The AHA Guidelines and Scientific Statements Handbook

Valentin Fuster

• Publisher: Wiley-Blackwell
• Year: 2011
• Print ISBN: 9781405184632
• eBook ISBN: 9781444359749
• Edition: 1
• Topic: Medicine
• Subtopic: Cardiology

Society-sanctioned guidelines on care are valuable tools, but accessing key information from the often complicated statements has been a daunting task. Now, practitioners and their institutions have a clear path to successful application of guidelines from the American Heart Association. This book outlines the key AHA guidelines, Statements, and Performance Measures and includes comparisons with the associated European guidelines. This book also has a strong online component, which will alert users who sign up to new updates to the guidelines and other relevant information. It will also have links through to the full guidelines and statements.

1 CHRONIC STABLE ANGINA

Theodore D. Fraker, Stephan D. Fihn, and Raymond J. Gibbons

Introduction

Classification of angina pectoris

Demographics of angina pectoris

Patients with new onset or changing anginal symptoms

The development of practice guidelines

Asymptomatic individuals

Recommendations for the management of patients with chronic stable angina

Diagnosis

A. History and physical examination

B. Associated conditions

C. Noninvasive testing

D. Invasive testing: value of coronary angiography

Risk stratification

A. Clinical evaluation

B. Noninvasive testing

C. Use of exercise test results in patient management

D. Coronary angiography and left ventriculography

Treatment

A. Pharmacologic therapy

Coronary disease risk factors and evidence that treatment can reduce the risk for coronary disease events

Patient follow-up: monitoring of symptoms and anti-anginal therapy

Future issues

Special consideration for women

New information on percutaneous revascularization to be considered for the next chronic stable angina guideline

New therapeutic agents to be considered for the next chronic stable angina guideline

Introduction

Angina pectoris is a clinical syndrome characterized by discomfort in the chest, jaw, back or arm typically aggravated by exertion or emotional stress and relieved by rest or nitroglycerin. Angina pectoris is usually associated with epicardial coronary artery disease including one or more obstructions of greater than 70%, but it can also occur in patients with valvular heart disease, hypertrophic cardiomyopathy, or uncontrolled hypertension. Symptoms are thought to result from regional or global myocardial ischemia due to mismatch between myocardial oxygen supply and demand (Table 1.1). In women, angina pectoris can be seen in the absence of obvious epicardial coronary artery obstruction or other cardiac pathology, presumably due to coronary artery endothelial dysfunction or other factors. Chronic stable angina refers to anginal symptoms that occur daily, weekly or less frequently and are typically predictable and reproducible [1–4].

Table 1.1 Conditions provoking or exacerbating ischemia

Increased oxygen demand	Decreased oxygen supply
Noncardiac	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 fibrosis
Cardiac	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 cardiomyopathy

Classification of angina pectoris

Chest discomfort can be described as typical angina, atypical angina or non-anginal chest pain, depending 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 sometimes accompanied by radiation to the inner arm, jaw, back or epigastrium. What makes the discomfort “typical” is the predictable relationship to increased activity (implying increased myocardial oxygen consumption) and subsequent relief with rest or NTG (Table 1.2).

Table 1.2 Clinical classification of chest pain

Typical angina (definite)

(1) Substernal chest discomfort with a characteristic quality and duration that is (2) provoked by exertion or emotional stress and (3) relieved by rest or NTG.

Atypical angina (probable)

Meets two of the above characteristics.

Noncardiac chest pain

Meets one or none of the typical anginal characteristics.

Modified from Diamond, IACC, 1983.

The severity of angina pectoris is customarily described using the Canadian Cardiovascular Society Classification System (Table 1.3).

Table 1.3 Grading of angina pectoris by the Canadian Cardiovascular Society Classification System

Class I

Ordinary physical activity does not cause angina, such as walking, climbing stairs. Angina (occurs) with strenuous, rapid or prolonged exertion at work or recreation.

Class II

Slight 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 blocks on the level and climbing more than one flight of ordinary stairs at a normal pace and in normal condition.

Class III

Marked limitations of ordinary physical activity. Angina occurs on walking one to two blocks on the level and climbing one flight of stairs in normal conditions at a normal pace.

Class IV

Inability 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 with permission.

Demographics of angina pectoris

Coronary artery disease, the principal cause of angina pectoris, is thought to be present in 13,200,000 American adults, about half of whom (6,500,000 or 3.8% of the population) have angina pectoris or chest pain [4]. The incidence of stable angina is about 400,000 persons per year and there are an estimated 63,000 hospital discharges per year (2003) [4]. The annual mortality rate is hard to assess in the US since angina pectoris is rarely listed on death certificates as the cause of death. Data from the European Society of Cardiology estimates the annual mortality rate ranges from 0.9–1.4% and the annual incidence of non-fatal MI ranges from 0.5–2.6% [3]. Only about 20% of cardiac events are preceded by long-standing angina [4].

