The AHA guidelines and scientific statements handbook 2009ed

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The AHA guidelines and scientific statements handbook 2009ed

  1. 1. The AHA Guidelines and Scientific Statements HandbookThe AHA Guidelines and Scientific Statements HandbookEdited by Valentin Fuster © 2009 American Heart AssociationISBN: 978-1-405-18463-2
  2. 2. The AHA Guidelines andScientific Statements HandbookEdited byValentin FusterMount Sinai School of MedicineOne Gustave Levy PlaceBox 1030New YorkUSA A John Wiley & Sons, Ltd., Publication
  3. 3. This edition first published 2009, © 2009 American Heart AssociationAmerican Heart Association National Center, 7272 Greenville Avenue, Dallas, TX 75231, USAFor further information on the American Heart Association:www.americanheart.orgBlackwell Publishing was acquired by John Wiley & Sons in February 2007. Blackwell’s publishing program has beenmerged with Wiley’s global Scientific, Technical and Medical business to form Wiley-Blackwell.Registered office: John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UKEditorial offices: 9600 Garsington Road, Oxford, OX4 2DQ, UK The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK 111 River Street, Hoboken, NJ 07030-5774, USAFor details of our global editorial offices, for customer services and for information about how to apply for permission toreuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwellThe right of the author to be identified as the author of this work has been asserted in accordance with the Copyright,Designs and Patents Act 1988.All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any formor by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright,Designs and Patents Act 1988, without the prior permission of the publisher.Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available inelectronic books.Designations used by companies to distinguish their products are often claimed as trademarks. All brand names andproduct names used in this book are trade names, service marks, trademarks or registered trademarks of their respectiveowners. The publisher is not associated with any product or vendor mentioned in this book. This publication is designed toprovide accurate and authoritative information in regard to the subject matter covered. It is sold on the understanding thatthe publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required,the services of a competent professional should be sought.The contents of this work are intended to further general scientific research, understanding, and discussion only and arenot intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatment byphysicians for any particular patient. The publisher and the author make no representations or warranties with respectto the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including withoutlimitation any implied warranties of fitness for a particular purpose. In view of ongoing research, equipment modifications,changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, anddevices, the reader is urged to review and evaluate the information provided in the package insert or instructions for eachmedicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and foradded warnings and precautions. Readers should consult with a specialist where appropriate. The fact that an organizationor Website is referred to in this work as a citation and/or a potential source of further information does not mean that theauthor or the publisher endorses the information the organization or Website may provide or recommendations it maymake. Further, readers should be aware that Internet Websites listed in this work may have changed or disappearedbetween when this work was written and when it is read. No warranty may be created or extended by any promotionalstatements for this work. Neither the publisher nor the author shall be liable for any damages arising herefrom.Library of Congress Cataloging-in-Publication DataThe AHA guidelines and scientific statements handbook / edited by Valentin Fuster. p. ; cm. ISBN 978-1-4051-8463-2 1. Heart–Diseases–Treatment–Handbooks, manuals, etc. 2. Cardiology–Handbooks, manuals, etc. I. Fuster,Valentin. II. American Heart Association. III. Title: Guidelines and statements handbook. [DNLM: 1. Heart Diseases–therapy–Practice Guideline. 2. Heart Diseases–diagnosis–Practice Guideline. 3. HeartDiseases–prevention & control–Practice Guideline. 4. Practice Guidelines as Topic. WG 210 A285 2009] RC669.15.A39 2009 616.1′2–dc22 2008030329ISBN: 9781405184632A catalogue record for this book is available from the British Library.Set in 9.25 on 12 pt Minion by SNP Best-set Typesetter Ltd., Hong KongPrinted in Singapore by Fabulous Printers Pte Ltd1 2009
  4. 4. ContentsContributors viiPreface x 1 Chronic Stable Angina 1 Theodore D. Fraker, Stephan D. Fihn, and Raymond J. Gibbons 2 Unstable Angina/Non-ST-Elevation Myocardial Infarction 25 Jeffrey L. Anderson and Nanette Kass Wenger 3 ST-Elevation Myocardial Infarction 46 Elliott M. Antman 4 Cardiac Rehabilitation and Secondary Prevention Programs 91 Mark A. Williams and Gary J. Balady 5 Secondary Prevention for Patients With Coronary and Other Atherosclerotic Vascular Disease 108 Sidney C. Smith, Jr. 6 Percutaneous Coronary Intervention 117 Sidney C. Smith, Jr. 7 Coronary Artery Bypass Graft Surgery 134 Cullen D. Morris, Kim Eagle, Robert A. O’Rourke, and Robert A. Guyton 8 Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery 152 Lee A. Fleisher 9 Lower Extremity Peripheral Artery Disease 165 Alan T. Hirsch and Ziv J. Haskal10 Cholesterol Management in the Context of Risk Factor Profile 187 Scott M. Grundy11 Hypertension 196 Clive Rosendorff12 Cardiovascular Disease Prevention in Women 214 Kathy Berra and Nanette Kass Wenger13 Heart Failure 223 Sharon A. Hunt and Mariell Jessup14 Cardiomyopathies 236 Barry J. Maron v
  5. 5. Contents15 Atrial Fibrillation 244 Valentin Fuster and Lars Rydén16 Supraventricular Arrhythmias 255 Carina Blomström-Lundqvist and Melvin Scheinman17 Ventricular Arrhythmias and Sudden Cardiac Death 270 A. John Camm and Douglas P. Zipes18 Valvular Heart Disease 293 Robert O. Bonow19 Infective Endocarditis 312 Larry M. Baddour, Kathryn A. Taubert, Michael H. Gewitz, and Walter R. Wilson20 Cardiac CT Imaging 336 Matthew J. Budoff and Allen J. TaylorAppendix Update on Coronary Artery Bypass Surgery: Current and Future Trends 347 Robert A. O’RourkeOther Statements Published in 2008 353Index 355COI Table 373vi
  6. 6. List of ContributorsJeffrey L. Anderson, MD, FACC, FAHA Kathy Berra, MSN, ANP, FAAN, FAHAAssociation Chief of Cardiology Stanford Prevention Research CenterCardiology Department Stanford University Medical SchoolLDS Hospital Hoover Pavilion, Room N2298th Avenue C Street 211 Quarry Road N241Salt Lake City, UT 84143-0001, USA Stanford, CA 94305-5705, USAElliott M. Antman, MD, FAHA Carina Blomström-Lundqvist, MDProfessor of Medicine Department of CardiologyHarvard Medical School Uppsala University HospitalDirector, CCU S-751 85 UppsalaCardiovascular Division SwedenBrigham and Women’s HospitalSenior Investigator Robert O. Bonow, MD, MACC, FAHATIMI Study Group Goldberg Distinguished Professor75 Francis Street Northwestern University Feinberg School ofBoston, MA 02115-6106, USA Medicine Chief, Division of CardiologyLarry M. Baddour, MD Co-Director, Bluhm Cardiovascular InstituteProfessor of Medicine Northwestern Memorial HospitalMayo Clinic 201 East Huron Street, Suite 10-240200 1st. Street SW Chicago, IL 60611-2996, USARochester, MN 55905-0002, USA Matthew J. Budoff, MD, FAHA, FACCGary J. Balady, MD, FAHA Association Professor of MedicineDirector, Non Invasive Cardiac Labs Division of CardiologyDirector, Preventive Cardiology Los Angeles Biomedical Research Institute atBoston Medical Center Harbor-UCLAProfessor of Medicine 1124 West Carson Street, RB2Boston University School of Medicine Torrance, CA 90502-2006, USA883 East Newton StreetBoston, MA 02118-2308, USA vii
