Chronic stable angina prognosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S.

Overview

Reduced LV function, number and location of stenoses, workload in METs calculated using Duke score are the strongest predictors of survival in patients with chronic stable angina.

Prognosis

Mortality

  • The estimated annual mortality rate in patients with chronic stable angina ranges from 0.9% - 1.4%[1][2][3] with an annual incidence of non-fatal MI between 0.5%[4] and 2.6%.[5]
  • The Framingham Heart Study[6][7] revealed the 2-year incidence rates of non-fatal MI and coronary heart disease death for men and women who initially presented with stable angina was 14.3% MI and 5.5% CAD death in men, and 6.2% MI and 3.8% CAD death in women.
  • Relative risk based on anginal characteristics in elderly associated with no comorbidities:[8]
Characteristic 1-yr Mortality Rate (%)
Non anginal pain 0.4
Atypical angina 0.8
Stable angina 1.3
Progressive 1.5
Unstable 1.7

Factors that Affect Long Term Prognosis in Patients with Chronic Stable Angina

  • Number of stenoses (patients with three-vessel disease have a higher mortality rate in comparison to patients with single vessel disease).
Table 1:Coronary Artery Disease Prognostic Index[8]
Extent of CAD Prognostic Weight (0-100) 5-year Mortality Rate (%)
(assuming medical treatment only)
1-vessel disease, 75% 23 7
>1-vessel disease, 50-74% 23 7
1-vessel disease, ≥ 95% 32 9
2-vessel disease 37 12
2-vessel disease, both ≥ 95% 42 14
1-vessel disease, ≥ 95% proximal LAD 48 17
2-vessel disease, ≥ 95% LAD 48 17
2-vessel disease, ≥ 95% proximal LAD 56 21
3-vessel disease 56 21
3-vessel disease, ≥ 95% in at least 1 63 27
3-vessel disease, 75% proximal LAD 67 33
3-vessel disease, ≥ 95% proximal LAD 74 41
  • Associated risk factors[9] that contribute to poor outcomes are:

Duke Score (Exercise Treadmill Test)[10]

  • Workload in METs assessed using the DUKE Score is an important factor in estimating the prognosis of patients with chronic stable angina.
  • Duke score = [(exercise duration in minutes) - (5 x ST segment deviation in millimeters) - (4 x treadmill angina index)]
  • Angina index:
  • 0 for no angina,
  • 1 for angina, and
  • 2 if angina is the reason for stopping the test.
CAD risk probability (DTS) 4-year survival Annual mortality
Low probability (more than 5 DTS) 99% 0.25%
Moderate probability (-10 to 4 DTS) 95% 1.25%
High probability (less than -10 DTS) 79% 5%

For more information about prognosis of excercise stress testing, click here.

ESC Guidelines- Pharmacological therapy to improve prognosis in patients with stable angina (DO NOT EDIT)[11]

Class I
"1. Aspirin 75 mg daily in all patients without specific contraindications (i.e. active GI bleeding, aspirin allergy, or previous aspirin intolerance). (Level of Evidence: A)"
"2. Statin therapy for all patients with coronary artery disease. (Level of Evidence: A)"
"3. ACE-inhibitor therapy in patients with coincident indications for ACE-inhibition, such as hypertension, heart failure, LV dysfunction, prior MI with LV dysfunction, or diabetes. (Level of Evidence: A)"
"4. Oral beta-blocker therapy in patients post-MI or with heart failure. (Level of Evidence: A)"
Class IIa
"1. ACE-inhibitor therapy in all patients with angina and proven coronary artery disease. (Level of Evidence: B)"
"2. Clopidogrel as an alternative antiplatelet agent in patients with stable angina who cannot take aspirin (e.g. aspirin allergic). (Level of Evidence: B)"
"3. High dose statin therapy in high-risk (0.2% annual CV mortality) patients with proven coronary artery disease. (Level of Evidence: B)"
Class IIa
"1. Fibrate therapy in patients with low HDL and high triglycerides who have diabetes or the metabolic syndrome. (Level of Evidence: B)"
"2. Fibrate or nicotinic acid as adjunctive therapy to statin in patients with low HDL and high triglycerides at high risk (0.2% annual CV mortality). (Level of Evidence: C)"

ESC Guidelines- Revascularization to improve prognosis in patients with stable angina (DO NOT EDIT)[11]

