Chronic stable angina revascularization: Difference between revisions

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You can read in greater detail about specific revascularization approaches for the treatment of chronic stable angina by clicking on the link below for that topic:
You can read in greater detail about specific revascularization approaches for the treatment of chronic stable angina by clicking on the link below for that topic:



Revision as of 20:12, 31 October 2016

Chronic stable angina Microchapters

Acute Coronary Syndrome Main Page

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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

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Positron Emission Tomography

Ambulatory ST Segment Monitoring

Electron Beam Tomography

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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

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Chronic stable angina revascularization On the Web

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Risk calculators and risk factors for Chronic stable angina revascularization

Editors-In-Chief: C. Michael Gibson, M.S., M.D. [1] Phone:617-632-7753; Cafer Zorkun, M.D., Ph.D. [2]; Associate Editors-In-Chief: John Fani Srour, M.D.; Smita Kohli, M.D.; Rim Halaby

Overview

The goal of the treatment of chronic stable angina is to reduce the symptoms, delay the progression of atherosclerosis, and prevent cardiovascular events. In order to achieve these goals, lifestyle modifications and medical therapy are the first line treatment. Revascularization is done to increase survival in specific conditions where the stenosis of the coronary arteries is anatomically and functionally significant and the symptoms are refractory to medical therapy. There are currently two well-established revascularization approaches for the treatment of chronic stable angina caused by coronary atherosclerosis: CABG and PCI. Since the introduction of coronary artery bypass surgery in 1967 and percutaneous transluminal coronary angioplasty (PTCA) in 1977, research has supported the effective usage of both strategies for treatment of patients with chronic stable angina. However, as with any treatment method, both methodologies have weaknesses. The choice between PCI and CABG is based upon anatomy and other factors such as left ventricular function and the presence or absence of diabetes. In general, PTCA is reserved for single or some cases of two vessel disease, while CABG is reserved for patients with two or three vessel disease or left main disease. With the availability of drug-eluting stents, PCI is increasingly being performed for many lesions including more complex ones.

Revascularization

Indications for Revascularization Therapy

Increase Survival

  • Increased survival following revascularization depends on the location, severity, and number of lesions; the presence or absence of left ventricular dysfunction is an important factor as well. Therefore, revascularization is recommended in the following situations:
    • More than 50% stenosis of the left main coronary:
      • CABG is indicated
      • PCI is not indicated when patients are good candidates for CABG or when the anatomy is not favorable.
    • More than 70% stenosis of three major coronary artery or proximal left anterior descending artery:
  • Patients who would also have a survival benefit from revascularization (PCI or CABG) are survivors of sudden cardiac death secondary to ischemia induced tachycardia, where ischemia is caused by more than 70% stenosis of a major coronary artery:

Relief of Symptoms Refractory to Medical Therapy

  • Coronary angiography should be performed in the following settings:
    • More than 70% stenosis of a non left main artery or more than 50% stenosis of left main artery
  • The definition of inadequate response to medical therapy can be fairly broad and depends largely on the patient's lifestyle, occupation and expectations:
    • At one extreme are patients who are limited by angina pectoris despite optimal drug treatments and lifestyle modifications, including achievement of optimal weight and cessation of smoking.
    • At the other end are patients in whom we can consider medical therapy to have failed if control of angina pectoris requires higher doses of anti-anginal medications that cause side effects.
  • The following patients should also be considered:

Considerations

  • PCI should not be done in patients that will not be compliant with dual antiplatelet therapies.
  • Patients with diabetes and advanced three-vessel coronary artery disease have shown lower mortality and myocardial infarction rates and higher risk of strokes when undergoing CABG compared to PCI with drug eluting stents.[2]

Revascularization: Further Readings

2012 AHA guidelines for the management of chronic stable angina[3]

Heart Team Approach Revascularization Guidelines[3]

Class I
"1. A Heart Team approach to revascularization is recommended in patients with unprotected left main or complex CAD"(Level of Evidence:C ) "
Class I
"1. Calculation of the STS and SYNTAX scores is reasonable in patients with unprotected left main and complex CAD "(Level of Evidence:B ) "

You can read in greater detail about specific revascularization approaches for the treatment of chronic stable angina by clicking on the link below for that topic:

References

  1. 1.0 1.1 Qaseem A, Fihn SD, Dallas P, et al. Management of patients with stable ischemic heart disease: Executive summary of a clinical practice guideline from the American College of Physicians, American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med 2012.
  2. Farkouh ME, Domanski M, Sleeper LA, Siami FS, Dangas G, Mack M; et al. (2012). "Strategies for Multivessel Revascularization in Patients with Diabetes". N Engl J Med. doi:10.1056/NEJMoa1211585. PMID 23121323.
  3. 3.0 3.1 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.

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