Chronic stable angina echocardiography

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Overview

Historical Perspective

Classification

Classic
Chronic Stable Angina
Atypical
Walk through Angina
Mixed Angina
Nocturnal Angina
Postprandial Angina
Cardiac Syndrome X
Vasospastic Angina

Differentiating Chronic Stable Angina from Acute Coronary Syndromes

Pathophysiology

Epidemiology and Demographics

Risk Stratification

Pretest Probability of CAD in a Patient with Angina

Prognosis

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Test Selection Guideline for the Individual Basis

Laboratory Findings

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Chest X Ray

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Myocardial Perfusion Scintigraphy with Thallium

Echocardiography

Exercise Echocardiography

Computed coronary tomography angiography(CCTA)

Positron Emission Tomography

Ambulatory ST Segment Monitoring

Electron Beam Tomography

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Coronary Angiography

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ACC/AHA Guidelines for Alternative Therapies in patients with Refractory Angina

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Noninvasive Testing in Asymptomatic Patients
Risk Stratification by Coronary Angiography
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Editors-In-Chief: C. Michael Gibson, M.S., M.D. [2]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [3]; Smita Kohli, M.D.; Lakshmi Gopalakrishnan, M.B.B.S.

Overview

Echocardiography is useful to evaluate ventricular function[1] and detect ischemia induced regional wall motion abnormality that occurs at rest, during exercise or with pharmacologic stress test. As a testing modality, two-dimensional echocardiography is often coupled with other testing modalities to detect regional wall motion abnormalities that most frequently occur during induced myocardial ischemia associated with coronary artery disease (CAD). Potential paired testing modalities include: upright treadmill exercise, supine bicycle ergometry, pacing, and pharmacologic stress, particularly with dobutamine. Patients with CAD may respond more adversely to testing modalities than their counterparts. Often, an adverse outcome such as the inability to perform a bicycle ergometry test or exercise treadmill protocol can be characterized as a poor prognostic factor.

Echocardiography

Indications

  • Echocardiography is typically useful in patients with murmurs,[2] previous MI[3] history and ECG changes suggestive of hypertrophic cardiomyopathy.[4]
  • Regardless of the etiology, diastolic dysfunction has a major impact on the functional status, treatment and prognosis of heart failure.
  • There is also an independent association observed between diastolic heart failure and history of ischemic heart disease, further emphasizing the use of echocardiography in patients with signs and symptoms suggestive of heart failure.[5][6]
  • Resting echocardiography, doppler imaging and strain rate measurement[7] have improved the ability to identify undetected diastolic dysfunction[8] in chronic stable angina patients without heart failure.

ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina (DO NOT EDIT)[9]

Echocardiography (Rest) for Diagnosis of Cause of Chest Pain in Patients With Suspected Chronic Stable Angina Pectoris (DO NOT EDIT)[9]

Patients able to exercise

Class I

"1. Exercise stress with nuclear MPI or echocardiography is recommended for patients with an intermediate to high pretest probability of IHD who have an uninterpretable ECG and at least moderate physical functioning or no disabling comorbidity (Level of Evidence: B)"

Class IIa

"1. Exercise stress with nuclear MPI or echocardiography is reasonable for patients with an intermediate to high pretest probability of obstructive IHD who have an interpretable ECG and at least moderate physical functioning or no disabling comorbidity (Level of Evidence: B)"

Class IIb

"1. For patients with a low pretest probability of obstructive IHD who do require testing, standard exercise stress echocardiography might be reasonable, provided the patient has an interpretable ECG and at least moderate physical functioning or no disabling comorbidity (Level of Evidence: B)"

Class III

"1. 1. Pharmacological stress with nuclear MPI, echocardiography, or CMR is not recommended for patients who have an interpretable ECG and at least moderate physical functioning or no disabling comorbidity. (Level of Evidence: C)"

