Chronic stable angina assessing the pretest probability of coronary artery disease: Difference between revisions

Jump to navigation Jump to search
No edit summary
 
(35 intermediate revisions by 10 users not shown)
Line 1: Line 1:
{{SI}}
__NOTOC__
{{WikiDoc Cardiology Network Infobox}}
{{Chronic stable angina}}
{{CMG}}


'''Associate Editor-in-Chief:''' Smita Kohli, M.D.
{{CMG}}; '''Associate Editor-in-Chief:''' Smita Kohli, M.D.


==Overview==
==Overview==
Pretest probability is defined as the probability of the target disorder before the result of a diagnostic test is known.  A number of studies have emphasized the importance of pretest probability of [[coronary artery disease|coronary artery disease (CAD)]].<ref name="pmid7258092">Diamond GA, Forrester JS (1981) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=7258092 Improved interpretation of a continuous variable in diagnostic testing: probabilistic analysis of scintigraphic rest and exercise left ventricular ejection fractions for coronary disease detection.] ''Am Heart J'' 102 (2):189-95. PMID: [http://pubmed.gov/7258092 7258092]</ref> Once a thorough patient [[Chronic stable angina symptoms|history]] and [[Physical examination|physical examination]] is complete, it is important to assess the probability of underlying CAD, as this helps both the physician and the patient to determine the next step in the [[Chronic stable angina test selection guideline for the individual basis|diagnosis]] and [[Chronic stable angina treatment|treatment]]. In patients with [[Chronic stable angina definition|chronic stable angina]], the strongest predictors contributing to underlying significant [[CAD]] include: the age, gender and type of pain (typical, atypical) experienced.<ref name="pmid7258092">Diamond GA, Forrester JS (1981) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=7258092 Improved interpretation of a continuous variable in diagnostic testing: probabilistic analysis of scintigraphic rest and exercise left ventricular ejection fractions for coronary disease detection.] ''Am Heart J'' 102 (2):189-95. PMID: [http://pubmed.gov/7258092 7258092]</ref>


Once the history and physical examination is complete, it is important to assess the probability of [[coronary artery disease]] as this helps both the physician and the patient to decide what next step in diagnosis and treatment should be taken. There have been a lot of studies emphasizing the importance of assessing pretest probability of [[CAD]] for every patient. Diamond and Forrester<ref> Improved interpretation of a continuous variable in diagnostic testing: probabilistic analysis of scintigraphic rest and exercise left ventricular ejection fractions for coronary disease detection.
==Pretest Probability==
*Pretest probability is defined as the probability of the target disorder before the result of a diagnostic test is known.
*The pretest probability is especially useful for:
:*Deciding whether it is worth proceeding with testing at all (this is referred to as the test threshold)
:*Selecting the type of diagnostic test
:*Interpreting the results of a diagnostic test
:*Choosing whether to start therapy: a) without further testing (this is referred to as the treatment threshold) or b) while awaiting further testing


Diamond GA, Forrester JS.
==Calculating the Pretest Probability for Coronary Artery Disease==
*The first step is to categorize the nature of the chest pain or discomfort. This can be done as follows:
:*Typical angina (definite): The characteristics of typical angina include:
::# Substernal chest discomfort of characteristic quality and duration
::# The pain is provoked by exercise or emotional stress
::# The pain is relieved by rest or [[NTG]]
:*Atypical angina (probable): Meets two of the above criteria
:*Non-anginal pain: Meets one or zero of the anginal characteristics.
*Based on the ACC/AHA 2002 guidelines,<ref name="pmid12515758">Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12515758 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).] ''Circulation'' 107 (1):149-58.[http://content.onlinejacc.org/cgi/reprint/41/1/159.pdf] PMID: [http://pubmed.gov/12515758 12515758]</ref> the  pretest probability can be classified into:
:*Low probability: less than 10%-20%;
:*Intermediate probability: between 20%-80%;
:*High probability: more than 80%-90%.
*A quick way to assess this is shown in Table 1.<ref name="pmid17998462">Fraker TD, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J et al. (2007)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=17998462 2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina.] ''Circulation'' 116 (23):2762-72.[http://content.onlinejacc.org/cgi/reprint/50/23/2264.pdf] PMID: [http://pubmed.gov/17998462 17998462]</ref><ref name="pmid15238371">Snow V, Barry P, Fihn SD, Gibbons RJ, Owens DK, Williams SV et al. (2004) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15238371 Evaluation of primary care patients with chronic stable angina: guidelines from the American College of Physicians.] ''Ann Intern Med'' 141 (1):57-64. PMID: [http://pubmed.gov/15238371 15238371]</ref><ref name="pmid7055887">Diamond GA, Forrester JS (1982) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=7055887 Probability of CAD.] ''Circulation'' 65 (3):641-2. PMID: [http://pubmed.gov/7055887 7055887]</ref>


