ACC/AHA/ACPASIM Practice Guidelines

ACC/AHA/ACPASIM 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)
Committee Members

Raymond J. Gibbons, MD, FACC, Chair; Kanu Chatterjee, MB, FACC; Jennifer Daley, MD, FACP;
John S. Douglas, MD, FACC; Stephan D. Fihn, MD, MPH, FACP; Julius M. Gardin, MD, FACC;
Mark A. Grunwald, MD, FAAFP; Daniel Levy, MD, FACC; Bruce W. Lytle, MD, FACC;
Robert A. ORourke, MD, FACC; William P. Schafer, MD, FACC; Sankey V. Williams, MD, FACP
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Task Force Members

James L. Ritchie, MD, FACC, Chair; Raymond J. Gibbons, MD, FACC, Vice Chair;
Melvin D. Cheitlin, MD, FACC; Kim A. Eagle, MD, FACC; Timothy J. Gardner, MD, FACC;
Arthur Garson, Jr, MD, MPH, FACC; Richard O. Russell, MD, FACC;
Thomas J. Ryan, MD, FACC; Sidney C. Smith, Jr, MD, FACC

I. Introduction formed to make recommendations regarding the diagnosis

A. Organization of Committee and and treatment of patients with known or suspected cardiovas-
Evidence Review cular disease. Ischemic heart disease is the single leading
The American College of Cardiology/American Heart Asso- cause of death in the United States. The most common
ciation (ACC/AHA) Task Force on Practice Guidelines was manifestation of this disease is chronic stable angina. Recog-
nizing the importance of the management of this common
entity and the absence of national clinical practice guidelines
ACC/AHA/ACPASIM Guidelines for the Management of Patients in this area, the task force formed the Committee on Man-
With Chronic Stable Angina: Executive Summary and Recommenda- agement of Patients With Chronic Stable Angina to develop
tions was approved by the American College of Cardiology Board of
guidelines for the management of stable angina. Because this
Trustees in March 1999, by the American Heart Association Science
Advisory and Coordinating Committee in March 1999, and by the problem is frequently encountered in the practice of internal
ACPASIM Board of Regents in February 1999. medicine, the task force invited the American College of
When citing this document, the American College of Cardiology, the PhysiciansAmerican Society of Internal Medicine (ACP
American Heart Association, and the American College of Physicians
American Society of Internal Medicine request that the following citation ASIM) to serve as a partner in this effort by identifying 3
format be used: Gibbons RJ, Chatterjee K, Daley J, et al. ACC/AHA/ACP general internists to serve on the committee.
ASIM guidelines for the management of patients with chronic stable angina: The guidelines are arbitrarily divided into 4 sections:
executive summary and recommendations: a report of the American College
diagnosis, risk stratification, treatment, and patient follow-up.
of Cardiology/American Heart Association Task Force on Practice Guide-
lines (Committee on Management of Patients With Chronic Stable Angina). Experienced clinicians will quickly recognize that the distinc-
Circulation. 1999;99:2829 2848. tions between these sections may be arbitrary and unrealistic
This document is available on the World Wide Web sites of the American for individual patients. However, for most clinical decision
College of Cardiology (www.acc.org) and the American Heart Association
(www.americanheart.org). A single reprint of the executive summary and making, these divisions are helpful and facilitate the presen-
recommendations is available by calling 800-242-8721 (US only) or writing tation and analysis of the available evidence. Detailed evi-
the American Heart Association, 7272 Greenville Ave, Dallas, TX 75231- dence was developed whenever possible.
4596. Ask for reprint No. 71-0167. To obtain a reprint of the full text
The weight of the evidence was ranked highest (A) if the
published in the June 1999 issue of the Journal of the American College of
Cardiology, ask for reprint No. 71-0166. To purchase additional reprints data were derived from multiple randomized clinical trials
(specify version and reprint number): Up to 999 copies, call 800-611-6083 involving large numbers of patients and intermediate (B) if
(US only) or fax 413-665-2671; 1000 or more copies call 214-706-1466, fax the data were derived from a limited number of randomized
214-691-6342, or E-mail [email protected]
(Circulation. 1999;99:2829-2848.) trials involving small numbers of patients or careful analyses
1999 American College of Cardiology and American Heart Asso- of nonrandomized studies or observational regis-tries. A low
ciation, Inc. rank (C) was given when expert consensus was the primary
Circulation is available at http://www.circulationaha.org basis for the recommendation.
2829
 2830 ACC/AHA/ACPASIM Practice Guidelines: Executive Summary

The customary ACC/AHA classifications I, II, and III are The magnitude of the problem can be easily summarized:
used in tables that summarize both the evidence and expert chronic stable angina affects many millions of Americans,
opinion and provide final recommendations for both patient with associated annual costs that are measured in tens of
evaluation and therapy: billions of dollars.
Class I: Conditions for which there is evidence and/or
general agreement that a given procedure or treatment is
useful and effective. II. Diagnosis
Class II: Conditions for which there is conflicting
evidence and/or a divergence of opinion about the useful- A. History and Physical
ness/efficacy of a procedure or treatment. Recommendations
Class IIa: Weight of evidence/opinion is in favor of
usefulness/efficacy. Class I
Class IIb: Usefulness/efficacy is less well established In patients presenting with chest pain, a detailed symptom
by evidence/opinion. history, focused physical examination, and directed risk
Class III: Conditions for which there is evidence and/or factor assessment should be performed. With this infor-
general agreement that the procedure/treatment is not mation, the clinician should estimate the probability of
useful/effective and in some cases may be harmful. significant CAD (ie, low, intermediate, high). (Level of
The full text of the guidelines is published in the June 1999 Evidence: B)
issue of the Journal of the American College of Cardiology;
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the executive summary is published in the June 1, 1999, issue Definition of Angina
of Circulation. This document was approved for publication Angina is a clinical syndrome characterized by discomfort
by the governing bodies of the American College of Cardi- in the chest, jaw, shoulder, back, or arm. It is typically
ology, the American Heart Association, and the American aggravated by exertion or emotional stress and relieved by
College of PhysiciansAmerican Society of Internal nitroglycerin. Angina usually occurs in patients with CAD
Medicine. involving $1 large epicardial artery. However, angina can
also occur in individuals with valvular heart disease,
B. Scope of the Guidelines hypertrophic cardiomyopathy, and uncontrolled hyperten-
These guidelines are intended to apply to adult patients with
sion. It can be present in patients with normal coronaries
stable chest pain syndromes and known or suspected ische-
and myocardial ischemia related to spasm or endothelial
mic heart disease. Patients who have ischemic equivalents,
dysfunction.
such as dyspnea on exertion or arm pain with exertion, are
After the history of the pain is obtained, the physician
included in these guidelines. Some patients with ischemic
heart disease may become asymptomatic with appropriate should classify the symptom complex. One classification
therapy. As a result, the follow-up sections of the guidelines scheme for chest pain in many studies uses 3 groups
may apply to patients who were previously symptomatic. typical angina, atypical angina, or noncardiac chest pain
However, the diagnosis, risk stratification, and treatment (Table 1). Patients with noncardiac chest pain are generally
sections of the guidelines are intended to apply to symptom- at lower risk for ischemic heart disease. As indicated on
atic patients. Asymptomatic patients with silent ischemia or the flow diagram, the history and appropriate diagnostic
known coronary artery disease (CAD) that has been detected tests will usually focus on noncardiac causes of chest pain.
in the absence of symptoms are beyond the scope of these After a detailed chest pain history is taken, the presence of
guidelines. Pediatric patients are also beyond the scope of risk factors for CAD should be determined. Hyperlipidemia,
these guidelines because ischemic heart disease is unusual in diabetes, hypertension, cigarette smoking, and a family his-
such patients and is primarily related to the presence of tory of premature CAD are all important. Past history of
coronary artery anomalies. These guidelines also do not apply cerebrovascular or peripheral vascular disease increase the
to patients with chest pain syndromes following cardiac likelihood that CAD will be present.
transplantation or early after revascularization or to those
with acute ischemic syndromes such as myocardial infarction
(MI) or unstable angina. TABLE 1. Clinical Classification of Chest Pain
The 3 flow diagrams that follow summarize the manage-
Typical angina (definite)
ment of stable angina in 3 algorithms: clinical assessment
(1) Substernal chest discomfort with a characteristic quality and duration
(Figure 1), stress testing/angiography (Figure 2), and treat-
that is (2) provoked by exertion or emotional stress and (3) relieved by rest
ment (Figure 3). The treatment mnemonic (Figure 4) is or nitroglycerin
intended to highlight the 10 treatment elements that the
Atypical angina (probable)
committee considered most important.
Meets 2 of the above characteristics
C. Magnitude of the Problem Noncardiac chest pain
Ischemic heart disease remains a major public health prob- Meets #1 of the typical angina characteristics
lem. Chronic stable angina is the initial manifestation of Modified from Diamond GA. A clinically relevant classification of chest
ischemic heart disease in approximately one half of patients. discomfort. J Am Coll Cardiol. 1983;1:574. Letter.
 Gibbons et al June 1, 1999 2831

