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

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6 ESC <strong>Guidelines</strong>improvement in outcome with more aggressive investigationand treatment. On the other hand, it is also important toselect those patients with a less severe form of disease,with a good outcome, thereby avoiding unnecessary invasiveand non-invasive tests and procedures.Conventional risk factors for the development ofCAD, 26,53–55,56 hypertension, hypercholesterolaemia 56–59diabetes, 60–65 and smoking 26 have an adverse influence onprognosis in those with established disease, presumablythrough their effect on disease progression. However, appropriatetreatment can reduce or abolish these risks. Otherfactors predictive of long-term prognosis of patients withstable angina have been determined from the follow-up ofthe large control groups of randomized trials aimed at evaluatingthe effectiveness of revascularization 66,67 and otherobservational data. In general, the outcome is worse inpatients with reduced LV function, a greater number ofdiseased vessels, more proximal locations of coronarystenosis, greater severity of lesions, more severe angina,more extensive ischaemia, and greater age.LV function is the strongest predictor of survival inpatients with chronic stable coronary disease; the nextmost important factor is the distribution and severity ofcoronary stenosis. Left main (LM) disease, three-vesseldisease, and the proximal involvement of the left anteriordescending are common characteristics predicting a pooroutcome and increase the risk of ischaemic events. 68Myocardial revascularization can reduce the risk of deathin selected anatomical subgroups, 69 reduce the number ofischaemic episodes (ACIP), 70 and in some instances mayimprove the LV function in high-risk patients. 71,72 However,disease progression and the occurrence of acute eventsmay not necessarily be related to the severity of stenosisat coronary arteriography. In all patients, smaller lipidfilled plaques are present in addition to those that causesevere stenoses. As discussed earlier, these ‘vulnerableplaques’ have a greater likelihood to rupture. 14 Thus,the risk of acute events is related to the overall plaqueburden and to plaque vulnerability. Although an areaof great research interest, our capabilities to identifyvulnerable plaque remain limited.Diagnosis and assessmentDiagnosis and assessment of angina involves clinical assessment,laboratory tests, and specific cardiac investigations.Clinical assessment related to diagnosis and basic laboratoryinvestigations are dealt with in this section. Cardiac specificinvestigations may be non-invasive or invasive and may beused to confirm the diagnosis of ischaemia in patients withsuspected stable angina, to identify or exclude associatedconditions or precipitating factors, for risk stratification,and to evaluate the efficacy of treatment. Some should beused routinely in all patients; others provide redundantinformation except in particular circumstances; someshould be easily available to cardiologists and generalphysicians, yet others may be considered as tools forresearch. In practice, diagnostic and prognostic assessmentsare conducted in tandem rather than separately, and manyof the investigations used for diagnosis also offer prognosticinformation. For the purposes of description and presentationof the evidence, the individual investigative techniquesare discussed subsequently with recommendationsfor diagnosis. Specific cardiac investigations routinely usedfor risk stratification purposes are discussed separately inthe following section.Symptoms and signsA careful history remains the cornerstone of the diagnosis ofangina pectoris. In the majority of cases, it is possible tomake a confident diagnosis on the basis of the historyalone, although physical examination and objective testsare necessary to confirm the diagnosis and assess theseverity of underlying disease.The characteristics of discomfort related to myocardialischaemia (angina pectoris) have been extensively describedand may be divided into four categories, location, character,duration, and relation to exertion and other exacerbating orrelieving factors. The discomfort caused by myocardialischaemia is usually located in the chest, near thesternum, but may be felt anywhere from the epigastriumto the lower jaw or teeth, between the shoulder blades orin either arm to the wrist and fingers. The discomfort isusually described as pressure, tightness, or heaviness, sometimesstrangling, constricting, or burning. The severity ofthe discomfort varies greatly and is not related to the severityof the underlying coronary disease. Shortness of breathmay accompany angina, and chest discomfort may be alsobe accompanied by less specific symptoms such as fatigueor faintness, nausea, burping, restlessness, or a sense ofimpending doom.The duration of the discomfort is brief, no more than 10 minin the majority of cases, and more commonly even minutesless. An important characteristic is the relation to exercise,specific activities, or emotional stress. Symptoms classicallydeteriorate with increased levels of exertion, such aswalking up an incline, or against a breeze and rapidly disappearwithin a few minutes, when these causal factors abate.Exacerbations of symptoms after a heavy meal or first thingin the morning are classical features of angina. Buccal or sublingualnitrates rapidly relieve angina, and a similar rapidresponse may be observed with chewing nifedipine capsules.Non-anginal pain lacks the characteristic qualitiesdescribed, may involve only a small portion of the left hemithorax,and last for several hours or even days. It is usuallynot relieved by nitroglycerin (although it may be in the caseof oesophageal spasm) and may be provoked by palpation.Noncardiac causes of pain should be evaluated in such cases.Definitions of typical and atypical angina have beenpreviously published, 73 summarized on Table 2. It isTable 2Clinical classification of chest painTypical angina (definite)Atypical angina (probable)Non-cardiac chest painMeets three of the followingcharacteristics† Substernal chest discomfort ofcharacteristic qualityand duration† Provoked by exertion oremotional stress† Relieved by rest and/or GTNMeets two of these characteristicsMeets one or none ofthe characteristics
