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__NOTOC__
{{Chronic stable angina}}
{{Chronic stable angina}}
'''Editor-In-Chief:''' [[C. Michael Gibson, M.S., M.D.]] [mailto:mgibson@perfuse.org] Phone:617-632-7753; '''Associate Editor(s)-in-Chief:''' {{CZ}}; Smita Kohli, M.D.; [[Lakshmi Gopalakrishnan]], M.B.B.S.
 
'''Editor-In-Chief:''' [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com]; '''Associate Editor(s)-in-Chief:''' {{CZ}}; Smita Kohli, M.D.; [[Lakshmi Gopalakrishnan|Lakshmi Gopalakrishnan, M.B.B.S.]]; {{AA}}


==Overview==
==Overview==
A resting 12-lead ECG is recorded in all patients with suspected angina pectoris. However, a normal resting ECG does not exclude the diagnosis of [[ischemia]]. The abnormalities observed on resting ECG are ST-segment changes, [[LVH]], [[LBBB]], signs of [[CAD]] such as previous [[MI]] or abnormal repolarization patterns <ref name="pmid10728321">Kléber AG (2000) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10728321 ST-segment elevation in the electrocardiogram: a sign of myocardial ischemia.] ''Cardiovasc Res'' 45 (1):111-8. PMID: [http://pubmed.gov/10728321 10728321]</ref>. An ECG recorded during pain helps to identify an underlying [[Coronary Vasospasm|vasospasm]].  
A resting 12-lead ECG is performed and recorded in all patients with suspected angina pectoris. However, a normal resting ECG does not exclude the diagnosis of [[ischemia]]. Abnormalites commonly observed on resting ECG include: ST-segment changes, [[left ventricular hypertrophy|left ventricular hypertrophy (LVH)]], left branch bundle blockage ([[LBBB]]), signs of [[coronary artery disease|coronary artery disease (CAD)]] such as previous [[myocardial infarction|myocardial infarction (MI)]] or abnormal repolarization patterns.<ref name="pmid10728321">Kléber AG (2000) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10728321 ST-segment elevation in the electrocardiogram: a sign of myocardial ischemia.] ''Cardiovasc Res'' 45 (1):111-8. PMID: [http://pubmed.gov/10728321 10728321]</ref> An ECG recorded during pain helps to identify an underlying [[Coronary vasospasm|vasospasm]].


==Electrocardiography at Rest==
==Electrocardiography==
*The Electrocardiography (ECG) is critical not only to add support to the clinical suspicion of [[CAD]] but also to provide prognostic information based on the pattern and magnitude of the abnormalities.  
===Indication===
As a testing modality, electrocardiography (ECG) is critical not only to add support to the clinical suspicion of [[CAD]] but also to provide prognostic information based on the pattern and magnitude of the abnormalities.  


*It is in normal range in approximately half of patients with chronic stable angina without a history of previous [[myocardial infarction]]. In the others, a variety of ECG finding may suggest an [[ischemic heart disease]].  
===Diagnostic Criteria===
*In approximately half of all patients with chronic stable angina without a history of previous [[myocardial infarction]], ECG values may be within normal range. In others, a variety of ECG findings may be present and be suggestive of an [[ischemic heart disease]].


*'''Q waves''' may suggest prior [[myocardial infarction]], but in the absence of a clinical history of previous [[myocardial infarction]] or [[CAD]],  
*Q waves may suggest prior [[myocardial infarction]], but in the absence of a clinical history of previous [[myocardial infarction]] or [[CAD]],  
:*Q waves may also be caused by other conditions, including [[hypertrophic cardiomyopathy]], [[left ventricular hypertrophy]], dilated non ischemic cardiomyopathy and accessory conduction pathways.  
:*Q waves may also be caused by other conditions, including [[hypertrophic cardiomyopathy]], [[left ventricular hypertrophy]], dilated non ischemic cardiomyopathy and accessory conduction pathways.  
:*Isolated Q waves in lead III or QS pattern in V1 and V2 are nonspecific for diagnosis.
:*Isolated Q waves in lead III or QS pattern in V1 and V2 are nonspecific for diagnosis.


