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

ESC <strong>Guidelines</strong> 21Figure 5 Prognostic stratification according to combined clinical and exercise variables. 52,270–273,681–683declines, mortality increases. A resting EF of less than 35% isassociated with an annual mortality rate greater than 3% peryear. 67,123,124,280Long-term follow-up data from the CASS registry showedthat 72% of the deaths occurred in the 38% of the populationthat had either LV dysfunction or severe coronary disease.The 12-year survival rate of patients with EF .50% was35–49% 280 and ,35% were 73, 54, and 21%, respectively(P , 0.0001). The prognosis of patients with a normal ECGand low clinical risk for severe CAD is, on the other hand,excellent. 261Ventricular function affords additional prognostic informationto coronary anatomy, with reported 5-year survivalrates of a man with stable angina and three-vessel diseaseranging from 93% in those with normal ventricular functionto 58% with reduced ventricular function. 67 Impaired ventricularfunction may be inferred from extensive Q-wave onECG, symptoms or signs of heart failure, or measured noninvasivelyby echocardiography, radionuclide techniques orcontrast ventriculography at the time of coronaryarteriography.Clinical evaluation as outlined earlier may indicate whichpatients have heart failure, and thus at substantiallyincreased risk for future cardiovascular events. However,the prevalence of asymptomatic ventricular dysfunction isnot inconsiderable, 281–283 and has been reported to be ashigh as twice that of clinical heart failure, with the presenceof ischaemic heart disease a major risk factor for itsoccurrence.Ventricular dimensions have been shown to contributeuseful prognostic information which is incremental to theresults of exercise testing in a stable angina population with2-year follow-up. 284 In a study of hypertensive patientswithout angina, the use of echocardiography to assess ventricularstructure and function was associated with reclassificationfrom medium/low risk to high risk in 37% of patients, 285and the European guidelines for the management of hypertensionrecommend an echocardiogram for patients withhypertension. 286 Diabetic patients with angina also requireparticular attention. Echocardiography in diabetic individualswith angina has the advantage of identifying LVH and diastolicas well as systolic dysfunction, all of which are more prevalentin the diabetic population. Thus, an estimation of ventricularfunction is desirable in risk stratification of patients withstable angina, and an assessment for ventricular hypertrophy(by echocardiography or MRI), as well as assessment of ventricularfunction is particularly pertinent in patients with hypertensionor diabetes. For most other patients the choice ofinvestigation to determine ventricular function will be dependenton the other tests which have been performed or areplanned, or the level of risk estimated by other methods. Forexample, in a patient who has a stress imaging test it may bepossible to estimate ventricular function from this testwithout additional investigation, or a patient scheduled tohave coronary arteriography on the basis of a strongly positiveexercise test at low workload, in the absence of prior MI, orother indications for echocardiography, may have ventricularsystolic function assessed at the time of arteriography.Recommendations for risk stratification by echocardiographicevaluation of ventricular function in stable anginaClass I(1) Resting echocardiography in patients with prior MI,symptoms or signs of heart failure, or resting ECGabnormalities (level of evidence B)(2) Resting echocardiography in patients with hypertension(level of evidence B)(3) Resting echocardiography in patients with diabetes(level of evidence C)Class IIa(1) Resting echocardiography in patients with a normalresting ECG without prior MI who are not otherwise tobe considered for coronary arteriography (level ofevidence C)