Figure 1. Clinical assessment. AHCPR

indicates Agency for Health Care Policy
and Research.
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B. Associated Conditions 3. Chest x-ray in patients with signs or symptoms of

congestive heart failure, valvular heart disease, peri-
Recommendations for Initial Laboratory Tests
cardial disease, or aortic dissection/aneurysm. (Level
for Diagnosis of Evidence: B)
Class I
1. Hemoglobin. (Level of Evidence: C) Class IIa
2. Fasting glucose. (Level of Evidence: C) Chest x-ray in patients with signs or symptoms of pulmo-
3. Fasting lipid panel, including total cholesterol, HDL nary disease. (Level of Evidence: B)
cholesterol, triglycerides, and calculated LDL cholesterol.
(Level of Evidence: C) Class IIb

1. Chest x-ray in other patients. (Level of Evidence: C)

C. Noninvasive Testing
2. Electron beam computed tomography. (Level of Ev-
1. ECG/Chest X-Ray idence: B)
Recommendations for Electrocardiography, Chest A rest 12 lead ECG should be recorded in all patients with
X-Ray, or Electron Beam Computed Tomography symptoms suggestive of angina pectoris; however, it will be
in the Diagnosis of Chronic Stable Angina normal in #50% of patients with chronic stable angina. A
Class I normal rest ECG does not exclude severe CAD. Evidence of
prior Q-wave MI on the ECG or ST-T wave changes
1. Rest ECG in patients without an obvious noncardiac consistent with myocardial ischemia favors the diagnosis of
cause of chest pain. (Level of Evidence: B) angina pectoris. ECG evidence of left ventricular (LV)
2. Rest ECG during an episode of chest pain. (Level of hypertrophy increases the probability that chest discomfort is
Evidence: B) angina pectoris.
 2832 ACC/AHA/ACPASIM Practice Guidelines: Executive Summary

Figure 2. Stress testing/angiography.

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The chest roentgenogram is often normal in patients with 2. Patients with a low pretest probability of CAD by
stable angina pectoris. Its usefulness as a routine test is not age, gender, and symptoms. (Level of Evidence: B)
well established. It is more likely to be abnormal in patients 3. Patients taking digoxin with ECG baseline ST-
with previous MI, those with a noncoronary artery cause of segment depression <1 mm. (Level of Evidence: B)
chest pain, and those with noncardiac chest discomfort. 4. Patients with ECG criteria for LV hypertrophy and
2. Exercise ECG for Diagnosis <1 mm of baseline ST-segment depression. (Level of
Evidence: B)
Recommendations for the Diagnosis of Obstructive
CAD With Exercise ECG Testing Without an Class III
Imaging Modality
Class I 1. Patients with the following baseline ECG
Patients with an intermediate pretest probability of CAD abnormalities:
based on age, gender, and symptoms, including those with a. Preexcitation (Wolff-Parkinson-White) syn-
complete right bundle-branch block or <1 mm of rest ST drome. (Level of Evidence: B)
depression (exceptions are listed below in classes II and b. Electronically paced ventricular rhythm. (Level
III). (Level of Evidence: B) of Evidence: B)
c. More than 1 mm of rest ST depression. (Level of
Class IIa Evidence: B)
Patients with suspected vasospastic angina. (Level of d. Complete left bundle-branch block. (Level of
Evidence: C) Evidence: B)
Class IIb 2. Patients with an established diagnosis of CAD due to
prior MI or coronary angiography; however, testing
1. Patients with a high pretest probability of CAD by can assess functional capacity and prognosis, as
age, gender, and symptoms. (Level of Evidence: B) discussed in section III. (Level of Evidence: B)
 Gibbons et al June 1, 1999 2833
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Figure 3. Treatment. NTG indicates nitroglycerin; NCEP, National Cholesterol Education Program; and JNC, Joint National Committee.

Exercise testing is a well-established procedure that has If the diagnosis remains uncertain after the history, phys-
been in widespread clinical use for many decades. Inter- ical examination, ECG, and chest x-ray, exercise ECG testing
pretation of the exercise test should include symptomatic should be the next step in most patients. Diagnostic testing is
response, exercise capacity, hemodynamic response, and most valuable when the pretest probability of obstructive
ECG response. The occurrence of ischemic chest pain CAD is intermediate: for example, when a 50-year-old man
consistent with angina is important, particularly if it forces has atypical angina and the probability of CAD is '50% (see
termination of the test. Abnormalities in exercise capacity, Table 2). In these conditions, the test result has the largest
systolic blood pressure response to exercise, and heart rate effect on the posttest probability of disease and thus on
response to exercise are important findings. The most clinical decisions. The exact definition of the upper and lower
important ECG findings are ST depression and elevation. boundaries of intermediate probability (eg, 10% and 90%,
The most commonly used definition for a positive exercise 20% and 80%, or 30% and 70%) is a matter of physician
test is $1 mm of horizontal or downsloping ST-segment judgment in an individual situation. When the probability of
depression or elevation for $60 to 80 ms after the end of obstructive CAD is high, a positive test result only confirms
the QRS complex. the high probability of disease, and a negative test result may
 2834 ACC/AHA/ACPASIM Practice Guidelines: Executive Summary
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Figure 4. Treatment mnemonic: the 10 most important treatment elements of stable angina management.

not decrease the probability of disease enough to make a clinical tive predictor of restenosis, with sensitivities ranging from
difference. When the probability of obstructive CAD is very 40% to 55%, significantly less than those obtainable with
low, a negative test result only confirms the low probability of single photon emission computed tomography (SPECT) or
disease, and a positive test result may not increase the probability exercise echocardiography. The lower sensitivity of exercise
of disease enough to make a clinical difference. ECG (compared with imaging techniques) as well as its
The exercise ECG has a number of limitations in symp- inability to localize disease limits its utility in the manage-
tomatic patients after coronary bypass surgery. Rest ECG ment of symptomatic patients after percutaneous
abnormalities are frequent, and if an imaging test is not interventions.
incorporated in the study, more reliance must be paid to
3. Echocardiography (Rest)
symptom status, hemodynamic response, and exercise capac-
ity. Because of these considerations, together with the need to Recommendations for Echocardiography for
document the site of ischemia, stress imaging tests are Diagnosis of Cause of Chest Pain in Patients With
preferred in this group. Suspected Chronic Stable Angina Pectoris
Restenosis is the 1 major limitation of percutaneous coro-
Class I
nary interventions and remains a major consideration in
patients with recurrent symptoms between 6 and 12 months 1. Patients with a systolic murmur suggestive of aortic
later. Unfortunately, symptom status is an unreliable index to stenosis and/or hypertrophic cardiomyopathy. (Lev-
development of restenosis. The exercise ECG is an insensi- el of Evidence: C)
 Gibbons et al June 1, 1999 2835

TABLE 2. Pretest Likelihood of CAD in Symptomatic Patients According to Age

and Sex*
Nonanginal Chest
Pain Atypical Angina Typical Angina

Age, y Men Women Men Women Men Women

30 39 4 2 34 12 76 26
4049 13 3 51 22 87 55
5059 20 7 65 31 93 73
6069 27 14 72 51 94 86
*Each value represents percent with significant CAD on catheterization.
Data from (1) Diamond GA, Forester JS. Analysis of probability as an aid in the clinical diagnosis
of coronary-artery disease. N Engl J Med. 1979;300:1350 1358. (2) Chaitman BR, Bourassa MG,
Davis K, Rogers WJ, Tyras DH, Berger R, Kennedy JW, Fisher L, Judkins MP, Mock MB, Killip T.
Angiographic prevalence of high-risk coronary artery disease in patient subsets (CASS). Circulation.
1981;64:360 367.

