Chronic stable angina test selection guideline for the individual basis: Difference between revisions
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{{Chronic stable angina}} | {{Chronic stable angina}} | ||
'''Editor-in-Chief:''' [[C. Michael Gibson]], M.S.,M.D. [mailto:charlesmichaelgibson@gmail.com] Phone:617-632-7753; '''Associate Editor(s)-in-Chief:''' {{CZ}}; Smita Kohli, M.D. | |||
== | ==Overview== | ||
Criteria for test selection hinges largely on the current disease state of the individual patient and subsequent level of fitness for testing. Potential diagnostic testing modalities include: [[hronic stable angina exercise electrocardiography|exercise ECG]], [[hronic stable angina electrocardiography|ECG at rest]], [[Chronic stable angina exercise electrocardiography|exercise echocardiography]], [[Chronic stable angina exercise electrocardiography|echocardiography at rest]], and [[Chronic stable angina perfusion scintigraphy with pharmacologic stress|stress scintigraphy]]. | |||
*The [[Chronic stable angina exercise electrocardiography|exercise electrocardiography]] is the test of choice in | ==Test Selection Guidelines for the Individual Basis== | ||
:*Even when the [[Chronic stable angina exercise electrocardiography|exercise ECG]] is not necessary to establish the diagnosis of [[CAD]], it | *The [[Chronic stable angina exercise electrocardiography|exercise electrocardiography]] is the test of choice in patients with typical exertional [[angina]] with a normal [[Chronic stable angina electrocardiography|resting ECG]] who are able to exercise. | ||
:*If evidence for [[ischemia]] (by [[Chronic stable angina exercise electrocardiography|ECG]] or by perfusion scintigraphy or [[Chronic stable angina exercise echocardiography|echocardiography]]) is detected during the first stage of exercise, the | :*Even when the [[Chronic stable angina exercise electrocardiography|exercise ECG]] is not deemed clinically necessary to establish the diagnosis of [[coronary artery disease (CAD)]], it can be helpful in assessing CAD severity. | ||
:*If evidence for [[ischemia]] (by [[Chronic stable angina exercise electrocardiography|ECG]] or by perfusion [[scintigraphy]] or [[Chronic stable angina exercise echocardiography|echocardiography]]) is detected during the first stage of exercise, the incidence of three-vessel disease or left main coronary artery [[stenosis]] is greater than compared to cases more exercise is required to provoke a positive test. | |||
*[[Chronic stable angina exercise electrocardiography|Exercise electrocardiography]] in patients with suspected or established stable angina pectoris | *[[Chronic stable angina exercise electrocardiography|Exercise electrocardiography]] in patients with suspected or established stable angina pectoris can be a useful tool in determining usage of nonpharmacologic and pharmacologic therapeutic interventions. | ||
*In patients with [[Chronic stable angina definition|stable angina pectoris]],[[Chronic stable angina clinical subset- mixed angina pectoris|mixed angina]], [[Chronic stable angina clinical subset- postprandial angina pectoris|postprandial angina]],[[Chronic stable angina clinical subset- walk through angina pectoris|walk through angina]], or patients without prior [[myocardial infarction]], the [[Chronic stable angina exercise electrocardiography|exercise ECG]] | *In patients with [[Chronic stable angina definition|stable angina pectoris]], [[Chronic stable angina clinical subset- mixed angina pectoris|mixed angina]], [[Chronic stable angina clinical subset- postprandial angina pectoris|postprandial angina]], [[Chronic stable angina clinical subset- walk through angina pectoris|walk through angina]], or patients without prior [[myocardial infarction]], the [[Chronic stable angina exercise electrocardiography|exercise ECG]] can be an adequate means to assess the presence and severity of [[myocardial ischemia]]. | ||
*The diagnosis of [[Chronic stable angina clinical subset- syndrome X|metabolic syndrome]] is established by the presence of typical anginal discomfort that is accompanied by ischemic changes on [[Chronic stable angina exercise electrocardiography|exercise ECG]] (or exercise or [[Chronic stable angina perfusion scintigraphy with pharmacologic stress|stress scintigraphy]]) with subsequent demonstration of the absence of critical coronary artery obstruction on coronary arteriography. | *The diagnosis of [[Chronic stable angina clinical subset- syndrome X|metabolic syndrome]] is established by the presence of typical anginal discomfort that is accompanied by ischemic changes on [[Chronic stable angina exercise electrocardiography|exercise ECG]] (or exercise or [[Chronic stable angina perfusion scintigraphy with pharmacologic stress|stress scintigraphy]]) with subsequent demonstration of the absence of critical coronary artery obstruction on coronary arteriography. | ||
*In women with typical [[angina]], [[Chronic stable angina exercise electrocardiography|exercise ECG]] | *In women with typical [[angina]], [[Chronic stable angina exercise electrocardiography|exercise ECG]] can be an adequate testing means. However, due to a higher incidence of false positive test results in stress [[ECG]] in women, exercise perfusion [[scintigraphy]] or [[Chronic stable angina exercise echocardiography|exercise echocardiography]] should also be considered as a reasonable testing alternative, often with fewer specificity issues. | ||
