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Guidelines for the Management of Patients with Chronic Stable Angina: Diagnosis and Risk Stratification

Sankey V. Williams, MD; Stephan D. Fihn, MD, MPH; and Raymond J. Gibbons, MD
[+] Article and Author Information

From University of Pennsylvania, Philadelphia, Pennsylvania; VA Puget Sound Health Care System and University of Washington, Seattle, Washington; and Mayo Medical Center, Rochester, Minnesota.


*This paper, written by Sankey V. Williams, MD, Stephan D. Fihn, MD, MPH, and Raymond J. Gibbons, MD, was based on the American College of Cardiology/American Heart Association/American College of Physicians–American Society of Internal Medicine Practice Guidelines for the Management of Patients with Chronic Stable Angina. Members of the Committee on Guidelines for Chronic Stable Angina were Raymond J. Gibbons, MD, Chair; Kanu Chatterjee, MB; Jennifer Daley, MD; John S. Douglas, MD; Stephan D. Fihn, MD, MPH; Julius M. Gardin, MD; Mark A. Grunwald, MD; Daniel Levy, MD; Bruce W. Lytle, MD; and Sankey V. Williams, MD.

Requests for Single Reprints: Sankey V. Williams, MD, 1220 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104-6021; e-mail, sankey@wharton.upenn.edu.

Current Author Addresses: Dr. Williams: Division of General Internal Medicine, 1220 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104-6021.

Dr. Fihn: VA Puget Sound Hospital, 1660 South Columbian Way (152), Seattle, WA 98108.

Dr. Gibbons: Department of Cardiology, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905.


Ann Intern Med. 2001;135(7):530-547. doi:10.7326/0003-4819-135-7-200110020-00014
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Patients with suspected chronic stable angina can be evaluated in three stages. In stage one, the clinician uses information from the history, physical examination, laboratory tests for diabetes and hyperlipidemia, and resting electrocardiography to estimate the patient's probability of coronary artery disease (CAD). In stage two, additional testing for patients with a low probability of CAD focuses on diagnosing noncoronary causes of chest pain. Patients with a high probability of CAD have stress tests to assess their risk from CAD, and patients with an intermediate probability of CAD have stress tests to estimate the probability of CAD and assess their risk from CAD. Most patients with new-onset angina can start stress testing with exercise electrocardiography. The initial stress test should be a stress imaging procedure for patients with rest ST-segment depression greater than 1 mm, complete left bundle-branch block, ventricular paced rhythm, preexcitation syndrome, or previous revascularization with percutaneous coronary angioplasty or coronary artery bypass grafting. Patients who cannot exercise can have an imaging procedure with stress induced by pharmacologic agents. In stage three, patients with a predicted average annual cardiac mortality rate between 1% and 3% should have a stress imaging study or coronary angiography with left ventriculography. Those with a known left ventricular dysfunction should have cardiac catheterization. Patients with CAD who have an estimated annual mortality rate greater than 3% should have cardiac catheterization to determine whether their anatomy is suitable for revascularization. Patients with an estimated annual mortality rate less than 1% can begin to receive medical therapy.

Figures

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Figure 1.
Diagnosis of chest pain.45

Comorbid conditions and patient preferences.

ACC = American College of Cardiology; AHA = American Heart Association; AHCPR = Agency for Health Care Policy and Research; CABG = coronary artery bypass grafting; ECG = electrocardiography; LV = left ventricular; MI = myocardial infarction; PTCA = percutaneous transluminal coronary angioplasty. See references and for the AHCPR Unstable Angina Guideline and the ACC–AHA Valvular Heart Disease Guideline, respectively. * Rest pain lasting more than 20 minutes, age older than 65 years, ST and T-wave changes, and pulmonary edema.

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Figure 2.
Stress testing and angiography.

ECG = electrocardiography.

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