Patients with new onset or changing anginal symptoms

Patients who present with a history of angina that has recently started or has changed in frequency, severity or pattern are often classified as having unstable angina. These patients can be subdivided by their short-term risk of death (Table 1.4). Patients at high or moderate risk often have an acute coronary syndrome caused by coronary artery plaques that have ruptured. Their risk of death is intermediate, between that of patients with acute MI and patients with stable angina. The initial evaluation of high- or moderate-risk patients with unstable angina is best carried out in the inpatient setting. However, low-risk patients with unstable angina have a short-term risk similar to that of patients with stable angina. Their evaluation can be accomplished safely and expeditiously in an outpatient setting. The recommendations made in these guidelines do not apply to patients with high- or moderate-risk unstable angina but are applicable to the low-risk unstable angina group.

Table 1.4 Short-term risk of death or nonfatal myocardial infarction in patients with unstable angina

High risk	Intermediate risk	Low risk
At least one of the following features must be present:	No high-risk features but must have any of the following:	No high- or intermediate-risk feature but may have any of the following:
Prolonged ongoing (>20 min) rest pain	Prolonged (>20 min) rest angina, now resolved, with moderate or high likelihood of CAD	Increased angina frequency, severity, or duration
Pulmonary edema, most likely related to ischemia	Rest angina (>20 min or relieved with sublingual nitroglycerin)	Angina provoked at a lower threshold
Angina at rest with dynamic ST changes ≥1 mm	Nocturnal angina	New onset angina with onset 2 weeks to 2 months prior to presentation
Angina with new or worsening MR murmur	Angina with dynamic T-ware changes	Normal or unchanged ECG
Angina with S3 or new/worsening rales	New onset CCSC III or IV angina in the past 2 weeks with moderate or high likelihood of CAD
Angina with hypotension	Pathologic Q waves or resting ST depression ≤1 mm in multiple lead groups (anterior, inferior, lateral)
	Age >65 years

CCSC 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 such as this. Therefore, the table is meant to offer general guidance and illustration rather than rigid algorithms.

The development of practice guidelines

The American College of Cardiology/American Heart Association Task Force on Practice Guidelines met in 2001 and 2002 to update the 1999 Guidelines for the Management of Patients with Chronic Stable Angina. This guideline was published in 2003. In 2007, a subgroup of the writing committee updated the 2002 Chronic Stable Guideline to be consistent with the AHA/ACC Guidelines for Secondary Prevention for Patients with Coronary and Other Atherosclerotic Vascular Disease. In 2006, the European Society of Cardiology [3] published its own guideline which differs somewhat from the ACC/AHA guideline. Both sets of guidelines will be considered in this chapter.

The Classification of Recommendations (COR) and Level of Evidence (LOE) are expressed in the ACC/AHA/ESC format (see table in front of book). These recommendations are evidence-based from published data where applicable.

Asymptomatic individuals

This chapter and the recommendations that follow are intended to apply to symptomatic patients. These were the focus of the original 1999 guideline. The 2002 update included additional sections and recommendations for asymptomatic patients with known or suspected coronary artery disease (CAD). Such individuals are often identified on the basis of evidence of a previous myocardial infarction by history and/or electrocardiographic changes, coronary angiography, or an abnormal noninvasive test, including coronary calcification on computed tomography (CT). Multiple ACC/AHA guidelines, scientific statements and expert consensus documents have discouraged the use of noninvasive tests, including ambulatory monitoring, treadmill testing, stress echocardiography, stress myocardial perfusion, and CT, in asymptomatic individuals. Their inclusion in the 2002 guideline did not represent an endorsement of such tests for the purposes of screening, but rather an acknowledgment of the clinical reality that asymptomatic patients may present for ...

Table of contents

• Cover
• Title
• Copyright
• List of Contributors
• Preface
• 1 CHRONIC STABLE ANGINA
• 2 UNSTABLE ANGINA/NON-ST-ELEVATION MYOCARDIAL INFARCTION
• 3 ST-ELEVATION MYOCARDIAL INFARCTION
• 4 CARDIAC REHABILITATION AND SECONDARY PREVENTION PROGRAMS
• 5 SECONDARY PREVENTION FOR PATIENTS WITH CORONARY AND OTHER ATHEROSCLEROTIC VASCULAR DISEASE
• 6 PERCUTANEOUS CORONARY INTERVENTION
• 7 CORONARY ARTERY BYPASS GRAFT SURGERY
• 8 PERIOPERATIVE CARDIOVASCULAR EVALUATION AND CARE FOR NONCARDIAC SURGERY
• 9 LOWER EXTREMITY PERIPHERAL ARTERY DISEASE
• 10 CHOLESTEROL MANAGEMENT IN THE CONTEXT OF RISK FACTOR PROFILE
• 11 HYPERTENSION
• 12 CARDIOVASCULAR DISEASE PREVENTION IN WOMEN
• 13 HEART FAILURE
• 14 CARDIOMYOPATHIES
• 15 ATRIAL FIBRILLATION
• 16 SUPRAVENTRICULAR ARRHYTHMIAS
• 17 VENTRICULAR ARRHYTHMIAS AND SUDDEN CARDIAC DEATH
• 18 VALVULAR HEART DISEASE
• 19 INFECTIVE ENDOCARDITIS
• 20 CARDIAC CT IMAGING
• APPENDIX UPDATE ON CORONARY ARTERY BYPASS SURGERY: CURRENT AND FUTURE TRENDS
• OTHER STATEMENTS PUBLISHED IN 2008
• Index
• COI Table