Chronic stable angina patient follow-up

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Aysha Aslam, M.B.B.S[3]

Overview

Ongoing follow-up of the patient with chronic stable angina is necessary to monitor symptoms and to optimize antianginal therapy. It is generally recommended that these patients be evaluated every 4-6 months during first year of diagnosis/initiation of therapy and annually thereafter. Based upon clinical judgement, if the patient is poorly responsive to therapy, if the episodes are severe or frequent, or if the patient is fragile with multiple co-morbidities, they may need to be seen more frequently. During a follow-up visit, the patient should be asked about the frequency and severity of their anginal symptoms, their level of exercise capacity, whether they have been able to modify his/her risk factors, how well they are tolerating and complying with the therapy and whether he/she has developed new illnesses or co-morbidities.

ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina (DO NOT EDIT)[1][2]

Patient Follow-Up, Monitoring of Symptoms and Antianginal Therapy(DO NOT EDIT)[1][2]

Clinical Evaluation, Echocardiography During Routine, Periodic Follow-Up

Class I
"1. Patients with SIHD should receive periodic follow-up, at least annually, that includes all of the following:

a. Assessment of symptoms and clinical function; b. Surveillance for complications of SIHD, including heart failure and arrhythmias;. c. Monitoring of cardiac risk factors; and d. Assessment of the adequacy of and adherence to recommended lifestyle changes and medical therapy. (Level of Evidence: C) "

Class IIa
"2. Assessment of LV ejection fraction and segmental wall motion by echocardiography or radionuclide imaging is recommended in patients with new or worsening heart failure or evidence of intervening MI by history or ECG. (Level of Evidence: C) "
Class IIb
"1. Periodic screening for important comorbidities that are prevalent in patients with SIHD, including diabetes mellitus, depression, and chronic kidney disease might be reasonable. (Level of Evidence: C) "
"2. A resting 12-lead ECG at 1-year or longer intervals between studies in patients with stable symptoms might be reasonable.(Level of Evidence: C) "
Class III
"1. Measurement of LV function with a technology such as echocardiography or radionuclide imaging is not recommended for routine periodic reassessment of patients who have not had a change in clinical status or who are at low risk of adverse cardiovascular events (Level of Evidence: C)"

Noninvasive Testing in Known SIHD

Follow-Up Noninvasive Testing in Patients With Known SIHD: New, Recurrent, or Worsening Symptoms Not Consistent With Unstable Angina

Patients able to exercise

Class I
"1. Standard exercise ECG testing is recommended in patients with known SIHD who have new or worsening symptoms not consistent with UA and who have a) at least moderate physical functioning and no disabling comorbidity and b) an interpretable ECG (Level of Evidence: B) "
Class IIa
"1. Exercise with nuclear MPI or echocardiography is reasonable in patients with known SIHD who have new or worsening symptoms not consistent with UA and who have a) at least moderate physical functioning and no disabling comorbidity, b) previously required imaging with exercise stress, or c) known multivessel disease or high risk for multivessel disease (Level of Evidence: B) "
Class III
"1. Pharmacological stress imaging with nuclear MPI, echocardiography, or CMR is not recommended in patients with known SIHD who have new or worsening symptoms not consistent with UA and who are capable of at least moderate physical functioning or have no disabling comorbidity (. (Level of Evidence: C) "

Patients unable to exercise

Class I
"1. Pharmacological stress imaging with nuclear MPI or echocardiography is recommended in patients with known SIHD who have new or worsening symptoms not consistent with UA and who are incapable of at least moderate physical functioning or have disabling comorbidity. (Level of Evidence: B) "
Class IIa
"1. Pharmacological stress imaging with CMR is reasonable in patients with known SIHD who have new or worsening symptoms not consistent with UA and who are incapable of at least moderate physical functioning or have disabling comorbidity (Level of Evidence: B) "
Class III (No Benefit)
"1. Standard exercise ECG testing should not be performed in patients with known SIHD who have new or worsening symptoms not consistent with UA and who a) are incapable of at least moderate physical functioning or have disabling comorbidity or b) have an uninterpretable ECG(Level of Evidence: C)"

Irrespective of the ability to exercise

Class IIb
"1. CCTA for assessment of patency of CABG or of coronary stents 3 mm or larger in diameter might be reasonable in patients with known SIHD who have new or worsening symptoms not consistent with UA, irrespective of ability to exercise (Level of Evidence: B) "
"2. CCTA might be reasonable in patients with known SIHD who have new or worsening symptoms not consistent with UA, irrespective of ability to exercise, in the absence of known moderate or severe calcification or if the CCTA is intended to assess coronary stents less than 3 mm in diameter (Level of Evidence: B) "
Class III
"1. CCTA should not be performed for assessment of native coronary arteries with known moderate or severe calcification or with coronary stents less than 3mm in diameter in patients with known SIHD who have new or worsening symptoms not consistent with UA, irrespective of ability to exercise. (Level of Evidence: B) "

Noninvasive Testing in Known SIHD

Class IIa
"1. Nuclear MPI, echocardiography, or CMR with either exercise or pharmacological stress can be useful for follow-up assessment at 2-year or longer intervals in patients with SIHD with prior evidence of silent ischemia or who are at high risk for a recurrent

cardiac event and a) are unable to exercise to an adequate workload, b) have an uninterpretable ECG, or c) have a history of incomplete coronary revascularization. (Level of Evidence: C) "

Class IIa
"1. Standard exercise ECG testing performed at 1-year or longer intervals might be considered for follow-up assessment in patients with SIHD who have had prior evidence of silent ischemia or are at high risk for a recurrent cardiac event and are able to exercise to an

adequate workload and have an interpretable ECG (Level of Evidence: C) "

"2. In patients who have no new or worsening symptoms or no prior evidence of silent ischemia and are not at high risk for a recurrent cardiac event, the usefulness of annual surveillance exercise ECG testing is not well established. (Level of Evidence: C)(Level of Evidence: C) "
Class III
"1. Nuclear MPI, echocardiography, or CMR, with either exercise or pharmacological stress or CCTA, is not recommended for follow-up assessment in patients with SIHD, if performed more frequently than at a) 5-year intervals after CABG or b) 2-year intervals after PCI (Level of Evidence: C) "

References

  1. 1.0 1.1 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.
  2. 2.0 2.1 Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS; et al. (2003). "ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on the Management of Patients With Chronic Stable Angina)". J Am Coll Cardiol. 41 (1): 159–68. PMID 12570960.

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