Chronic stable angina risk stratification cardiac stress imaging in patients who are able to exercise

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [4]; Associate Editor-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S.

Overview

Cardiac stress imaging consisting of echocardiography and myocardial perfusion scan, which are assessed both at rest and during stress, provide a useful way to stratify the risk of underlying coronary artery disease (CAD) and hence aid in the management of chronic stable angina. Cardiac stress imaging in a patient who is able to exercise is indicated in the presence of resting ECG abnormalities or in patients who are on digoxin. A normal post-stress thallium scan indicates a low probability of underlying CAD, however, a normal image in a patient with high-risk treadmill scores requires further evaluation.

Stress Echocardiography

• In patients with chronic stable angina, stress echocardiography is routinely used to stratify the risk of underlying coronary artery disease and as an alternative to stress thallium scan for detecting inducible myocardial ischemia.

• During stress, the extent and severity of abnormal contractile response is expressed as wall motion score index (WMSI)

Contractile response	Peak WMSI	Cardiac event rate
Normal response	1.0	0.9% per year
Mild-to-moderate contractile dysfunction	1.1–1.7	3.1% per year
Severe contractile dysfunction	greater than 1.7	5.2% per year

Myocardial perfusion imaging

• In patients with high pretest likelihood of coronary artery disease but without known CAD, myocardial perfusion scan or stress myocardial perfusion single-photon emission computed tomography (SPECT) yields incremental prognostic value and enhanced risk stratification.

• In patients with known CAD,a normal stress thallium test is associated with a annual mortality rate of 0.5% to 0.9%.

• A normal post-stress thallium scan indicates a low probability of underlying CAD. However, a normal scan in a patient with high-risk treadmill scores warrants further evaluation.

• Scintigraphic features suggestive of adverse cardiac events include:

• Cavity dilatation,
• Low ejection fraction,
• End-systolic and end-diastolic volumes,
• Post-stress myocardial stunning.

ACC / AHA Guidelines- Cardiac Stress Imaging for Risk Stratification of Patients With Chronic Stable Angina Who Are Able to Exercise (DO NOT EDIT)

“

Class I 1. 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 IIb 1. 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 III 1. 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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ESC Guidelines- Risk Stratification according to Exercise Stress ECG in patients Who Can Exercise (DO NOT EDIT)

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Class I 1. All patients without significant resting ECG abnormalities undergoing initial evaluation. (Level of Evidence: B) 2. Patients with stable coronary artery disease after a significant change in symptom level. (Level of Evidence: C) Class IIa 1. Patients post-revascularization with a significant deterioration in symptomatic status. (Level of Evidence: B)

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ESC Guidelines- Risk Stratification according to Exercise Stress Imaging (Perfusion or Echocardiography) in patients Who Can Exercise (DO NOT EDIT)

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Class I 1. Patients with resting ECG abnormalities, LBBB, more than 1 mm ST depression, paced rhythm, or Wolff Parkinson White syndrome which prevent accurate interpretation of ECG changes during stress. (Level of Evidence: C) 2. Patients with a non-conclusive exercise ECG, but intermediate or high probability of disease. (Level of Evidence: B) Class IIa 1. In patients with a deterioration in symptoms post-revascularization. (Level of Evidence: B) 2. As an alternative to exercise ECG in patients where facilities, cost, and personnel resources allow. (Level of Evidence: B)

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Vote on and Suggest Revisions to the Current Guidelines

• 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

• Guidelines on the management of stable angina pectoris: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology

• TheACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina

• The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina