Guidelines on the Management of Stable Angina Pectoris ... - Cardio

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14 ESC <strong>Guidelines</strong>and there is little evidence to support its routine deploymentas a prognostic implement in this clinical setting. 225,226Ambulatory monitoring may have a role, however, inpatients in whom vasospastic angina is suspected. Finally,in patients with stable angina and suspected major arrhythmias,Holter monitoring is an important method of diagnosingarrhythmias. Repeated ambulatory ECG monitoring asmeans to evaluate patients with chronic stable angina isnot recommended.Recommendations for ambulatory ECG for initialdiagnostic assessment of anginaClass I(1) Angina with suspected arrhythmia (level of evidence B)Class IIa(1) Suspected vasospastic angina (level of evidence C)Non-invasive techniques to assess coronary calcificationand coronary anatomyComputed tomography. Although spatial resolution andmovement artefact have for a long time been limitingfactors in computed tomography (CT) cardiac imaging, considerableadvances in technology have been made in recentyears to overcome these issues. Two modalities of CTimaging have developed to improve spatial and temporalresolution in CT, ultra-fast or electron beam CT (EBCT),and multi-detector or multi-slice CT (MDCT). These havebeen accompanied by improvements in processing softwareto facilitate interpretation of the images acquired. Bothtechniques have been validated as effective in the detectionof coronary calcium and quantification of the extent of coronarycalcification. 227–230 The Agatston score, 231 the mostcommonly used score, is based on the area and density ofcalcified plaques. It is computed by specific software andis used to quantify the extent of coronary calcification.Calcium is deposited in atherosclerotic plaques within thecoronary arteries. Coronary calcification increases with age,and nomograms have been developed to facilitate interpretationof calcium scores relative to the expected values for agiven age and gender. 232 The extent of coronary calcificationcorrelates more closely with the overall burden of plaquethan with the location or severity of stenoses. 233 Thus inpopulation-based studies detection of coronary calciummay identify those at higher risk of significant coronarydisease, but assessment of coronary calcification is not recommendedroutinely for the diagnostic evaluation ofpatients with stable angina. 234,235Image acquisition times and resolution for EBCT and MDCThave been shortened to the extent that CT coronary arteriographycan be performed by injection of intravenous contrastagents. 236 MDCT or multi-slice CT appears to be the mostpromising of the two techniques in terms of non-invasiveimaging of the coronary arteries, with preliminary studiessuggesting excellent definition, and the possibility of examiningarterial wall and plaque characteristics. Sensitivity andspecificity (segment-specific) of CT angiography for thedetection of coronary disease has been reported to be 95and 98%, respectively, using 16-slice CT scanners. 237 Studiesusing 64 detector scanning report sensitivities and specificitiesof 90–94% and 95–97%, respectively, and importantly, anegative predictive value of 93–99%. 238,239 Non-invasive CTarteriography holds considerable promise for the future ofthe diagnostic assessment of coronary disease. Optimal useof this rapidly developing technology will harness the skillsof both radiology and cardiology disciplines, with cardiologynecessarily taking the lead in selection of patients for investigationby this method, and appropriate management basedon the results. At present, although the diagnostic accuracyof this technique has been reported, the prognostic utility,and the exact place in the hierarchy of investigations instable angina has not yet been fully defined. A conservativesuggestion for its use would be in patients with a lowpre-test (,10%) probability of disease with an equivocalfunctional test (exercise ECG or stress imaging).Recommendations for the use of CT angiography instable anginaClass IIb(1) Patients with a low pre-test probability of disease, witha non-conclusive exercise ECG or stress imaging test(level of evidence C)Magnetic resonance arteriography. Similar to the case of CT,advances in magnetic resonance technology permit noninvasiveMR contrast coronary arteriography, 205 and holdthe potential for plaque characterization. 240 Advantages ofthe technique include the considerable potential for evaluationof overall cardiac anatomy and function. However, atpresent this can only be regarded as a valuable tool forresearch and is not recommended as routine clinicalpractice in the diagnostic evaluation of stable angina.Invasive techniques to assess coronary anatomyCoronary arteriographyCoronary arteriography is generally undertaken as part of aseries of tests to establish a diagnosis and ascertain treatmentoptions. Non-invasive testing can establish the likelihoodof the presence of obstructive coronary disease withan acceptable degree of certainty, and through appropriaterisk stratification may be used to determine the need forcoronary arteriography for further risk stratification purposes.However, it may be contraindicated for reasons ofdisability or serious comorbidity, or offer inconclusiveresults. After a resuscitated cardiac arrest or life threateningventricular arrhythmia, a definitive diagnosis regardingthe presence or absence of coronary disease is useful inclinical decision-making. 241,242 In addition, non-invasivetesting does not allow assessment of suitability for revascularizationwhich may be considered for symptomatic as wellas prognostic grounds. Coronary arteriography holds afundamental position in the investigation of patients withstable angina, providing reliable anatomical information toidentify the presence or absence of coronary lumen stenosis,define therapeutic options (suitability of medical treatmentor myocardial revascularization), and determine prognosis.Methods used to perform coronary arteriography haveimproved substantially resulting in the reduction of complicationrates and rapid ambulation. The composite rate ofmajor complications associated with routine diagnosticcatheterization in patients is between 1 and 2%. The compositerate of death, MI, or stroke is of the order of 0.1–0.2%. 243Intravascular ultrasoundIntravascular ultrasound is a technique that allows productionof ultrasound images from within the (coronary)
