Chronic stable angina risk stratification cardiac stress imaging in patients who are able to exercise: Difference between revisions

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(New page: __NOTOC__ {{Chronic stable angina}} {{CMG}}; '''Associate Editors-in-Chief:''' {{CZ}}; Smita Kohli, M.D. ==ACC / AHA Guidelines- Cardiac Stress Imaging for Risk Stratification of Patients...)
 
(/* ESC Guidelines- Risk Stratification according to Exercise Stress Imaging (Perfusion or Echocardiography) in patients Who Can Exercise (DO NOT EDIT){{cite journal| author=Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F et al.| title=...)
 
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__NOTOC__
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{{Chronic stable angina}}
{{Chronic stable angina}}
{{CMG}}; '''Associate Editors-in-Chief:''' {{CZ}}; Smita Kohli, M.D.


==ACC / AHA Guidelines- Cardiac Stress Imaging for Risk Stratification of Patients With Chronic Stable Angina Who Are Able to Exercise (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=10351980 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: [http://pubmed.gov/10351980 10351980]</ref>==
{{CMG}}; '''Associate Editor-In-Chief:''' [[Lakshmi Gopalakrishnan|Lakshmi Gopalakrishnan, M.B.B.S.]]
{{cquote|
===Class I===
'''1.''' Exercise myocardial perfusion imaging or [[Chronic stable angina exercise echocardiography|exercise echocardiography]] to identify the extent, severity, and location of [[ischemia]] in patients who do not have [[left bundle-branch block]] or an electronically paced ventricular rhythm and have either an abnormal rest [[ECG]] or are using [[digoxin]]. ''(Level of Evidence: B)''


'''2.''' [[Dipyridamole]] or [[adenosine]] myocardial perfusion imaging in patients with [[left bundle-branch block]] or electronically paced ventricular rhythm. ''(Level of Evidence: B)''
==Overview==
Cardiac stress imaging consisting of echocardiography and myocardial perfusion scan, which are assessed both at rest and during stress, provide a useful way to stratify the risk of underlying [[coronary artery disease]] (CAD) and hence aid in the management of [[chronic stable angina]]. Cardiac stress imaging in a patient who is able to exercise is indicated in the presence of [[Chronic stable angina risk stratification electrocardiogram/chest x-ray|resting ECG abnormalities]] or in patients who are on [[digoxin]]. A [[Chronic stable angina myocardial perfusion scintigraphy|normal post-stress thallium scan]] indicates a low probability of underlying [[CAD]], however, a normal image in a patient with [[Chronic stable angina risk assessment in patients with an intermediate or high probability of coronary artery disease| high-risk treadmill scores]] requires further evaluation.<ref name="pmid9494023">Hachamovitch R, Berman DS, Shaw LJ, Kiat H, Cohen I, Cabico JA et al. (1998) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9494023 Incremental prognostic value of myocardial perfusion single photon emission computed tomography for the prediction of cardiac death: differential stratification for risk of cardiac death and myocardial infarction.] ''Circulation'' 97 (6):535-43. PMID: [http://pubmed.gov/9494023 9494023]</ref>


'''3.''' Exercise myocardial perfusion imaging or [[Chronic stable angina exercise echocardiography|exercise echocardiography]] to assess the functional significance of coronary lesions (if not already known) in planning [[PTCA]]. ''(Level of Evidence: B)''
==Stress Echocardiography==
*In patients with chronic stable angina, [[Chronic stable angina exercise echocardiography|stress echocardiography]] is routinely used to stratify the risk of underlying [[coronary artery disease]] and as an alternative to [[Chronic stable angina myocardial perfusion scintigraphy|stress thallium scan]] for detecting inducible [[myocardial ischemia]].<ref name="pmid8989689">Chaudhry FA (1996) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=8989689 The role of stress echocardiography versus stress perfusion: a view from the other side.] ''J Nucl Cardiol'' 3 (6 Pt 2):S66-74. PMID: [http://pubmed.gov/8989689 8989689]</ref>


