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

22 ESC <strong>Guidelines</strong>Risk stratification using coronary arteriographyDespite the recognized limitations of coronary arteriographyto identify vulnerable plaques which are likely to lead toacute coronary events, the extent, severity of luminalobstruction, and location of coronary disease on coronaryarteriography have been convincingly demonstrated to beimportant prognostic indicators in patients withangina. 67,124,287,288Several prognostic indices have been used to relatedisease severity to the risk of subsequent cardiac events;the simplest and most widely used is the classification ofdisease into one vessel, two vessel, three vessel, or LMCAD. In the CASS registry of medically treated patients,the 12-year survival rate of patients with normal coronaryarteries was 91% compared with 74% for those with onevesseldisease, 59% for those with two vessel disease and50% for those with three vessel disease (P , 0.001). 280Patients with severe stenosis of the LM coronary arteryhave a poor prognosis when treated medically. The presenceof severe proximal left anterior descending artery (LAD)disease also significantly reduces the survival rate. The5-year survival rate with three-vessel disease plus greaterthan 95% proximal LAD stenosis was reported to be 54% comparedwith a rate of 79% with three-vessel disease withoutLAD stenosis. 288 However, it should be appreciated that inthese ‘older’ studies preventive therapy was not at thelevel of current recommendations regarding both lifestyleand drug therapy. Accordingly, absolute estimates of riskderived from these studies, in general, over-estimate therisk of future events.Recent angiographic studies indicate that a direct correlationexists between the angiographic severity of coronarydisease and the amount of angiographically insignificantplaques in the coronary tree. 289 The higher mortality ratesin patients with multivessel disease may be a consequenceof a higher number of mildly stenotic and non-stenoticplaques that are potential sites for acute coronary eventsthan those with one-vessel disease.The major focus in non-invasive risk stratification is onsubsequent patient mortality, with the rationale to identifypatients in whom coronary arteriography and subsequentrevascularization might decrease mortality, that is thosewith three-vessel disease, LM CAD, and proximal anteriordescending CAD. 69,290When appropriately used, non-invasive tests have anacceptable predictive value for adverse events; this ismost true when the pre-test probability of severe CAD islow. When the estimated annual cardiovascular mortalityrate is less than or equal to 1%, the use of coronary arteriographyto identify patients whose prognosis can be improvedis likely to be inappropriate; in contrast it is appropriate forpatients whose cardiovascular mortality risk is greater than2% per annum. Decisions regarding the need to proceed toarteriography in the intermediate risk group, those with anannual cardiovascular mortality of 1–2% should be guidedby a variety of factors including the patient’s symptoms,functional status, lifestyle, occupation, comorbidity, andresponse to initial therapy.With increasing public and media interest in availablemedical technology, widespread access to the internet andother sources of information, patients will often have considerableinformation regarding investigation and treatmentoptions for their condition. It is the duty of the physician toensure that the patient is fully informed of their risk andthe potential benefits or lack of benefit of any particularprocedure, and to guide their decision appropriately.Some patients may still consider medical treatmentrather than intervention, or an element of doubt regardingdiagnosis, to be unacceptable regardless of the evidencepresented to them. Coronary arteriography should not beperformed in patients with angina who refuse invasive procedures,prefer to avoid revascularization, who are notcandidates for PCI or CABG, or in whom it will not improvequality of life.Recommendations for risk stratification by coronaryarteriography in patients with stable anginaClass I(1) Patients determined to be at high risk for adverseoutcome on the basis of non-invasive testing even ifthey present with mild or moderate symptoms ofangina (level of evidence B)(2) Severe stable angina (Class 3 of CanadianCardiovascular Society Classification (CCS), particularlyif the symptoms are inadequately responding tomedical treatment (level of evidence B)(3) Stable angina in patients who are being considered formajor non-cardiac surgery, especially vascular surgery(repair of aortic aneurysm, femoral bypass, carotidendarterectomy) with intermediate or high risk featureson non-invasive testing (level of evidence B)Class IIa(1) Patients with an inconclusive diagnosis on non-invasivetesting, or conflicting results from different noninvasivemodalities (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)Special diagnostic considerations: anginawith ‘normal’ coronary arteriesThe clinicopathological correlation of symptoms with coronaryanatomy varies widely in angina from typical symptomsof angina due to significant coronary lesions causing transientischaemia when myocardial demand is increased, toclearly non-cardiac chest pain with normal coronary arteriesFigure 6 Schematic representation of clinico-pathological variants inangina.