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

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16 ESC <strong>Guidelines</strong>anti-anginal therapy in stable coronary disease publishedsince 2000 are illustrated in Figure 1. The rate of cardiovasculardeath in the PEACE 252 study was less than 1% perannum, whereas in ‘high-risk’ populations such as in diabeticMICRO-HOPE 253 population and the IONA 254 population theannualized cardiovascular mortality rate was .2%. For thepurposes of these guidelines, unless qualified differently inthe text, if an individual with angina is determined on thebasis of a well validated risk prediction model, to haveannual cardiovascular mortality of .2% that individual isdeemed high risk, whereas an annual cardiovascular mortalityof ,1% is considered low risk, and 1–2% intermediaterisk.The clinical evaluation, the response to stress testing,the quantification of ventricular function, and the extentof CAD are the four key pieces of information to stratifypatient’s risk. 66–68,124,255,256 However, not all patients willrequire invasive assessment of the coronary anatomy, particularlyif their clinical evaluation and non-invasivetesting establish that they are in a low-risk group. The riskassessment hierarchy can be described as:(1) Risk stratification by clinical evaluation(2) Risk stratification by response to stress testing(3) Risk stratification by ventricular function(4) Risk stratification by coronary anatomyThe route through these successive tests may not alwaysbe directly linear. For example in a patient with a highpre-test probability of disease, severe angina, and otherhigh-risk clinical features such as signs of heart failure,may proceed directly from clinical evaluation to coronaryarteriography, with perfusion scintigraphy afterwards toevaluate myocardial viability. However, risk stratificationgenerally follows a pyramidal structure, with all patientsrequiring risk stratification by clinical evaluation as themost basic requirement, proceeding in the majority to noninvasiveassessment of ischaemia and ventricular function,and finally coronary arteriography in a selected proportion.A summary of the recommendations for the routine use ofinvestigations in evaluation of stable angina with correspondinglevels of evidence related to diagnosis and prognosis,is presented in Table 7, and an algorithm for the initialevaluation of patients presenting with clinical symptomssuggestive of angina is depicted in Figure 2.Risk stratification using clinical evaluationThe clinical history and physical examination can providevery important prognostic information. ECG can be convenientlyincorporated in risk stratification at this level,and the results of the laboratory tests discussed in the previoussection may modify risk estimation further. Diabetes,hypertension, current smoking, and elevated total cholesterol(untreated or elevated despite treatment) have beenshown to be predictive of adverse outcome in patientswith stable angina or other populations with established coronarydisease. 56,58,257–259 Increasing age is an importantfactor to consider, as are prior MI, 66,123 symptoms andsigns of heart failure, 66,123,124 and the pattern of occurrence(recent onset or progressive), and severity of angina,particularly if unresponsive to therapy. 255,260Pryor et al. 261 studied a total of 1030 consecutive outpatientsreferred to non-invasive testing for suspectedCAD; the information from the initial history, physical examination,ECG, and chest radiograph was used to predict coronaryanatomy, i.e. the likelihood of any significant coronarydisease, severe disease, and significant left main (LM)disease and to estimate 3 years survival. These estimateswere compared with those based on treadmill testing.Compared with the treadmill exercise test, initialevaluation was slightly better able to distinguish patientswith or without CAD and was similar in the ability toidentify patients at increased risk for dying or with anatomicallysevere disease. Although much of the informationobtained by physicians during the initial assessment isFigure 1 Cardiovascular mortality and myocardial infarction in contemporary trials of stable coronary disease or angina: CAMELOT, 467 PEACE, 252 ACTION, 493EUROPA, 461 HOPE, 460 IONA, 254 and MICRO-HOPE. 253
ESC <strong>Guidelines</strong> 17Table 7Summary of recommendations for routine non-invasive investigations in evaluation of stable anginaTest For Diagnosis For PrognosisClass ofrecommendationLevel ofevidenceClass ofrecommendationLevel ofevidenceLaboratory testsFull blood count, creatinine I C I BFasting glucose I B I BFasting lipid profile I B I BHs-C-reactive protein, homocysteine, lp(a), apoA,IIb B IIb Band apoBECGInitial evaluation I C I BDuring episode of angina I BRoutine periodic ECG on successive visits IIb C IIb CAmbulatory ECG monitoringSuspected arrhythmia I BSuspected vasopastic angina IIa CIn suspected angina with normal exercise test IIa CCXRSuspected heart failure or abnormalI B I Bcardiac auscultationSuspected significant pulmonary disease I BEchocardiogramSuspected heart failure, abnormal auscultation,I B I Babnormal ECG, Qwaves, BBB, andmarked ST changesPrevious MI I BHypertension or diabetes mellitus I C I B/CIntermediate or low-risk patient not due toIIaChave alternative assessment of LV functionExercise ECGFirst line for initial evaluation,I B I Bunless unable to exercise/ECG not evaluablePatients with known CAD andIBsignificant deterioration in symptomsRoutine periodic testing once angina controlled IIb C IIb CExercise imaging technique (echo or radionucleotide)Initial evaluation in patients with uninterpretable ECG I B I BPatients with non-conclusive exercise testI B I B(but adequate exercise tolerance)Angina post-revascularization IIa B IIa BTo identify location of ischaemiaIIaBin planning revascularizationAssessment of functional severity ofIIaCintermediate lesions on arteriographyPharmacological stress imaging techniquePatients unable to exercise I B I BPatients with non-conclusive exercise test due toI B I Bpoor exercise toleranceTo evaluate myocardial viability IIa BOther indications as for exerciseIIa B IIa Bimaging where local facilities favourpharmacological rather than exercise stressNon-invasive CT arteriographyPatients with low probability ofdisease and non-conclusive or positive stress testIIbCsubjective, their study confirms the importance of thatinformation in identifying patients likely to benefit fromfurther testing and supports the development of strategiesthat use the physician’s initial assessment in the evaluationprocess.Typical angina has been shown to be a significant prognosticfactor in patients undergoing coronary arteriography,however, the relation of typical angina to prognosis ismediated by its relation to the extent of coronary disease.But the pattern of angina occurrence, angina frequency,and resting ECG abnormalities are independent predictorsof survival and survival free of MI, and may be combinedin a simple weighted score (Figure 3) to predict outcome,particularly in the first year after assessment.
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Guidelines on the Management of Stable Angina Pectoris ... - Cardio

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