Class I
"1. CABG for significant left main CAD or its equivalent (i.e. severe stenosis of ostial/proximal segment of left descending and circumflex coronary arteries). (Level of Evidence: A)"
"2. CABG for significant proximal stenosis of three major vessels, particularly in those patients with abnormal LV function or with early or extensive reversible ischaemia on functional testing. (Level of Evidence: A)"
"3. CABG for one- or two-vessel disease with high-grade stenosis of proximal LAD with reversible ischaemia on non-invasive testing. (Level of Evidence: A)"
"4. CABG for significant disease with impaired LV function and viability demonstrated by non-invasive testing. (Level of Evidence: B)"
Class IIa
"1. CABG for one- or two-vessel CAD without significant proximal LAD stenosis in patients who have survived sudden cardiac death or sustained ventricular tachycardia. (Level of Evidence: B)"
"2. CABG for significant three-vessel disease in diabetics with reversible ischaemia on functional testing. (Level of Evidence: C)"
"3. PCI or CABG for patients with reversible ischaemia on functional testing and evidence of frequent episodes of ischaemia during daily activities. (Level of Evidence: C)"

References

  1. Rehnqvist N, Hjemdahl P, Billing E, Björkander I, Eriksson SV, Forslund L et al. (1996) Effects of metoprolol vs verapamil in patients with stable angina pectoris. The Angina Prognosis Study in Stockholm (APSIS) Eur Heart J 17 (1):76-81. PMID: 8682134
  2. Henderson RA, Pocock SJ, Clayton TC, Knight R, Fox KA, Julian DG et al. (2003) Seven-year outcome in the RITA-2 trial: coronary angioplasty versus medical therapy. J Am Coll Cardiol 42 (7):1161-70. PMID: 14522473
  3. Juul-Möller S, Edvardsson N, Jahnmatz B, Rosén A, Sørensen S, Omblus R (1992) Double-blind trial of aspirin in primary prevention of myocardial infarction in patients with stable chronic angina pectoris. The Swedish Angina Pectoris Aspirin Trial (SAPAT) Group. Lancet 340 (8833):1421-5. PMID: 1360557
  4. Pepine CJ, Handberg EM, Cooper-DeHoff RM, Marks RG, Kowey P, Messerli FH et al. (2003) A calcium antagonist vs a non-calcium antagonist hypertension treatment strategy for patients with coronary artery disease. The International Verapamil-Trandolapril Study (INVEST): a randomized controlled trial. JAMA 290 (21):2805-16. DOI:10.1001/jama.290.21.2805 PMID: 14657064
  5. Fox KM, Mulcahy D, Findlay I, Ford I, Dargie HJ (1996) The Total Ischaemic Burden European Trial (TIBET). Effects of atenolol, nifedipine SR and their combination on the exercise test and the total ischaemic burden in 608 patients with stable angina. The TIBET Study Group. Eur Heart J 17 (1):96-103. PMID: 8682138
  6. Kannel WB, Feinleib M (1972) Natural history of angina pectoris in the Framingham study. Prognosis and survival. Am J Cardiol 29 (2):154-63. PMID: 5058341
  7. Murabito JM, Evans JC, Larson MG, Levy D (1993) Prognosis after the onset of coronary heart disease. An investigation of differences in outcome between the sexes according to initial coronary disease presentation. Circulation 88 (6):2548-55. PMID: 8252666
  8. 8.0 8.1 8.2 Califf RM, Armstrong PW, Carver JR, D'Agostino RB, Strauss WE (1996) 27th Bethesda Conference: matching the intensity of risk factor management with the hazard for coronary disease events. Task Force 5. Stratification of patients into high, medium and low risk subgroups for purposes of risk factor management. J Am Coll Cardiol 27 (5):1007-19. PMID: 8609316
  9. Daly CA, De Stavola B, Sendon JL, Tavazzi L, Boersma E, Clemens F et al. (2006) Predicting prognosis in stable angina--results from the Euro heart survey of stable angina: prospective observational study. BMJ 332 (7536):262-7. DOI:10.1136/bmj.38695.605440.AE PMID: 16415069
  10. Johnson GG, Decker WW, Lobl JK, Laudon DA, Hess JJ, Lohse CM et al. (2008) Risk stratification of patients in an emergency department chest pain unit: prognostic value of exercise treadmill testing using the Duke score. Int J Emerg Med 1 (2):91-5. DOI:10.1007/s12245-008-0031-5 PMID: 19384658
  11. 11.0 11.1 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. PMID 16735367. doi:10.1093/eurheartj/ehl001. 

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