2. Evaluation of extent (severity) of ischemia (eg, LV 2. Exercise myocardial perfusion imaging or exercise
segmental wall motion abnormality) when the echocar- echocardiography in patients with prior revascular-
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diogram can be obtained during pain or within 30 ization (either percutaneous transluminal coronary
minutes after its abatement. (Level of Evidence: C) angioplasty [PTCA] or coronary artery bypass graft
[CABG]). (Level of Evidence: B)
Class IIb 3. Adenosine or dipyridamole myocardial perfusion
Patients with a click and/or murmur to diagnose mitral imaging in patients with an intermediate pretest
valve prolapse. (Level of Evidence: C) probability of CAD and 1 of the following baseline
ECG abnormalities:
Class III a. Electronically paced ventricular rhythm. (Level
Patients with a normal ECG, no history of MI, and no of Evidence: C)
signs or symptoms suggestive of heart failure, valvular b. Left bundle-branch block. (Level of Evidence: B)
heart disease, or hypertrophic cardiomyopathy. (Level of
Evidence: C) Class IIb
Echocardiography can be a useful tool for diagnosing
CAD. However, most patients undergoing a diagnostic eval- 1. Exercise myocardial perfusion imaging and exercise
echocardiography in patients with a low or high
uation for angina do not need an echocardiogram.
probability of CAD who have 1 of the following
Transthoracic echocardiographic imaging and Doppler re- baseline ECG abnormalities:
cording are useful when there is a murmur or other evidence a. Preexcitation (Wolff-Parkinson-White) syn-
of conditions such as aortic stenosis or hypertrophic cardio- drome. (Level of Evidence: B)
myopathy coexisting with CAD. Routine estimation of pa- b. More than 1 mm of ST depression. (Level of
rameters of global LV function such as LV ejection fraction Evidence: B)
are unnecessary for diagnosis of chronic angina pectoris. For 2. Adenosine or dipyridamole myocardial perfusion
example, in patients with suspected angina and a normal imaging in patients with a low or high probability of
ECG, no history of MI, and no physical signs or symptoms CAD and 1 of the following baseline ECG
abnormalities:
suggestive of heart failure, echocardiography (and radionu-
a. Electronically paced ventricular rhythm. (Level
clide imaging for LV function) are not indicated. of Evidence: C)
4. Stress Imaging Studies: Echocardiographic b. Left bundle-branch block. (Level of Evidence: B)
and Nuclear 3. Exercise myocardial perfusion imaging or exercise
echocardiography in patients with an intermediate
Recommendations for Cardiac Stress Imaging as probability of CAD who have 1 of the following:
the Initial Test for Diagnosis in Patients With a. Digoxin use with <1 mm ST depression on their
baseline ECG. (Level of Evidence: B)
Chronic Stable Angina Who Are Able to Exercise b. LV hypertrophy with <1 mm ST depression on
Class I their baseline ECG. (Level of Evidence: B)
4. Exercise myocardial perfusion imaging, exercise
1. Exercise myocardial perfusion imaging or exercise echocardiography, adenosine or dipyridamole myo-
echocardiography in patients with an intermediate cardial perfusion imaging, or dobutamine echocar-
pretest probability of CAD who have 1 of the diography as the initial stress test in a patient with a
following baseline ECG abnormalities: normal rest ECG who is not taking digoxin. (Level of
a. Preexcitation (Wolff-Parkinson-White) syn- Evidence: B)
drome. (Level of Evidence: B) 5. Exercise or dobutamine echocardiography in pa-
b. More than 1 mm of rest ST depression. (Level of tients with left bundle-branch block. (Level of Evi-
Evidence: B) dence: C)
 2836 ACC/AHA/ACPASIM Practice Guidelines: Executive Summary

Recommendations for Cardiac Stress Imaging as TABLE 3. Comparative Advantages of Stress

the Initial Test for Diagnosis in Patients With Echocardiography and Stress Radionuclide Perfusion Imaging
Chronic Stable Angina Who Are Unable in Diagnosis of CAD
to Exercise Advantages of Stress Echocardiography
1. Higher specificity
Class I
2. Versatility: more extensive evaluation of cardiac anatomy and function
1. Adenosine or dipyridamole myocardial perfusion 3. Greater convenience/efficacy/availability
imaging or dobutamine echocardiography in pa- 4. Lower cost
tients with an intermediate pretest probability of Advantages of Stress Perfusion Imaging
CAD. (Level of Evidence: B) 1. Higher technical success rate
2. Adenosine or dipyridamole stress myocardial perfu-
2. Higher sensitivity, especially for 1-vessel coronary disease
sion imaging or dobutamine echocardiography in
patients with prior revascularization (either PTCA 3. Better accuracy in evaluating possible ischemia when multiple rest LV
wall motion abnormalities are present
or CABG). (Level of Evidence: B)
4. More extensive published database, especially in evaluation of prognosis
Class IIb
D. Invasive Testing: Coronary Angiography
1. Adenosine or dipyridamole stress myocardial perfu-
Recommendations for Coronary Angiography to
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sion imaging or dobutamine echocardiography in

patients with a low or high probability of CAD in the Establish a Diagnosis in Patients With Suspected
absence of electronically paced ventricular rhythm Angina, Including Those With Known CAD Who
or left bundle-branch block. (Level of Evidence: B) Have a Significant Change in Anginal Symptoms
2. Adenosine or dipyridamole myocardial perfusion Class I
imaging in patients with a low or high probability of Patients with known or possible angina pectoris who have
CAD and 1 of the following baseline ECG survived sudden cardiac death. (Level of Evidence: B)
abnormalities:
a. Electronically paced ventricular rhythm. (Level Class IIa
of Evidence: C)
b. Left bundle-branch block. (Level of Evidence: B) 1. Patients with an uncertain diagnosis after noninva-
sive testing in whom the benefit of a more certain
Patients who are good candidates for cardiac stress testing diagnosis outweighs the risk and cost of coronary
with imaging, as opposed to routine treadmill and bicycle angiography. (Level of Evidence: C)
stress ECG, include those in the following categories (see 2. Patients who cannot undergo noninvasive testing
also section II.C.3): (1) complete left bundle-branch block, due to disability, illness, or morbid obesity. (Level of
Evidence: C)
electronically paced ventricular rhythm, preexcitation (Wolff-
3. Patients with an occupational requirement for a
Parkinson-White) syndrome and other similar ECG conduc- definitive diagnosis. (Level of Evidence: C)
tion abnormalities; (2) patients who have .1 mm of rest 4. Patients who by virtue of young age at onset of
ST-segment depression, including those with LV hypertrophy symptoms, noninvasive imaging, or other clinical
or taking drugs such as digitalis; (3) patients who are unable parameters are suspected of having a nonatheroscle-
to exercise to a level high enough to give meaningful results rotic cause of myocardial ischemia (coronary artery
on routine stress ECG; these patients should be considered for anomaly, Kawasaki disease, primary coronary ar-
pharmacological stress imaging tests; and (4) patients with tery dissection, radiation-induced vasculoplasty).
angina who have undergone prior revascularization or in (Level of Evidence: C)
whom considerations of functional significance of lesions or 5. Patients in whom coronary artery spasm is sus-
myocardial viability are important. pected and provocative testing may be necessary.
A summary of comparative advantages of stress nuclear (Level of Evidence: C)
perfusion imaging and stress echocardiographic techniques is 6. Patients with a high pretest probability of left main
or 3-vessel CAD. (Level of Evidence: C)
provided in Table 3. Echocardiographic and radionuclide
stress imaging have complementary roles, and both add value Class IIb
to routine stress ECG under the circumstances outlined
above. The choice of which test to perform depends greatly 1. Patients with recurrent hospitalization for chest pain
on issues of local expertise and available facilities as well as in whom a definite diagnosis is judged necessary.
those factors listed in Table 3. (Level of Evidence: C)
Because of its lower cost and generally greater portability, 2. Patients with an overriding desire for a definitive
stress echocardiography is more likely to be performed in the diagnosis and a greater-than-low probability of
physicians office than stress radionuclide imaging; the avail- CAD. (Level of Evidence: C)
ability of stress imaging in the office setting has both Class III
advantages and disadvantages. The quality of local expertise
and facilities should be important considerations when the 1. Patients with significant comorbidity in whom the
referring physician recommends a cardiac stress imaging test risk of coronary arteriography outweighs the benefit
for a patient. of the procedure. (Level of Evidence: C)
 Gibbons et al June 1, 1999 2837

2. Patients with an overriding personal desire for a

definitive diagnosis and a low probability of CAD.
(Level of Evidence: C)

This invasive technique for imaging the coronary artery

lumen remains the most accurate for the diagnosis of clini-
cally important obstructive coronary atherosclerosis and less
common nonatherosclerotic causes of possible chronic stable
angina pectoris, such as coronary artery spasm, coronary
anomaly, Kawasaki disease, primary coronary artery dissec-
tion, and radiation-induced coronary vasculopathy.
Direct referral for diagnostic coronary angiography may be
indicated in patients with chest pain possibly attributable to
myocardial ischemia when noninvasive testing is contraindi-
cated or unlikely to be adequate due to illness, disability, or Figure 5. Nomogram showing probability of severe (3-vessel or
left main) coronary disease based on a 5-point score. One point
physical characteristics. is awarded for each of the following variables: male gender, typ-
The diagnosis may be established in patients whose non- ical angina, history, ECG evidence of MI, diabetes, and use of
invasive testing result is abnormal but not clearly diagnostic insulin. Each curve shows the probability of severe coronary
disease as a function of age. From Hubbard BL, Gibbons RJ,
by using either stress imaging or coronary angiography. A
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Lapeyre AC, Zinsmeister AR, Clements IP. Identification of

stress imaging test may be recommended for a low-likelihood severe coronary artery disease using simple clinical parameters.
patient with an intermediate-risk treadmill result. Coronary Arch Intern Med. 1992;152:309 312.
angiography is usually more appropriate for a patient with a
high-risk treadmill result. implies normal rest LV function) and low clinical risk for
In patients with symptoms suggestive but not characteristic severe CAD is excellent.
of stable angina, direct referral to coronary angiography may On the chest roentgenogram, the presence of cardiomegaly,
be indicated if their occupation or activities could pose a risk an LV aneurysm, or pulmonary venous congestion is associ-
to themselves or others. In certain patients with typical or ated with a poorer long-term prognosis than normal chest
atypical symptoms suggestive of stable angina and a high x-ray findings.
pretest probability of severe CAD, direct referral to coronary
angiography may be indicated and prove cost-effective. C. Noninvasive Testing
1. Rest LV Function
III. Risk Stratification (Echocardiographic/Radionuclide Imaging)