  7. 7. ContributorsJohn Camm, MD Michael H. Gewitz, MD, FAHAProfessor of Clinical Cardiology Physician-in-Chief/Executive DirectorDivision of Cardiac and Vascular Sciences Maria Fareri Children’s Hospital at WestchesterSt. George’s University of London Medical CenterCranmer Terrace Professor and Vice Chair, PediatricsLondon, SW17 0RE Chief, Pediatric CardiologyUnited Kingdom New York Medical College Valhalla, NY 10595, USAKim A. Eagle, MD, FACCAlbion Walter Hewlett Professor of Internal Raymond J. Gibbons, MD, FAHAMedicine Professor of MedicineChief of Clinical Cardiology Mayo Clinic Fnd.- GondaDirector, Cardiovascular Center 200 1st Street SWUniversity of Michigan Cardiovascular Center Rochester, MN 55905-0001, USA1500 East Medical Drive, Suite 2131Ann Arbor, MI 48109-5852, USA Scott M. Grundy, MD, PhD, FAHA Director, Center for Human NutritionStephan D. Fihn, MD, MPH, FACP UT Southwestern Medical CenterChief Quality and Performance Officer Department of Clinical NutritionDepartment of Veterans Affairs 5323 Harry Hines Building1100 Olive Way STE 1400 Dallas, TX 75390-7200, USASeattle, WA 98101-3801, USA Robert A. Guyton, MD Professor and Chief, Division of CardiothoracicLee A. Fleisher, MD, FACC, FAHA SurgeryRobert Dunning Dripps Professor and Chair Department of SurgeryDepartment of Anesthesiology and Critical Care Emory University School of MedicineProfessor of Medicine 1365 Clifton Road NEUniversity of Pennsylvania School of Medicine Atlanta, GA 30322-1013, USA3400 Spruce Street, Suite 680 DullesPhiladelphia, PA 19104, USA Ziv J. Haskal, MD, FAHA, FSIR, FACR Professor and Vice Chair, RadiologyTheodore D. Fraker, Jr., MD, FACC Chief, Division of Interventional RadiologyProfessor of Clinical Medicine University of Maryland School of MedicineAssociate Division Director for Clinical Affairs and 22 E Greene StreetOperations Baltimore, MD 21201, USADivision of Cardiology, Department of MedicineThe Ohio State University College of Medicine Alan T. Hirsch, MD248 Davis Heart & Lung Research Institute, 473 Division of Epidemiology and Community HealthWest 12th Avenue School of Public HealthColumbus, OH 43210, USA University of Minnesota 1300 South 2nd Street, Suite 300Valentin Fuster, MD, PhD, FAHA Minneapolis, MN 55454, USAMount Sinai School of MedicineOne Gustave Levy Place Sharon A. Hunt, MD, FACC, FAHABox 1030 Professor, Division of Cardiovascular MedicineNew York, NY, USA Stanford University 300 Pasteur Drive, Falk CVRB Palo Alto, CA 94305, USAviii
  8. 8. ContributorsMariell Jessup MD, FAHA, FACC Sidney C. Smith, Jr., MD, FAHAProfessor of Medicine Professor of MedicineUniversity of Pennsylvania School of Medicine University of North Carolina at Chapel HillHeart Failure/Transplant Program Center for Cardiovascular Science and Medicine3400 Spruce Street CB # 7075, 6th Floor Burnett Womack BuildingPhiladelphia, PA 19104, USA 99 Manning Drive Chapel Hill, NC 27599-7075, USABarry J. Maron, MD, FACCDirector, Hypertrophic Cardiomyopathy Center Kathryn A. Taubert, PhD, FAHAMinneapolis Heart Institute Foundation Adjunct Professor, U Texas Southwestern Medical920 East 28th. Street, Suite 620 SchoolMinneapolis, MN 55407-1157, USA Senior Scientist, American Heart Association AHA National CenterCullen D. Morris, MD 7272 Greenville AvenueAssistant Professor of Surgery (Cardiothoracic) Dallas, TX 75231, USAThe Emory Clinic, Inc.Medical Director of Cardiothoracic Surgery Allen J. Taylor, MD, FAHAAthens Regional Medical Center Chief, Cardiology Service, Professor of Medicine1270 Prince Ave., Suite 303 Walter Reed Army Medical CenterAthens, GA 30606, USA 6900 Georgia Avenue, NW Building 2, Room 4A34Robert A. O’Rourke, MD, MACP, MACC, FAHA Washington, DC 20307-5001, USAProfessor of Medicine Emeritus Nanette Kass Wenger, MD, FAHAUniversity of Texas Health Science Center Professor of Medicine (Cardiology)116 Village Circle Emory University School of MedicineSan Antonio, TX 78232-2827, USA Chief of CardiologyClive Rosendorff, MD, PhD, DScMed, FAHA Grady Memorial HospitalMount Sinai School of Medicine Consultant, Emory Heart and Vascular Centerand the James J. Peters VA Medical Center 49 Jesse Hill Jr. Drive, SE130 West Kingsbridge Road Atlanta, GA 30303, USABronx, NY 10468-3904, USA Mark A. Williams, PhD, FACSM, FAACVPRLars Rydén, MD, FRCP, FESC Director, CVD Prevention and RehabilitationDepartment of Cardiology Cardiac Center of Creighton UniversityKarolinska University Hospital 3006 Webster Street171 76 Stockholm Omaha, NE 68131-2027, USASweden Walter R. Wilson, MDMelvin Scheinman, MD Professor of MedicineUniversity of California, San Francisco Mayo Clinic500 Parnassus Avenue 200 1st Street SWSan Francisco, CA 94143-2203, USA Rochester, MN 55905-0002, USA Douglas P. Zipes, MD, FAHA Distinguished Professor Indiana University School of Medicine Krannert Institute of Cardiology, Suite E315 1800 North Capitol Avenue Indianapolis, IN 46202, USA ix
  9. 9. PrefaceThe American Heart Association (AHA) has pro- This schema is summarized in the table on the facingduced science consistently for over 75 years. And for page, which also illustrates how the grading systemover 25 years, based on the best scientific medical provides an estimate of the size of the treatment effectevidence, the AHA has produced guidelines with the and an estimate of the certainty of the treatmentAmerican College of Cardiology Foundation, as well effect. In trying to mimic the significance of the green,as scientific statements, with a direct interest in yellow and red lights that guide the circulation of theensuring that all patients receive a good quality stan- vehicles, “The AHA Guidelines and Scientific State-dard of cardiovascular care. Thus, the AHA is con- ments Handbook” also uses similar colors in itsstantly looking for ways to improve adherence to recommendations. Thus, Class I or “must do” recom-guidelines by caregivers since heart disease, stroke, mendations are titled in green text; Class IIa and IIband other cardiovascular diseases remain the No. 1 or respectively “it is appropriate” and “it is not inap-killer in the United States and a leading cause of propriate” recommendations are titled in yellow text;permanent disability worldwide [1]. and Class III or “must not do” recommendations are Although adherence to guidelines should improve titled in red. Also, within the context of a user-patient care and outcomes, many studies have shown friendly and practical format, searching at the index,that the standard of care as defined by guidelines and for example, for the word “angina,” automatically willstatements does not sufficiently reach patients [2–4]. guide you to the various guidelines and statementsAccordingly, our objective is to try to enhance edu- that deal with “angina.”cation of caregivers through this simple and I cannot conclude this brief introduction withoutuser-friendly, summarized and updated “The AHA expressing my sincere thanks to all of the authors ofGuidelines and Scientific Statements Handbook” so the parent committees who, with their time andthat they may easily adhere to it and find it useful to effort, contributed to the original guidelines andimprove patient care and outcomes. Most of the statements; and, of course, I am particularly gratefulrecent AHA guidelines and statements are summa- to the authors of the handbook, who all served onrized and presented here, all in one text. We have also the parent committees and very generously contrib-asked authors to provide a “future directions” section uted to this project by meeting a very tight schedule.on each chapter, to expand upon recent trials and I warmly thank my collaborators at the Americanresearch that might affect guidelines in the future. Heart Association and Wiley-Blackwell for meetingWhen appropriate, a brief comparison to other once a week in a conference call at 5.30 am , andguidelines (usually from the European Society of I am particularly grateful to Ms Heather Goodell,Cardiology) is also provided, indicated in purple text. Ms Kate Newell and Mr Oliver Walter. Finally, IFurthermore, also refer to the website for this book, would like to express my deepest appreciation to thewww.Wiley.com/go/AHAGuidelineHandbook, as it American Heart Association for giving me thewill be sequentially updated with the latest statements opportunity to serve as Editor of this first edition ofand guideline news as well as providing succinct and “The AHA Guidelines and Scientific Statementshelpful bibliographies. Handbook”. Hopefully, this is the beginning of a In terms of format, the ACC/AHA Task Force on useful educational tool for the healthcare commu-Practice Guidelines have established schema for clas- nity and, most importantly, for the promotion ofsification of recommendations and level of evidence. cardiovascular health in our patients.x
