Chronic stable angina revascularization: Difference between revisions
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==Overview== | ==Overview== | ||
The | The goal of treatment for chronic stable angina is: to reduce symptoms, delay the progression of [[atherosclerosis]], and prevent cardiovascular events. To achieve this, medical therapy with revascularization may be used in applicable patients. The main indication for revascularization therapy (PCI or CABG), in chronic stable angina, are: | ||
* Patients with symptoms uncontrolled by optimal medical therapy (see [[Chronic stable angina treatment#Pharmacotherapy|Pharmacotherapy]] and [[Chronic stable angina treatment#Lifestyle modifications|Lifestyle modifications]] for stable angina). | |||
* Patients with symptoms uncontrolled | ::The definition of inadequate response to medical therapy can be fairly broad and depend 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. | |||
The definition of | ::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. | ||
* Patients who would have a survival benefit from revascularization (PCI or CABG). | * Patients who would have a survival benefit from revascularization (PCI or CABG). | ||
::This depends on the location, severity, and number of lesions; the presence or absence of left ventricular dysfunction is an important factor as well. | |||
This depends on the location, severity, and number of lesions; the presence or absence of left ventricular dysfunction is an important factor as well. | ::There is evidence and/or general agreement that coronary [[angiography]] should be performed to risk stratify patients with chronic stable angina in the following settings: | ||
::* Disabling anginal symptoms (Canadian Cardiovascular Society [[CCS]] classes III and IV) despite medical therapy. | |||
There is evidence and/or general agreement that coronary [[angiography]] should be performed to risk stratify patients with chronic stable angina in the following settings: | ::* High-risk criteria on noninvasive testing independent of the severity of [[angina]] (The amount and distribution of viable but jeopardized left ventricular myocardium and the percentage of irreversibly scarred [[myocardium]]). | ||
::* Survivors of sudden cardiac death or serious ventricular [[arrhythmia]]. | |||
* Disabling anginal symptoms (Canadian Cardiovascular Society [[CCS]] classes III and IV) despite medical therapy. | ::* Symptoms and signs of heart failure. | ||
* High-risk criteria on noninvasive testing independent of the severity of [[angina]] (The amount and distribution of viable but jeopardized left ventricular myocardium and the percentage of irreversibly scarred [[myocardium]]). | ::* Clinical features that suggest that the patient has a high likelihood of severe coronary artery disease. | ||
* Survivors of sudden cardiac death or serious ventricular [[arrhythmia]]. | :On the other hand, [[angiography]] is not recommended for patients with CCS class I or II angina that responds to medical therapy and, on noninvasive testing, shows no evidence of ischemia. | ||
* Symptoms and signs of heart failure. | |||
* Clinical features that suggest that the patient has a high likelihood of severe coronary artery disease. | |||
On the other hand, [[angiography]] is not recommended for patients with CCS class I or II angina that responds to medical therapy and, on noninvasive testing, shows no evidence of ischemia. | |||
There are currently two well-established revascularization approaches for the treatment of chronic stable angina caused by coronary [[atherosclerosis]]. Since the introduction of [[bypass]] surgery in 1967 and percutaneous transluminal coronary [[angioplasty]] [PTCA] in 1977, it has become clear that both strategies can contribute to the effective treatment of patients with chronic stable angina and both 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. | There are currently two well-established revascularization approaches for the treatment of chronic stable angina caused by coronary [[atherosclerosis]]. Since the introduction of [[bypass]] surgery in 1967 and percutaneous transluminal coronary [[angioplasty]] [PTCA] in 1977, it has become clear that both strategies can contribute to the effective treatment of patients with chronic stable angina and both 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. | ||
Revision as of 15:38, 16 November 2011
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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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Chronic stable angina revascularization On the Web | ||
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to Hospitals Treating Chronic stable angina revascularization | ||
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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.
Overview
The goal of treatment for chronic stable angina is: to reduce symptoms, delay the progression of atherosclerosis, and prevent cardiovascular events. To achieve this, medical therapy with revascularization may be used in applicable patients. The main indication for revascularization therapy (PCI or CABG), in chronic stable angina, are:
- Patients with symptoms uncontrolled by optimal medical therapy (see Pharmacotherapy and Lifestyle modifications for stable angina).
- The definition of inadequate response to medical therapy can be fairly broad and depend 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.
- Patients who would have a survival benefit from revascularization (PCI or CABG).
- This depends on the location, severity, and number of lesions; the presence or absence of left ventricular dysfunction is an important factor as well.
- There is evidence and/or general agreement that coronary angiography should be performed to risk stratify patients with chronic stable angina in the following settings:
- Disabling anginal symptoms (Canadian Cardiovascular Society CCS classes III and IV) despite medical therapy.
- High-risk criteria on noninvasive testing independent of the severity of angina (The amount and distribution of viable but jeopardized left ventricular myocardium and the percentage of irreversibly scarred myocardium).
- Survivors of sudden cardiac death or serious ventricular arrhythmia.
- Symptoms and signs of heart failure.
- Clinical features that suggest that the patient has a high likelihood of severe coronary artery disease.
- On the other hand, angiography is not recommended for patients with CCS class I or II angina that responds to medical therapy and, on noninvasive testing, shows no evidence of ischemia.
There are currently two well-established revascularization approaches for the treatment of chronic stable angina caused by coronary atherosclerosis. Since the introduction of bypass surgery in 1967 and percutaneous transluminal coronary angioplasty [PTCA] in 1977, it has become clear that both strategies can contribute to the effective treatment of patients with chronic stable angina and both 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 approaches for the treatment of stable angina
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.
PCI | CABG | PCI vs CABG | ACC/AHA Guidelines for Revascularization
See Also
Guidelines Resources
- The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina [1]
- The ACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina [2]
- The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina [3]
References
- ↑ Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999) 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: 10351980
- ↑ 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. PMID: 12515758
- ↑ 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. DOI:10.1161/CIRCULATIONAHA.107.187930 PMID: 17998462