Chronic stable angina exercise electrocardiography: Difference between revisions

Jump to navigation Jump to search
(/* ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina (DO NOT EDIT){{cite journal| author=Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al.| title=ACC/AHA/ACP-ASIM guidelines for the mana...)
No edit summary
Line 131: Line 131:
{{WikiDoc Help Menu}}
{{WikiDoc Help Menu}}
{{WikiDoc Sources}}
{{WikiDoc Sources}}
[[Category:Disease]]
[[Category:Ischemic heart diseases]]
[[Category:Cardiology]]
[[Category:Emergency medicine]]
[[Category:Intensive care medicine]]
[[Category:Up-To-Date]]
[[Category:Up-To-Date cardiology]]

Revision as of 15:24, 18 January 2013

Chronic stable angina Microchapters

Acute Coronary Syndrome Main Page

Home

Patient Information

Overview

Historical Perspective

Classification

Classic
Chronic Stable Angina
Atypical
Walk through Angina
Mixed Angina
Nocturnal Angina
Postprandial Angina
Cardiac Syndrome X
Vasospastic Angina

Differentiating Chronic Stable Angina from Acute Coronary Syndromes

Pathophysiology

Epidemiology and Demographics

Risk Stratification

Pretest Probability of CAD in a Patient with Angina

Prognosis

Diagnosis

History and Symptoms

Physical Examination

Test Selection Guideline for the Individual Basis

Laboratory Findings

Electrocardiogram

Exercise ECG

Chest X Ray

Myocardial Perfusion Scintigraphy with Pharmacologic Stress

Myocardial Perfusion Scintigraphy with Thallium

Echocardiography

Exercise Echocardiography

Computed coronary tomography angiography(CCTA)

Positron Emission Tomography

Ambulatory ST Segment Monitoring

Electron Beam Tomography

Cardiac Magnetic Resonance Imaging

Coronary Angiography

Treatment

Medical Therapy

Revascularization

PCI
CABG
Hybrid Coronary Revascularization

Alternative Therapies for Refractory Angina

Transmyocardial Revascularization (TMR)
Spinal Cord Stimulation (SCS)
Enhanced External Counter Pulsation (EECP)
ACC/AHA Guidelines for Alternative Therapies in patients with Refractory Angina

Discharge Care

Patient Follow-Up
Rehabilitation

Secondary Prevention

Guidelines for Asymptomatic Patients

Noninvasive Testing in Asymptomatic Patients
Risk Stratification by Coronary Angiography
Pharmacotherapy to Prevent MI and Death in Asymptomatic Patients

Landmark Trials

Case Studies

Case #1

Chronic stable angina exercise electrocardiography On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Chronic stable angina exercise electrocardiography

CDC onChronic stable angina exercise electrocardiography

Chronic stable angina exercise electrocardiography in the news

Blogs on Chronic stable angina exercise electrocardiography

to Hospitals Treating Chronic stable angina exercise electrocardiography

Risk calculators and risk factors for Chronic stable angina exercise electrocardiography

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [3] Phone:617-632-7753; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [4]; Smita Kohli, M.D.; Lakshmi Gopalakrishnan, M.B.B.S.

Overview

In patients with chronic stable angina, exercise ECG is more sensitive and specific to identify inducible ischemia and to diagnose coronary artery disease.[1] ECG abnormalities associated with MI include: down sloping of ST-segment depression or elevation, accompanying angina that occurs at a low workload during early stages of exercise and persistent for more than 3-minutes after exercise. The reliability of diagnosis is shown to improve with the evaluation of ST changes in relation to heart rate.[2] Bruce protocol or treadmill (expressed in terms of METs) or bicycle ergometer (expressed in terms of watts) are used to detect MI. Exercise ECG test must be terminated on the achievement of maximal predicted heart rate and/or if the patient becomes symptomatic or develops pain with significant ST-segment changes. Exercise ECG test also provides prognostic stratification to evaluate the response to medical therapy or revascularization.[3]

Indications

An exercise ECG is more useful than the resting ECG in detecting myocardial ischemia and evaluating the cause of chest pain.

Diagnostic criteria

ST-segment changes suggestive of coronary artery disease include:

  • Down sloping or horizontal ST segment depressions are highly suggestive of myocardial ischemia, particularly when:
  • It occurs at a low workload,
  • It occurs during early stages of exercise,
  • It persists for more than 3 minutes after exercise, or
  • It is accompanied by chest discomfort that is compatible with angina.

Sensitivity and Specificity

  • Exercise electrocardiography has a sensitivity of approximately 70% for detecting coronary artery disease.
  • Exercise electrocardiography has a specificity of approximately 75% for excluding coronary artery disease.
  • To assess the probability of coronary artery disease in an individual patient, the exercise ECG result must be integrated with the clinical presentation.
  • Conditions that increase the probability of exercise ECG yielding false positive results are:
  • On the other hand, a fall in systolic pressure of 10 mmHg or more during exercise or the appearance of a murmur of mitral regurgitation during exercise increases the probability that, an abnormal stress ECG is a true positive test result.

