Transcript Chronic stable angina

 ACC/AHA 2002 Guideline for the Management of
Patients With Chronic Stable Angina
 2007 Chronic Angina Focused Update of the
ACC/AHA 2002 Guidelines
Definition
 Clinical syndrome characterized by discomfort in the
chest, jaw, shoulder, back or arm
 Typically aggravated by exertion or emotional stress and
relieved by nitroglycerin.
Canadian Cardiovascular Society Classification
 Class I
Ordinary physical activity does not cause angina, such as walking, climbing
stairs.
 Class II
Slight limitation of ordinary activity. Angina on walking or climbing stairs
rapidly, walking uphill, walking or stair climbing after meals
 Class III
Marked limitations of ordinary physical activity. Angina on walking one to
two blocks on the level and climbing one flight of stairs
 Class IV
Inability to carry on any physical activity without discomfort—anginal
symptoms at rest.
Purpose of diagnosis and assessment
 Confirmation of presence of ischemia in patients with
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
suspected angina
Identification associated conditions or precipitating
factors
Risk stratification
To plan treatment options
Evaluation of efficacy of treatment
Diagnosis
ACC/AHA Guidelines for Routine Clinical Testing in
Patients with Chronic Stable Angina
LEVEL OF
EVIDENCE*
CLASS
INDICATION
I (indicated)
1. Rest ECG in patients without obvious noncardiac
B
cause of chest pain
2. Rest ECG during an episode of chest pain
B
3. Chest radiograph in patients with signs or
symptoms of congestive heart failure, valvular heart
B
disease, pericardial disease, or aortic dissection or
aneurysm
4. Hemoglobin
C
5. Fasting glucose
C
6. Fasting lipid panel
C
Exercise Electrocardiography
 Most valuable for diagnosis when the patient's other
clinical data suggest an intermediate probability of
coronary disease
 Uncertain value for patients with high or low pretest
probability of coronary disease
CLASS
INDICATION FOR EXERCICE ECG FOR DIAGNOSIS
LEVEL OF
EVIDENCE
I (indicated)
Patients with intermediate pretest probability of CAD
based on age, gender, and symptoms, including those with
B
complete RBBB or <1 mm of ST-segment depression at
rest
IIa
Patients with suspected vasospastic angina
(good supportive evidence)
C
CLASS
INDICATION FOR EXERCICE ECG FOR DIAGNOSIS
III (not indicated)
1. Patients with the following baseline electrocardiographic
abnormalities:
LEVEL OF
EVIDENCE
a. Preexcitation (Wolff-Parkinson-White) syndrome
B
b. Electronically paced ventricular rhythm
B
c. >1 mm of ST-segment depression at rest
B
d. Complete left bundle branch block
B
2. Patients with an established diagnosis of CAD because of
prior MI or CAG; however, testing can assess functional
capacity and prognosis
CLASS
INDICATION FOR ECHO FOR DIAGNOSIS
I (indicated) 1. Systolic murmur suggestive of aortic stenosis or HOCM
LEVEL OF
EVIDENCE*
C
2. Evaluation of extent (severity) of ischemia -LV segmental wall
motion abnormality when obtained during pain or within 30 min C
after
III (not
indicated)
Normal ECG, no history of MI, and no signs or symptoms
suggestive of heart failure, valvular heart disease, or HOCM
C
CARDIAC STRESS IMAGING
 Exercise stress testing is preferable to pharmacologic
stress testing when the patient can exercise
 Most useful for diagnosis in patients with an intermediate
probability of disease.
