GIBBONS
ET AL., MANAGEMENT OF PATIENTS WITH CHRONIC STABLE ANGINA UPDATE
http://www.acc.org/clinical/guidelines/stable/update_index.htm
ACC/AHA
2002 Guideline Update for the Management of Patients With Unstable
Angina and Non-ST-Segment Elevation Myocardial Infarction
A
Report of the American College of Cardiology/American Heart Association
Task Force on Practice Guidelines (Committee on the Management of
Patients With Unstable Angina)
This
is a Guideline Update of the 2000 Unstable Angina Guidelines. To
highlight the changes, deleted text is indicated by strikeout, and
revised text is presented in brown. A clean version of the document,
with changes fully incorporated, is available for download and print.
Figures
Figure
1. Map depicting coronary angiography rates in the U.S.
HRR = hospital referral region. From Wennberg et al. (11)
with permission.
Figure 2. Clinical assessment.
MI indicates myocardial infarction; LDL, low-density lipoprotein;
ACE, angiotensin-converting enzyme; PCI, percutaneous coronary intervention;
CABG, coronary artery bypass graft; ACC, American College of Cardiology;
AHA, American Heart Association;LV, left ventricular; and ECG,electrocardiogram.
Figure 3. Stress testing/angiography.
ECG indicates electrocardiogram.
Figure 4. Treatment. CAD indicates
coronary artery disease; NTG, nitroglycerin; MI, myocardial infarction;
NCEP, National Cholesterol Education Program; JNC, Joint National
Committee. *Conditions that exacerbate or provoke angina are medications
(vasodilators, excessive thyroid replacement, and vasoconstrictors),
other cardiac problems (tachyarrhythmias, bradyarrhythmias, valvular
heart disease, especially aortic stenosis), and other medical problems
(hypertrophic, cardiomyopathy, profound anemia, uncontrolled hypertension,
hyperthyroidism, hypoxemia). **At any point in this process, based
on coronary anatomy, severity of anginal symptoms, and patient preferences,
it is reasonable to consider evaluation for coronary revascularization.
Unless a patient is documented to have left main, three-vessel,
or two-vessel coronary artery disease with significant stenosis
of the proximal left anterior descending coronary artery, there
is no demonstrated survival advantage associated with revascularization
in low-risk patients with chronic stable angina; thus, medical therapy
should be attempted in most patients before considering percutaneous
coronary intervention or coronary artery bypass grafting.
Figure 5. Treatment mnemonic: the
10 most important elements of stable angina management.
Figure 6. 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, onevessel disease; two,
2-vessel disease; three, 3-vessel disease; LM, left main disease.
Data from Douglas and Hurst (333).
Figure 7. Nomogram showing the
probability of severe (three-vessel or left main) coronary disease
based on a five-point score. One point is awarded for each of the
following variables: male gender, typical angina, history and electrocardiographic
evidence of myocardial infarction, diabetes and use of insulin.
Each curve shows the probability of severe coronary disease as a
function of age. From Hubbard et al. (135),
with permission.
Figure 8. Nomogram for prediction
of five-year survival from clinical, physical examination and cardiac
catheterization findings. Asymp indicates asymptomatic; CAD, coronary
artery disease; MI, myocardial infarction; and Symp, symptomatic.
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.
Figure 9. Beta-blockers versus
calcium antagonists: angina relief. Source: Heidenreich PA, for
the UCSF-Stanford Evidence-based Practice Center (AHCPR).
Figure 10 . Beta-blockers versus
calcium antagonists: exercise time to 1-mm ST depression. The Subramanian
article reported similar information to the Bowles article. Source:
Heidenreich PA, for the UCSF-Stanford Evidence-based Practice Center
(AHCPR).
Figure 11 . This figure has been
updated to reflect this new information and the use of clopidogrel
as an alternative to aspirin when the latter is contraindicated.Reprinted
with permission from Smith et al. (1052).
