Note from the National Guideline Clearinghouse (NGC): This guideline is an update of the 1999 guideline on chronic stable angina, which was published by the American College of Physicians (ACP) (then the American College of Physicians-American Society of Internal Medicine) and the American College of Cardiology/American Heart Association (ACC/AHA). In 2002, the ACC/AHA published an updated guideline, which the ACP recognized as a scientifically valid review of the evidence and background paper [ACC/AHA 2002 guideline update 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 (Committee to Update the 1999 Guidelines for the Management of Patients With Chronic Stable Angina)]. This ACP guideline summarizes the recommendations of the 2002 ACC/AHA updated guideline and underscores the recommendations most likely to be important to physicians seeing patients in the primary care setting. See the companion documents field for a complete reference to the ACC/AHA guideline.
The levels of evidence (A, B, C) are defined at the end of the "Major Recommendations" field.
Estimating the Probability of Significant Coronary Artery Disease (CAD)
Recommendation 1: In patients presenting with chest pain, the probability of CAD should be estimated on the basis of patient age, sex, cardiovascular risk factors, and pain characteristics (level of evidence: B). Patients with intermediate or high probability should undergo risk stratification through further testing. For patients with a low probability of CAD, the decision to pursue further testing should be based on a shared discussion between the patient and clinician.
Estimating Prognosis on the Basis of Resting Left Ventricular Function
Recommendation 2: The following patients who have chronic stable angina or are asymptomatic should have left ventricular function measured by resting echocardiography or resting radionuclide angiography: patients with a history of myocardial infarction (MI), patients with pathologic Q waves, patients with symptoms or signs suggestive of heart failure, and patients with complex ventricular arrhythmias (level of evidence for all patients: B).
Exercise Testing for Diagnosis and Risk Stratification in Symptomatic Patients with Intermediate to High Probability of CAD
Recommendation 3: Exercise electrocardiography (ECG), using the Bruce protocol and Duke treadmill score, should be the initial test for risk stratification in patients with symptomatic chronic stable angina who are able to exercise and are not taking digoxin (level of evidence: B). Exercise ECG testing is also recommended after a significant change in anginal pattern (level of evidence: C). Exercise ECG testing is not recommended when the following confounding factors are found on resting ECG: preexcitation (Wolff–Parkinson–White) syndrome, electronically paced ventricular rhythm, more than 1 mm of ST depression at rest, and complete left bundle-branch block (level of evidence for all factors: B).
Risk Stratification with Stress Imaging Studies (Radionuclide Angiography and Echocardiography) in Symptomatic Patients
Recommendation 4: For patients with chronic stable angina who are able to exercise, do not have left bundle-branch block or an electronically paced ventricular rhythm, and have abnormal results on resting ECG or are using digoxin, exercise perfusion imaging or exercise echocardiography is recommended as the initial test for risk stratification (level of evidence: B).
Recommendation 5: For patients who are unable to exercise and do not have left bundle-branch block or an electronically paced ventricular rhythm, dipyridamole or adenosine myocardial perfusion imaging (level of evidence: B) or dobutamine echocardiography (level of evidence: B) is recommended as the initial test for risk stratification.
Recommendation 6: For patients with left bundle-branch block or electronically paced ventricular rhythm, dipyridamole or adenosine myocardial perfusion imaging is recommended regardless of ability to exercise (level of evidence: B).
Recommendation 7: For patients with left bundle-branch block or electronically paced ventricular rhythm, exercise or dobutamine echocardiography (level of evidence: C) and exercise myocardial perfusion imaging (level of evidence: C) are not recommended.
Risk Stratification in Asymptomatic Patients
Note: The American College of Cardiology/American Heart Association (ACC/AHA+ recommends against "screening" asymptomatic outpatients for coronary disease. However, the American College of Physicians (ACP) recognizes the clinical reality that primary care physicians and subspecialists are being consulted by asymptomatic patients who may have been inappropriately screened and present with "abnormal" results on ambulatory ECG monitoring, electron-beam computed tomography, or other tests. Most of the recommendations in this section are based on level C evidence, which denotes expert opinion from the ACC/AHA guideline. As a matter of policy, the ACP seldom makes clinical policy recommendations on the basis of expert opinion. However, this clinical situation has become a particularly important problem for ACP membership. Therefore, in the absence of any high-grade evidence (level A or B), the ACP has chosen to endorse the following recommendations from the ACC/AHA document, which in this case were developed by using expert opinion.
Exercise ECG
Asymptomatic patients who are able to exercise can usually be evaluated with exercise ECG. In this case, the recommendations for exercise stress testing for risk stratification in asymptomatic patients would be the same as for symptomatic patients and would depend on patients’ ability to exercise and the presence of abnormalities on resting ECG (see Recommendations 2 and 3 above).
Stress Imaging Studies (Radionuclide Angiography and Echocardiography)
The recommendations for the use of stress imaging (exercise or pharmacologic) in asymptomatic patients with abnormalities on ambulatory ECG monitoring or electron-beam computed tomography are the same as for symptomatic patients. They depend on whether the patient is able to exercise or whether abnormalities on resting ECG are present. In this case, the ACP recommends, on the basis of the opinion of the ACC/AHA, several options for further workup of asymptomatic patients.
Recommended options for cardiac stress imaging after exercise ECG for risk stratification in asymptomatic patients are as follows. Exercise myocardial perfusion imaging or exercise echocardiography may be performed in asymptomatic patients with an intermediate-risk or high-risk Duke treadmill score on exercise ECG (level of evidence: C). Adenosine or dipyridamole myocardial perfusion imaging or dobutamine echocardiography may be performed in asymptomatic patients with a previously inadequate exercise ECG (level of evidence: C). Asymptomatic patients with a low-risk Duke treadmill score on exercise ECG should not have exercise myocardial perfusion imaging, exercise echocardiography, adenosine or dipyridamole myocardial perfusion imaging, or dobutamine echocardiography (level of evidence: C).
Definitions
Levels of Evidence
Level A recommendation is based on evidence from multiple randomized clinical trials with large numbers of patients.
Level B recommendation is based on evidence from a limited number of randomized trials with small numbers of patients, careful analyses of nonrandomized studies, or observational registries.
Level C recommendation is based on expert consensus.