 Dobutamine perfusion imaging has significant limitations
because it does not provoke as great an increase in
coronary flow
 Dobutamine is the agent of choice for pharmacologic
stress echocardiography
CLASS
INDICATION FOR CARDIAC STRESS IMAGING
FOR DIAGNOSIS
I
1. Exercise myocardial perfusion imaging or exercise echo intermediate pretest probability of CAD with baseline ECG
abnormalities
Who Are Able to Exercise
LEVEL OF
EVIDENCE
a. Preexcitation (Wolff-Parkinson-White) syndrome
B
b. >1 mm of ST-segment depression at rest
B
2. Exercise myocardial perfusion imaging or exercise echo - prior
revascularization (either PCI or CABG)
B
3. Adenosine or dipyridamole myocardial perfusion imaging intermediate pretest probability of CAD & baseline ECG abnormalities:
a. Electronically paced ventricular rhythm
C
b. Left bundle branch block
B
LEVEL OF
CLASS
INDICATION CARDIAC STRESS IMAGING
I
1. Adenosine or dipyridamole myocardial perfusion imaging or
dobutamine echocardiography in patients with intermediate
pretest probability of CAD
B
2. Adenosine or dipyridamole myocardial perfusion imaging or
dobutamine echocardiography in patients with prior
revascularization (either PCI or CABG)
B
(indicated)
Who Are Unable to Exercise EVIDENCE*
CLASS INDICATION FOR CORONARY ANGIOGRAPHY FOR DIAGNOSIS
I
(indicated
IIa
(good
supportive
evidence)
)
LEVEL OF
EVIDENCE[
†
Patients with known or possible angina who have survived sudden cardiac
arrrest
B
1. Patients with an uncertain diagnosis after noninvasive testing
C
2. Patients who cannot undergo noninvasive testing because of disability, illness C
3. Patients with an occupational requirement for a definitive diagnosis
C
CLASS INDICATION FOR CORONARY ANGIOGRAPHY FOR DIAGNOSIS
IIa
4. Young patients , with noninvasive imaging, or other clinical parameters are
suspected of having a nonatherosclerotic cause for myocardial ischemia
LEVEL OF
EVIDENCE[
†
C
5. Patients in whom coronary artery spasm is suspected and provocative testing
C
may be necessary
6. Patients with high pretest probability of left main or triple-vessel CAD
C
Specific Patient Subsets
 Treadmill electrocardiographic testing is less accurate for
diagnosis in women than in men
 Imaging technologies is also compromised by technical
issues (e.g., breast tissue) in women
 currently are insufficient data to justify replacing standard
exercise testing with stress imaging in the initial
evaluation of women.
 RISK STRATIFICATION
EXERCISE TESTING for RISK ASSESSMENT AND PROGNOSIS in Intermediate or
High Probability of CAD
CLASS
I
IIb
INDICATION
LEVEL OF
EVIDENCE
1. Patients undergoing initial evaluation (exceptions are listed below in
Classes IIb and III)
B
2. Patients after a significant change in cardiac symptoms
C
1. Patients with the following electrocardiographic abnormalities:
a. Preexcitation (Wolff-Parkinson-White) syndrome
B
b. Electronically paced ventricular rhythm
B
c. >1 mm of ST-segment depression at rest
B
d. Complete left bundle branch block
B
EXERCISE TESTING for RISK ASSESSMENT AND PROGNOSIS in Intermediate or
High Probability of CAD
CLASS
III
INDICATION
Patients with severe comorbidity likely to limit life expectancy or prevent
revascularization
LEVEL OF
EVIDENCE
C
Cardiac Stress Imaging as Initial Test for Risk Stratification of Patients with Chronic
Stable Angina Who Are Able to Exercise
CLASS INDICATION
I
LEVEL OF
EVIDENCE
1. Exercise myocardial perfusion imaging or exercise echo to identify severity,
B
and location of ischemia in patients with abnormal rest ECG or using digoxin
2. Dipyridamole or adenosine myocardial perfusion imaging in patients with
left bundle branch block or electronically paced ventricular rhythm
B
3. Exercise myocardial perfusion imaging or exercise echocardiography to
assess the functional significance of coronary lesions when planning PCI
B
Cardiac Stress Imaging as Initial Test for Risk Stratification of Patients with
Chronic Stable Angina Who Are Able to Exercise
CLASS
INDICATION
LEVEL OF
EVIDENCE
III
1. Exercise myocardial perfusion imaging in patients with left bundle branch
block
C
2. In patients with severe comorbidity likely to limit life expectation or
prevent revascularization
C
Cardiac stress imaging as initial test for risk stratification of patients with
chronic stable angina who are unable to exercise
CLASS INDICATION
I
III
LEVEL OF
EVIDENCE
1. Dipyridamole or adenosine myocardial perfusion imaging or
dobutamine echocardiography to identify severity, and location of
ischemia
B
2. Dipyridamole or adenosine myocardial perfusion imaging in patients
with left bundle branch block or electronically paced ventricular rhythm
B
3. Dipyridamole or adenosine myocardial perfusion imaging or
dobutamine echocardiography to assess the functional significance of
coronary lesions when planning PCI
B
Patients with severe comorbidity likely to limit life expectation or prevent
C
revascularization
ACC/AHA Guideline Criteria for Noninvasive Risk Stratification
 High Risk (>3% Annual Mortality Rate)
1 Severe resting left ventricular dysfunction (LVEF < 0.35)
2 High-risk treadmill score (score ≤ −11)
3 Severe exercise left ventricular dysfunction (exercise LVEF < 0.35)
4 Stress-induced large perfusion defect (particularly if anterior)
5 Stress-induced multiple perfusion defects of moderate size
6 Large, fixed perfusion defect with LV dilation or increased lung uptake
7 Stress-induced moderate perfusion defect with LV dilation or increased
lung uptake
8 RWMA (involving more than two segments) developing at low dose of