  10. 10. Preface1. American Heart Association. Heart Disease and Stroke 4. LaBresh KA, Ellrod AG, Gliklich R, Lijestrand J, Peto R.Statistics–2008 Update. Dallas, Tex: American Heart Associa- Get with the guidelines for cardiovascular secondary preven-tion; 2008; Circulation. 2008;117:e25–e146. tion. Arch Intern Med. 2004;164:203–209.2. Jencks SF, Huff ED, Cuerdon T. Changes in the qualityof care delivered to Medicare beneficiaries, 1998–1999 to Valentin Fuster, MD, PhD2000–2001. JAMA. 2003;289:305–312. Past President American Heart Association3. Fox KAA, Goodman SG, Klein W, et al. Management of Past President World Heart Federationacute coronary syndromes: variation in practice and out- Director Mount Sinai Heart Center,come. Eur Heart J. 2002;23:1177–1189. New York, NYApplying Classification of Recommendations and Level of Evidence xi
  11. 11. Chronic Stable Angina 1 Theodore D. Fraker, Stephan D. Fihn, and Raymond J. GibbonsIntroductionClassification of angina pectoris IntroductionDemographics of angina pectoris Angina pectoris is a clinical syndrome characterizedPatients with new onset or changing anginal symptoms by discomfort in the chest, jaw, back or arm typicallyThe development of practice guidelinesAsymptomatic individuals aggravated by exertion or emotional stress andRecommendations for the management of patients with relieved by rest or nitroglycerin. Angina pectoris is chronic stable angina usually associated with epicardial coronary artery Diagnosis disease including one or more obstructions of A. History and physical examination greater than 70%, but it can also occur in patients B. Associated conditions with valvular heart disease, hypertrophic cardiomy- C. Noninvasive testing opathy, or uncontrolled hypertension. Symptoms D. Invasive testing: value of coronary angiography are thought to result from regional or global myo- Risk stratification cardial ischemia due to mismatch between myocar- A. Clinical evaluation dial oxygen supply and demand (Table 1.1). In B. Noninvasive testing women, angina pectoris can be seen in the absence C. Use of exercise test results in patient management D. Coronary angiography and left ventriculography of obvious epicardial coronary artery obstruction Treatment or other cardiac pathology, presumably due to A. Pharmacologic therapy coronary artery endothelial dysfunction or other Coronary disease risk factors and evidence that factors. Chronic stable angina refers to anginal treatment can reduce the risk for coronary symptoms that occur daily, weekly or less frequently disease events and are typically predictable and reproducible Patient follow-up: monitoring of symptoms and anti- [1–4]. anginal therapyFuture issues Special consideration for women New information on percutaneous revascularization to Classification of angina pectoris be considered for the next chronic stable angina Chest discomfort can be described as typical angina, guideline atypical angina or non-anginal chest pain, depend- New therapeutic agents to be considered for the next chronic stable angina guideline ing upon whether or not symptoms occur with increased myocardial oxygen demand and are relieved by rest or nitroglycerin. Typical angina is usually described as a sensation of chest tightness, heaviness, pressure, burning or squeezing some- times accompanied by radiation to the inner arm,The AHA Guidelines and Scientific Statements Handbook jaw, back or epigastrium. What makes the discom-Edited by Valentin Fuster © 2009 American Heart Association fort “typical” is the predictable relationship toISBN: 978-1-405-18463-2 increased activity (implying increased myocardial 1
  12. 12. The AHA Guidelines and Scientific Statements HandbookTable 1.1 Conditions provoking or exacerbating ischemiaIncreased oxygen demand Decreased oxygen supplyNoncardiac Noncardiac Hyperthermia Anemia Hyperthyroidism Hypoxemia Sympathomimetic toxicity (e.g., cocaine use) Pneumonia Hypertension Asthma Anxiety Chronic obstructive pulmonary disease Arteriovenous fistulae Pulmonary hypertension Interstitial pulmonary fibrosisCardiac Obstructive sleep apnea Hypertrophic cardiomyopathy Sickle cell disease Aortic stenosis Sympathomimetic toxicity (e.g., cocaine use) Dilated cardiomyopathy Hyperviscosity Tachycardia Polycythemia Ventricular Leukemia Supraventricular Thrombocytosis Hypergammaglobulinemia Cardiac Aortic stenosis Hypertrophic cardiomyopathyoxygen consumption) and subsequent relief with Table 1.2 Clinical classification of chest painrest or NTG (Table 1.2). The severity of angina pectoris is customarily Typical angina (definite)described using the Canadian Cardiovascular Society (1) Substernal chest discomfort with a characteristic quality andClassification System (Table 1.3). duration that is (2) provoked by exertion or emotional stress and (3) relieved by rest or NTG. Atypical angina (probable)Demographics of angina pectoris Meets two of the above characteristics.Coronary artery disease, the principal cause of Noncardiac chest painangina pectoris, is thought to be present in 13,200,000 Meets one or none of the typical anginal characteristics.American adults, about half of whom (6,500,000 or Modified from Diamond, IACC, 1983.3.8% of the population) have angina pectoris orchest pain [4]. The incidence of stable angina isabout 400,000 persons per year and there are anestimated 63,000 hospital discharges per year (2003)[4]. The annual mortality rate is hard to assess in the mortality rate ranges from 0.9–1.4 % and the annualUS since angina pectoris is rarely listed on death incidence of non-fatal MI ranges from 0.5–2.6% [3].certificates as the cause of death. Data from the Only about 20% of cardiac events are preceded byEuropean Society of Cardiology estimates the annual long-standing angina [4].2
  13. 13. Chapter 1 Chronic Stable AnginaTable 1.3 Grading of angina pectoris by the Canadian Cardiovascular Society Classification SystemClass IOrdinary physical activity does not cause angina, such as walking, climbing stairs. Angina (occurs) with strenuous, rapid or prolongedexertion at work or recreation.Class IISlight limitation of ordinary activity. Angina occurs on walking or climbing stairs rapidly, walking uphill, walking or stair climbing after meals,or in cold, or in wind, or under emotional stress, or only during the few hours after awakening. Angina occurs on walking more than 2 blockson the level and climbing more than one flight of ordinary stairs at a normal pace and in normal condition.Class IIIMarked limitations of ordinary physical activity. Angina occurs on walking one to two blocks on the level and climbing one flight of stairs innormal conditions at a normal pace.Class IVInability to carry on any physical activity without discomfort – anginal symptoms may be present at rest.Source: Campeau L. Grading of angina pectoris [letter]. Circulation, 1976;54:522–523. Copyright © 1976. American Heart Association. Inc. Reprinted withpermission. Chronic Stable Guideline to be consistent with thePatients with new onset or changing AHA/ACC Guidelines for Secondary Prevention foranginal symptoms Patients with Coronary and Other AtheroscleroticPatients who present with a history of angina that has Vascular Disease. In 2006, the European Society ofrecently started or has changed in