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(/* ACC / AHA Guidelines- Echocardiography, Treadmill Exercise Testing, Stress Imaging Studies, and Coronary Angiography During Patient Follow-Up (DO NOT EDIT)Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999)guidelines...)
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==ACC / AHA Guidelines- Echocardiography, Treadmill Exercise Testing, Stress Imaging Studies, and Coronary Angiography During Patient Follow-Up (DO NOT EDIT)<ref name="pmid10351980">Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10351980ACC/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: [http://pubmed.gov/10351980 10351980]</ref><ref name="pmid12515758">Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12515758 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. PMID: [http://pubmed.gov/12515758 12515758]</ref>==
==ACC / AHA Guidelines- Echocardiography, Treadmill Exercise Testing, Stress Imaging Studies, and Coronary Angiography During Patient Follow-Up (DO NOT EDIT)<ref name="pmid10351980">Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10351980ACC/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: [http://pubmed.gov/10351980 10351980]</ref><ref name="pmid12515758">Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12515758 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. PMID: [http://pubmed.gov/12515758 12515758]</ref>==
{{cquote|
===Class I===
'''1.''' [[Chest x-ray]] for patients with evidence of new or worsening [[congestive heart failure]]. ''(Level of Evidence: C)''


'''2.''' Assessment of [[LV ejection fraction]] and segmental wall motion in patients with new or worsening [[congestive heart failure]] or evidence of intervening [[MI]] by history or [[ECG]]. ''(Level of Evidence: C)''
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' [[Chest x-ray]] for patients with evidence of new or worsening [[congestive heart failure]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Assessment of [[LV ejection fraction]] and segmental wall motion in patients with new or worsening [[congestive heart failure]] or evidence of intervening [[MI]] by history or [[ECG]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' [[Echocardiography]] for evidence of new or worsening [[valvular heart disease]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' [[Treadmill exercise test]] for patients without prior [[revascularization]] who have a significant change in clinical status, are able to exercise, and do not have any of the [[ECG]] abnormalities listed below in number 5. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''5.''' Stress imaging procedures for patients without prior [[revascularization]] who have a significant change in clinical status and are unable to exercise or have 1 of the following [[ECG]] abnormalities: <nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''a.''' Preexcitation ([[Wolff-Parkinson-White syndrome|Wolff-Parkinson-White]]) syndrome. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''b.''' Electronically paced ventricular rhythm. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''c.''' More than 1 mm of rest ST depression. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''d.'''Complete [[left bundle-branch block]].  ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Stress imaging procedures for patients who have a significant change in clinical status and required a stress imaging procedure on their initial evaluation because of equivocal or intermediate-risk treadmill results. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.'''  Stress imaging procedures for patients with prior [[revascularization]] who have a significant change in clinical status. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''  <nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' [[Coronary angiography]] in patients with marked limitation of ordinary activity (CCS class III) despite maximal medical therapy. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|}


'''3.''' [[Echocardiography]] for evidence of new or worsening [[valvular heart disease]]. ''(Level of Evidence: C)''


'''4.''' [[Treadmill exercise test]] for patients without prior [[revascularization]] who have a significant change in clinical status, are able to exercise, and do not have any of the [[ECG]] abnormalities listed below in number 5. ''(Level of Evidence: C)''


'''5.''' Stress imaging procedures for patients without prior [[revascularization]] who have a significant change in clinical status and are unable to exercise or have 1 of the following [[ECG]] abnormalities:
:'''a.''' Preexcitation ([[Wolff-Parkinson-White syndrome|Wolff-Parkinson-White]]) syndrome. ''(Level of Evidence: C)''
:'''b.''' Electronically paced ventricular rhythm. ''(Level of Evidence: C)''
:'''c.''' More than 1 mm of rest ST depression. ''(Level of Evidence: C)''
:'''d.''' Complete [[left bundle-branch block]]. ''(Level of Evidence: C)''
'''6.''' Stress imaging procedures for patients who have a significant change in clinical status and required a stress imaging procedure on their initial evaluation because of equivocal or intermediate-risk treadmill results. ''(Level of Evidence: C)''
'''7.''' Stress imaging procedures for patients with prior [[revascularization]] who have a significant change in clinical status. ''(Level of Evidence: C)''
'''8.''' [[Coronary angiography]] in patients with marked limitation of ordinary activity (CCS class III) despite maximal medical therapy. ''(Level of Evidence: C)''