*The occurrence of '''ST segment depression''' and '''[[T wave inversion]]''' in the resting [[ECG]], and signs of [[left ventricular hypertrophy]], [[left bundle branch block]] (LBBB) and left anterior hemiblock [[LAH]] are compatible with, favors to, but are not specific for [[CAD]].  
*The occurrence of ST segment depression and [[T wave inversion]] in the resting [[ECG]], and signs of [[left ventricular hypertrophy]], [[left bundle branch block]] (LBBB) and left anterior hemiblock [[LAH]] are compatible with, and favors to, but are not specifically indicative of [[CAD]].  
:*A physician should consider these abnormal ECG findings as indications for further evaluation.  
:*A physician should consider these abnormal ECG findings as indications for further evaluation.  
:*'''Giant T-wave inversion''' in precordial leads is sometimes an important indicator of severe Left Anterior Descending (LAD) artery stenosis.
:*Giant T-wave inversion in precordial leads can be an important indicator of severe Left Anterior Descending ([[LAD]]) artery stenosis.
 
*ST segment changes in [[angina]] can be seen as '''downsloping, upsloping or horizontal [[ST segment depression]]'''.
 
[[Image:ST_depression.jpg|500px|center|]]
 


==ACC / AHA Guidelines- Resting ECG(DO NOT EDIT)<ref name="pmid10351980">Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10351980 ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina).] ''Circulation'' 99 (21):2829-48. PMID: [http://pubmed.gov/10351980 10351980]</ref>==
*ST segment changes in [[angina]] can be seen as downsloping, upsloping or horizontal [[ST segment depression]].
{{cquote|
===Class I===
1. Rest [[ECG]] in patients without an obvious noncardiac cause of [[chest pain]]. ''(Level of Evidence: B)''


2. Rest [[ECG]] during an episode of [[chest pain]]. ''(Level of Evidence: B)''}}
==ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina (DO NOT EDIT)<ref name="pmid23166210">{{cite journal| author=Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP et al.| title=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. | journal=Circulation | year= 2012 | volume= 126 | issue= 25 | pages= 3097-137 | pmid=23166210 | doi=10.1161/CIR.0b013e3182776f83 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23166210  }} </ref>==


==ESC Guidelines- Resting ECG for Initial diagnostic assessment of angina (DO NOT EDIT)<ref name="pmid16735367">{{cite journal| author=Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F et al.| title=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. | journal=Eur Heart J | year= 2006 | volume= 27 | issue= 11 | pages= 1341-81 | pmid=16735367 | doi=10.1093/eurheartj/ehl001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16735367 }} </ref>==
===Noninvasive Testing-ECG (DO NOT EDIT)<ref name="pmid23166210">{{cite journal| author=Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP et al.| title=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. | journal=Circulation | year= 2012 | volume= 126 | issue= 25 | pages= 3097-137 | pmid=23166210 | doi=10.1161/CIR.0b013e3182776f83 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23166210 }} </ref>===
{{cquote|
'''Resting electrocardiography to assess risk'''
===Class I (in all patients)===
{|class="wikitable"
'''1.''' Resting [[ECG]] while pain free. ''(Level of Evidence: C)''
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]


'''2.''' Resting [[ECG]] during episode of [[angina]]. ''(Level of Evidence: B)''}}
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' A resting ECG is recommended in patients without an obvious, noncardiac cause of chest pain. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}


==ESC Guidelines- Resting ECG for Routine reassessment in patients with chronic stable angina (DO NOT EDIT)<ref name="pmid16735367">{{cite journal| author=Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F et al.| title=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. | journal=Eur Heart J | year= 2006 | volume= 27 | issue= 11 | pages= 1341-81 | pmid=16735367 | doi=10.1093/eurheartj/ehl001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16735367  }} </ref>==
==ESC Guidelines- Resting ECG for Initial Diagnostic Assessment of Angina (DO NOT EDIT)<ref name="pmid16735367">{{cite journal| author=Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F et al.| title=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. | journal=Eur Heart J | year= 2006 | volume= 27 | issue= 11 | pages= 1341-81 | pmid=16735367 | doi=10.1093/eurheartj/ehl001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16735367  }} </ref>==
{{cquote|
===Class IIb===
'''1.''' Routine periodic [[ECG]] in the absence of clinical change. ''(Level of Evidence: C)''}}