frequency, severity Cardiology [3] published its own guideline whichor pattern are often classified as having unstable differs somewhat from the ACC/AHA guideline. Bothangina. These patients can be subdivided by their sets of guidelines will be considered in this chapter.short-term risk of death (Table 1.4). Patients at high The Classification of Recommendations (COR)or moderate risk often have an acute coronary syn- and Level of Evidence (LOE) are expressed in thedrome caused by coronary artery plaques that have ACC/AHA/ESC format (see table in front of book).ruptured. Their risk of death is intermediate, between These recommendations are evidence-based fromthat of patients with acute MI and patients with stable published data where applicable.angina. The initial evaluation of high- or moderate-risk patients with unstable angina is best carried out Asymptomatic individualsin the inpatient setting. However, low-risk patientswith unstable angina have a short-term risk similar to This chapter and the recommendations that followthat of patients with stable angina. Their evaluation are intended to apply to symptomatic patients.can be accomplished safely and expeditiously in an These were the focus of the original 1999 guideline.outpatient setting. The recommendations made in The 2002 update included additional sections andthese guidelines do not apply to patients with high- or recommendations for asymptomatic patients withmoderate-risk unstable angina but are applicable to known or suspected coronary artery disease (CAD).the low-risk unstable angina group. Such individuals are often identified on the basis of evidence of a previous myocardial infarction by history and/or electrocardiographic changes, coro-The development of practice guidelines nary angiography, or an abnormal noninvasive test,The American College of Cardiology/American Heart including coronary calcification on computedAssociation Task Force on Practice Guidelines met in tomography (CT). Multiple ACC/AHA guidelines,2001 and 2002 to update the 1999 Guidelines for the scientific statements and expert consensus docu-Management of Patients with Chronic Stable Angina. ments have discouraged the use of noninvasive tests,This guideline was published in 2003. In 2007, a sub- including ambulatory monitoring, treadmill testing,group of the writing committee updated the 2002 stress echocardiography, stress myocardial perfu- 3
  14. 14. The AHA Guidelines and Scientific Statements HandbookTable 1.4 Short-term risk of death or nonfatal myocardial infarction in patients with unstable anginaHigh risk Intermediate risk Low riskAt least one of the following features must No high-risk features but must have any of No high- or intermediate-risk feature but be present: the following: may have any of the following:Prolonged ongoing (>20 min) rest pain Prolonged (>20 min) rest angina, now Increased angina frequency, severity, or resolved, with moderate or high likelihood duration of CADPulmonary edema, most likely related to Rest angina (>20 min or relieved with Angina provoked at a lower threshold ischemia sublingual nitroglycerin)Angina at rest with dynamic ST changes Nocturnal angina New onset angina with onset 2 weeks to ≥1 mm 2 months prior to presentationAngina with new or worsening MR murmur Angina with dynamic T-ware changes Normal or unchanged ECGAngina with S3 or new/worsening rales New onset CCSC III or IV angina in the past 2 weeks with moderate or high likelihood of CADAngina with hypotension Pathologic Q waves or resting ST depression ≤1 mm in multiple lead groups (anterior, inferior, lateral) Age >65 yearsCCSC indicates Canadian Cardiovascular Society Classification.Note: Estimation of the short-term risks of death and nonfatal MI in unstable angina is a complex multivariable problem that cannot be fully specified in a table suchas this. Therefore, the table is meant to offer general guidance and illustration rather than rigid algorithms.sion, and CT, in asymptomatic individuals. Their Diagnosisinclusion in the 2002 guideline did not represent an A. History and physical examinationendorsement of such tests for the purposes of screen- Recommendationing, but rather an acknowledgment of the clinical Class Ireality that asymptomatic patients may present for In patients presenting with chest pain, a detailedfurther evaluation after abnormal tests. In general, symptom history, focused physical examination, andthe recommendations that appeared in the 2002 directed risk-factor assessment should be performed.update for asymptomatic individuals were qualita- With this information, the clinician should estimatetively similar to those that appear here for symptom- the probability of significant CAD (i.e., low (i.e.,atic patients. In some cases, either the class of the ≤5%), intermediate (>5% and <90%), or highrecommendation or the level of evidence, or both, [≥90%]) (Tables 1.5 and 1.6). (Level of Evidence:were lower for asymptomatic patients. Interested B)readers may consult the 2002 guideline update oneither the ACC or AHA website (www.american- B. Associated conditionsheart.org or www.acc.org). Recommendations for initial laboratory tests for diagnosis Class IRecommendations for the management of 1 Hemoglobin. (Level of Evidence: C)patients with chronic stable angina 2 Fasting glucose. (Level of Evidence: C; B)Note: Recommendations in black are from the 3 Fasting lipid panel, including total cholesterol,ACC/AHA guideline and recommendations in high density lipoprotein (HDL) cholesterol, triglyc-purple are from the European Society of Cardio- erides, and calculated low-density lipoprotein (LDL)logy guideline. cholesterol. (Level of Evidence: C; B)4
  15. 15. Chapter 1 Chronic Stable AnginaTable 1.5 Pretest likelihood of CAD in symptomatic patients according to age and sex* (combined Diamond/Forrester and CASS Data) Nonanginal Chest pain Atypical angina Typical anginaAge (years) Men Women Men Women Men Women30–39 4 2 34 12 76 2640-49 13 3 51 22 87 5550–59 20 7 65 31 93 7360–69 27 14 72 51 94 86* Each value represents the percent with significant CAD on catheterization.Table 1.6 Comparing pretest likelihoods of CAD in low-risk symptomatic patients with high-risk symptomatic patients – Duke Database Nonanginal Chest pain Atypical angina Typical anginaAge (years) Men Women Men Women Men Women35 y 3–35 1–19 8–59 2–39 30–88 10–7845 y 9–47 2–22 21–70 5–43 51–92 20–7955 y 23–59 4–25 45–79 10–47 80–95 38–8265 y 49–69 9–29 71–86 20–51 93–97 56–84Each value represents the percent with significant CAD. The first is the percentage for a low-risk, mid-decade patient without diabetes, smoking, or hyperlipidemia.The second is that of the same age patient with diabetes, smoking, and hypelipidemia. Both high- and low-risk patients have normal resting ECGs. If ST-T-wavechanges or Q waves had been present, the likelihood of CAD would be higher in each entry of the table.4 Full blood count including Hb and white cell C. Noninvasive testingcount (Level of Evidence: B) 1. ECG/chest X-ray: Recommendations for5 Creatinine (Level of Evidence: C) electrocardiography, chest X-ray, or electron-beam6 Markers of myocardial damage if evaluation sug- computed tomography in the diagnosis of chronicgests clinical instability or acute coronary syndrome stable angina(Level of Evidence: A) Class I7 Thyroid function if clinically indicated (Level of 1 A rest ECG in patients without an obvious non-Evidence: C) cardiac cause of chest pain is recommended. (Level of Evidence: B)Class IIa 2 A rest ECG during an episode of chest pain isOral glucose tolerance test (Level of Evidence: B) recommended. (Level of Evidence: B)Class IIb 3 A chest X-ray in patients with signs or symptoms1 Hs C-reactive protein (Level of Evidence: B) of congestive heart failure (CHF), valvular heart2 Lipoprotein a, ApoA, and ApoB (Level of disease, pericardial disease, or aortic dissection/Evidence: B) aneurysm is recommended. (Level of Evidence:3 Homocysteine (Level of Evidence: B) B)4 HbA1c (Level of Evidence: B) 4 A resting ECG is recommended while the patient5 NT-BNP (Level of Evidence: B) is pain-free. (Level of Evidence: C) 5