Treadmill exercise test

  • Variables of the Treadmill Exercise Test which indicate the high risk are:
  • Short exercise duration less than 5 METs,
  • Significant ST segment depression (magnitude ≥2 mm, starts at exercise stage I or II, duration of exercise test is <5 minutes and ≥5 leads with ST changes,
  • Significant changes in blood pressure: low peak systolic blood pressure (<130 mm Hg), significant decrease in systolic blood pressure during the test (below the resting standing blood pressure),
  • Inability to attain to the target heart rate,
  • Presence of exercise induced angina,
  • Presence of frequent ventricular ectopy (e.g. couplets or tachycardia) at low workload.


ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina (DO NOT EDIT)[4]

Diagnosis of Obstructive CAD With Exercise ECG Testing Without an Imaging Modality (DO NOT EDIT)[4]

Class I
"1. Patients with an intermediate pretest probability of CAD based on age, gender, and symptoms, including those with complete right bundle-branch block or less than 1 mm of rest ST depression (exceptions are listed below in classes II and III). (Level of Evidence: B)"
Class III
"1. Patients with the following baseline ECG abnormalities:
a. Preexcitation (Wolff-Parkinson-White syndrome). (Level of Evidence: B)
b. Electronically paced ventricular rhythm. (Level of Evidence: B)
c. More than 1 mm of rest ST depression. (Level of Evidence: B)
d. Complete left bundle-branch block. (Level of Evidence: B)"
"2. Patients with an established diagnosis of CAD due to prior MI or coronary angiography; however, testing can assess functional capacity and prognosis. (Level of Evidence: B)"'
Class IIa
"1. Patients with suspected vasospastic angina. (Level of Evidence: C)"
Class IIb
"1. Patients with a high pretest probability of CAD by age, gender, and symptoms. (Level of Evidence: B)"
"2. Patients with a low pretest probability of CAD by age, gender, and symptoms. (Level of Evidence: B)"
"3. Patients taking digoxin with ECG baseline ST segment depression less than 1 mm. (Level of Evidence: B)"
"4. Patients with ECG criteria for LV hypertrophy and less than 1 mm of baseline ST segment depression. (Level of Evidence: B)"

ESC Guidelines- Exercise ECG for Initial diagnostic assessment of angina (DO NOT EDIT) [5]

Class I

1. Patients with symptoms of angina and intermediate pre-test probability of coronary artery disease based on age, gender, and symptoms, unless unable to exercise or displays ECG changes which make ECG non-evaluable. (Level of Evidence: B)

Class IIb

1. Patients with more than 1 mm ST-depression on resting ECG or taking digoxin. (Level of Evidence: B)

2. In patients with low pre-test probability (less than 10% probability) of coronary disease based on age, gender, and symptoms. (Level of Evidence: B)

ESC Guidelines- Exercise ECG for Routine re-assessment in patients with chronic stable angina (DO NOT EDIT)[5]

Class IIb

1. Routine periodic exercise ECG in the absence of clinical change. (Level of Evidence: C)

Related Chapter

Vote on and Suggest Revisions to the Current Guidelines

Guideline Resources

  • The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina [4]
  • Guidelines on the management of stable angina pectoris: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology [5]
  • TheACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina [6]
  • The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina [7]

References

  1. Ashley EA, Myers J, Froelicher V (2000) Exercise testing in clinical medicine. Lancet 356 (9241):1592-7. DOI:10.1016/S0140-6736(00)03138-X PMID: 11075788
  2. Elamin MS, Boyle R, Kardash MM, Smith DR, Stoker JB, Whitaker W et al. (1982) Accurate detection of coronary heart disease by new exercise test. Br Heart J 48 (4):311-20. PMID: 6127094
  3. Mark DB, Shaw L, Harrell FE, Hlatky MA, Lee KL, Bengtson JR et al. (1991) Prognostic value of a treadmill exercise score in outpatients with suspected coronary artery disease. N Engl J Med 325 (12):849-53. DOI:10.1056/NEJM199109193251204 PMID: 1875969
  4. 4.0 4.1 4.2 Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM; et al. (1999). "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. 99 (21): 2829–48. PMID 10351980.
  5. 5.0 5.1 5.2 Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F; et al. (2006). "Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology". Eur Heart J. 27 (11): 1341–81. doi:10.1093/eurheartj/ehl001. PMID 16735367.
  6. Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS et al. (2003) 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 107 (1):149-58.[1] PMID: 12515758
  7. Fraker TD, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J et al. (2007)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 116 (23):2762-72.[2] PMID: 17998462

Template:WikiDoc Sources