients with a low-risk Duke treadmill score. (Level of Evidence: C) |
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ACC / AHA Guidelines- Coronary Angiography for Risk Stratification in Asymptomatic Patients (DO NOT EDIT)[2]
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Class IIa1. Patients with high-risk criteria that suggest ischemia on noninvasive testing. (Level of Evidence: C) Class IIb1. Patients with inadequate prognostic information after noninvasive testing. (Level of Evidence: C) Class III1. Patients who prefer to avoid revascularization. (Level of Evidence: C) |
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See Also
Sources
- The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina [1]
- TheACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina [2]
- The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina [3]
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 Gibbons RJ, Chatterjee K, Daley J, et al. ACC/AHA/ACP–ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Chronic Stable Angina). Circulation. 1999; 99: 2829–2848. PMID 10351980
- ↑ 2.0 2.1 2.2 Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, Ferguson TB Jr, Fihn SD, Fraker TD Jr, Gardin JM, O'Rourke RA, Pasternak RC, Williams SV, Gibbons RJ, Alpert JS, Antman EM, Hiratzka LF, Fuster V, Faxon DP, Gregoratos G, Jacobs AK, Smith SC Jr; American College of Cardiology; American Heart Association Task Force on Practice Guidelines. Committee on the Management of Patients With Chronic Stable Angina. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina). Circulation. 2003 Jan 7; 107 (1): 149-58. PMID 12515758
- ↑ Fraker TD Jr, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, Ferguson TB Jr, Gardin JM, O'Rourke RA, Williams SV, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Buller CE, Creager MA, Ettinger SM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Page RL, Riegel B, Tarkington LG, Yancy CW; American College of Cardiology; American Heart Association; American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group. 2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina. Circulation. 2007 Dec 4; 116 (23): 2762-72. Epub 2007 Nov 12. PMID 17998462