  16. 16. The AHA Guidelines and Scientific Statements HandbookClass IIa Class IIIA chest X-ray in patients with signs or symptoms of 1 Exercise ECG is not recommended in patientspulmonary disease is reasonable. (Level of Evidence: with the following baseline ECG abnormalities.B) a. Pre-excitation (Wolff–Parkinson–White) syn- drome. (Level of Evidence: B)Class IIb b. Electronically paced ventricular rhythm. (Level1 A chest X-ray in other patients may be consid- of Evidence: B)ered. (Level of Evidence: C) c. More than 1 mm of ST depression at rest.2 Electron-beam computed tomography may be (Level of Evidence: B)considered. (Level of Evidence: B) d. Complete left bundle-branch block. (Level of3 A routine periodic ECG in the absence of clinical Evidence: B)change may be considered. (Level of Evidence: 2 Exercise ECG is not recommended in patientsC) with an established diagnosis of CAD owing to prior MI or coronary angiography; however, testing can assess functional capacity and pro-2. Recommendations for diagnosis of obstructive gnosis, as discussed in Section III. (Level of Evidence:CAD with exercise ECG testing without an imaging B)modalityClass IExercise ECG is recommended in patients with an 3. Echocardiography: Recommendations forintermediate pretest probability of CAD (>5% and echocardiography for diagnosis of cause of chest<90%) based on age, gender, and symptoms, includ- pain in patients with suspected chronic stableing those with complete right bundle-branch block angina pectorisor less than 1 mm of ST depression at rest (excep- Class Itions are listed below in classes II and III). (Level of 1 Echocardiography is recommended for patientsEvidence: B) (See Tables 1.5 and 1.6). with systolic murmur suggestive of aortic stenosis or hypertrophic cardiomyopathy (Level of Evidence:Class IIa C, B)Exercise ECG is reasonable in patients with 2 Echocardiography is recommended for evalua-suspected vasospastic angina. (Level of Evidence: tion of extent (severity) of ischemia (e.g., LVC) segmental wall-motion abnormality) when the echocardiogram can be obtained during pain or within 30 min after its abatement. (Level of Evidence:Class IIb C)1 Exercise ECG may be considered in patients with 3 Echocardiography is recommended for patientsa high pretest probability of CAD by age, gender, with suspected heart failure (Level of Evidence:and symptoms. (Level of Evidence: B) B).2 Exercise ECG may be considered in patients with 4 Echocardiography is recommended for patientsa low pretest probability of CAD by age, gender, and with prior MI (Level of Evidence: B).symptoms. (Level of Evidence: B) 5 Echocardiography is recommended for patients3 Exercise ECG may be considered in patients with LBBB, Q waves or other significant patho-taking digoxin whose ECG has less than 1 mm of logical changes on ECG, including electrocardio-baseline ST-segment depression. (Level of Evidence: graphic left anterior hemiblock (Level ofB) Evidence: C).4 Exercise ECG may be considered in patients withECG criteria for LVH and less than 1 mm of baselineST-segment depression. (Level of Evidence: B) Class IIb5 Routine periodic exercise ECG may be reasonable Echocardiography may be considered in patientsin the absence of clinical change. (Level of Evidence: with a click or murmur to diagnose mitral valveC) prolapse [15]. (Level of Evidence: C)6
  17. 17. Chapter 1 Chronic Stable AnginaTable 1.7 Comparative advantages of stress echocardiography 3 Adenosine or dipyridamole myocardial perfusionand stress radionuclide perfusion imaging in diagnosis of CAD imaging is recommended in patients with an inter- mediate pretest probability of CAD and one of theAdvantages of stress echocardiography following baseline ECG abnormalities: 1. Higher specificity a. Electronically paced ventricular rhythm. (Level 2. Versatility – more extensive evaluation of cardiac anatomy of Evidence: C) and function b. Left bundle-branch block. (Level of Evidence: 3. Greater convenience/efficacy/availability B) 4. Lower cost 4 Exercise myocardial perfusion imaging or exer- cise echocardiography is recommended in patientsAdvantages of stress perfusion imaging with a non-conclusive exercise ECG but reason- 1. Higher technical success rate able exercise tolerance, who do not have a high 2. Higher sensitivity – especially for single vessel coronary probability of significant coronary disease and in disease involving the left circumflex whom the diagnosis is still in doubt. (Level of 3. Better accuracy in evaluating possible ischemia when multiple Evidence: B) resting IV wall motion abnormalities are present 4. More extensive published database – especially in evaluation Class IIa of prognosis Exercise myocardial perfusion imaging or exercise echocardiography is reasonable in the following circumstances: 1 Patients with prior revascularization (PCI orClass III CABG) in whom localization of ischaemia is impor-Echocardiography is not recommended in patients tant. (Level of evidence: B)with a normal ECG, no history of MI, and no signs 2 As an alternative to exercise ECG in patientsor symptoms suggestive of heart failure, valvular where facilities, costs, and personnel resources allow.heart disease, or hypertrophic cardiomyopathy. (Level of evidence: B)(Level of Evidence: C) 3 As an alternative to exercise ECG in patients with a low pre-test probability of disease such as women with atypical chest pain. (Level of Evidence: B)4. Stress imaging studies: echocardiographic and 4 To assess functional severity of intermediatenuclear recommendations for cardiac stress imaging lesions on coronary arteriography. (Level of Evi-as the initial test for diagnosis in patients with dence: C)chronic stable angina who are able to exercise 5 To localize ischaemia when planning revascular-See Table 1.7. ization options in patients who have already hadClass I arteriography. (Level of Evidence: B)1 Exercise myocardial perfusion imaging or exer- 6 Pharmacological stress imaging techniques [eithercise echocardiography is recommended in patients echocardiography or perfusion] are reasonable withwith an intermediate pretest probability of CAD the same Class I indications outlined above, wherewho have one of the following baseline ECG local facilities favor pharmacologic rather than exer-abnormalities: cise stress. (Level of Evidence: B) a. Pre-excitation (Wolff–Parkinson–White) syn- drome. (Level of Evidence: B) Class IIb b. More than 1 mm of ST depression at rest. 1 Exercise myocardial perfusion imaging or exer- (Level of Evidence: B) cise echocardiography may be considered in patients2 Exercise myocardial perfusion imaging or exer- with a low or high probability of CAD who have onecise echocardiography is recommended in patients of the following baseline ECG abnormalities:with prior revascularization (either PCI or CABG). a. Pre-excitation (Wolff–Parkinson–White) syn-(Level of Evidence: B) drome. (Level of Evidence: B) 7
