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

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42 ESC <strong>Guidelines</strong>Table 8Summary of recommendations for revascularization in stable anginaIndication For prognosis a For symptoms b StudiesClass ofrecommendationLevel ofevidenceClass ofrecommendationLevel ofevidencePCI (assuming suitable anatomy for PCI, appropriate risk stratification, and discussion with the patient)Angina CCS classes I–IV despite medical therapyI A ACME and MASSwith one-vessel diseaseAngina CCS classes I–IV despite medical therapyI A RITA 2 and VA-ACMEwith multi-vessel disease (non-diabetic)Stable angina with minimal (CCS class I) symptoms IIb C ACIPon medication and one-, two-, or three-vesseldisease but objective evidence of large ischaemiaCABG (assuming suitable anatomy for surgery, appropriate risk stratification, and discussion with the patient)Angina and LM stem disease I A I A CASS, EuropeanCoronary Surgerystudy, VA Study,and Yusefmeta-analysisAngina and three-vessel disease with objective I A I Alarge ischaemiaAngina and three-vessel disease with poorI A I Aventricular functionAngina with two- or three-vessel disease including I A I Asevere disease of the proximal LADAngina CCS classes I–IV with multi-vesseldisease (diabetic)IIa B I B BARI, GABI, ERACI-I,SoS, ARTs,Yusef et al.,Hoffman et al.Angina CCS classes I–IV with multi-vesselIAdisease (non-diabetic)Angina CCS classes I–IV despite medical therapyI B MASSand one-vessel disease including severedisease of the proximal LADAngina CCS classes I–IV despite medical therapyIIbBand one-vessel disease not including severedisease of the proximal LADAngina with minimal (CCS class I) symptoms onmedication and one-, two-, or three-vesseldisease but objective evidence of large ischaemiaIIb C ACIPRecommendations for revascularization on symptomatic grounds take into account the range of symptomatic grades for which evidence is available andshould be construed in this fashion rather than as a directive to perform revascularization across the entire range of symtomatology.CCS, Canadian Cardiovascular Society.a Relates to effects on mortality, cardiac or cardiovascular mortality, or mortality combined with MI.b Relates to changes in angina class, exercise duration, time to angina on treadmill testing, repeat hospitalization for angina, or other parameters offunctional capacity or quality of life.(4) completeness of revascularization. If considering PCIfor multi-vessel disease, is there a high probabilitythat PCI will provide complete revascularization or atleast in the same range as CABG?(5) diabetic status(6) local hospital experience in cardiac surgery and interventionalcardiology(7) patient’s preferenceContraindications to myocardial revascularization comprisethe following.(1) Patients with one- or two-vessel CAD without significantproximal LAD stenosis who have mild or no symptomsand have not received an adequate trial of medicaltherapy or have no demonstrable ischaemia or only alimited area of ischaemia/viability on non-invasivetesting(2) Borderline (50–70%) coronary stenosis in location otherthan LM and no demonstrable ischaemia on noninvasivetesting(3) Non-significant (,50%) coronary stenosis(4) High risk of procedure-related morbidity or mortality(.10–15% mortality risk) unless the risk of the procedureis balanced by an expected significant improvementin survival or the patient’s quality of life withoutthe procedure is extremely poorConstant rapid developments in PCI and CABG, as well assignificant progress in medical treatment and secondary preventionof stable angina, have generated the need for largerandomizd trials comparing different treatment strategies in
ESC <strong>Guidelines</strong> 43selected groups of patients. Many questions in the managementof stable angina remain incompletely answered, andfurther questions are generated by the development ofnew treatment modalities, necessitating the constant revisionand updating of these guidelines and a need for practisingclinicians to remain abreast of current literature in thearea in the interim.Recommendations for revascularization to improveprognosis in patients with stable anginaClass I(1) CABG for significant LM CAD or its equivalent (i.e.severe stenosis of ostial/proximal segment of left descendingand circumflex coronary arteries) (level of evidenceA)(2) CABG for significant proximal stenosis of three majorvessels, particularly in those patients with abnormalLV function or with early or extensive reversible ischaemiaon functional testing (level of evidence A)(3) CABG for one- or two-vessel disease with high-gradestenosis of proximal LAD with reversible ischaemia onnon-invasive testing (level of