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

20 ESC <strong>Guidelines</strong>multivariable analysis including several exercise variables ina given patient such as the combination of heart rate atpeak exercise, ST-segment depression, the presence orabsence of angina during the test, peak workload, andST-segment slope. 152,271–273The Duke treadmill score (DTS) is a well validated scorewhich combines exercise time, ST-deviation, and anginaduring exercise to calculate the patient’s risk. 152,272 TheDTS equals the exercise time in minutes minus (five timesthe ST-segment deviation, during or after exercise in millimetres)minus (four times the angina index, which has avalue of ‘0’ if there is no angina, ‘1’ if angina occurs, and‘2’ if the angina is the reason for stopping the test(Figure 4). In the original description of this score in a populationwith suspected CAD, two-thirds of patients withscores indicating low-risk had a 4-year survival rate of 99%(average annual mortality rate 0.25%), and the 4% who hadscores indicating high-risk had a 4-year survival rate of 79%(average annual mortality rate 5%). The combination ofexercise and clinical parameters, with or without the useof scores such as the DTS, has been shown to be an effectivemethod of discriminating between high- and low-risk groupswithin a population presenting with known or suspectedcoronary disease (Figure 5).Stress echocardiography. Stress echocardiography may alsobe used effectively to stratify patients according to theirrisk of subsequent cardiovascular events 158,274 and similarlyhas an excellent negative predictive value, 275,276 in patientswith a negative test having a hard event rate (death or MI) of,0.5%/year. The risk of future events is influenced both bythe number of resting regional wall motion abnormalitiesand inducible wall motion abnormalities on stress echocardiography,with more resting abnormalities and a greateramount of inducible ischaemia associated with higherrisk. 155 Identification of a high risk cohort allows for appropriatefurther investigation and/or intervention.Stress perfusion scintigraphy. SPECT perfusion scintigraphyis a useful method of non-invasive risk stratification,readily identifying those patients at greatest risk for subsequentdeath and MI. Normal stress myocardial perfusionimages are highly predictive of a benign prognosis. Severalstudies involving thousands of patients have found that anormal stress perfusion study is associated with a subsequentrate of cardiac death and MI of less than 1% peryear, which is nearly as low as that of the general population.169,170,277 The only exceptions would appear inpatients with normal perfusion images with either a highrisktreadmill ECG score or severe resting LV dysfunction. 278In contrast, abnormal findings on stress perfusionscintigraphy have been associated with severe CAD, andFigure 4 Duke treadmill score. 272subsequent cardiac events. Large stress-induced perfusiondefects, defects in multiple coronary artery territories,transient post-stress ischaemic LV dilatation, and in patientsstudied with 201 Th, increased lung uptake 279 on postexerciseor pharmacological stress images are all adverseprognostic indicators. 158,174,277,278The results of planar and SPECT perfusion scintigraphy canbe used to identify a ‘high-risk’ patient subset. Thesepatients, who have a greater than 3% annual mortalityrate, should be considered for early coronary arteriography,as their prognosis may be improved by revascularization.Exercise scintigraphy offers greater prognostic informationthan pharmacological stress imaging because of the informationregarding symptoms, exercise tolerance, andhaemodynamic response to exercise which is additive tothat obtained from perfusion data alone.Recommendations for risk stratification according toexercise stress ECG in stable angina in patients who canexerciseClass I(1) All patients without significant resting ECG abnormalitiesundergoing initial evaluation (level of evidence B)(2) Patients with stable coronary disease after a significantchange in symptom level (level of evidence C)Class IIa(1) Patients post-revascularization with a significantdeterioration in symptomatic status (level of evidenceB)Recommendations for risk stratification according toexercise stress imaging (perfusion or echocardiography)in stable angina in patients who can exerciseClass I(1) Patients with resting ECG abnormalities, LBBB, .1 mmST-depression, paced rhythm, or WPW which preventaccurate interpretation of ECG changes during stress(level of evidence C)(2) Patients with a non-conclusive exercise ECG, but intermediateor high probability of disease (level of evidenceB)Class IIa(1) In patients with a deterioration in symptoms postrevascularization(level of evidence B)(2) As an alternative to exercise ECG in patients wherefacilities, cost, and personnel resources allow (levelof evidence B)Recommendations for risk stratification according topharmacological stress imaging (perfusion or echocardiography)in stable anginaClass I(1) Patients who cannot exerciseOther class I and II indications as for exercise stressimaging (perfusion or echocardiography) in stable angina inpatients who can exercise, but where local facilities donot include exercise imaging.Risk stratification using ventricular functionThe strongest predictor of long-term survival is LV function.In patients with stable angina as LV ejection fraction (EF)