===Class IIb===
*During stress, the extent and severity of abnormal contractile response is expressed as wall motion score index (WMSI).<ref name="pmid13678935">Yao SS, Qureshi E, Sherrid MV, Chaudhry FA (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=13678935 Practical applications in stress echocardiography: risk stratification and prognosis in patients with known or suspected ischemic heart disease.] ''J Am Coll Cardiol'' 42 (6):1084-90. PMID: [http://pubmed.gov/13678935 13678935]</ref>
'''1.''' Exercise or [[dobutamine]] [[echocardiography]] in patients with [[left bundle-branch block]]. ''(Level of Evidence: C)''
{| border="1" align="center" style="background:lightskyblue"
|-
| bgcolor="CornFlowerBlue" |'''Contractile response'''
| bgcolor="CornFlowerBlue" |'''Peak WMSI'''
| bgcolor="CornFlowerBlue" |'''Cardiac event rate'''
|-
| Normal response
| 1.0
| 0.9% per year
|-
| Mild-to-moderate contractile dysfunction
| 1.1–1.7
| 3.1% per year
|-
| Severe contractile dysfunction
| greater than 1.7
| 5.2% per year
|}


'''2.''' Exercise, [[dipyridamole]], [[adenosine]] myocardial perfusion imaging, or exercise or [[dobutamine]] [[echocardiography]] as the initial test in patients who have a normal rest [[ECG]] and are not taking [[digoxin]]. ''(Level of Evidence: B)''
==Myocardial Perfusion Imaging==
*In patients with [[Chronic stable angina assessing the pretest probability of coronary artery disease#Pretest Probability|high pretest likelihood]] of [[coronary artery disease]] but without known [[CAD]], [[Chronic stable angina myocardial perfusion scintigraphy|myocardial perfusion scan]] or stress myocardial perfusion single-photon emission computed tomography ([[SPECT]]) yields incremental prognostic value and enhanced risk stratification.<ref name="pmid10736294">Beller GA, Zaret BL (2000) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10736294 Contributions of nuclear cardiology to diagnosis and prognosis of patients with coronary artery disease.] ''Circulation'' 101 (12):1465-78. PMID: [http://pubmed.gov/10736294 10736294]</ref><ref name="pmid11854122">Hachamovitch R, Berman DS, Kiat H, Cohen I, Friedman JD, Shaw LJ (2002) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11854122 Value of stress myocardial perfusion single photon emission computed tomography in patients with normal resting electrocardiograms: an evaluation of incremental prognostic value and cost-effectiveness.] ''Circulation'' 105 (7):823-9. PMID: [http://pubmed.gov/11854122 11854122]</ref><ref name="pmid14736438">Hachamovitch R, Hayes SW, Friedman JD, Cohen I, Berman DS (2004) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=14736438 Stress myocardial perfusion single-photon emission computed tomography is clinically effective and cost effective in risk stratification of patients with a high likelihood of coronary artery disease (CAD) but no known CAD.] ''J Am Coll Cardiol'' 43 (2):200-8. PMID: [http://pubmed.gov/14736438 14736438]</ref>


===Class III===
*In patients with known [[CAD]],a normal [[Chronic stable angina myocardial perfusion scintigraphy|stress thallium test]] is associated with a annual mortality rate of 0.5% to 0.9%.<ref name="pmid14736437">Poornima IG, Miller TD, Christian TF, Hodge DO, Bailey KR, Gibbons RJ (2004) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=14736437 Utility of myocardial perfusion imaging in patients with low-risk treadmill scores.] ''J Am Coll Cardiol'' 43 (2):194-9. PMID: [http://pubmed.gov/14736437 14736437]</ref>
'''1.''' Exercise myocardial perfusion imaging in patients with left [[bundle-branch block]]. ''(Level of Evidence: C)''