Figure 12 . Pooled risk ratios
for various end points from six randomized controlled trials comparing
percutaneous transluminal coronary angioplasty (PTCA) with medical
treatment in patients with nonacute coronary heart disease. CABG
indicates coronary artery bypass grafting. n = 953 for PTCA and
951 for medical treatment. Reprinted with permission from Bucher
C, et al., Percutaneous transluminal coronary angioplasty versus
medical treatment for non-acute coronary heart disease: meta-analysis
of randomised controlled trials. BMJ 2000;321:73-77 (1027).
Tables
Table
1. Recent Clinical Practice Guidelines and Policy Statements
That Overlap With This Guideline
Table 2. Death Rates Due to Diseases
of the Heart and Cancer,United States–1995
Table 3. Medicare Experience With
Commonly Used DRGs Involving Patients With Stable Angina
Table 4. Medicare Fees and Volumes
of Commonly Used Diagnostic Procedures for Chronic Stable Angina
Table 5. Clinical
Classification of Chest Pain
Table
6. Three Principal Presentations of
Unstable Angina (2,893)
Table
7. Grading of Angina Pectoris by the Canadian Cardiovascular
Society Classification System (46)
Table
8. Short-Term Risk of Death or Nonfatal Myocardial Infarction
in Patients With Unstable Angina (2,893)
Table
9. Pretest Likelihood of CAD in Symptomatic Patients According
to Age and Sex* (Combined Diamond/Forrester and CASS Data) (38,42)
Table 10. Comparing Pretest Likelihoods
of CAD in Low-Risk Symptomatic Patients With High-Risk Symptomatic
Patients—Duke Database (41)
Table
11. Alternative Diagnoses to Angina for Patients With Chest
Pain
Table 12. Conditions Provoking
or Exacerbating Ischemia
Table 13. Exercise SPECT Scintigraphy—Without
Correction for Referral Bias
Table 14. Exercise Echocardiography—Without
Correction for Referral Bias
Table
15. Adenosine SPECT Scintigraphy—Without Correction
for Referral Bias
Table 16. Dobutamine Echocardiography—Without
Correction for Referral Bias
Table 17. Noninvasive Tests Before
and After Adjustment for Referral Bias
Table 18.
Comparative Advantages of Stress Echocardiography and Stress Radionuclide
Perfusion Imaging in Diagnosis of CAD
Table 19. Studies Examining the
Incremental Value of Exercise Imaging Studies for the Prediction
of Severe CAD and Subsequent Cardiac Events in Patients With a Normal
Resting ECG*
Table 20. Survival
According to Risk Groups Based on Duke Treadmill Scores
Table 21.
Prognostic
Value of Stress Myocardial Imaging in Definite or Suspected Chronic
Stable Angina
Table 22. Prognostic Value of Stress
Echocardiography in Definite or Suspected Coronary Heart Disease
(Studies With n > 100, Not Recent MI, Both Positive/Negative
Echocardiograms)
Table 23. Noninvasive Risk Stratification
Table
24. CAD
Prognostic Index
Table
24a. Disease-Specific Measures for Patients With Chronic
Stable Angina
Table 24b. Beneficial Effects
of ACE Inhibition in Patients With Diabetes Mellitus
Table
25. Properties
of Beta-Blockers in Clinical Use
Table
26. Randomized Trials in Stable Angina Comparing Beta-Blockers
and Calcium Antagonists
Table 27. Properties of Calcium Antagonists
in Clinical Use
Table 28. Nitroglycerin and Nitrates
in Angina
Table 29. Recommended Drug Therapy
(Calcium Antagonist vs. Beta-Blocker) in Patients With Angina and
Associated Conditions
Table 30. Smoking Cessation for the
Primary Care Clinician
Table 31. Randomized
Controlled Trials Examining the Effects of Exercise Training on
Exercise Capacity in Patients With Stable Angina
Table 32. Randomized Controlled Trials
Examining the Effects of Exercise Training on Symptoms and Objective
Measures of Ischemia
Table 33. Randomized Controlled
Trials Examining the Effects of Exercise Training on Lipids and
Angiographic Progression
Table 33a. Characteristics Used
to Define the Metabolic Syndrome
Table 34. Randomized Trials and
Meta-Analyses of Garlic Therapy for Risk Treatment of Risk Factors
Table 34a . Other Therapies and
Refractory Angina—Evidence Table
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