A. Clinical Assessment Recommendations for Measurement of Rest LV

Useful information that is relevant to prognosis can be Function by Echocardiography or Radionuclide
obtained from the history. This information includes demo- Angiography in Patients With Chronic
graphic characteristics such as age and gender as well as a Stable Angina
medical history with a focus on hypertension, diabetes,
Class I
hypercholesterolemia, smoking, peripheral arterial disease,
and previous MI. 1. Echocardiography or radionuclide angiography
Several studies have examined the value of clinical param- (RNA) in patients with a history of prior MI, patho-
eters for identifying the presence of severe (3-vessel or left logical Q waves, or symptoms or signs suggestive of
main) CAD. One study developed a 5-point cardiac risk score heart failure to assess LV function. (Level of Evi-
based on clinical parameters that were independently predic- dence: B)
tive of severe (3-vessel or left main) CAD: age, typical 2. Echocardiography in patients with a systolic mur-
angina, diabetes, gender, and prior MI by history and ECG mur suggesting mitral regurgitation to assess its
severity and etiology. (Level of Evidence: C)
(Figure 5). Some patients have a high likelihood (.1 chance
3. Echocardiography or RNA in patients with complex
in 2) of severe disease on the basis of clinical parameters ventricular arrhythmias to assess LV function. (Lev-
alone. Such patients should be considered for direct referral to el of Evidence: B)
angiography.
Risk stratification of patients with stable angina by use of Class III
clinical parameters may facilitate development of clearer
1. Routine periodic reassessment of stable patients for
indications of referral for exercise testing and cardiac
whom no new change in therapy is contemplated.
catheterization. (Level of Evidence: C)
2. Patients with a normal ECG, no history of MI, and
B. ECG/Chest X-Ray no symptoms or signs suggestive of heart failure.
Patients with chronic stable angina who have rest ECG (Level of Evidence: B)
abnormalities are at greater risk than those with normal In the chronic stable angina patient who has a history of
ECGs. The prognosis of patients with a normal ECG (which documented MI and/or Q waves on ECG, measurement of
 2838 ACC/AHA/ACPASIM Practice Guidelines: Executive Summary

global LV systolic function (eg, ejection fraction) may be TABLE 4. Survival According to Risk Groups Based on Duke
important in choosing appropriate medical or surgical therapy Treadmill Scores
and making recommendations about activity level, rehabili-
4-Year Annual
tation, and work status. Similarly, in patients who, in addition
Risk Group, Score % of Total Survival Mortality, %
to chronic stable angina, have clinical signs or symptoms of
heart failure, cardiac imaging may be helpful in establishing Low ($5) 62 0.99 0.25
pathophysiological mechanisms and guiding therapy. For Moderate (210 to 4) 34 0.95 1.25
example, a patient with heart failure might have predomi- High (,210) 4 0.79 5.0
nantly systolic LV dysfunction, predominantly diastolic dys-
function, mitral or aortic valve disease, some combination of
these abnormalities, or a noncardiac cause for symptoms. The larization. The results of exercise testing may also be used to
best treatment for the patient can be planned more rationally titrate medical therapy to the desired level of effectiveness.
knowing the status of LV systolic and diastolic function (by The choice of stress test should be based on the patients
echocardiography or radionuclide imaging), valvular func- rest ECG, physical ability to perform exercise, local exper-
tion, and pulmonary artery pressure (by transthoracic echo- tise, and available technologies. Risk assessment in patients
Doppler techniques). with a normal ECG who are not taking digoxin usually should
LV global systolic function and volumes have been well start with the exercise test. In contrast, a stress-imaging
documented as important predictors of prognosis in patients
technique should be used for patients with widespread rest ST
with cardiac disease, including those with chronic stable
angina. An important measure of LV global systolic function depression (.1 mm), complete left bundle-branch block,
ventricular paced rhythm, or preexcitation. Patients unable to
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is LV ejection fraction, which is the fraction (or percent) of

LV diastolic volume ejected by the heart on each beat. exercise because of physical limitations such as reduced
exercise capacity, arthritis, amputations, severe peripheral
2. Exercise Testing for Risk Stratification and Prognosis vascular disease, or severe chronic obstructive pulmonary
disease should undergo pharmacological stress testing in
Recommendations for Risk Assessment and combination with imaging.
Prognosis in Patients With an Intermediate or One of the strongest and most consistent prognostic mark-
High Probability of CAD ers is the maximum exercise capacity. Exercise capacity is
Class I measured by maximal exercise duration, maximum MET
level achieved (1 MET is the standard basal oxygen uptake of
1. Patients undergoing initial evaluation. (Exceptions 3.5 mL z kg 21 z min21), maximum workload achieved, max-
are listed below in classes IIb and III.) (Level of imum heart rate, and double product. The specific variable
Evidence: B)
used to measure exercise capacity is less important than the
2. Patients after a significant change in cardiac symp-
toms. (Level of Evidence: C) inclusion of exercise capacity in the assessment. The trans-
lation of exercise duration or workload into METs provides a
Class IIb standard measure of performance regardless of the type of
exercise test or protocol used.
1. Patients with the following ECG abnormalities: A second group of prognostic markers is related to
a. Preexcitation (Wolff-Parkinson-White) syn- exercise-induced ischemia. ST-segment depression and ele-
drome. (Level of Evidence: B)
vation (in leads without pathological Q waves and not in
b. Electronically paced ventricular rhythm. (Level
of Evidence: B) aVR) best summarize the prognostic information related to
c. More than 1 mm of rest ST depression. (Level of ischemia. Other variables are less powerful, including angina,
Evidence: B) the number of leads with ST-segment depression, the config-
d. Complete left bundle-branch block. (Level of uration of ST depression (downsloping, horizontal, or upslop-
Evidence: B) ing), and the duration of ST deviation into the recovery phase.
2. Patients who have undergone cardiac catheteriza- The Duke Treadmill Score combines this information and
tion to identify ischemia in the distribution of a provides a way to calculate risk. The Duke Treadmill Score
coronary lesion of borderline severity. (Level of equals the exercise time in minutes minus (5 times the
Evidence: C) ST-segment deviation, during or after exercise, in millime-
3. Postrevascularization patients who have a signifi- ters) minus (4 times the angina index, which has a value of 0
cant change in anginal pattern suggesting ischemia. if there is no angina, 1 if angina occurs, and 2 if angina is the
(Level of Evidence: C)
reason for stopping the test).
Class III The Duke Treadmill Score may be used to predict average
Patients with severe comorbidity likely to limit life expect- annual cardiac mortality (Table 4). Patients with a predicted
ancy or prevent revascularization. (Level of Evidence: C) average annual cardiac mortality rate #1% per year can be
Unless cardiac catheterization is indicated, patients with managed medically without the need for cardiac catheteriza-
suspected or known CAD who present with new or changing tion. Patients with a predicted average annual cardiac mor-
symptoms suggestive of ischemia should undergo stress tality rate $3% per year should be referred for cardiac
testing to assess the risk of future cardiac events. Further- catheterization. Patients with a predicted average annual
more, documentation of exercise-induced ischemia is desir- cardiac mortality rate of 1% to 3% per year, including those
able for most patients who are being evaluated for revascu- with suspected LV dysfunction, should have either cardiac
 Gibbons et al June 1, 1999 2839

catheterization or an exercise imaging study. Those with 3. Dipyridamole or adenosine myocardial perfusion
known LV dysfunction should have cardiac catheterization. imaging or dobutamine echocardiography to assess
the functional significance of coronary lesions (if not
3. Stress Imaging Studies (Radionuclide already known) in planning PTCA. (Level of Evi-
and Echocardiography) dence: B)

Recommendations for Cardiac Stress Imaging for Class IIb

Risk Stratification of Patients With Chronic Stable Dobutamine echocardiography in patients with left
Angina Who Are Able to Exercise bundle-branch block. (Level of Evidence: C)