Am Heart J. 1981 Aug;102(2):189-95.
<center>'''Table 1: Pretest Probability of Coronary Artery Disease'''


PMID: 7258092</ref> showed in their study that age, gender and type of pain are strong predictors for the likelihood of [[CAD]]. Multiple subsequent prospective studies have confirmed their conclusion.
{| border="1" align="center" style="background:LightSkyBlue"
|-
| bgcolor="CornFlowerBlue" |'''Age''' (yrs)
| bgcolor="CornFlowerBlue" |'''Gender'''
| bgcolor="CornFlowerBlue" |'''Non-anginal pain'''
| bgcolor="CornFlowerBlue" |'''Atypical angina'''
| bgcolor="CornFlowerBlue" |'''Typical angina'''
|-
| 30-39
| Men
| Low
| Intermediate
| Intermediate
|-
|
| Women
| Low
| Low
| Intermediate
|-
| 40-49
| Men
| Intermediate
| Intermediate
| High
|-
|
| Women
| Low
| Low
| Intermediate
|-
| 50-59
| Men
| Intermediate
| Intermediate
| High
|-
|
| Women
| Low
| Intermediate
| Intermediate
|-
| 60-69
| Men
| Intermediate
| Intermediate
| High
|-
|
| Women
| Intermediate
| Intermediate
| High
|}</center>


===Pretest Probability===
==References==
 
{{Reflist|2}}
====Definition====
{{WikiDoc Help Menu}}
Pretest Probability is defined as the probability of the target disorder before the result of a diagnostic test is known. The pretest probability is especially useful for:
{{WikiDoc Sources}}
* deciding whether its worth testing at all(test threshold)
[[Category:Disease]]
* selecting type of diagnostic test
[[Category:Ischemic heart diseases]]
* interpreting the results of a diagnostic test
[[Category:Cardiology]]
* choosing whether to start therapy: a)without further testing(treatment threshold); b)while awaiting further testing
[[Category:Emergency medicine]]
 
[[Category:Intensive care medicine]]
====Calculating the pretest probability for coronary artery disease====
[[Category:Up-To-Date]]
First step is to categorize the type of chest pain or discomfort. This can be done as follows:
[[Category:Up-To-Date cardiology]]
* Typical angina(definite)
# substernal chest discomfort with chracteristic quality and duration
# provoked by exercise or emotional stress
# relieved by rest or[[NTG]]
* Atypical angina(probable)-meets 2 of the above criteria
* Nonanginal pain- meets one or zero of the anginal characteristics.
 
Next step is to calculate the pretest probability of CAD based on age, gender and type of pain. Pretest probability can be classified into low, intermediate and high probability.

Latest revision as of 16:55, 6 February 2013

Chronic stable angina Microchapters

Acute Coronary Syndrome Main Page

Home

Patient Information

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

Diagnosis

History and Symptoms

Physical Examination

Test Selection Guideline for the Individual Basis

Laboratory Findings

Electrocardiogram

Exercise ECG

Chest X Ray

Myocardial Perfusion Scintigraphy with Pharmacologic Stress

Myocardial Perfusion Scintigraphy with Thallium

Echocardiography

Exercise Echocardiography

Computed coronary tomography angiography(CCTA)

Positron Emission Tomography

Ambulatory ST Segment Monitoring

Electron Beam Tomography

Cardiac Magnetic Resonance Imaging

Coronary Angiography

Treatment

Medical Therapy

Revascularization

PCI
CABG
Hybrid Coronary Revascularization

Alternative Therapies for Refractory Angina

Transmyocardial Revascularization (TMR)
Spinal Cord Stimulation (SCS)
Enhanced External Counter Pulsation (EECP)
ACC/AHA Guidelines for Alternative Therapies in patients with Refractory Angina

