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

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{{Chronic stable angina}}
{{Chronic stable angina}}
{{CMG}}; '''Associate Editors-in-Chief:''' {{CZ}}; Smita Kohli, M.D.
{{CMG}}; '''Associate Editors-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 [[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 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>


==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>==
==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>==
{{cquote|
{{cquote|
===Class I===
===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)''
'''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]]. ''(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)''
'''2.''' [[Dipyridamole]] or [[adenosine]] [[Chronic stable angina perfusion scintigraphy with pharmacologic stress|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 [[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)''
'''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 [[PTCA]]. ''(Level of Evidence: B)''


===Class IIb===
===Class IIb===
'''1.''' Exercise or [[dobutamine]] [[echocardiography]] in patients with [[left bundle-branch block]]. ''(Level of Evidence: C)''
'''1.''' [[Chronic stable angina exercise echocardiography|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)''
'''2.''' [[Chronic stable angina myocardial perfusion scintigraphy|Exercise]], [[dipyridamole]], [[adenosine]] [[Chronic stable angina perfusion scintigraphy with pharmacologic stress|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]]. ''(Level of Evidence: B)''


===Class III===
===Class III===
'''1.''' Exercise myocardial perfusion imaging in patients with left [[bundle-branch block]]. ''(Level of Evidence: C)''
'''1.''' [[Chronic stable angina myocardial perfusion scintigraphy|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)''}}
'''2.''' [[Chronic stable angina myocardial perfusion scintigraphy|Exercise]], [[dipyridamole]], [[adenosine]] [[Chronic stable angina perfusion scintigraphy with pharmacologic stress|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 [[revascularization]]. ''(Level of Evidence: C)''}}


==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|
{{cquote|
===Class I===
===Class I===
'''1.''' All patients without significant resting [[ECG]] abnormalities undergoing initial evaluation. ''(Level of Evidence: B)''
'''1.''' All patients without significant [[Chronic stable angina risk stratification electrocardiogram/chest x-ray|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)''
'''2.''' Patients with stable [[coronary artery disease]] after a significant change in symptom level. ''(Level of Evidence: C)''


===Class IIa===
===Class IIa===
'''1.''' Patients post-revascularization with a significant deterioration in symptomatic status. ''(Level of Evidence: B)''}}
'''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)<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 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>==
{{cquote|
{{cquote|
===Class I===
===Class I===
'''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. ''(Level of Evidence: C)''
'''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. ''(Level of Evidence: C)''


'''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]]. ''(Level of Evidence: B)''
'''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]]. ''(Level of Evidence: B)''


===Class IIa===
===Class IIa===
'''1.''' In patients with a deterioration in symptoms postrevascularization. ''(Level of Evidence: B)''
'''1.''' In patients with a deterioration in symptoms post-[[revascularization]]. ''(Level of Evidence: B)''


'''2.''' As an alternative to [[Chronic stable angina exercise electrocardiography|exercise ECG]] in patients where facilities, cost, and personnel resources allow. ''(Level of Evidence: B)''}}
'''2.''' As an alternative to [[Chronic stable angina exercise electrocardiography|exercise ECG]] in patients where facilities, cost, and personnel resources allow. ''(Level of Evidence: B)''}}

Revision as of 21:56, 25 July 2011

Chronic stable angina Microchapters

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [4]; Associate Editors-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 low probability of underlying CAD, however, a normal image in a patient with high-risk treadmill scores requires further evaluation. [1]

ACC / AHA Guidelines- Cardiac Stress Imaging for Risk Stratification of Patients With Chronic Stable Angina Who Are Able to Exercise (DO NOT EDIT)[2]

“

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 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)

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)

”

ESC Guidelines- Risk Stratification according to Exercise Stress ECG in patients Who Can Exercise (DO NOT EDIT)[3]

“

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)[3]

“

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)

”

Vote on and Suggest Revisions to the Current Guidelines

Sources

  • Guidelines on the management of stable angina pectoris: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology [3]
  • The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina [2]
  • TheACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina [4]
  • The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina [5]

References

  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. ↑ 2.0 2.1 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
  3. ↑ 3.0 3.1 3.2 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.
  4. ↑ 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.[2] PMID: 12515758
  5. ↑ 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.[3] PMID: 17998462


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