'''2.''' Exercise, [[dipyridamole]], [[adenosine]] myocardial perfusion imaging, or exercise or [[dobutamine]] [[echocardiography]] in patients with severe [[comorbidity]] likely to limit life expectation or prevent [[revascularization]]. ''(Level of Evidence: C)''}}
*A [[Chronic stable angina myocardial perfusion scintigraphy|normal post-stress thallium scan]] indicates a low probability of underlying [[CAD]]. However, a [[Chronic stable angina myocardial perfusion scintigraphy|normal scan]] in a patient with [[Chronic stable angina risk assessment in patients with an intermediate or high probability of coronary artery disease| high-risk treadmill scores]] warrants further evaluation.<ref name="pmid9494023">Hachamovitch R, Berman DS, Shaw LJ, Kiat H, Cohen I, Cabico JA et al. (1998) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9494023 Incremental prognostic value of myocardial perfusion single photon emission computed tomography for the prediction of cardiac death: differential stratification for risk of cardiac death and myocardial infarction.] ''Circulation'' 97 (6):535-43. PMID: [http://pubmed.gov/9494023 9494023]</ref><ref name="pmid14736437">Poornima IG, Miller TD, Christian TF, Hodge DO, Bailey KR, Gibbons RJ (2004) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=14736437 Utility of myocardial perfusion imaging in patients with low-risk treadmill scores.] ''J Am Coll Cardiol'' 43 (2):194-9. PMID: [http://pubmed.gov/14736437 14736437]</ref>
 
*Scintigraphic features suggestive of adverse cardiac events include:<ref name="pmid14736439">Beller GA, Watson DD (2004) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=14736439 Risk stratification using stress myocardial perfusion imaging: don't neglect the value of clinical variables.] ''J Am Coll Cardiol'' 43 (2):209-12. PMID: [http://pubmed.gov/14736439 14736439]</ref>
:*Cavity dilatation,
:*Low [[ejection fraction]],
:*End-systolic and end-diastolic volumes,
:*Post-stress myocardial stunning.
 
==ACC / AHA Guidelines- Cardiac Stress Imaging for Risk Stratification of Patients With Chronic Stable Angina Who Are Able to Exercise (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=10351980 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. [http://circ.ahajournals.org/content/99/21/2829.full.pdf] PMID: [http://pubmed.gov/10351980 10351980]</ref>==
{|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.''' [[Chronic stable angina myocardial perfusion scintigraphy|Exercise myocardial perfusion imaging]] or [[Chronic stable angina exercise echocardiography|exercise echocardiography]] to identify the extent, severity, and location of [[ischemia]] in patients who do not have [[left bundle-branch block]] or an electronically paced ventricular rhythm and have either an [[Chronic stable angina risk stratification electrocardiogram/chest x-ray|abnormal rest ECG]] or are using [[digoxin]]. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' [[Chronic stable angina perfusion scintigraphy with pharmacologic stress|Dipyridamole or adenosine]] myocardial perfusion imaging in patients with [[left bundle-branch block]] or electronically paced ventricular rhythm. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' [[Chronic stable angina myocardial perfusion scintigraphy|Exercise myocardial perfusion imaging]] or [[Chronic stable angina exercise echocardiography|exercise echocardiography]] to assess the functional significance of coronary lesions (if not already known) in planning [[Chronic stable angina revascularization percutaneous coronary intervention(PCI)|PTCA]]. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]
 
|-
| bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' [[Chronic stable angina myocardial perfusion scintigraphy|Exercise myocardial perfusion imaging]] in patients with [[left bundle-branch block]]. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LightCoral"|<nowiki>"</nowiki>'''2.''' [[Chronic stable angina myocardial perfusion scintigraphy|Exercise]], [[Chronic stable angina perfusion scintigraphy with pharmacologic stress|dipyridamole, adenosine]] myocardial perfusion imaging, or [[Chronic stable angina exercise echocardiography|exercise]] or [[dobutamine]] echocardiography in patients with severe comorbidity likely to limit life expectation or prevent [[Chronic stable angina revascularization|revascularization]]. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
 