  18. 18. The AHA Guidelines and Scientific Statements Handbook b. More than 1 mm of ST depression. (Level of Class IIb Evidence: B) 1 Adenosine or dipyridamole stress myocardial per-2 Adenosine or dipyridamole myocardial perfusion fusion imaging or dobutamine echocardiographyimaging may be considered in patients with a low or may be considered in patients with a low or highhigh probability of CAD and one of the following probability of CAD in the absence of electronicallybaseline ECG abnormalities: paced ventricular rhythm or left bundle-branch a. Electronically paced ventricular rhythm. (Level block. (Level of Evidence: B) of Evidence: C) 2 Adenosine or dipyridamole myocardial perfusion b. Left bundle-branch block. (Level of Evidence: imaging may be considered in patients with a low or B) a high probability of CAD and one of the following3 Exercise myocardial perfusion imaging or exer- baseline ECG abnormalities:cise echocardiography may be considered in patients a. Electronically paced ventricular rhythm. (Levelwith an intermediate probability of CAD who have of Evidence: C)one of the following: b. Left bundle-branch block. (Level of Evidence: a. Digoxin use with less than 1 mm ST depression B) on the baseline ECG. (Level of Evidence: 3 Dobutamine echocardiography in patients with B) left bundle-branch block. (Level of Evidence: C) b. LVH with less than 1 mm ST depression on the baseline ECG. (Level of Evidence: B) 6. Recommendations for ambulatory ECG for4 Exercise myocardial perfusion imaging, exercise initial diagnostic assessment of anginaechocardiography, adenosine or dipyridamole myo- Class Icardial perfusion imaging, or dobutamine echocar- An ambulatory ECG is recommended for anginadiography may be considered as the initial stress test with suspected arrhythmia. (Level of Evidence:in a patient with a normal rest ECG who is not B)taking digoxin. (Level of Evidence: B)5 Exercise or dobutamine echocardiography may Class IIabe considered in patients with left bundle-branch An ambulatory ECG may be reasonable for sus-block. (Level of Evidence: C) pected vasospastic angina. (Level of Evidence: C)5. Recommendations for cardiac stress imaging asthe initial test for diagnosis in patients with chronic 7. Recommendations for the use of CTstable angina who are unable to exercise angiography in stable angina(Pharmacological stress with imaging techniques Class IIb[either echocardiography or perfusion] is recom- CT angiography may be considered in patients withmended in the initial assessment of angina with a low pre-test probability of disease, with a noncon-the same Class I, IIa and IIb indications outlined clusive exercise ECG or stress imaging test. (Level ofabove, if the patient is unable to exercise Evidence: C)adequately.) D. Invasive testing: value of coronaryClass I angiography1 Adenosine or dipyridamole myocardial perfusion Recommendations for coronary angiography toimaging or dobutamine echocardiography is recom- establish a diagnosis in patients with suspectedmended in patients with an intermediate pretest angina, including those with known CAD who haveprobability of CAD. (Level of Evidence: B) a significant change in anginal symptoms2 Adenosine or dipyridamole stress myocardial per- Class Ifusion imaging or dobutamine echocardiography 1 Coronary angiography is recommended inis recommended in patients with prior revascul- patients with known or possible angina pectoris whoarization (either PCI or CABG). (Level of have survived sudden cardiac death. (Level of Evi-Evidence: B) dence: B)8
  19. 19. Chapter 1 Chronic Stable Angina2 Coronary angiography is recommended in Class IIbpatients with severe stable angina (Class 3 or 1 Coronary angiography may be considered ingreater of Canadian Cardiovascular Society Classifi- patients with recurrent hospitalization for chest paincation, with a high pre-test probability of disease, in whom a definite diagnosis is judged necessary.particularly if the symptoms are inadequately (Level of Evidence: C)responding to medical treatment.) (Level of Evi- 2 Coronary angiography may be considered indence: B) patients with an overriding desire for a definitive3 Coronary angiography is recommended in diagnosis and a greater-than-low probability ofpatients with serious ventricular arrhythmias. (Level CAD. (Level of Evidence: C)of Evidence: C)4 Coronary angiography is recommended in Class IIIpatients previously treated by myocardial revascu- 1 Coronary angiography is not recommended inlarization (PCI, CABG), who develop early recur- patients with significant comorbidity in whom therence of moderate or severe angina pectoris. (Level risk of coronary arteriography outweighs the benefitof Evidence: C) of the procedure. (Level of Evidence: C) 2 Coronary angiography is not recommended in patients with an overriding personal desire for aClass IIa definitive diagnosis and a low probability of CAD.1 Coronary angiography is reasonable in patients (Level of Evidence: C)with an uncertain diagnosis after noninvasive testingin whom the benefit of a more certain diagnosisoutweighs the risk and cost of coronary angiogra-phy. (Level of Evidence: C) Risk stratification2 Coronary angiography is reasonable in patients The recommendations that follow are for risk strati-who cannot undergo noninvasive testing because of fication by clinical evaluation, including ECG anddisability, illness, or morbid obesity. (Level of Evi- laboratory tests, in stable angina.dence: C)3 Coronary angiography is reasonable in patientswith an occupational requirement for a definitive A. Clinical evaluationdiagnosis. (Level of Evidence: C) Class I4 Coronary angiography is reasonable in patients 1 A detailed clinical history and physical examina-who by virtue of young age at onset of symptoms, tion is recommended including BMI and/or waistnoninvasive imaging, or other clinical parameters circumference in all patients, also including aare suspected of having a nonatherosclerotic cause full description of symptoms, quantification offor myocardial ischemia (coronary artery anomaly, functional impairment, past medical history, andKawasaki disease, primary coronary artery dissec- cardiovascular risk profile. (Level of Evidence: B)tion, radiation-induced vasculopathy). (Level of Evi- (Figure 1.1).dence: C) 2 Resting ECG in all patients is recommended.5 Coronary angiography is reasonable in patients (Level of Evidence: B)in whom coronary artery spasm is suspected andprovocative testing may be necessary. (Level ofEvidence: C) B. Noninvasive testing6 Coronary angiography is reasonable in patients Recommendations for measurement of rest LVwith a high pretest probability of left main or three- function by echocardiography or radionuclidevessel CAD. (Level of Evidence: C) angiography in patients with chronic stable angina7 Coronary angiography is reasonable in patients Class Iwith a high risk of restenosis after PCI, if PCI has 1 Echocardiography or RNA is recommended inbeen performed in a prognostically important site. patients with a history of prior MI, pathologic Q(Level of Evidence: C) waves, or symptoms or signs suggestive of heart 9
  20. 20. The AHA Guidelines and Scientific Statements Handbook 1.0 and no symptoms or signs suggestive of CHF. (Level of Evidence: B)Predicted probability 0.8 0.6 Recommendations for exercise testing risk 0.4 assessment and prognosis in patients with an intermediate or high probability of CAD 0.2 Class I 0.0 1 Exercise testing is recommended in patients 30 35 40 45 50 55 60 65 70 75 80 undergoing initial evaluation. (Exceptions are listed Age, y below in Classes IIb and III) (Level of Evidence:Fig. 1.1 Nomogram showing the probability of severe (three- B)vessel or left main) coronary disease based on a five-point score. 2 Exercise testing is recommended in patients afterOne point is awarded for each of the following variables: male a significant change in cardiac symptoms. (Level ofgender, typical angina, history and electrocardiographic evidence of Evidence: C). (Tables 1.8, 1.9 and 1.10).myocardial infarction, diabetes and use of insulin. Each curveshows the probability of severe coronary disease as a function ofage. From Hubbard et al. with permission. Class IIa Exercise testing is reasonable in patients post- revascularization with a significant deterioration infailure to assess LV function. (Level of Evidence: symptomatic status. (Level of Evidence: B)B)2 Echocardiography is recommended in patients Class IIbwith a systolic murmur that suggests mitral regurgi- 1 Exercise testing may be considered in patientstation to assess its severity and etiology. (Level of with the following ECG abnormalities:Evidence: C) a. Pre-excitation (Wolff-Parkinson-White) syn-3 Echocardiography or RNA is recommended in drome. (Level of Evidence: B)patients with complex ventricular arrhythmias to b. Electronically paced ventricular rhythm. (Levelassess LV function. (Level of Evidence: B) of Evidence: B)4 Resting echocardiography is recommended in c. More than 1 mm of ST depression at