American College of Cardiology

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