ESC <strong>Guidelines</strong> 7important when taking the history to identify those patientswith unstable angina, which may be associated with plaquerupture, who are at significantly higher risk of an acutecoronary event in the short-term. Unstable angina maypresent in one of the three ways: (i) as rest angina, i.e.pain of characteristic nature and location, but occurring atrest and for prolonged periods, up to 20 min; (ii) rapidlyincreasing or crescendo angina, i.e. previously stableangina, which progressively increases in severity and intensityand at lower threshold over a short period, 4 weeks orless; or (iii) new onset angina, i.e. recent onset of severeangina, such that the patient experiences marked limitationof ordinary activity within 2 months of initial presentation.The investigation and management of suspected unstableangina is dealt with in guidelines for the management of ACS.For patients with stable angina, it is also useful to classifythe severity of symptoms using a grading system such as thatof the Canadian Cardiovascular Society Classification(Table 3). This is useful in determining the functional impairmentof the patient and quantifying response to therapy.The Canadian Cardiovascular Society Classification 74 iswidely used as a grading system for angina to quantify thethreshold at which symptoms occur in relation to physicalactivities. Alternative classification systems such as DukeSpecific Activity Index 75 and Seattle angina questionnaire 76may also be used in determining the functional impairmentof the patient and quantifying response to therapy and mayoffer superior prognostic capability. 77Physical examination of a patient with (suspected) anginapectoris is important to assess the presence of hypertension,valvular heart disease, or hypertrophic obstructive cardiomyopathy.Physical examination should include assessmentof body-mass index (BMI) and waist circumference to assistevaluation of the metabolic syndrome, 78,79 evidence ofnon-coronary vascular disease which may be asymptomatic,and other signs of comorbid conditions. However, there areno specific signs in angina pectoris. During or immediatelyafter an episode of myocardial ischaemia, a third or fourthheart sound may be heard and mitral insufficiency mayalso be apparent during ischaemia. Such signs are,however, elusive and non-specific.Table 3 Classification of angina severity according to theCanadian Cardiovascular SocietyClassClass IClass IIClass IIIClass IVLevel of symptoms‘Ordinary activity does not cause angina’Angina with strenuous or rapidor prolonged exertion only‘Slight limitation of ordinary activity’Angina on walking or climbing stairs rapidly,walking uphill or exertion after meals, incold weather, when under emotional stress,or only during the first few hours after awakening‘Marked limitation of ordinary physical activity’Angina on walking one or two blocks a on the levelor one flight of stairs at a normal pace undernormal conditions‘Inability to carry out any physical activitywithout discomfort’ or ‘angina at rest’a Equivalent to 100–200 m.Laboratory testsLaboratory investigations may be loosely grouped into thosethat provide information related to possible causes ofischaemia, those that may be used to establish cardiovascularrisk factors and associated conditions, and those thatmay be used to determine prognosis. Some laboratory investigationsare used for more than one of these purposes andmay be applied routinely in all patients, whereas otherinvestigations should be reserved for use where clinicalhistory and/or examination indicates a particular need fortheir application.Haemoglobin and, where there is clinical suspicion of athyroid disorder, thyroid hormones provide informationrelated to possible causes of ischaemia. The full bloodcount incorporating total white cell count as well as haemoglobinmay also add prognostic information. 80 If there isclinical suspicion of instability, biochemical markers of myocardialdamage such as troponin or CKMB (creatine kinasemyocardial band), measured by mass assay, should beemployed to exclude myocardial injury. If these markersare elevated, management should continue as for an ACSrather than stable angina. After initial assessment, thesetests are not recommended as routine investigationsduring each subsequent evaluation.Fasting plasma glucose 60,61,63,64,81,82,83,84 and fasting lipidprofile including total cholesterol (TC), high density lipoprotein(HDL) cholesterol, and low density lipoprotein(LDL) cholesterol, 55–58 and triglycerides 54,85 should be evaluatedin all patients with suspected ischaemic disease,including stable angina, to establish the patient’s riskprofile and ascertain the need for treatment. Lipid profileand glycaemic status should be re-assessed periodically todetermine efficacy of treatment and in non-diabeticpatients to detect new development of diabetes. There isno evidence to support recommendations for how regularlyreassessment should take place. Consensus suggests annualmeasurement. Patients with very high levels of lipids, inwhom the progress of any intervention needs to be monitored,should have measurements more frequently.Patients with diabetes should be managed accordingly.Serum creatinine is a simple but crude method to evaluaterenal function. Renal dysfunction may occur due to associatedcomorbidity 86–91 such as hypertension, diabetes orrenovascular disease and has a negative impact on prognosisin patients with CVD, 92,93 giving good grounds for measurementat initial evaluation in all patients with suspectedangina. The Cockcroft–Gault formula 94 may be used toestimate creatinine clearance based on age, sex, weight,and serum creatinine. The commonly used formula is asfollows: ((140—age (years)) (actual weight (kg)))/(72 serum creatinine (mg/dL)), with multiplication by a factorof 0.85 if female.In addition to the well-recognized association betweenadverse cardiovascular outcome and diabetes, elevationsof fasting or post-glucose challenge glycaemia have alsobeen shown to predict adverse outcome in stable coronarydisease independently of conventional risk factors. 95–101Although HbAIc predicts outcome in the general population,there is less data in those with CAD. 101,102 Obesity, and inparticular evidence of the metabolic syndrome, is predictiveof adverse cardiovascular outcome in patients with establisheddisease as well as asymptomatic populations. 78,79,103The presence of the metabolic syndrome can be determined
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