Class I Class III

Dipyridamole or adenosine myocardial perfusion imaging
1. Exercise myocardial perfusion imaging or exercise or dobutamine echocardiography in patients with severe
echocardiography to identify the extent, severity, comorbidity likely to limit life expectation or prevent
and location of ischemia in patients who do not have revascularization. (Level of Evidence: C)
left bundle-branch block or an electronically paced Stress imaging studies employing radionuclide myocardial
ventricular rhythm and have either an abnormal perfusion imaging techniques or 2-dimensional echocardiog-
rest ECG or are using digoxin. (Level of Evidence: B)
raphy at rest and during stress are useful for risk stratification
2. Dipyridamole or adenosine myocardial perfusion
imaging in patients with left bundle-branch block or and determination of the most beneficial management strat-
electronically paced ventricular rhythm. (Level of egy for patients with chronic stable angina. Whenever possi-
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Evidence: B) ble, treadmill or bicycle exercise should be used as the most

3. Exercise myocardial perfusion imaging or exercise appropriate form of stress because it provides the most
echocardiography to assess the functional signifi- information concerning patient symptoms, cardiovascular
cance of coronary lesions (if not already known) in function, and hemodynamic response during usual forms of
planning PTCA. (Level of Evidence: B) activity. In fact, the inability to perform a bicycle or exercise
treadmill test is a strong negative prognostic factor for
Class IIb
patients with chronic CAD.
1. Exercise or dobutamine echocardiography in pa- In patients who cannot perform an adequate amount of
tients with left bundle-branch block. (Level of Evi- bicycle or treadmill exercise, various types of pharmacolog-
dence: C) ical stress are useful for risk stratification. The selection of
2. Exercise, dipyridamole, adenosine myocardial per- the type of pharmacological stress will depend on specific
fusion imaging, or exercise or dobutamine echocar- patient factors such as the patients heart rate and blood
diography as the initial test in patients who have a pressure, the presence or absence of bronchospastic disease,
normal rest ECG and are not taking digoxin. (Level the presence of left bundle-branch block or a pacemaker, and
of Evidence: B) the likelihood of ventricular arrhythmias.
Class III Normal poststress thallium scan results are highly predic-
tive of a benign prognosis even in patients with known
1. Exercise myocardial perfusion imaging in patients coronary disease. A collation of 16 studies involving 3594
with left bundle-branch block. (Level of Evidence: C) patients followed up for a mean of 29 months indicated a rate
2. Exercise, dipyridamole, adenosine myocardial per- of cardiac death and MI of 0.9% per year, which is nearly as
fusion imaging, or exercise or dobutamine echocar- low as that of the general population. In a recent prospective
diography in patients with severe comorbidity likely study of 5183 consecutive patients who underwent myocar-
to limit life expectation or prevent revascularization. dial perfusion studies during stress and later at rest, patients
(Level of Evidence: C) with normal scans were at low risk (,0.5% per year) for
cardiac death and MI during 6426226 days of mean follow-
Recommendations for Cardiac Stress Imaging as
up, and rates of both outcomes increased significantly with
the Initial Test for Risk Stratification of Patients
worsening scan abnormalities. The presence of a normal
With Chronic Stable Angina Who Are Unable
thallium stress test result indicates such a low likelihood of
to Exercise
significant CAD that coronary arteriography is usually not
Class I indicated as a subsequent test unless the patient has a
high-risk Duke treadmill score.
1. Dipyridamole or adenosine myocardial perfusion Stress echocardiography (with the aid of digital acquisition
imaging or dobutamine echocardiography to iden- and storage of quad-screen images) is both sensitive and
tify the extent, severity, and location of ischemia in
specific for detecting inducible myocardial ischemia in pa-
patients who do not have left bundle-branch block or
electronically paced ventricular rhythm. (Level of tients with chronic stable angina (see section II.C.4). In
Evidence: B) comparison with standard exercise treadmill testing, stress
2. Dipyridamole or adenosine myocardial perfusion echocardiography provides additional clinical value for de-
imaging in patients with left bundle-branch block or tecting and localizing myocardial ischemia. The results of
electronically paced ventricular rhythm. (Level of stress echocardiography may provide important prognostic
Evidence: B) value. Several studies indicate that patients at low, interme-
 2840 ACC/AHA/ACPASIM Practice Guidelines: Executive Summary

diate, and high risk for cardiac events can be stratified by the When the pretest probability of severe CAD is high, direct
presence or absence of inducible wall motion abnormalities referral for coronary angiography without noninvasive testing
on stress echocardiography testing. A positive stress echocar- is probably most cost-effective because the total number of
diographic study can be useful in determining the location tests is reduced.
and severity of inducible ischemia, even in a patient with a Coronary angiography, the traditional gold standard for
high pretest likelihood that disease is present. A negative clinical assessment of coronary atherosclerosis, has limita-
tions. It is not a reliable indicator of the functional signifi-
stress echocardiographic evaluation predicts a low risk for
cance of a coronary stenosis and is insensitive in detection of
future cardiovascular events. a thrombus (an indicator of disease activity). More impor-
However, the value of a negative stress echocardiography tantly, coronary angiography is ineffective in determining
study compared with a negative thallium study needs to be which plaques have characteristics likely to lead to acute
further documented because there is a much smaller amount coronary events, that is, the vulnerable plaque with large lipid
of follow-up data in comparison with radionuclide imaging. core, thin fibrous cap, and increased macrophages. Serial
angiographic studies performed before and after acute events
D. Coronary Angiography and and early after MI suggest that plaques resulting in unstable
Left Ventriculography angina and MI commonly produced ,50% stenosis before
the acute event and were therefore angiographically silent.
Coronary Angiography for Risk Stratification in Patients
Despite these limitations of coronary angiography, the
With Chronic Stable Angina
extent and severity of coronary disease and LV dysfunction
Recommendations identified on angiography are the most powerful predictors of
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long-term patient outcome. Several prognostic indexes have

Class I been used to relate disease severity to the risk of subsequent
cardiac events; the simplest and most widely used is the
1. Patients with disabling (Canadian Cardiovascular So- classification of disease into 1-, 2-, or 3-vessel or left main
ciety [CCS] classes III and IV) chronic stable angina coronary artery disease. In the Coronary Artery Surgery
despite medical therapy. (Level of Evidence: B) Study (CASS) registry of medically treated patients, the
2. Patients with high-risk criteria on noninvasive testing 12-year survival rate of patients with normal coronary arteries
regardless of anginal severity. (Level of Evidence: B) was 91% compared with 74% for those with 1-vessel disease,
3. Patients with angina who have survived sudden 59% for those with 2-vessel disease, and 40% for those with
cardiac death or serious ventricular arrhythmia. 3-vessel disease. It has been known for many years that
(Level of Evidence: B) patients with significant stenosis of the left main coronary
4. Patients with angina and symptoms and signs of artery have a poor prognosis when treated medically. The
congestive heart failure. (Level of Evidence: C) impact of LV dysfunction on survival was quite dramatic. In
5. Patients with clinical characteristics that indicate a the CASS registry, the 12-year survival rate was 73% for
high likelihood of severe CAD. (Level of Evidence: C) patients with an ejection fraction between 50% and 100%,
Class IIa 54% for those with an ejection fraction between 35%
and 49%, and only 21% for those with an ejection
1. Patients with significant LV dysfunction (ejection fraction ,35%.
fraction <45%), CCS class I or II angina, and
demonstrable ischemia but less than high-risk crite- IV. Treatment
ria on noninvasive testing. (Level of Evidence: C)
Recommendations for Pharmacotherapy to
2. Patients with inadequate prognostic information af-
ter noninvasive testing. (Level of Evidence: C) Prevent MI and Death and Reduce Symptoms
Class I
Class IIb
1. Aspirin in the absence of contraindications. (Level of
Patients with CCS class I or II angina, preserved LV
Evidence: A)
function (ejection fraction >45%), and less than high-risk
2. b-Blockers as initial therapy in the absence of
criteria on noninvasive testing. (Level of Evidence: C)
contraindications in patients with prior MI. (Level of
Class III Evidence: A)
3. b-Blockers as initial therapy in the absence of
1. Patients with CCS class I or II angina who respond contraindications in patients without prior MI. (Lev-
to medical therapy and have no evidence of ischemia el of Evidence: B)
on noninvasive testing. (Level of Evidence: C) 4. Calcium antagonists* and/or long-acting nitrates as
2. Patients who prefer to avoid revascularization. (Lev- initial therapy when b-blockers are contraindicated.
el of Evidence: C) (Level of Evidence: B)
Patients identified as having increased risk on the basis of 5. Calcium antagonists* and/or long-acting nitrates in
an assessment of clinical data and noninvasive testing are combination with b-blockers when initial treatment
generally referred for coronary arteriography even if their with b-blockers is not successful. (Level of Evidence: B)
symptoms are not severe. Noninvasive testing that is used 6. Calcium antagonists* and/or long-acting nitrates as
appropriately is less costly than coronary angiography and a substitute for b-blockers if initial treatment with
has an acceptable predictive value for adverse events. This is b-blockers leads to unacceptable side effects. (Level
most true when the pretest probability of severe CAD is low. of Evidence: C)
 Gibbons et al June 1, 1999 2841