evidence A)(4) CABG for significant disease with impaired LV functionand viability demonstrated by non-invasive testing(level of evidence B)Class IIa(1) CABG for one- or two-vessel CAD without significantproximal LAD stenosis in patients who have survivedsudden cardiac death or sustained ventricular tachycardia(level of evidence B)(2) CABG for significant three-vessel disease in diabeticswith reversible ischaemia on functional testing (levelof evidence C)(3) PCI or CABG for patients with reversible ischaemia onfunctional testing and evidence of frequent episodesof ischaemia during daily activities (level of evidence C)Recommendations for revascularization to improvesymptoms in patients with stable anginaClass I(1) CABG for multi-vessel disease technically suitable forsurgical revascularization in patients with moderateto-severesymptoms not controlled by medicaltherapy, in whom risks of surgery do not outweighpotential benefits (level of evidence A)(2) PCI for one-vessel disease technically suitable forpercutaneous revascularization in patients withmoderate-to-severe symptoms not controlled bymedical therapy, in whom procedural risks do not outweighpotential benefits (level of evidence A)(3) PCI for multi-vessel disease without high-risk coronaryanatomy, technically suitable for percutaneous revascularizationin patients with moderate-to-severe symptomsnot controlled by medical therapy, in whomprocedural risks do not outweigh potential benefits(level of evidence A)Class IIa(1) PCI for one-vessel disease technically suitable forpercutaneous revascularization in patients with mildto-moderatesymptoms which are nonethelessunacceptable to the patient, in whom proceduralrisks do not outweigh potential benefits (level of evidenceA)(2) CABG for one-vessel disease technically suitable forsurgical revascularization in patients with moderateto-severesymptoms not controlled by medicaltherapy, in whom operative risk does not outweighpotential benefit (level of evidence A)(3) CABG for multi-vessel disease technically suitable forsurgical revascularization in patients with mildto-moderatesymptoms which are nonetheless unacceptableto the patient, in whom operative risk does notoutweigh potential benefit (level of evidence A)(4) PCI for multi-vessel disease technically suitable forpercutaneous revascularization in patients withmild-to-moderate symptoms which are nonethelessunacceptable to the patient, in whom procedural risksdo not outweigh potential benefits (level of evidence A)Class IIb(1) CABG for one-vessel disease technically suitable forsurgical revascularization in patients with mild-tomoderatesymptoms which are nonetheless unacceptableto the patient, in whom operative risk is notgreater than the estimated annual mortality (level ofevidence B)Treatment of stable angina: multi-targeted treatment of amulti-faceted diseaseIn his/her lifetime, the patient with stable angina may meetepisodes of exercise/stress-induced symptomatic myocardialischaemia (angina pectoris), silent ischaemia, progressiveangina, acute coronary syndromes (unstable angina and MI),acute and chronic heart failure, and life-threatening arrhythmias.Prolonged periods of stability may alternate withperiods of instability (sudden progression and acute coronarysyndromes). According to the state of the disease, a patientwill require treatment aimed at retardation of the progressionof disease (prevention), management of symptomatic disease(angina pectoris), management of acute coronary syndromes,and management of heart failure or life-threatening arrhythmias.The physician should be prepared to offer the appropriatetherapy at the appropriate time. The different modes ofpreventive therapy, symptomatic medical therapy, such aspercutaneous and surgical coronary revascularization andmanagement of arrhythmias, are all rapidly evolving and soit is recommended that an individual physician operateswithin a team which can offer the appropriate therapy atthe appropriate time with the appropriate skills.Special subgroupsWomenThe evaluation of chest pain in women is less straightforwardthan in men at multiple levels, because of genderdifferences in presentation and disease manifestation 619and also the preponderance of male-specific data in thepublished literature.There are numerous differences in the epidemiology andprimary manifestation of CHD in women and men. Stableangina is the most frequent initial manifestation of CHD inwomen, but MI or sudden death the most frequent initialmanifestation in men. 40,41,620 Although the incidence of
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Guidelines on the Management of Stable Angina Pectoris ... - Cardio

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