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' [[Chronic stable angina exercise echocardiography|Exercise]] or [[dobutamine]] echocardiography in patients with [[left bundle-branch block]]. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' [[Chronic stable angina myocardial perfusion scintigraphy|Exercise]], [[Chronic stable angina perfusion scintigraphy with pharmacologic stress|dipyridamole, adenosine]] myocardial perfusion imaging, or [[Chronic stable angina exercise echocardiography|exercise]] or [[dobutamine]] echocardiography as the initial test in patients who have a [[Chronic stable angina risk stratification electrocardiogram/chest x-ray|normal rest ECG]] and are not taking [[digoxin]]. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}


==ESC Guidelines- Risk Stratification according to Exercise Stress ECG in patients Who Can Exercise (DO NOT EDIT)<ref name="pmid16735367">{{cite journal| author=Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F et al.| title=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. | journal=Eur Heart J | year= 2006 | volume= 27 | issue= 11 | pages= 1341-81 | pmid=16735367 | doi=10.1093/eurheartj/ehl001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16735367  }} </ref>==
==ESC Guidelines- Risk Stratification according to Exercise Stress ECG in patients Who Can Exercise (DO NOT EDIT)<ref name="pmid16735367">{{cite journal| author=Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F et al.| title=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. | journal=Eur Heart J | year= 2006 | volume= 27 | issue= 11 | pages= 1341-81 | pmid=16735367 | doi=10.1093/eurheartj/ehl001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16735367  }} </ref>==
{{cquote|
===Class I===
'''1.''' All patients without significant resting [[ECG]] abnormalities undergoing initial evaluation. ''(Level of Evidence: B)''


'''2.''' Patients with stable coronary disease after a significant change in symptom level. ''(Level of Evidence: C)''
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[European society of cardiology#Classes of Recommendations|Class I]]
 
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' All patients without significant [[Chronic stable angina risk stratification electrocardiogram/chest x-ray|resting ECG abnormalities]] undergoing initial evaluation. ''([[European society of cardiology#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Patients with stable [[coronary artery disease]] after a significant change in symptom level. ''([[European society of cardiology#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}


===Class IIa===
{|class="wikitable"
'''1.''' Patients post-revascularization with a significant deterioration in symptomatic status. ''(Level of Evidence: B)''
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[European society of cardiology#Classes of Recommendations|Class IIa]]


'''2.''' As an alternative to exercise ECG in patients where facilities, cost, and personnel resources allow. ''(Level of Evidence: B)''}}
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Patients [[Chronic stable angina revascularization|post-revascularization]] with a significant deterioration in symptomatic status. ''([[European society of cardiology#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}


==See Also==
==ESC Guidelines- Risk Stratification according to Exercise Stress Imaging (Perfusion or Echocardiography) in patients Who Can Exercise (DO NOT EDIT)<ref name="pmid16735367">{{cite journal| author=Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F et al.| title=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. | journal=Eur Heart J | year= 2006 | volume= 27 | issue= 11 | pages= 1341-81 | pmid=16735367 | doi=10.1093/eurheartj/ehl001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16735367  }} </ref>==
*[[The Living Guidelines: Chronic Stable Angina Pectoris | The Chronic Stable Angina Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines]]


==Sources==
{|class="wikitable"
*Guidelines on the management of stable angina pectoris: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology <ref name="pmid16735367">{{cite journal| author=Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F et al.| title=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. | journal=Eur Heart J | year= 2006 | volume= 27 | issue= 11 | pages= 1341-81 | pmid=16735367 | doi=10.1093/eurheartj/ehl001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16735367  }} </ref>
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[European society of cardiology#Classes of Recommendations|Class I]]