7. Sublingual nitroglycerin or nitroglycerin spray for reduction in the risk of adverse cardiovascular events. In
the immediate relief of angina. (Level of Evidence: C) patients with unstable angina, aspirin decreased the short- and
8. Lipid-lowering therapy in patients with documented long-term risk of fatal and nonfatal MI. In the Physicians
or suspected CAD and LDL cholesterol >130 mg/dL Health Study, aspirin (325 mg) given on alternate days to
with a target LDL of <100 mg/dL. (Level of Evi- asymptomatic persons was associated with a decreased inci-
dence: A)
dence of MI.
*Short-acting dihydropyridine calcium antagonists
should be avoided. Lipid-Lowering Agents
In the Scandinavian Simvastatin Survival Study, treatment
Class IIa with HMG-coenzyme reductase inhibitors in patients with
documented CAD (including stable angina) with a baseline
1. Clopidogrel when aspirin is absolutely contraindi-
total cholesterol level of 212 to 308 mg/dL was associated
cated. (Level of Evidence: B)
2. Long-acting nondihydropyridine calcium antago- with a significant reduction in the risk of fatal and nonfatal
nists* instead of b-blockers as initial therapy. (Level MI and the need for revascularization. Other studies also have
of Evidence: B) reported similar benefits of statins in patients with docu-
3. Lipid-lowering therapy in patients with documented mented or suspected CAD, even with lower lipid levels. In
or suspected CAD and LDL cholesterol 100 to 129 general, modification of diet and exercise are less effective
mg/dL, with a target LDL of 100 mg/dL. (Level of than statins in achieving the target levels of cholesterol and
Evidence: B) LDL; thus, lipid-lowering pharmacotherapy is usually re-
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*Short-acting dihydropyridine calcium antagonists quired in patients with stable angina.

should be avoided.
Pharmacotherapy to Reduce Ischemia and
Class IIb Relieve Symptoms
Low-intensity anticoagulation with warfarin in addition
to aspirin. (Level of Evidence: B) b-Blockers
All b-blockers appear to be equally effective in angina
Class III pectoris. In patients with chronic, stable, exertional angina,
b-blockers decrease heart rate and blood pressure during
1. Dipyridamole. (Level of Evidence: B) exercise, and the onset of angina or the ischemic threshold is
2. Chelation therapy. (Level of Evidence: B) delayed or avoided. In the treatment of stable angina, it is
conventional to adjust the dose of these drugs to reduce the
A. Overview of Treatment rest heart rate to 55 to 60 beats per minute. In patients with
The treatment of stable angina has 2 major purposes. The first
more severe angina, the heart rate can be reduced below 50
is to prevent MI and death (and thereby increase the quan-
beats per minute, provided that there are no symptoms
tity of life). The second is to reduce the symptoms of angina
associated with bradycardia and that heart block does not
and the occurrence of ischemia, which should improve the
develop. b-Blocker therapy limits the increase in heart rate
quality of life.
during exercise, which should not exceed 75% of the heart
Therapy directed toward preventing death has the highest
rate response associated with the onset of ischemia.
priority. When 2 therapeutic strategies are compared, the one
In the absence of contraindications, b-blockers are pre-
with a definite or very likely advantage in preventing MI and
ferred as initial therapy. The evidence for this approach is
death should usually be selected. For example, coronary
strongest in the presence of prior MI, for which this class of
artery bypass surgery is the preferred therapy for patients with
drugs has been shown to reduce mortality.
significant left main CAD because it prolongs life. Patient
education and preference are important components in this Calcium Antagonists
decision-making process and are covered in subsequent Calcium antagonists, including the newer, second-generation
sections. vasoselective dihydropyridine agents and nondihydropyridine
Pharmacological therapy directed toward prevention of MI drugs such as verapamil and diltiazem, decrease coronary
and death has expanded greatly in recent years with the vascular resistance and increase coronary blood flow. All of
emergence of evidence that demonstrates the efficacy of these agents cause dilatation of the epicardial conduit vessels
lipid-lowering agents for this purpose. The committee be- and the arteriolar resistance vessels. Dilatation of the epicar-
lieves that the emergence of such medical therapy for the dial coronary arteries is the principal mechanism that allows
prevention of MI and death represents a new treatment calcium antagonists to relieve vasospastic angina. Calcium
paradigm that should be recognized by all health profession- antagonists also concurrently decrease myocardial oxygen
als involved in the care of patients with stable angina. demand, primarily by reduction of systemic vascular resis-
tance and reduction in arterial pressure.
Pharmacotherapy to Prevent MI and Death Short-acting dihydropyridine calcium antagonists have the
Antiplatelet Agents potential to enhance the risk of adverse cardiac events and
Aspirin exerts its antithrombotic effect by inhibiting cyclo- should be avoided. Long-acting calcium antagonists, includ-
oxygenase and synthesis of platelet thromboxane A2. It is ing slow-release and long-acting dihydropyridines and non-
effective in preventing first heart attacks. The use of aspirin in dihydropyridines, are effective in relieving symptoms. They
.3000 patients with stable angina was associated with a 33% are appropriate initial therapy in patients with contraindica-
 2842 ACC/AHA/ACPASIM Practice Guidelines: Executive Summary

tions to b-blockers, as a substitute for b-blockers in patients be content with a reduction in symptoms that enables perfor-
who develop unacceptable side effects to b-blockers, or in mance of only limited activities of daily living.
combination with b-blockers when initial therapy with The committee agreed that for most patients the goal of
b-blockers is not successful. treatment should be complete or near-complete elimination of
anginal chest pain and a return to normal activities and a
Long-Acting Nitrates functional capacity of CCS class I angina. This goal should be
In patients with exertional stable angina, nitrates improve
accomplished with minimal side effects of therapy. This
exercise tolerance, increase the time to onset of angina, and
definition of successful therapy must be modified in light of
decrease ST-segment depression during the treadmill exercise
the clinical characteristics and preferences of each patient.
test. Combined with b-blockers or calcium antagonists, ni-
trates produce greater antianginal and anti-ischemic effects in Initial Treatment
patients with stable angina. The initial treatment of the patient should include all elements
in the following mnemonic:
Selection of Pharmacological Therapy Versus
Revascularization
In patients with stable exertional angina, medical therapy A. Aspirin and Antianginal therapy
appears to be as effective as angioplasty. In the Randomized B. b-Blocker and Blood pressure
Intervention Treatment of Angina (RITA-II) Trial, medical C. Cigarette smoking and Cholesterol
therapy in patients with CCS class II or III angina reduced the D. Diet and Diabetes
risk of nonfatal and fatal MI compared with angioplasty. E. Education and Exercise
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However, angioplasty relieved symptoms more effectively

than medical therapy. In the VA cooperative study, there was In constructing a flow diagram to reflect the treatment
no difference in prognosis between patients treated with process, the committee thought that it was clinically helpful
medical therapy compared with surgical therapy except in to divide the entire treatment process into 2 subdivisions:
those with left main coronary artery stenosis. However, antianginal treatment and education and risk factor modifica-
revascularization provided more relief of symptoms than tion. The assignment of each of the treatment elements to 1 of
medical therapy. The quality of life after revascularization these 2 subdivisions is self-evident, with the possible excep-
appears to be better with surgery or angioplasty than with tion of aspirin. Given the fact that aspirin clearly reduces the
medical therapy. As discussed below in the revascularization risk of subsequent heart attack and death but has no known
section, if the patient is known to have left main coronary benefit in preventing angina, the committee thought that it
artery stenosis, 3-vessel CAD, or 2-vessel CAD with proxi- was best assigned to the education and risk factor subdivision
mal left anterior coronary artery stenosis, revascularization by as reflected in the flow diagram.
a catheter-based technique or surgery should be offered. The All patients with angina should receive a prescription for
choice of therapy should be determined not only by the sublingual nitroglycerin and education about its proper use. It
results of randomized trials but also by the patients is particularly important for patients to recognize that this is
preference. a short-acting drug with no known long-term consequences
Definition of Successful Treatment of Chronic so that they will not be reluctant to use it.
Stable Angina If the patients history has a prominent feature of rest and
The treatment of chronic stable angina has 2 complementary nocturnal angina suggesting vasospasm, initiation of therapy
objectives: to reduce the risk of mortality and morbid events with long-acting nitrates and calcium antagonists is
and reduce symptoms. From the patients perspective, the appropriate.
latter is often of greater concern. The cardinal symptom of As mentioned previously, medications or conditions that
stable CAD is anginal chest pain or equivalent symptoms are known to provoke or exacerbate angina must be recog-
such as exertional dyspnea. Often the patient suffers not only nized and treated appropriately. On occasion, angina may
from the discomfort of the symptom itself but also from resolve with the appropriate treatment of these conditions. If
accompanying limitations on activities and the associated so, no further antianginal therapy is required. Most often,
anxiety that the symptoms may produce. Uncertainty about angina is improved but not relieved by the treatment of such
prognosis may be another source of anxiety. For some conditions, and further therapy should then be initiated.
patients, the predominant symptoms may be palpitations or The committee favored the use of a b-adrenoreceptor
syncope caused by arrhythmias or fatigue, edema, or orthop- blocker as initial therapy in the absence of contraindications.
nea caused by heart failure. The evidence for this approach is strongest in the presence of
Because of the variation in symptom complexes among prior MI, for which this class of drugs has been shown to
patients and their unique perceptions, expectations, and pref- reduce mortality. Because these drugs have also been shown
erences, it is impossible to create a definition of treatment to reduce mortality in the treatment of patients with isolated
success that is universally accepted. For example, given an hypertension who are at lower risk for mortality than patients
otherwise healthy, active patient, the treatment goal may be with stable angina, the committee favored their use as initial
complete elimination of chest pain and a return to vigorous therapy even in the absence of prior MI.
physical activity. Conversely, an elderly patient with more If serious contraindications with the b-adrenoreceptor
severe angina and several coexisting medical problems may blockers exist, unacceptable side effects occur with their use,
 Gibbons et al June 1, 1999 2843