rest.patients with hypertension. (Level of Evidence: (Level of Evidence: B)B) d. Complete left bundle-branch block. (Level of5 Resting echocardiography is recommended in Evidence: B)patients with diabetes. (Level of Evidence: C) 2 Exercise testing may be considered in patients who have undergone cardiac catheterization toClass IIa identify ischemia in the distribution of coronaryResting echocardiography is recommended in lesion of borderline severity. (Level of Evidence:patients with a normal resting ECG without prior C)MI who are not otherwise to be considered for coro- 3 Exercise testing may be considered in post-revas-nary arteriography. (Level of Evidence: C) cularization patients who have a significant change in anginal pattern suggestive of ischemia. (Level of Evidence: C)Class III1 Echocardiography or RNA is not recommendedfor routine periodic reassessment of stable patients Class IIIfor whom no new change in therapy is contem- Exercise testing is not recommended in patientsplated. (Level of Evidence: C) with severe comorbidity likely to limit life expec-2 Echocardiography or RNA is not recommended tancy or prevent revascularization. (Level of Evi-in patients with a normal ECG, no history of MI, dence: C)10
  21. 21. Chapter 1 Chronic Stable AnginaTable 1.8 Survival according to risk groups based on Duke Treadmill ScoresRisk group (score) Percentage of total Four-year survival Annual mortality (percent)Low (≥+5) 62 0.99 0.25Moderate (−10 to +4) 34 0.95 1.25High (<−10) 4 0.79 5.0The Duke treadmill score equals the exercise time in minutes minus (5 times the ST-segment deviation, during or after exercise, in millimeters).Table 1.9 Noninvasive risk stratificationHigh-risk (greater than 3% annual mortality rate) 1. Severe resting left ventricular dysfunction (LVEF < 35%) 2. High-risk treadmill score (score ≤−11) 3. Severe exercise left ventricular dysfunction (exercise LVEF < 35%) 4. Stress-induced large perfusion defect (particularly if anterior) 5. Stress-induced multiple perfusion defects of moderate size 6. Large, fixed perfusion defect with LV dilation or increased lung uptake (thallium-201) 7. Stress-induced moderate perfusion defect with LV dilation or increased lung uptake (thallium-201) 8. Echocardiographic wall motion abnormality (involving greater than two segments) developing at low dose of dobutamine (≤10 mg/kg/ min) or at a low heart rate (<120 beats/min) 9. Stress echocardiographic evidence of extensive ischemiaIntermediate-risk (1–3% annual mortality rate) 1. Mild/moderate resting left ventricular dysfunction (LVEF = 35% to 49%) 2. Intermediate-risk treadmill score (−11 < score < 5) 3. Stress-induced moderate perfusion defect without LV dilation or increased lung intake (thallium-201) 4. Limited stress echocardiographic ischemia with a wall motion abnormality only at higher doses of dobutamine involving less than or equal to two segmentsLow-risk (less than 1% annual mortality rate) 1. Low-risk treadmill score (score ≥5) 2. Normal or small myocardial perfusion defect at rest or with stress* 3. Normal stress echocardiographic wall motion or no change of limited resting wall motion abnormalities during stress** Although the published data are limited, patients with these findings will probably not be at low risk in the presence of either a high-risk treadmill score or severeresting left ventricular dysfunction (LVEF < 35%).C. Use of exercise test results in patient Recommendations for cardiac stress imaging as themanagement initial test for risk stratification of patients withRecommendation for exercise testing in patients chronic stable angina who are able to exercisewith chest pain 6 months or more after Class Irevascularization 1 Exercise myocardial perfusion imaging or exer-Class IIb cise echocardiography is recommended to identifyExercise testing may be considered in patients with the extent, severity, and location of ischemia ina significant change in anginal pattern suggestive of patients who do not have left bundle-branch blockischemia. (Level of Evidence: B) or an electronically paced ventricular rhythm and 11
  22. 22. The AHA Guidelines and Scientific Statements HandbookTable 1.10 CAD Prognostic IndexExtent of CAD Prognostic weight (0–100) 5-Year survival rate (%)*1-vessel disease, 75% 23 93>1-vessel disease, 50% to 74% 23 931-vessel disease, ≥95% 32 912-vessel disease 37 882-vessel disease, both ≥95% 42 861-vessel disease, ≥95% proximal LAD 48 832-vessel disease, ≥95% LAD 48 832-vessel disease, ≥95% proximal LAD 56 793-vessel disease 56 793-vessel disease, ≥95% m at least 1 63 733-vessel disease, 75% proximal LAD 67 673-vessel disease, ≥95% proximal LAD 74 59* Assuming medical treatment only. CAD indicates coronary artery disease; LAD, left anterior descending artery. From Califf RM, Armstrong PW. Carver JR, et al:Task Force 5. Stratification of patients into high-, medium- and low-risk subgroups for purposes of risk factor management. J Am Coll Cardiol.1996;27:964–1047.who either have an abnormal rest ECG or are using 3 Pharmacological stress imaging techniques [eitherdigoxin. (Level of Evidence: B) echocardiography or perfusion] are reasonable with2 Dipyridamole or adenosine myocardial perfusion the same Class I indications outlined above, whereimaging is recommended in patients with left local facilities favor pharmacologic rather than exer-bundle-branch block or electronically paced ven- cise stress (Level of Evidence: B)tricular rhythm. (Level of Evidence: B)3 Exercise myocardial perfusion imaging or exer- Class IIbcise echocardiography is recommended to assess the 1 Exercise or dobutamine echocardiography mayfunctional significance of coronary lesions (if not be considered in patients with left bundle-branchalready known) in planning PCI. (Level of Evidence: block. (Level of Evidence: C)B) 2 Exercise, dipyridamole, or adenosine myocardial4 Exercise myocardial perfusion imaging or exercise perfusion imaging, or exercise or dobutamine echo-echocardiography is recommended in patients with cardiography may be considered as the initial test ina non-conclusive exercise ECG, but intermediate or patients who have a normal rest ECG and who arehigh probability of disease. (Level of Evidence: B) not taking digoxin. (Level of Evidence: B)Class IIa Class III1 Exercise myocardial perfusion imaging or exer- 1 Exercise myocardial perfusion imaging is not rec-cise echocardiography is reasonable in patients with ommended in patients with left bundle-brancha deterioration in symptoms post-revascularization. block. (Level of Evidence: C)(Level of Evidence B) 2 Exercise, dipyridamole, or adenosine myocardial2 Exercise myocardial perfusion imaging or exer- perfusion imaging, or exercise or dobutamine echo-cise echocardiography is reasonable as an altern- cardiography is not recommended in patients withative to exercise ECG in patients, in which facilities, severe comorbidity likely to limit life expecta-cost, and personnel resources allow. (Level of Evi- tion or prevent revascularization. (Level of Evi-dence: B) dence: C)12