==Vote on and Suggest Revisions to the Current Guidelines==
{|class="wikitable"
*[[The Living Guidelines: Chronic Stable Angina Pectoris | The Chronic Stable Angina Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines]]
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[European society of cardiology#Classes of Recommendations|Class I]]


==Sources==
|-
*Guidelines on the management of stable angina pectoris: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology <ref name="pmid16735367">{{cite journal| author=Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F et al.| title=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. | journal=Eur Heart J | year= 2006 | volume= 27 | issue= 11 | pages= 1341-81 | pmid=16735367 | doi=10.1093/eurheartj/ehl001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16735367  }} </ref>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Resting [[ECG]] while pain free. ''([[European society of cardiology#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Resting [[ECG]] during episode of [[Chronic stable angina definition|angina]]. ''([[European society of cardiology#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}


*The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina <ref name="pmid10351980">Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10351980 ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina).] ''Circulation'' 99 (21):2829-48. PMID: [http://pubmed.gov/10351980 10351980]</ref>
==ESC Guidelines- Resting ECG for Routine Reassessment in Patients with Chronic Stable Angina (DO NOT EDIT)<ref name="pmid16735367">{{cite journal| author=Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F et al.| title=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. | journal=Eur Heart J | year= 2006 | volume= 27 | issue= 11 | pages= 1341-81 | pmid=16735367 | doi=10.1093/eurheartj/ehl001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16735367  }} </ref>==


*TheACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina <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. PMID: [http://pubmed.gov/12515758 12515758]</ref>
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[European society of cardiology#Classes of Recommendations|Class IIb]]


*The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina <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://dx.doi.org/10.1161/CIRCULATIONAHA.107.187930 DOI:10.1161/CIRCULATIONAHA.107.187930] PMID: [http://pubmed.gov/17998462 17998462]</ref>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Routine periodic [[ECG]] in the absence of clinical change. ''([[European society of cardiology#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}


==References==
==References==
{{Reflist|2}}
{{reflist|2}}


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Latest revision as of 20:07, 28 October 2016

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Smita Kohli, M.D.; Lakshmi Gopalakrishnan, M.B.B.S.; Aysha Anwar, M.B.B.S[3]

Overview

A resting 12-lead ECG is performed and recorded in all patients with suspected angina pectoris. However, a normal resting ECG does not exclude the diagnosis of ischemia. Abnormalites commonly observed on resting ECG include: ST-segment changes, left ventricular hypertrophy (LVH), left branch bundle blockage (LBBB), signs of coronary artery disease (CAD) such as previous myocardial infarction (MI) or abnormal repolarization patterns.[1] An ECG recorded during pain helps to identify an underlying vasospasm.

Electrocardiography

Indication

As a testing modality, electrocardiography (ECG) is critical not only to add support to the clinical suspicion of CAD but also to provide prognostic information based on the pattern and magnitude of the abnormalities.

Diagnostic Criteria

  • In approximately half of all patients with chronic stable angina without a history of previous myocardial infarction, ECG values may be within normal range. In others, a variety of ECG findings may be present and be suggestive of an ischemic heart disease.
  • A physician should consider these abnormal ECG findings as indications for further evaluation.
  • Giant T-wave inversion in precordial leads can be an important indicator of severe Left Anterior Descending (LAD) artery stenosis.

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

Noninvasive Testing-ECG (DO NOT EDIT)[2]

Resting electrocardiography to assess risk

Class I
"1. A resting ECG is recommended in patients without an obvious, noncardiac cause of chest pain. (Level of Evidence: B)"

ESC Guidelines- Resting ECG for Initial Diagnostic Assessment of Angina (DO NOT EDIT)[3]

Class I
"1. Resting ECG while pain free. (Level of Evidence: C)"
"1. Resting ECG during episode of angina. (Level of Evidence: B)"

ESC Guidelines- Resting ECG for Routine Reassessment in Patients with Chronic Stable Angina (DO NOT EDIT)[3]

Class IIb
"1. Routine periodic ECG in the absence of clinical change. (Level of Evidence: C)"

References

  1. ↑ Kléber AG (2000) ST-segment elevation in the electrocardiogram: a sign of myocardial ischemia. Cardiovasc Res 45 (1):111-8. PMID: 10728321
  2. ↑ 2.0 2.1 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.
  3. ↑ 3.0 3.1 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. doi:10.1093/eurheartj/ehl001. PMID 16735367.


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