ESC <strong>Guidelines</strong> 15arteries by passing an ultrasound catheter into the coronaryartery lumen. 244 Intravascular ultrasound allows for accuratemeasurement of coronary luminal diameter, assessmentof eccentric lesions and Glagovian remodelling, and quantificationof atheroma and calcium deposition. It also allowsfor detailed assessment of interventional target lesions,stent placement, apposition and expansion, and transplantvasculopathy. The technique has afforded advantages interms of our understanding of atherosclerotic plaque depositionand progression, offering considerably improvedqualitative and quantitative assessment of coronaryanatomy compared with contrast arteriography and doubtless,has an important role in specialized clinical settings,particularly as an adjunct to coronary intervention.However, it is more appropriately used in highly specificclinical settings and for research purposes than widespreadapplication as a first line investigation for coronarydisease. 245,246Invasive assessment of functional severity of coronarylesionsThe functional severity of coronary lesions visualized angiographicallymay be assessed invasively by means of measuringeither the coronary flow velocity (coronary vasodilatoryreserve), or intracoronary artery pressure fractional flowreserve (FFR). 7,247 Both techniques involve inducing hyperaemiathrough intracoronary injection of vasodilatingagents. The coronary vasodilatory reserve (CVR) is theratio of hyperaemic to basal flow velocity and reflects flowresistance through the epicardial artery and the correspondingmyocardial bed. It is dependent on microcirculation aswell as severity of the lesion in the epicardial vessel.FFR 248 is calculated as the ratio of distal coronary pressureto aortic pressure measured during maximal hyperaemia.A normal value for FFR is 1.0 regardless of the status ofthe microcirculation, and an FFR ,0.75 is deemedpathological.Physiological measurements as described may facilitatediagnosis in cases of intermediate angiographic stenoses,(visually estimated stenosis 30–70%). FFR measurement hasbeen shown to be useful in differentiating between patientswith favourable long-term outcome (i.e. patients withFFR .0.75) who do not need revascularization; and patientswho require revascularization (i.e. patients withFFR ,0.75) 249 but this investigation is best reserved forspecific clinical circumstances or in deciding suitability forrevascularization rather than routine use.Recommendations for coronary arteriography for thepurposes of establishing a diagnosis in stable anginaClass I(1) Severe stable angina (Class 3 or greater of CanadianCardiovascular Society Classification), with a highpre-test probability of disease, particularly if the symptomsare inadequately responding to medical treatment(level of evidence B)(2) Survivors of cardiac arrest (level of evidence B)(3) Patients with serious ventricular arrhythmias (level ofevidence C)(4) Patients previously treated by myocardial revascularization(PCI, CABG) who develop early recurrenceof moderate or severe angina pectoris (level ofevidence C)Class IIa(1) Patients with an inconclusive diagnosis on non-invasivetesting, or conflicting results from different noninvasivemodalities at intermediate to high risk ofcoronary disease (level of evidence C)(2) Patients with a high risk of restenosis after PCI if PCIhas been performed in a prognostically important site(level of evidence C)Risk stratificationThe long-term prognosis of stable angina is variable, and therange of treatment options has expanded considerably fromsimple symptomatic control to potent and often expensivestrategies to improve prognosis. When discussing risk stratificationin stable angina, risk refers primarily to the risk ofcardiovascular death, but the term is often more looselyapplied to incorporate cardiovascular death and MI, or insome cases even wider combinations of cardiovascular endpoints.The process of risk stratification serves a dualpurpose, to facilitate an informed response to queriesregarding prognosis from patients themselves, employers,insurers, non-cardiology specialists considering treatmentoptions for comorbid conditions and others, and secondlyto assist in choosing appropriate treatment.For certain management options, particularly revascularizationand/or intensified pharmacological therapy, prognosticbenefit is only apparent in high-risk subgroups, withlimited if any benefit in those whose prognosis is alreadygood. This mandates identification of those patients athighest risk, and therefore most likely to benefit frommore aggressive treatment, early in the assessment ofstable angina.A 10-year cardiovascular mortality of .5% (.0.5% perannum) is determined to be high risk for the purpose ofimplementing primary prevention guidelines. 250 However,absolute levels of what constitutes high-risk and low-riskare not clearly defined for those with establishedCVD. 68,251 This problem is linked to difficulties in comparingrisk prediction systems across different populations, determiningaccuracy of individualized predictions of risk, andsynthesis of multiple components of risk, often studied separately,into an estimate of risk for an individual. Added tocontinuously evolving public and professional perceptionsof what constitutes high- and low-risk over the past fourto five decades (since many of the initial risk predictorswere defined), the reasons for this lack of definition arenot easily overcome.However, while awaiting development of a robust andportable risk prediction model which incorporates all potentialaspects of risk stratification, there is an alternativepragmatic approach, based on clinical trial data. Theinherent problems with bias when interpreting and generalizingclinical trial data must be recognized, but such dataoffer an estimate of the levels of absolute risk achievablewith modern conventional treatment even in patients withproven vascular disease. This in turn facilitates anestimation of what may be accepted as constituting high,low, and intermediate risk in a contemporary setting forthe purposes of determining the threshold for invasiveinvestigation or intensified pharmacological therapy.The cardiovascular mortality and MI rate observed in theplacebo arms of large trials of secondary prevention or
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