{{cquote|
===Class IIb===
===Class IIb===
'''1.''' Annual treadmill exercise testing in patients who have no change in clinical status, can exercise, have none of the [[ECG]] abnormalities listed in number 5 above, and have an estimated annual mortality of >1%. ''(Level of Evidence: C)''
'''1.''' Annual treadmill exercise testing in patients who have no change in clinical status, can exercise, have none of the [[ECG]] abnormalities listed in number 5 above, and have an estimated annual mortality of >1%. ''(Level of Evidence: C)''

Revision as of 15:43, 24 October 2012

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Overview

Ongoing follow-up of the patient with chronic stable angina is necessary to monitor symptoms and to optimize antianginal therapy. It is generally recommended that these patients be evaluated every 4-6 months during first year of diagnosis / initiation of therapy and annually thereafter. Based upon clinical judgement, if the patient is poorly responsive to therapy, if the episodes are severe or frequent, or if the patient is fragile with multiple co-morbidities, they may need to be seen more frequently.

During a follow-up visit, the patient should be asked about the frequency and severity of their anginal symptoms, their level of exercise capacity, whether they have been able to modify his/her risk factors, how well they are tolerating and complying with the therapy and whether he/she has developed new illnesses or co-morbidities.

Guidelines for obtaining imaging studies during follow-up visits are listed below:

ACC / AHA Guidelines- Echocardiography, Treadmill Exercise Testing, Stress Imaging Studies, and Coronary Angiography During Patient Follow-Up (DO NOT EDIT)[1][2]

Class I
"1. Chest x-ray for patients with evidence of new or worsening congestive heart failure. (Level of Evidence: C) "
"2. Assessment of LV ejection fraction and segmental wall motion in patients with new or worsening congestive heart failure or evidence of intervening MI by history or ECG. (Level of Evidence: C) "
"3. Echocardiography for evidence of new or worsening valvular heart disease. (Level of Evidence: C) "
"4. Treadmill exercise test for patients without prior revascularization who have a significant change in clinical status, are able to exercise, and do not have any of the ECG abnormalities listed below in number 5. (Level of Evidence: C) "
"5. Stress imaging procedures for patients without prior revascularization who have a significant change in clinical status and are unable to exercise or have 1 of the following ECG abnormalities: "
"a. Preexcitation (Wolff-Parkinson-White) syndrome. (Level of Evidence: C) "
"b. Electronically paced ventricular rhythm. (Level of Evidence: C) "
"c. More than 1 mm of rest ST depression. (Level of Evidence: C) "
"d.Complete left bundle-branch block. (Level of Evidence: C) "
"1. Stress imaging procedures for patients who have a significant change in clinical status and required a stress imaging procedure on their initial evaluation because of equivocal or intermediate-risk treadmill results. (Level of Evidence: C) "
"2. Stress imaging procedures for patients with prior revascularization who have a significant change in clinical status. (Level of Evidence: C) "
"3. Coronary angiography in patients with marked limitation of ordinary activity (CCS class III) despite maximal medical therapy. (Level of Evidence: C) "



“

Class IIb

1. Annual treadmill exercise testing in patients who have no change in clinical status, can exercise, have none of the ECG abnormalities listed in number 5 above, and have an estimated annual mortality of >1%. (Level of Evidence: C)

Class III

1. Echocardiography or radionuclide imaging for assessment of LV ejection fraction and segmental wall motion in patients with a normal ECG, no history of MI, and no evidence of congestive heart failure. (Level of Evidence: C)

2. Repeat treadmill exercise testing in <3 years in patients who have no change in clinical status and an estimated annual mortality <1% on their initial evaluation as demonstrated by 1 of the following:

a. Low-risk Duke treadmill score (without imaging). (Level of Evidence: C)
b. Low-risk Duke treadmill score with negative imaging. (Level of Evidence: C)
c. Normal LV function and a normal coronary angiogram. (Level of Evidence: C)
d. Normal LV function and insignificant CAD. (Level of Evidence: C)

3. Stress imaging procedures for patients who have no change in clinical status and a normal rest ECG, are not taking digoxin, are able to exercise, and did not require a stress imaging procedure on their initial evaluation because of equivocal or intermediate-risk treadmill results. (Level of Evidence: C)

4. Repeat coronary angiography in patients with no change in clinical status, no change on repeat exercise testing or stress imaging, and insignificant CAD on initial evaluation. (Level of Evidence: C)

”

See Also

Guidelines Resources

  • The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina [1]
  • The ACC/AHA 2002 Guideline Update 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

  1. ↑ 1.0 1.1 Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999)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
  2. ↑ 2.0 2.1 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. PMID: 12515758
  3. ↑ 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. DOI:10.1161/CIRCULATIONAHA.107.187930 PMID: 17998462

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