Chronic stable angina test selection guideline for the individual basis
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Cafer Zorkun, M.D., Ph.D. [2]; Associate Editor-in-Chief: Smita Kohli, M.D.
Test selection guideline for the individual basis
The exercise electrocardiography is the test of choice in patient with typical exertional angina with a normal resting ECG who is able to exercise. Even when the exercise ECG is not necessary to establish the diagnosis of CAD, it is very helpful in assessing its severity. If evidence for ischemia (by electrocardiography or by perfusion scintigraphy or echocardiography) is detected during the first stage of exercise, the likelihood of the presence of three-vessel disease or left main coronary artery stenosis is greater than if more exercise is required to provoke a positive test.
Exercise electrocardiography in patients with suspected or established stable angina pectoris is also useful to decide about nonpharmacologic and pharmacologic therapeutic interventions.
In patients with stable angina pectoris, mixed angina, walk through angina, postprandial angina or patients without prior myocardial infarction, the exercise ECG is usually adequate to assess the presence and severity of myocardial ischemia.
The diagnosis of metabolic syndrome is established by the presence of typical anginal discomfort that is accompanied by ischemic changes on exercise ECG (or exercise or stress scintigraphy) with subsequent demonstration of the absence of critical coronary artery obstruction on coronary arteriography.
In women with typical angina, exercise ECG is also usually adequate. However, because of the higher incidence of false positive test results in stress ECG in women, exercise perfusion scintigraphy or echocardiography is a reasonable alternative and should also be considered.
Exercise perfusion scintigraphy should be considered as the test of choice when stress ECGs are uninterpretable, as in patients with (BBB) bundle branch block, interventricular conduction defects, left ventricular hypertrophy with baseline ST segment or T-wave abnormalities, pre excitation syndromes or ST segment changes owing to electrolyte imbalance or digitalis therapy. Stress perfusion scintigraphy is a more accurate method than the stress electrocardiography to determine the extent and distribution of ischemia.
In group of patients who are unable to exercise, adenosine or dipyridamole perfusion scintigraphy and dobutamine echocardiography are the preferred noninvasive tests to assess the presence and extent of myocardial ischemia. These are often recommended in patients with a blunted heart rate response because of antianginal therapy.
In patients with moderate or severe obstructive pulmonary airway diseases and poor exercise tolerance, dobutamine echocardiography is preferable diagnostic test to dipyridamole or adenosine scintigraphy.
Not all noninvasive or invasive tests that are available for the diagnosis of CAD and myocardial ischemia are applicable to all clinical subsets of patients with stable angina.
For patients with stable exertional angina, mixed angina, postprandial angina, walk-through angina, and nocturnal angina within 1 to 2 hours after the rest, it is desirable to select tests that are likely to induce myocardial ischemia by increasing myocardial oxygen requirements. In these patients, exercise ECG, exercise or stress perfusion scintigrahpy and echocardiography are designed to provoke ischemia.
In patients with stable angina pectoris, particularly those with documented prior myocardial infarction, assessment of left ventricular systolic function is necessary to select the appropriate therapy. In this group of patients, assessment for myocardial ischemia and ventricular function can be performed by the combination of a test for ischemia; exercise ECG and a LV function test (i.e., echocardiography at rest), or echocardiography both at rest and exercise.
See Also
Sources
- TheACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina [1]
- The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina [2]
- The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina[3]
References
- ↑ Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, Ferguson TB Jr, Fihn SD, Fraker TD Jr, Gardin JM, O'Rourke RA, Pasternak RC, Williams SV, Gibbons RJ, Alpert JS, Antman EM, Hiratzka LF, Fuster V, Faxon DP, Gregoratos G, Jacobs AK, Smith SC Jr; American College of Cardiology; American Heart Association Task Force on Practice Guidelines. Committee on the Management of Patients With Chronic Stable Angina. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina). Circulation. 2003 Jan 7; 107 (1): 149-58. PMID 12515758
- ↑ Gibbons RJ, Chatterjee K, Daley J, et al. ACC/AHA/ACP–ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Chronic Stable Angina). Circulation. 1999; 99: 2829–2848. PMID 10351980
- ↑ Fraker TD Jr, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, Ferguson TB Jr, Gardin JM, O'Rourke RA, Williams SV, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Buller CE, Creager MA, Ettinger SM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Page RL, Riegel B, Tarkington LG, Yancy CW; American College of Cardiology; American Heart Association; American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group. 2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina. Circulation. 2007 Dec 4; 116 (23): 2762-72. Epub 2007 Nov 12. PMID 17998462