Chronic stable angina test selection guideline for the individual basis: Difference between revisions

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*Not all noninvasive or invasive tests available for the diagnosis of [[coronary artery disease]] and [[myocardial ischemia]] are applicable to all clinical subsets of patients with stable angina.  
*Not all noninvasive or invasive tests available for the diagnosis of [[coronary artery disease]] and [[myocardial ischemia]] are applicable to all clinical subsets of patients with stable angina.  


*For patients with [[Chronic stable angina definition|stable exertional angina]], [[Chronic stable angina clinical subset- mixed angina pectoris|mixed angina]], [[Chronic stable angina clinical subset- postprandial angina pectoris|postprandial angina]], [[Chronic stable angina clinical subset- walk through angina pectoris|walk through angina]], and [[Chronic stable angina clinical subset- nocturnal angina pectoris|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, [[Chronic stable angina exercise electrocardiography|exercise ECG]], exercise or [[Chronic stable angina perfusion scintigraphy with pharmacologic stress|stress perfusion scintigraphy]] and [[Chronic stable angina exercise echocardiography|exercise echocardiography]] are designed to provoke [[ischemia]].  
*For patients with [[Chronic stable angina definition|stable exertional angina]], [[Chronic stable angina clinical subset- mixed angina pectoris|mixed angina]], [[Chronic stable angina clinical subset- postprandial angina pectoris|postprandial angina]], [[Chronic stable angina clinical subset- walk through angina pectoris|walk through angina]], and [[Chronic stable angina clinical subset- nocturnal angina pectoris|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, [[Chronic stable angina exercise electrocardiography|exercise ECG]], exercise or [[Chronic stable angina perfusion scintigraphy with pharmacologic stress|stress perfusion scintigraphy]] and [[Chronic stable angina exercise echocardiography|exercise echocardiography]] are designed to provoke [[ischemia]].  


*In patients with stable [[angina pectoris]], particularly those with documented prior [[myocardial infarction]], an assessment of left ventricular systolic function is necessary for selection of an appropriate therapy method. In this group of patients, assessment for [[myocardial ischemia]] and ventricular function can be performed by the combination of a test for [[ischemia]]; [[Chronic stable angina exercise electrocardiography|exercise ECG]] and a LV function test (i.e., [[Chronic stable angina echocardiography|echocardiography at rest]]), or echocardiography both, at [[Chronic stable angina echocardiography|rest]] and [[Chronic stable angina exercise echocardiography|during exercise]].
*In patients with stable [[angina pectoris]], particularly those with documented prior [[myocardial infarction]], an assessment of left ventricular systolic function is necessary for selection of an appropriate therapy method. In this group of patients, assessment for [[myocardial ischemia]] and ventricular function can be performed by the combination of a test for [[ischemia]]; [[Chronic stable angina exercise electrocardiography|exercise ECG]] and a LV function test (i.e., [[Chronic stable angina echocardiography|echocardiography at rest]]), or echocardiography both, at [[Chronic stable angina echocardiography|rest]] and [[Chronic stable angina exercise echocardiography|during exercise]].

Latest revision as of 21:01, 4 February 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

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Case #1

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Editor-in-Chief: C. Michael Gibson, M.S.,M.D. [1] Phone:617-632-7753; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Smita Kohli, M.D.

Overview

Criteria for test selection hinges largely on the current disease state of the individual patient and subsequent level of fitness for testing. Potential diagnostic testing modalities include: exercise ECG, ECG at rest, exercise echocardiography, echocardiography at rest, and stress scintigraphy.

Test Selection Guidelines for the Individual Basis

  • Even when the exercise ECG is not deemed clinically necessary to establish the diagnosis of coronary artery disease (CAD), it can be helpful in assessing CAD severity.
  • If evidence for ischemia (by ECG or by perfusion scintigraphy or echocardiography) is detected during the first stage of exercise, the incidence of three-vessel disease or left main coronary artery stenosis is greater than compared to cases more exercise is required to provoke a positive test.
  • Exercise electrocardiography in patients with suspected or established stable angina pectoris can be a useful tool in determining usage of nonpharmacologic and pharmacologic therapeutic interventions.
  • 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 can be an adequate testing means. However, due to a higher incidence of false positive test results in stress ECG in women, exercise perfusion scintigraphy or exercise echocardiography should also be considered as a reasonable testing alternative, often with fewer specificity issues.

References

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