dobutamine or at low heart rate (<120 beats/min)
9 Stress echocardiographic evidence of extensive ischemia
ACC/AHA Guideline Criteria for Noninvasive Risk Stratification
 Intermediate Risk
(1%-3% annual mortality rate)
1 Mild or moderate LV dysfunction (LVEF = 0.35-0.49)
2 Intermediate-risk treadmill score (−11 < score < 5)
3 Stress-induced moderate perfusion defect without LV dilation or increased
lung intake
4 Limited stress echocardiographic ischemia with a wall motion abnormality
only at higher doses of dobutamine involving two segments or less
• Low Risk
(<1% Annual Mortality Rate)
1 Low-risk treadmill score (score ≥ 5)
2 Normal or small myocardial perfusion defect at rest or with stress*
3 Normal stress echocardiographic wall motion or no change of limited resting
wall motion abnormalities during stress
Coronary Angiography for Risk Stratification in Chronic Stable
Angina
CLASS
I
INDICATION
1. Canadian Cardiovascular Society [CCS] Classes III and IV chronic stable
angina despite medical therapy
LEVEL OF
EVIDENCE
B
2. Patients with high-risk criteria on noninvasive testing regardless of anginal
B
severity
3. Patients with angina who have survived sudden cardiac death or serious
ventricular arrhythmia
B
4. Patients with angina and symptoms and signs of CHF
C
5. Patients with clinical characteristics that indicate a high likelihood of severe
C
CAD
Coronary Angiography for Risk Stratification in Patients with Chronic Stable
Angina
IIa
III
1. Patients with significant LV dysfunction (ejection fraction > 0.45), CCS Class I or II
angina, and demonstrable ischemia but no high-risk criteria on noninvasive testing
C
2. Patients with inadequate prognostic information after noninvasive testing
C
1. Patients with CCS Class I or II angina who respond to medical therapy and who
have no evidence of ischemia on noninvasive testing
C
2. Patients who prefer to avoid revascularization
C
Pharmacotherapy for Chronic Stable Angina
CLASS
INDICATION
LEVEL OF
EVIDENCE
I
1. Aspirin in the absence of contraindications
A
2. Beta blockers as initial therapy in the absence of contraindications in patients with
A
or without prior myocardial infarction
3. ACE inhibitor in all patients with CAD who also have diabetes and/or LV systolic
dysfunction
A
4. Angiotensin receptor blockers -intolerant of ACE inhibitors
A
5. LDL-lowering therapy in patients with documented or suspected CAD and LDL-C >
A
130 mg/dL, with a target LDL < 100 mg/dL
Pharmacotherapy for Chronic Stable Angina
CLASS
INDICATION
LEVEL OF
EVIDENCE
I
5. Sublingual nitroglycerin or nitroglycerin spray for the immediate relief of angina
B
6. Calcium antagonists or long-acting nitrates as initial therapy for reduction of
symptoms when beta blockers are contraindicated
B
7. Calcium antagonists or long-acting nitrates in combination with beta blockers
when initial treatment with beta blockers is not successful
B
8. Calcium antagonists and long-acting nitrates as a substitute for beta blockers if
initial treatment with beta blockers leads to unacceptable side effects
C
9. Aldosterone blockade - post-MI patients without significant renal dysfunction or
hyperkalemia EF< 40%, with diabetes or heart failure
A
Pharmacotherapy for Chronic Stable Angina
CLASS
INDICATION
LEVEL OF
EVIDENCE
IIa
1. Clopidogrel when aspirin is absolutely contraindicated
B
2. Long-acting nondihydropyridine calcium antagonists instead of beta
blockers as initial therapy
B
3. ACE inhibitor in patients with CAD or other vascular disease
B
Treatment of Risk Factors
CLASS
INDICATION
LEVEL OF
EVIDENCE
I
1. Treatment of hypertension according to Joint National Conference VII guidelines
A
2. Smoking cessation therapy
B
3. Management of diabetes
C
4. Comprehensive cardiac rehabilitation program (including exercise)
B
5. LDL-lowering therapy in patients with documented or suspected CAD and LDL- ≥
130 mg/dL, with a target LDL < 100 mg/dL
A
6. Weight reduction in obese patients in the presence of hypertension,
hyperlipidemia, or diabetes mellitus
C
Treatment of Risk Factors
CLASS
INDICATION
LEVEL OF
EVIDENCE
IIa
1. In patients with documented or suspected CAD and LDL-C = 100129 mg/dL, several therapeutic options are available:
B
a. Lifestyle and/or drug therapies to lower LDL-C to <100 mg/dL;
further reduction to below 70 mg/dL is reasonable
B
b. Weight reduction and increased physical activity in persons with
the metabolic syndrome
B
c. Use of nicotinic acid or fibric acid for elevated triglyceride or low
HDL cholesterol levels
B
Specific Goals for Risk Reduction in Chronic Stable Angina
RISK FACTOR OR
STRATEGY
GOAL
Smoking
Complete cessation
Blood pressure
140/90 mm Hg
Lipid management
Primary goal: LDL < 100 mg/dL; further reduction of LDL-C to
<70 mg/dL is reasonable (Class IIa)
Secondary goal: If triglycerides ≥ 200 mg/dL, then non–HDL-C should
be <130 mg/dL TG≥ 500 – fibrate +niacin – before LDL lowering
Physical activity
Minimum goal: 30 min daily
Weight management
BMI: 18.5-24.9 kg/m2
Diabetes management
HbA1c < 7%
Specific Goals for Risk Reduction Strategies in Chronic Stable
Angina
Antiplatelet
agents,
anticoagulants
All patients—indefinite use of aspirin 75-162mg/day
Consider clopidogrel as an alternative
Warfarin -in patients after MI when clinically indicated or for those not able to take
aspirin or clopidogrel INR = 2.0-3.0
ACE inhibitors
Start and continue indefinitely
-LVEF ≤ 40% and in those with hypertension, diabetes, or chronic kidney disease -- unless contraindicated.