*The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina <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=10351980 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: [http://pubmed.gov/10351980 10351980]</ref>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Patients with [[Chronic stable angina risk stratification electrocardiogram/chest x-ray|resting ECG abnormalities]], [[LBBB]], more than 1 mm [[ST depression]], paced rhythm, or [[Wolff Parkinson White syndrome]] which prevent accurate interpretation of [[ECG]] changes during stress. ''([[European society of cardiology#Level of Evidence|Level of Evidence: C]])''
<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Patients with a non-conclusive [[Chronic stable angina exercise electrocardiography|exercise ECG]], but [[Chronic stable angina risk assessment in patients with an intermediate or high probability of coronary artery disease|intermediate or high probability of disease]]. ''([[European society of cardiology#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}


*TheACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina <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>
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[European society of cardiology#Classes of Recommendations|Class IIa]]


*The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina <ref name="pmid17998462">Fraker TD, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J et al. (2007) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=17998462 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. [http://dx.doi.org/10.1161/CIRCULATIONAHA.107.187930 DOI:10.1161/CIRCULATIONAHA.107.187930] PMID: [http://pubmed.gov/17998462 17998462]</ref>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' In patients with a deterioration in symptoms [[Chronic stable angina revascularization|post-revascularization]]. ''([[European society of cardiology#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' As an alternative to [[Chronic stable angina exercise electrocardiography|exercise ECG]] in patients where facilities, cost, and personnel resources allow. ''([[European society of cardiology#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}


==References==
==References==
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Latest revision as of 18:19, 29 January 2013

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2]; Associate Editor-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S.

Overview

Cardiac stress imaging consisting of echocardiography and myocardial perfusion scan, which are assessed both at rest and during stress, provide a useful way to stratify the risk of underlying coronary artery disease (CAD) and hence aid in the management of chronic stable angina. Cardiac stress imaging in a patient who is able to exercise is indicated in the presence of resting ECG abnormalities or in patients who are on digoxin. A normal post-stress thallium scan indicates a low probability of underlying CAD, however, a normal image in a patient with high-risk treadmill scores requires further evaluation.[1]

Stress Echocardiography

  • During stress, the extent and severity of abnormal contractile response is expressed as wall motion score index (WMSI).[3]
Contractile response Peak WMSI Cardiac event rate
Normal response 1.0 0.9% per year
Mild-to-moderate contractile dysfunction 1.1–1.7 3.1% per year
Severe contractile dysfunction greater than 1.7 5.2% per year

Myocardial Perfusion Imaging

  • Scintigraphic features suggestive of adverse cardiac events include:[8]
  • Cavity dilatation,
  • Low ejection fraction,
  • End-systolic and end-diastolic volumes,
  • Post-stress myocardial stunning.

ACC / AHA Guidelines- Cardiac Stress Imaging for Risk Stratification of Patients With Chronic Stable Angina Who Are Able to Exercise (DO NOT EDIT)[9]

Class I
"1. Exercise myocardial perfusion imaging or exercise echocardiography to identify the extent, severity, and location of ischemia in patients who do not have left bundle-branch block or an electronically paced ventricular rhythm and have either an abnormal rest ECG or are using digoxin. (Level of Evidence: B)"
"2. Dipyridamole or adenosine myocardial perfusion imaging in patients with left bundle-branch block or electronically paced ventricular rhythm. (Level of Evidence: B)"
"3. Exercise myocardial perfusion imaging or exercise echocardiography to assess the functional significance of coronary lesions (if not already known) in planning PTCA. (Level of Evidence: B)"
Class III
"1. Exercise myocardial perfusion imaging in patients with left bundle-branch block. (Level of Evidence: C)"
"2. Exercise, dipyridamole, adenosine myocardial perfusion imaging, or exercise or dobutamine echocardiography in patients with severe comorbidity likely to limit life expectation or prevent revascularization. (Level of Evidence: C)"
Class IIb
"1. Exercise or dobutamine echocardiography in patients with left bundle-branch block. (Level of Evidence: C)"
"2. Exercise, dipyridamole, adenosine myocardial perfusion imaging, or exercise or dobutamine echocardiography as the initial test in patients who have a normal rest ECG and are not taking digoxin. (Level of Evidence: B)"