Patients unable to exercise

Class I

"1. Pharmacological stress with nuclear MPI or echocardiography is recommended for patients with an intermediate to high pretest probability of IHD who are incapable of at least moderate physical functioning or have disabling comorbidity (Level of Evidence: B)"

Class IIa

"1. Pharmacological stress echocardiography is reasonable for patients with a low pretest probability of IHD who require testing and are incapable of at least moderate physical functioning or have disabling comorbidity. (Level of Evidence: C)"

Other

Class IIa

"1. CCTA is reasonable for patients with an intermediate pretest probability of IHD who a) have continued symptoms with prior normal test findings, or b) have inconclusive results from prior exercise or pharmacological stress testing, or c) are unable to undergo stress with nuclear MPI or echocardiography. (Level of Evidence: C)"

ESC Guidelines- Echocardiography for Initial Diagnostic Assessment of Angina (DO NOT EDIT)[10]

Class I
"1. Patients with abnormal auscultation suggesting valvular heart disease or hypertrophic cardiomyopathy. (Level of Evidence: B)"
"2. Patients with suspected heart failure. (Level of Evidence: B)"
"3. Patients with prior MI. (Level of Evidence: B)"
"4. Patients with LBBB, Q waves, or other significant pathological changes on ECG, including ECG criteria for LVH. (Level of Evidence: C)"

References

  1. Cheitlin MD, Alpert JS, Armstrong WF, Aurigemma GP, Beller GA, Bierman FZ et al. (1997) ACC/AHA guidelines for the clinical application of echocardiography: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on Clinical Application of Echocardiography). Developed in collaboration with the American Society of Echocardiography. J Am Coll Cardiol 29 (4):862-79. PMID: 9091535
  2. Attenhofer Jost CH, Turina J, Mayer K, Seifert B, Amann FW, Buechi M et al. (2000) Echocardiography in the evaluation of systolic murmurs of unknown cause. Am J Med 108 (8):614-20. PMID: 10856408
  3. Marchioli R, Avanzini F, Barzi F, Chieffo C, Di Castelnuovo A, Franzosi MG et al. (2001) Assessment of absolute risk of death after myocardial infarction by use of multiple-risk-factor assessment equations: GISSI-Prevenzione mortality risk chart. Eur Heart J 22 (22):2085-103. DOI:10.1053/euhj.2000.2544 PMID: 11686666
  4. Nagueh SF, Bachinski LL, Meyer D, Hill R, Zoghbi WA, Tam JW et al. (2001) Tissue Doppler imaging consistently detects myocardial abnormalities in patients with hypertrophic cardiomyopathy and provides a novel means for an early diagnosis before and independently of hypertrophy. Circulation 104 (2):128-30. PMID: 11447072
  5. O'Mahony MS, Sim MF, Ho SF, Steward JA, Buchalter M, Burr M (2003)Diastolic heart failure in older people. Age Ageing 32 (5):519-24. PMID: [1]
  6. Fonseca C, Mota T, Morais H, Matias F, Costa C, Oliveira AG et al. (2004) The value of the electrocardiogram and chest X-ray for confirming or refuting a suspected diagnosis of heart failure in the community. Eur J Heart Fail 6 (6):807-12, 821-2. DOI:10.1016/j.ejheart.2004.09.004 PMID: 15542421
  7. Yip G, Abraham T, Belohlavek M, Khandheria BK (2003) Clinical applications of strain rate imaging. J Am Soc Echocardiogr 16 (12):1334-42. DOI:10.1067/j.echo.2003.09.004 PMID: 14652617
  8. Beattie RC, Spence J (1991) Auditory brainstem response to clicks in quiet, notch noise, and highpass noise. J Am Acad Audiol 2 (2):76-90. PMID: 1768877
  9. 9.0 9.1 Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP; et al. (2012). "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 126 (25): 3097–137. doi:10.1161/CIR.0b013e3182776f83. PMID 23166210.
  10. Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F; et al. (2006). "Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology". Eur Heart J. 27 (11): 1341–81. doi:10.1093/eurheartj/ehl001. PMID 16735367.

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