Beta blockers
Start in all postmyocardial infarction and acute patients (arrhythmia, inducible
ischemia). Continue for 6 mo minimum. Observe usual contraindications. Use as
needed to manage angina, rhythm, or blood pressure in all patients
Revascularization with Percutaneous Coronary Intervention and Coronary
Artery Bypass Grafting in Stable Angina
CLASS
INDICATION
LEVEL OF
EVIDENCE
I
1. CABG for patients with significant left main coronary disease
A
2. CABG for patients with triple-vessel disease. The survival benefit is greater in
patients with abnormal LV function (LVEF < 0.50).
A
3. CABG for patients with double-vessel disease with significant proximal LAD
CAD and either abnormal LV function (ejection fraction <50%) or demonstrable
ischemia on noninvasive testing
A
4. PCI for patients with double- or triple-vessel disease with significant proximal
LAD CAD, who have anatomy suitable for catheter-based therapy and normal LV
function and who do not have treated diabetes
B
Revascularization with PCI or CABG in Stable Angina
CLASS
I
INDICATION
LEVEL OF
EVIDENCE
5. PCI or CABG for patients with single- or double-vessel CAD without
significant proximal LAD CAD but with a large area of viable myocardium B
and high-risk criteria on noninvasive testing
6. CABG for patients with single- or double-vessel CAD without
significant proximal LAD CAD who survived sudden cardiac death or
sustained VT
C
7. In patients with prior PCI-- CABG, or PCI for recurrent stenosis
associated with a large area of viable myocardium or high-risk criteria on C
noninvasive testing
8. PCI or CABG for patients who have not been successfully treated by
medical therapy and can undergo revascularization with acceptable risk
B
Revascularization with PCI or CABG in Stable Angina
CLASS
INDICATION
LEVEL OF
EVIDENCE
1. Repeat CABG for patients with multiple saphenous vein graft stenoses, especially
with significant stenosis of a graft supplying the LAD;
IIa
C
PCI for focal saphenous vein graft lesions or multiple stenoses in poor candidates for
reoperative surgery.
2. PCI or CABG for patients with single- or double-vessel CAD without significant
proximal LAD disease but with a moderate area of viable myocardium and
demonstrable ischemia on noninvasive testing
B
3. Use of PCI or CABG for patients with single-vessel disease with significant
proximal LAD disease
B
Patient Follow-up
LEVEL OF
EVIDENCE
CLASS
INDICATION
I
1. LVEF and RWMA by echocardiography or radionuclide imaging with new
C
or worsening CHF or evidence of intervening MI
2 Echocardiography for new or worsening valvular heart disease
C
3 Treadmill exercise test for patients without prior revascularization who
have a significant change in clinical status, are able to exercise
C
Patient Follow-up
5. Stress radionuclide imaging or stress echocardiography for pts with
I
significant change in clinical status and are unable to exercise or have one of the C
following electrocardiographic abnormalities:
a. Preexcitation (Wolff-Parkinson-White) syndrome
b. Electronically paced ventricular rhythm
c. >1 mm of ST-segment depression at rest
d. Complete left bundle branch block
Patient Follow-up
I
6. Stress radionuclide imaging or stress echocardiography procedures for patients
who have a significant change in clinical status and required a stress imaging
C
procedure on their initial evaluation
7. Stress radionuclide imaging or stress echocardiography procedures for patients
C
with prior revascularization who have a significant change in clinical status
8. Coronary angiography in patients with marked limitation of ordinary activity
(CCS Class III) despite maximal medical therapy
C