*Exercise perfusion scintigraphy should be considered as the test of choice when stress ECGs are uninterpretable, as in patients with (BBB) [[bundle branch block]], interventricular conduction defects, [[left ventricular hypertrophy]] with baseline ST segment or T-wave abnormalities, pre excitation syndromes or ST segment changes owing to electrolyte imbalance or digitalis therapy. [[Chronic stable angina perfusion scintigraphy with pharmacologic stress| | *Exercise perfusion [[scintigraphy]] should be considered as the test of choice when stress ECGs are uninterpretable, as in patients with (BBB) [[bundle branch block]], interventricular conduction defects, [[left ventricular hypertrophy]] with baseline ST segment or T-wave abnormalities, pre-excitation syndromes or ST segment changes owing to electrolyte imbalance or digitalis therapy. In these cases, [[Chronic stable angina perfusion scintigraphy with pharmacologic stress|stress perfusion scintigraphy]] can be a more accurate method than the [[Chronic stable angina exercise electrocardiography|stress electrocardiography]] to determine the extent and distribution of [[ischemia]]. | ||
*In | *In patients who are classified as unable to exercise, [[adenosine]] or [[dipyridamole]] [[Chronic stable angina perfusion scintigraphy with pharmacologic stress|perfusion scintigraphy]] and [[dobutamine]] [[echocardiography]] are the preferred noninvasive tests to assess the presence and extent of [[myocardial ischemia]]. These methods are also recommended in patients with a blunted [[heart rate]] response as a result of [[antianginal therapy]]. | ||
*In patients with moderate or severe [[chronic obstructive pulmonary airway diseases]] and poor exercise tolerance, [[dobutamine]] [[echocardiography]] is | *In patients with moderate or severe [[chronic obstructive pulmonary airway diseases]] and poor exercise tolerance, [[dobutamine]] [[echocardiography]] is the preferred diagnostic test instead of [[adenosine]] or [[dipyridamole]] [[Chronic stable angina perfusion scintigraphy with pharmacologic stress|perfusion scintigraphy]]. | ||
*Not all noninvasive or invasive tests | *Not all noninvasive or invasive tests available for the diagnosis of [[coronary artery disease]] and [[myocardial ischemia]] are applicable to all clinical subsets of patients with stable angina. | ||
*For patients with [[Chronic stable angina definition|stable exertional angina]], [[Chronic stable angina clinical subset- mixed angina pectoris|mixed angina]], [[Chronic stable angina clinical subset- postprandial angina pectoris|postprandial angina]], [[Chronic stable angina clinical subset- walk through angina pectoris|walk through angina]], and [[Chronic stable angina clinical subset- nocturnal angina pectoris| | *For patients with [[Chronic stable angina definition|stable exertional angina]], [[Chronic stable angina clinical subset- mixed angina pectoris|mixed angina]], [[Chronic stable angina clinical subset- postprandial angina pectoris|postprandial angina]], [[Chronic stable angina clinical subset- walk through angina pectoris|walk through angina]], and [[Chronic stable angina clinical subset- nocturnal angina pectoris|nocturnal angina]] within 1 to 2 hours after the rest, it is desirable to select tests that are likely to induce [[myocardial ischemia]] by increasing myocardial oxygen requirements. In these patients, [[Chronic stable angina exercise electrocardiography|exercise ECG]], exercise or [[Chronic stable angina perfusion scintigraphy with pharmacologic stress|stress perfusion scintigraphy]] and [[Chronic stable angina exercise echocardiography|exercise echocardiography]] are designed to provoke [[ischemia]]. | ||
*In patients with stable [[angina pectoris]], particularly those with documented prior [[myocardial infarction]], | *In patients with stable [[angina pectoris]], particularly those with documented prior [[myocardial infarction]], an assessment of left ventricular systolic function is necessary for selection of an appropriate therapy method. In this group of patients, assessment for [[myocardial ischemia]] and ventricular function can be performed by the combination of a test for [[ischemia]]; [[Chronic stable angina exercise electrocardiography|exercise ECG]] and a LV function test (i.e., [[Chronic stable angina echocardiography|echocardiography at rest]]), or echocardiography both, at [[Chronic stable angina echocardiography|rest]] and [[Chronic stable angina exercise echocardiography|during exercise]]. | ||
==References== | ==References== | ||
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Latest revision as of 21:01, 4 February 2013
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Chronic stable angina Microchapters | ||
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Classification | ||
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Differentiating Chronic Stable Angina from Acute Coronary Syndromes | ||
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Diagnosis | ||
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Alternative Therapies for Refractory Angina | ||
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Discharge Care | ||
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Guidelines for Asymptomatic Patients | ||
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Case Studies | ||
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Editor-in-Chief: C. Michael Gibson, M.S.,M.D. [1] Phone:617-632-7753; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Smita Kohli, M.D.