or angina persists despite their use, calcium antagonists result, many should also have improved physical function and
should then be administered. survival.
If serious contraindications to calcium antagonists exist,
unacceptable side effects occur with their use, or angina C. Therapy of Associated Conditions
persists despite their use, long-acting nitrate therapy should Coexisting medical conditions may affect the selection of
then be prescribed. pharmacological agents for the management of chronic stable
At any point, on the basis of coronary anatomy, severity of angina. For the patient with aortic valve stenosis or hyper-
anginal symptoms, and patient preferences, it is reasonable to trophic obstructive cardiomyopathy, nitrates may induce
consider evaluation for coronary revascularization. As dis- hypotension and further compromise myocardial oxygen
cussed earlier, certain categories of patients have a demon- delivery. The coexistence of heart failure in patients with
strated survival advantage with revascularization. However, chronic stable angina poses a special therapeutic challenge. A
in most low-risk patients for whom there is no demonstrated growing body of evidence suggests potential benefits of
survival advantage associated with revascularization, medical b-blockers in patients with heart failure; however, because of
therapy should be attempted before angioplasty or surgery is negative inotropic properties, they must be used judiciously
considered. The extent of the effort that should be undertaken in this setting. There is little evidence of benefit of calcium
with medical therapy obviously depends on the individual antagonists in the setting of ischemic dilated cardiomyopathy.
patient. In general, the committee thought that low-risk In patients with asthma, b-blockers are contraindicated be-
patients should be treated with at least 2, and preferably all 3, cause of the likelihood of exacerbation of bronchospasm. In
patients with heart block, b-blocking agents and heart-rate
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of the available classes of drugs before medical therapy is

considered a failure. limiting calcium antagonists (diltiazem, verapamil) should be
avoided because they decrease atrioventricular nodal conduc-
B. Education tion. In patients with severe peripheral vascular disease,
Because the presentation of ischemic heart disease is often b-blockers may worsen symptoms. For patients with mi-
dramatic and because of impressive recent technological graine headaches, b-blockers and calcium antagonists may be
advances, healthcare providers tend to focus on diagnostic beneficial, whereas nitrates may worsen the headaches.
and therapeutic interventions, often overlooking critically
important aspects of high quality care. Chief among these D. Coronary Disease Risk Factors and Evidence
neglected areas is the education of patients. In the 1995
That Treatment Can Reduce the Risk for
National Ambulatory Medical Care Survey, counseling about
Coronary Disease Events
physical activity and diet occurred during only 19% and 23%, Recommendations for Treatment of Risk Factors
respectively, of general medical visits. This shortcoming was Class I
observed across specialties, including cardiology, internal
medicine, and family practice. 1. Treatment of hypertension according to Joint National
Effective education is critical to enlisting patients full and Conference VI guidelines. (Level of Evidence: A)
meaningful participation in therapeutic and preventive efforts 2. Smoking cessation therapy. (Level of Evidence: B)
and in allaying their natural concerns and anxieties. This in 3. Management of diabetes. (Level of Evidence: C)
turn is likely to lead to a patient who not only is better 4. Exercise training program. (Level of Evidence: B)
5. Lipid-lowering therapy in patients with documented
informed but who is also able to achieve a better quality of
or suspected CAD and LDL >130 mg/dL, with a
life and is more satisfied with his or her care. Education about target LDL <100 mg/dL. (Level of Evidence: A)
what to do at the onset of symptoms of a possible acute MI is 6. Weight reduction in obese patients in the presence of
particularly important. hypertension, hyperlipidemia, or diabetes mellitus.
A variety of principles should be followed to help ensure (Level of Evidence: C)
that educational efforts are successful.
Class IIa
1. Assess the patients baseline understanding. Lipid-lowering therapy in patients with documented or
2. Elicit the patients desire for information. suspected CAD and LDL cholesterol 100 to 129 mg/dL,
3. Use epidemiological and clinical evidence. with a target LDL of <100 mg/dL. (Level of Evidence: B)
4. Use ancillary personnel and professional patient educa-
Class IIb
tors when appropriate.
5. Use professionally prepared resources when available. 1. Hormonal replacement therapy in postmenopausal
6. Develop a plan with the patient. women in the absence of contraindications. (Level of
7. Involve family members in educational efforts. Evidence: B)
8. Remind, repeat, and reinforce. 2. Weight reduction in obese patients in the absence of
hypertension, hyperlipidemia, or diabetes mellitus.
In summary, patient education requires a substantial time (Level of Evidence: C)
investment by primary-care providers and specialists using an 3. Folate therapy in patients with elevated homocys-
organized and thoughtful approach. The potential rewards for teine levels. (Level of Evidence: C)
patients are also substantial in terms of improved quality of 4. Vitamin C and E supplementation. (Level of Evi-
life, satisfaction, and adherence to medical therapy. As a dence: B)
 2844 ACC/AHA/ACPASIM Practice Guidelines: Executive Summary