Discharge Care

Patient Follow-Up
Rehabilitation

Secondary Prevention

Guidelines for Asymptomatic Patients

Noninvasive Testing in Asymptomatic Patients
Risk Stratification by Coronary Angiography
Pharmacotherapy to Prevent MI and Death in Asymptomatic Patients

Landmark Trials

Case Studies

Case #1

Chronic stable angina assessing the pretest probability of coronary artery disease On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Chronic stable angina assessing the pretest probability of coronary artery disease

CDC onChronic stable angina assessing the pretest probability of coronary artery disease

Chronic stable angina assessing the pretest probability of coronary artery disease in the news

Blogs on Chronic stable angina assessing the pretest probability of coronary artery disease

to Hospitals Treating Chronic stable angina assessing the pretest probability of coronary artery disease

Risk calculators and risk factors for Chronic stable angina assessing the pretest probability of coronary artery disease

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [3]; Associate Editor-in-Chief: Smita Kohli, M.D.

Overview

Pretest probability is defined as the probability of the target disorder before the result of a diagnostic test is known. A number of studies have emphasized the importance of pretest probability of coronary artery disease (CAD).[1] Once a thorough patient history and physical examination is complete, it is important to assess the probability of underlying CAD, as this helps both the physician and the patient to determine the next step in the diagnosis and treatment. In patients with chronic stable angina, the strongest predictors contributing to underlying significant CAD include: the age, gender and type of pain (typical, atypical) experienced.[1]

Pretest Probability

  • Pretest probability is defined as the probability of the target disorder before the result of a diagnostic test is known.
  • The pretest probability is especially useful for:
  • Deciding whether it is worth proceeding with testing at all (this is referred to as the test threshold)
  • Selecting the type of diagnostic test
  • Interpreting the results of a diagnostic test
  • Choosing whether to start therapy: a) without further testing (this is referred to as the treatment threshold) or b) while awaiting further testing

Calculating the Pretest Probability for Coronary Artery Disease

  • The first step is to categorize the nature of the chest pain or discomfort. This can be done as follows:
  • Typical angina (definite): The characteristics of typical angina include:
  1. Substernal chest discomfort of characteristic quality and duration
  2. The pain is provoked by exercise or emotional stress
  3. The pain is relieved by rest or NTG
  • Atypical angina (probable): Meets two of the above criteria
  • Non-anginal pain: Meets one or zero of the anginal characteristics.
  • Based on the ACC/AHA 2002 guidelines,[2] the pretest probability can be classified into:
  • Low probability: less than 10%-20%;
  • Intermediate probability: between 20%-80%;
  • High probability: more than 80%-90%.
  • A quick way to assess this is shown in Table 1.[3][4][5]
Table 1: Pretest Probability of Coronary Artery Disease
Age (yrs) Gender Non-anginal pain Atypical angina Typical angina
30-39 Men Low Intermediate Intermediate
Women Low Low Intermediate
40-49 Men Intermediate Intermediate High
Women Low Low Intermediate
50-59 Men Intermediate Intermediate High
Women Low Intermediate Intermediate
60-69 Men Intermediate Intermediate High
Women Intermediate Intermediate High

References

  1. 1.0 1.1 Diamond GA, Forrester JS (1981) Improved interpretation of a continuous variable in diagnostic testing: probabilistic analysis of scintigraphic rest and exercise left ventricular ejection fractions for coronary disease detection. Am Heart J 102 (2):189-95. PMID: 7258092
  2. 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). Circulation 107 (1):149-58.[1] PMID: 12515758
  3. Fraker TD, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J et al. (2007)2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina. Circulation 116 (23):2762-72.[2] PMID: 17998462
  4. Snow V, Barry P, Fihn SD, Gibbons RJ, Owens DK, Williams SV et al. (2004) Evaluation of primary care patients with chronic stable angina: guidelines from the American College of Physicians. Ann Intern Med 141 (1):57-64. PMID: 15238371
  5. Diamond GA, Forrester JS (1982) Probability of CAD. Circulation 65 (3):641-2. PMID: 7055887

Template:WikiDoc Sources