Chronic stable angina risk stratification in asymptomatic patients by noninvasive testing

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Chronic stable angina risk stratification in asymptomatic patients by noninvasive testing On the Web

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

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

Noninvasive Testing for the Diagnosis of Obstructive CAD and Risk Assessment Recommendations(DO NOT EDIT)[1]

Advanced Testing: Resting and Stress Noninvasive Testing

Resting Imaging to Assess Cardiac Structure and Function

Class I
"1. Assessment of resting left ventricular (LV) systolic and diastolic ventricular function and evaluation for abnormalities of myocardium, heart valves, or pericardium are recommended with the use of Doppler echocardiography in patients with known or suspected IHD and a prior MI, pathological Q waves, symptoms or signs suggestive of heart failure, complex ventricular arrhythmias, or an undiagnosed heart murmur (Level of Evidence: B)"
Class IIb
"1. Assessment of cardiac structure and function with resting echocardiography may be considered in patients with hypertension or diabetes mellitus and an abnormal ECG. (Level of Evidence: C)"
"2. Measurement of LV function with radionuclide imaging may be considered in patients with a prior MI or pathological Q waves, provided there is no need to evaluate symptoms or signs suggestive of heart failure, complex ventricular arrhythmias, or an undiagnosed heart murmur. "(Level of Evidence: C)"
Class III
"1. Echocardiography, radionuclide imaging, CMR, and cardiac computed tomography are not recommended for routine assessment of LV function in patients with a normal ECG, no history of MI, no symptoms or signs suggestive of heart failure, and no complex ventricular arrhythmias. (Level of Evidence: C)"
"2. Routine reassessment (>1 year) of LV function with technologies such as echocardiography radionuclide imaging, CMR, or cardiac computed tomography is not recommended in patients with no change in clinical status and for whom no change in therapy is contemplated.. (Level of Evidence: C)"

Stress Testing and Advanced Imaging in Patients With Known SIHD Who Require Noninvasive Testing for Risk Assessment

Patients able to exercise
Class I
"1. Standard exercise ECG testing is recommended for risk assessment in patients with SIHD who are able to exercise to an adequate workload and have an interpretable ECG (Level of Evidence: B)"
"2. The addition of either nuclear MPI or echocardiography to standard exercise ECG testing is recommended for risk assessment in patients with SIHD who are able to exercise to an adequate workload but have an uninterpretable ECG not due to left bundle branch block or ventricular pacing (Level of Evidence: B)"
Class IIa
"1. The addition of either nuclear MPI or echocardiography to standard exercise ECG testing is reasonable for risk assessment in patients with SIHD who are able to exercise to an adequate workload and have an interpretable ECG . (Level of Evidence: B)"
"2. CMR with pharmacological stress is reasonable for risk assessment in patients with SIHD who are able to exercise to an adequate workload but have an uninterpretable ECG . "(Level of Evidence: B)"
Class IIb
"1. CCTA may be reasonable for risk assessment in patients with SIHD who are able to exercise to an adequate workload but have an uninterpretable ECG. (Level of Evidence: B)"
Class III
"1. Pharmacological stress imaging (nuclear MPI, echocardiography, or CMR) or CCTA is not recommended for risk assessment in patients with SIHD who are able to exercise to an adequate workload and have an interpretable ECG.. (Level of Evidence: C)"
Patients unable to exercise
Class I
"1. Pharmacological stress with either nuclear MPI or echocardiography is recommended for risk assessment in patients with SIHD who are unable to exercise to an adequate workload regardless of interpretability of ECG. (Level of Evidence: B)"
Class IIa
"1. Pharmacological stress CMR is reasonable for risk assessment in patients with SIHD who are unable to exercise to an adequate workload regardless of interpretability of ECG . (Level of Evidence: B)"
"2. CCTA can be useful as a first-line test for risk assessment in patients with SIHD who are unable to exercise to an adequate workload regardless of interpretability of ECG . "(Level of Evidence:C)"

Regardless of patients ability to exercise

Class I
"1. Pharmacological stress with either nuclear MPI or echocardiography is recommended for risk assessment in patients with SIHD who have left bundle-branch block on ECG, regardless of ability to exercise to an adequate workload (Level of Evidence: B)"
"2. Either exercise or pharmacological stress with imaging (nuclear MPI, echocardiography, or CMR) is recommended for risk assessment in patients with SIHD who are being considered for revascularization of known coronary stenosis of unclear physiological significance (Level of Evidence: B)"
Class IIa
"1. CCTA can be useful for risk assessment in patients with SIHD who have an indeterminate result from functional testing . (Level of Evidence: C)"
Class IIb
"1. CCTA might be considered for risk assessment in patients with SIHD unable to undergo stress imaging or as an alternative to invasive coronary angiography when functional testing indicates a moderate- to high-risk result and knowledge of angiographic coronary anatomy is unknown. (Level of Evidence: C)"
Class III
"1. A request to perform either a) more than 1 stress imaging study or b) a stress imaging study and a CCTA at the same time is not recommended for risk assessment in patients with SIHD. (Level of Evidence: C)"

References

  1. 1.0 1.1 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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