Overview
Criteria for test selection hinges largely on the current disease state of the individual patient and subsequent level of fitness for testing. Potential diagnostic testing modalities include: exercise ECG, ECG at rest, exercise echocardiography, echocardiography at rest, and stress scintigraphy.
Test Selection Guidelines for the Individual Basis
- The exercise electrocardiography is the test of choice in patients with typical exertional angina with a normal resting ECG who are able to exercise.
- Even when the exercise ECG is not deemed clinically necessary to establish the diagnosis of coronary artery disease (CAD), it can be helpful in assessing CAD severity.
- If evidence for ischemia (by ECG or by perfusion scintigraphy or echocardiography) is detected during the first stage of exercise, the incidence of three-vessel disease or left main coronary artery stenosis is greater than compared to cases more exercise is required to provoke a positive test.
- Exercise electrocardiography in patients with suspected or established stable angina pectoris can be a useful tool in determining usage of nonpharmacologic and pharmacologic therapeutic interventions.
- In patients with stable angina pectoris, mixed angina, postprandial angina, walk through angina, or patients without prior myocardial infarction, the exercise ECG can be an adequate means to assess the presence and severity of myocardial ischemia.
- The diagnosis of metabolic syndrome is established by the presence of typical anginal discomfort that is accompanied by ischemic changes on exercise ECG (or exercise or stress scintigraphy) with subsequent demonstration of the absence of critical coronary artery obstruction on coronary arteriography.
- In women with typical angina, exercise ECG can be an adequate testing means. However, due to a higher incidence of false positive test results in stress ECG in women, exercise perfusion scintigraphy or exercise echocardiography should also be considered as a reasonable testing alternative, often with fewer specificity issues.
- Exercise perfusion scintigraphy should be considered as the test of choice when stress ECGs are uninterpretable, as in patients with (BBB) bundle branch block, interventricular conduction defects, left ventricular hypertrophy with baseline ST segment or T-wave abnormalities, pre-excitation syndromes or ST segment changes owing to electrolyte imbalance or digitalis therapy. In these cases, stress perfusion scintigraphy can be a more accurate method than the stress electrocardiography to determine the extent and distribution of ischemia.
- In patients who are classified as unable to exercise, adenosine or dipyridamole perfusion scintigraphy and dobutamine echocardiography are the preferred noninvasive tests to assess the presence and extent of myocardial ischemia. These methods are also recommended in patients with a blunted heart rate response as a result of antianginal therapy.
- In patients with moderate or severe chronic obstructive pulmonary airway diseases and poor exercise tolerance, dobutamine echocardiography is the preferred diagnostic test instead of adenosine or dipyridamole perfusion scintigraphy.
- Not all noninvasive or invasive tests available for the diagnosis of coronary artery disease and myocardial ischemia are applicable to all clinical subsets of patients with stable angina.
- For patients with stable exertional angina, mixed angina, postprandial angina, walk through angina, and nocturnal angina within 1 to 2 hours after the rest, it is desirable to select tests that are likely to induce myocardial ischemia by increasing myocardial oxygen requirements. In these patients, exercise ECG, exercise or stress perfusion scintigraphy and exercise echocardiography are designed to provoke ischemia.
- In patients with stable angina pectoris, particularly those with documented prior myocardial infarction, an assessment of left ventricular systolic function is necessary for selection of an appropriate therapy method. In this group of patients, assessment for myocardial ischemia and ventricular function can be performed by the combination of a test for ischemia; exercise ECG and a LV function test (i.e., echocardiography at rest), or echocardiography both, at rest and during exercise.