  23. 23. Chapter 1 Chronic Stable AnginaRecommendations for cardiac stress imaging as the Class IIIinitial test for risk stratification of patients with Dipyridamole or adenosine myocardial perfusionchronic stable angina who are unable to exercise imaging or dobutamine echocardiography is notClass I recommended in patients with severe comorbidity1 Dipyridamole or adenosine myocardial perfusion likely to limit life expectation or prevent revascular-imaging or dobutamine echocardiography is recom- ization. (Level of Evidence: C)mended to identify the extent, severity, and locationof ischemia in patients who do not have left bundle- D. Coronary angiography andbranch block or electronically paced ventricular left ventriculographyrhythm. (Level of Evidence: B) Recommendations for coronary angiography2 Dipyridamole or adenosine myocardial perfusion for risk stratification in patients with chronicimaging is recommended in patients with left stable anginabundle-branch block or electronically paced ven- See Figure 1.2.tricular rhythm. (Level of Evidence: B)3 Dipyridamole or adenosine myocardial perfusion Class Iimaging or dobutamine echocardiography is recom- 1 Coronary angiography is recommended inmended to assess the functional significance of coro- patients with disabling (Canadian Cardiovascularnary lesions (if not already known) in planning PCI. Society [CCS] classes III and IV) chronic stable(Level of Evidence: B) angina despite medical therapy. (Level of Evidence: B) (Table 1.11).Class IIb 2 Coronary angiography is recommended inDobutamine echocardiography may be considered patients with high-risk criteria on noninvasivein patients with left bundle-branch block. (Level of testing (Table 1.10) regardless of anginal severity.Evidence: C) (Level of Evidence: B) (Table 1.11). 50 Men %of men 40with 1-, 2-,3-vessel 30left main 20or no CAD N 1 2 3 1 2 3 1 2 3on coronary 10 LM N LM N LMangiography 0 Mild stable Disabling stable Progression effort angina angina angina 70 Women %of women 60 50 N Normal or <50%with 1-, 2-, Stenosis3-vessel N 40 1 1-vessel diseaseleft main 30 N N 2 2-vessel diseaseor no CAD 3 3-vessel disease 20on coronary 1 2 LM Left main diseaseangiography 10 1 2 3 LM 1 2 3 LM 0 Mild stable Disabling stable Progression effort angina angina anginaFig. 1.2 Coronary angiography findings in patients with chronic effort-induced angina pectoris. Top: Percentage of men with one-vessel,two-vessel, three-vessel, left main or no coronary artery disease on coronary angioraphy. Bottom: Percentage of women with one-vessel, two-vessel, three-vessel, left main, or no coronary artery disease on coronary angiography. N indicates normal or <50% stenosis; 1, one-vesseldisease; 2, two-vessel disease; 3, three-vessel disease; LM, left main disease. Data from Douglas and Hurst. 13
  24. 24. The AHA Guidelines and Scientific Statements HandbookTable 1.11 Properties of beta-blockers in clinical useDrugs Selectivity Partial agonist activity Usual dose for anginaPropranolol None No 20–80 mg twice dailyMetoprolol β1 No 50–200 mg twice dailyAtenolol β1 No 50–200 mg/dayNadolol None No 40–80 mg/dayTimolol None No 10 mg twice dailyAcebutolol β1 Yes 200–600 mg twice dailyBetaxolol β1 No 10–20 mg/dayBisoprolol β1 No 10 mg/dayEsmolol (intravenous) β1 No 50–300 mcg/kg/minLabetalol* None Yes 200–600 mg twice dailyPindolol None Yes 2.5–7.5 mg 3 times daily* Labetalol is a combined alpha- and β-blocker.3 Coronary angiography is recommended in Class IIbpatients with angina who have survived sudden 1 Coronary angiography may be considered incardiac death or serious ventricular arrhythmia. patients with CCS class I or II angina, preserved LV(Level of Evidence: B) function (ejection fraction greater than 45%), and4 Coronary angiography is recommended in less than high-risk criteria on noninvasive testing.patients with angina and symptoms and signs of (Level of Evidence: C)CHF. (Level of Evidence: C) 2 Coronary angiography may be considered in5 Coronary angiography is recommended in patients patients with CCS class III or IV angina, which withwith clinical characteristics that indicate a high likeli- medical therapy improves to class I or II. (Level ofhood of severe CAD. (Level of Evidence: C) Evidence: C)6 Coronary angiography is recommended in patients 3 Coronary angiography may be considered inwith stable angina in patients who are being considered patients with CCS class I or II angina but intolerancefor major noncardiac surgery, especially vascular (unacceptable side effects) to adequate medicalsurgery (repair of aortic aneurysm, femoral bypass, therapy. (Level of Evidence: C)carotid endarterectomy) with intermediate or high riskfeatures on noninvasive testing. (Level of Evidence: B) Class III 1 Coronary angiography is not recommended inClass IIa patients with CCS class I or II angina who respond to1 Coronary angiography is reasonable in patients medical therapy and who have no evidence of isch-with significant LV dysfunction (ejection fraction emia on noninvasive testing. (Level of Evidence: C)less than 45%), CCS class I or II angina, and demon- 2 Coronary angiography is not recommended instrable ischemia but less than high-risk criteria on patients who prefer to avoid revascularization. (Levelnoninvasive testing. (Level of Evidence: C) of Evidence: C)2 Coronary angiography is reasonable in patientswith inadequate prognostic information after non-invasive testing. (Level of Evidence: C) Recommendations for investigation in patients with3 Coronary angiography is reasonable in patients the classical triad of Syndrome Xwith a high risk of restenosis after PCI, if PCI has Class Ibeen performed in a prognostically important site. A resting echocardiogram is recommended in(Level of Evidence: C) patients with angina and normal or non-obstructed14
  25. 25. Chapter 1 Chronic Stable Anginacoronary arteries to assess for presence of ventricu- indefinitely in all patients unless contraindicated.lar hypertrophy and/or diastolic dysfunction. (Level (Level of Evidence: A)of Evidence: C) 2 Beta-blockers as initial therapy is recommended to reduce symptoms in the absence of contraindica-Class IIb tions in patients with prior MI (Level of Evidence: A)1 Intracoronary acetylcholine is reasonable during or without prior MI. (Level of Evidence: B)coronary arteriography, if the arteriogram is visually Test the effects of a beta-1 blocker, and titrate to fullnormal, to assess endothelium dependent coronary dose; consider the need for 24 h protection againstflow reserve, and exclude vasospasm. (Level of Evi- ischemia. (Level of Evidence: A) (Table 1.12).dence: C) 3 It is beneficial to start and continue beta-blocker2 Intracoronary ultrasound, coronary flow reserve, therapy indefinitely in all patients who have had MI,or fractional flow reserve are reasonable measure- acute coronary syndrome, or left ventricular dys-ments to exclude missed obstructive lesions, if function with or without heart failure symptoms,angiographic appearances are suggestive of unless contraindicated. (Level of Evidence: A)a non-obstructive lesion rather than completely 4 ACE inhibitors should be started and continuednormal, and stress imaging techniques identify an indefinitely in all patients with left ventricular ejec-extensive area of ischaemia. (Level of Evidence: C) tion fraction less than or equal to 40% and in those with hypertension, diabetes, or chronic kidney diseaseTreatment unless contraindicated. (Level of Evidence: A)A. Pharmacologic therapy 5 ACE inhibitors should be started and continuedRecommendations for pharmacotherapy to prevent indefinitely in patients who are not lower risk (lowerMI and death and to reduce symptoms risk defined as those with normal left ventricular ejec-Class I tion fraction in whom cardiovascular risk factors are1 Aspirin should be started at 75 to 162 mg per day well controlled and revascularization has been per-(75 mg per day in ESC guideline) and continued formed), unless contraindicated. (Level of Evidence: B)Table 1.12 Nitroglycerin and nitrates in anginaCompound Route Dose Duration of effectNitroglycerin Sublingual tablets 0.3–0.6 mg up to 1.5 mg 11/2–7 min Spray 0.4 mg as needed Similar to sublingual tablets Ointment 2% 6 × 6 in., 15 × 15 cm 7.5–40 mg Effect up to 7 h Transdermal 0.2–0.8 mg/h every 12 h 8–12 h during intermittent therapy Oral sustained release 2.5–13 mg 4–8 h Buccal 1–3 mg 3 times daily 3–5 h Intravenous 5–200 mcg/min Tolerance in 7–8 hIsosorbide dinitrate Sublingual 2.5–15 mg Up to 60 min Oral 5–80 mg, 2–3 times daily Up to 8 h Spray 1.25 mg daily 2–3 min Chewable 5 mg 2–21/2 h Oral slow release 40 mg 1–2 daily Up to 8 h Intravenous 1.25–5.0 mg/h Tolerance in 7–8 h Ointment 100 mg/24 h Not effectiveIsosorbide mononitrate Oral 20 mg twice daily 12–24 h 60–240 mg once dailyPentaerythritol tetranitrate Sublingual 10 mg as needed Not knownErythritol tetranitrate Sublingual 5–10 mg as needed Not known Oral 10–30 3 times daily Not known 15

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