ESC Guidelines- Risk Stratification according to Exercise Stress ECG in patients Who Can Exercise (DO NOT EDIT)[10]

Class I
"1. All patients without significant resting ECG abnormalities undergoing initial evaluation. (Level of Evidence: B)"
"2. Patients with stable coronary artery disease after a significant change in symptom level. (Level of Evidence: C)"
Class IIa
"1. Patients post-revascularization with a significant deterioration in symptomatic status. (Level of Evidence: B)"

ESC Guidelines- Risk Stratification according to Exercise Stress Imaging (Perfusion or Echocardiography) in patients Who Can Exercise (DO NOT EDIT)[10]

Class I
"1. Patients with resting ECG abnormalities, LBBB, more than 1 mm ST depression, paced rhythm, or Wolff Parkinson White syndrome which prevent accurate interpretation of ECG changes during stress. (Level of Evidence: C)

"

"2. Patients with a non-conclusive exercise ECG, but intermediate or high probability of disease. (Level of Evidence: B)"
Class IIa
"1. In patients with a deterioration in symptoms post-revascularization. (Level of Evidence: B)"
"2. As an alternative to exercise ECG in patients where facilities, cost, and personnel resources allow. (Level of Evidence: B)"

References

  1. ↑ 1.0 1.1 Hachamovitch R, Berman DS, Shaw LJ, Kiat H, Cohen I, Cabico JA et al. (1998) Incremental prognostic value of myocardial perfusion single photon emission computed tomography for the prediction of cardiac death: differential stratification for risk of cardiac death and myocardial infarction. Circulation 97 (6):535-43. PMID: 9494023
  2. ↑ Chaudhry FA (1996) The role of stress echocardiography versus stress perfusion: a view from the other side. J Nucl Cardiol 3 (6 Pt 2):S66-74. PMID: 8989689
  3. ↑ Yao SS, Qureshi E, Sherrid MV, Chaudhry FA (2003) Practical applications in stress echocardiography: risk stratification and prognosis in patients with known or suspected ischemic heart disease. J Am Coll Cardiol 42 (6):1084-90. PMID: 13678935
  4. ↑ Beller GA, Zaret BL (2000) Contributions of nuclear cardiology to diagnosis and prognosis of patients with coronary artery disease. Circulation 101 (12):1465-78. PMID: 10736294
  5. ↑ Hachamovitch R, Berman DS, Kiat H, Cohen I, Friedman JD, Shaw LJ (2002) Value of stress myocardial perfusion single photon emission computed tomography in patients with normal resting electrocardiograms: an evaluation of incremental prognostic value and cost-effectiveness. Circulation 105 (7):823-9. PMID: 11854122
  6. ↑ Hachamovitch R, Hayes SW, Friedman JD, Cohen I, Berman DS (2004) Stress myocardial perfusion single-photon emission computed tomography is clinically effective and cost effective in risk stratification of patients with a high likelihood of coronary artery disease (CAD) but no known CAD. J Am Coll Cardiol 43 (2):200-8. PMID: 14736438
  7. ↑ 7.0 7.1 Poornima IG, Miller TD, Christian TF, Hodge DO, Bailey KR, Gibbons RJ (2004) Utility of myocardial perfusion imaging in patients with low-risk treadmill scores. J Am Coll Cardiol 43 (2):194-9. PMID: 14736437
  8. ↑ Beller GA, Watson DD (2004) Risk stratification using stress myocardial perfusion imaging: don't neglect the value of clinical variables. J Am Coll Cardiol 43 (2):209-12. PMID: 14736439
  9. ↑ 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. [1] PMID: 10351980
  10. ↑ 10.0 10.1 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.

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