5. Identification and appropriate treatment of clinical hypertension treatment. By 1993, there were 17 randomized
depression. (Level of Evidence: C) trials of therapy in .47 000 patients of both sexes, all races,
6. Intervention directed at psychosocial stress reduc- and a wide spectrum of blood pressures. The beneficial
tion. (Level of Evidence: C) effects of hypertension treatment on cardiovascular disease
Class III risk have been confirmed in individual trials and meta-anal-
yses. More recent trials in older patients with systolic hyper-
1. Chelation therapy. (Level of Evidence: C) tension have underscored the benefits to be derived from
2. Garlic. (Level of Evidence: C) blood pressure lowering in the elderly. A recent meta-analysis
3. Acupuncture. (Level of Evidence: C) found that the absolute reduction of coronary events in older
subjects (2.7/1000 person-years) was more than twice as great
Categorization of Coronary Disease Risk Factors
The 27th Bethesda Conference proposed that CAD risk as that in younger subjects (1.0/1000 person-years). This
factors be categorized both on the strength of evidence for finding contrasts with clinical practice in which hypertension
causation and the evidence that risk factor modification can is often less aggressively treated in older persons.
reduce risk for clinical CAD events. Category I risk factors Hypertensive patients with chronic stable angina are at
were clearly associated with an increase in coronary disease high risk for cardiovascular disease morbidity and mortality.
risk, for which interventions have been shown to reduce the The benefits and safety of hypertension treatment in such
incidence of coronary disease events. patients have been established. Treatment begins with non-
Such risk factors must be identified and, when present, pharmacological means. When lifestyle modifications and
treated as part of an optimal secondary prevention strategy in dietary alterations adequately reduce blood pressure, pharma-
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patients with chronic stable angina. They are common in this cological intervention is unnecessary. The modest benefit of
patient group and readily amenable to modification, and their antihypertensive therapy for coronary event reduction in
treatment can affect clinical outcome favorably. For these clinical trials may underestimate the efficacy of this therapy
reasons, they are discussed in these guidelines in greater in hypertensive patients with established coronary disease
detail than other risk factors. Lipid-lowering therapy has because in general, the higher the absolute risk of the
already been discussed because definitive evidence from population, the greater the magnitude of response to therapy.
randomized trials has shown that it is highly beneficial.
Diabetes Mellitus
Smoking Cessation Although better metabolic control in persons with type I
Randomized clinical trials of smoking cessation have not diabetes has been shown to lower the risk for microvascular
been performed in patients with chronic stable angina. Three complications, there is little information about the benefits of
randomized smoking cessation trials have been performed in tighter metabolic control in type I or II diabetes with regard
a primary prevention setting. Smoking cessation was associ- to reducing the risk for coronary disease in either primary or
ated with a reduction in cardiac event rates of 7% to 47% in secondary prevention settings. At present, it is worthwhile to
these trials. The rapidity of risk reduction after smoking pursue strict glycemic control in diabetic persons with
cessation is consistent with known adverse effects of smoking chronic stable angina in the belief that this approach will
on fibrinogen levels and platelet adhesion. Other rapidly prevent some microvascular complications and may also
reversible effects of smoking include increased blood car- reduce the risk for other cardiovascular disease complica-
boxyhemoglobin levels, reduced HDL cholesterol, and coro- tions, but convincing data from clinical trials are lacking.
nary artery vasoconstriction. The common coexistence of other modifiable factors in the
Patients with symptomatic coronary disease form the group diabetic patient contributes to increased coronary disease risk
most receptive to treatments directed to smoking cessation. and must be managed aggressively. These risk factors include
Taylor and coworkers have shown that #32% of patients will hypertension, obesity, and increased LDL-cholesterol levels.
stop smoking at the time of a cardiac event and that this rate Elevated triglyceride levels and low HDL-cholesterol levels
can be significantly enhanced to 61% by a nurse-managed are also common in persons with diabetes.
smoking cessation program. New behavioral and pharmaco-
Obesity
logical approaches to smoking cessation are available for use
Obesity is a common condition associated with increased risk
by trained healthcare professionals. Few physicians are ade-
for coronary disease and mortality. Obesity is associated with
quately trained in smoking cessation techniques. Identifica-
and contributes to other coronary disease risk factors, includ-
tion of experienced allied healthcare professionals who can
ing high blood pressure, glucose intolerance, low levels of
implement smoking cessation programs for patients with
HDL cholesterol, and elevated triglyceride levels. Hence,
coronary disease is a priority. The importance of a structured
much of the increased CAD risk associated with obesity is
approach cannot be overemphasized. The rapidity and mag-
mediated by these risk factors. It is likely that weight
nitude of risk reduction, as well as the other health-enhancing
reduction in obese patients with coronary disease can reduce
benefits of smoking cessation, argue for the incorporation of
the risk for future coronary events because weight reduction
smoking cessation in all programs of secondary prevention of
will improve these other modifiable risk factors and reduce
coronary disease.
the increased myocardial oxygen demand imposed by obe-
Hypertension sity. Therefore, weight reduction is indicated in all obese
The first and second Veterans Affairs Cooperative studies patients with chronic stable angina, although no clinical trials
were the first to definitively demonstrate the benefits of have specifically examined the effect of weight loss on risk
 Gibbons et al June 1, 1999 2845

for coronary disease events. Referral to a dietitian is often 4. PTCA for patients with 2- or 3-vessel disease with
necessary to maximize the likelihood of success of a dietary significant proximal left anterior descending CAD,
weight loss program. who have anatomy suitable for catheter-based ther-
apy, normal LV function, and who do not have
Inactive Lifestyle: Exercise Training treated diabetes. (Level of Evidence: B)
Any discussion of exercise training must acknowledge that it 5. PTCA or CABG for patients with 1- or 2-vessel CAD
will not only usually be incorporated into a multifactorial without significant proximal left anterior descending
intervention program but will have multiple effects. It is very CAD but with a large area of viable myocardium
difficult to separate the effects of exercise training from the and high-risk criteria on noninvasive testing. (Level
multiple secondary effects that it may have on confounding of Evidence: B)
variables. For example, exercise training may lead to changes 6. CABG for patients with 1- or 2-vessel CAD without
in weight, sense of well-being, and use of antianginal significant proximal left anterior descending CAD who
medication. have survived sudden cardiac death or sustained ven-
Multiple randomized, controlled trials comparing exercise tricular tachycardia. (Level of Evidence: C)
7. In patients with prior PTCA, CABG or PTCA for
training with a no-exercise control group have demon-
recurrent stenosis associated with a large area of
strated a statistically significant improvement in exercise viable myocardium and/or high-risk criteria on non-
tolerance in the exercise group versus the control group. Four invasive testing. (Level of Evidence: C)
randomized trials have examined the potential benefit of 8. PTCA or CABG for patients who have not been
exercise training on objective measures of ischemia. Three of successfully treated (see text) by medical therapy
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those studies demonstrated a reduction in objective measures and can undergo revascularization with acceptable
of ischemia in patients randomized to the exercise group risk. (Level of Evidence: B)
compared with the control group.
Multiple randomized trials have examined the potential Class IIa
benefit of exercise training in the management of lipids.
1. Repeat CABG for patients with multiple saphenous
Some of these trials have examined exercise training alone;
vein graft stenoses, especially when there is signifi-
others have studied exercise training as part of a multifacto- cant stenosis of a graft supplying the left anterior
rial intervention. The preponderance of evidence clearly descending coronary artery. PTCA may be appro-
suggests that exercise training is beneficial and associated priate for focal saphenous vein graft lesions or
with a reduction in total cholesterol, LDL cholesterol, and multiple stenoses in poor candidates for reoperative
triglycerides in comparison with controlled therapy but has surgery. (Level of Evidence: C)
little effect on HDL cholesterol. Not surprisingly, these 2. PTCA or CABG for patients with 1- or 2-vessel CAD
reductions in lipids have been associated with less disease without significant proximal left anterior descending
progression using angiographic follow-up. However, exercise CAD but with a moderate area of viable myocardium
training alone is unlikely to be sufficient in patients with a and demonstrable ischemia on noninvasive testing.
lipid disorder. (Level of Evidence: B)
Considering its effects on lipid levels and disease progres- 3. PTCA or CABG for patients with 1-vessel disease
sion, it is attractive to hypothesize that exercise training will with significant proximal left anterior descending
CAD. (Level of Evidence: B)
reduce the subsequent risk of cardiac events. However, only
1 clinical trial has examined the impact of exercise training Class IIb
on subsequent cardiac events in patients with stable angina.
Although this trial suggested a favorable effect of exercise 1. Compared with CABG, PTCA for patients with 3- or
training on patient outcome, it was not definitive. 2-vessel disease with significant proximal left anterior
descending CAD who have anatomy suitable for
E. Revascularization for Chronic Stable Angina catheter-based therapy and who have treated diabetes
or abnormal LV function. (Level of Evidence: B)
Recommendations for Revascularization With
2. PTCA for patients with significant left main coro-
PTCA (or Other Catheter-Based Techniques) and nary disease who are not candidates for CABG.
CABG in Patients With Stable Angina (Level of Evidence: C)
Class I 3. PTCA for patients with 1- or 2-vessel CAD without
significant proximal left anterior descending CAD who
1. CABG for patients with significant left main coro- have survived sudden cardiac death or sustained ven-
nary disease. (Level of Evidence: A) tricular tachycardia. (Level of Evidence: C)
2. CABG for patients with 3-vessel disease. The sur-
vival benefit is greater in patients with abnormal LV Class III
function (ejection fraction <50%). (Level of Evi-
dence: A) 1. PTCA or CABG for patients with 1- or 2-vessel CAD
3. CABG for patients with 2-vessel disease with signif- without significant proximal left anterior descending
icant proximal left anterior descending CAD and CAD who
either abnormal LV function (ejection fraction a. Have mild symptoms that are unlikely due to
<50%) or demonstrable ischemia on noninvasive myocardial ischemia or have not received an
testing. (Level of Evidence: A) adequate trial of medical therapy and
 2846 ACC/AHA/ACPASIM Practice Guidelines: Executive Summary

1) Have only a small area of viable myocardium or PTCA Versus Medical Treatment
2) Have no demonstrable ischemia on noninvasive The initial randomized study that compared PTCA with
testing. (Level of Evidence: C) medical management alone for the treatment of chronic stable
2. PTCA or CABG for patients with borderline angina was the Veterans Affairs Angioplasty Compared to
coronary stenoses (50% to 60% diameter in loca- Medicine (ACME) Trial, which involved patients with
tions other than the left main) and no demonstra- 1-vessel disease and exercise-induced ischemia. In a 6-month
ble ischemia on noninvasive testing. (Level of follow-up, the death rate was expectedly low for both the
Evidence: C) PTCA and medically treated groups, and 64% of the PTCA
3. PTCA or CABG for patients with insignificant group were free of angina versus 46% of the medically treated
coronary stenosis (<50% diameter). (Level of
group (P,0.01).
Evidence: C)
A second randomized trial comparing initial PTCA versus
4. PTCA in patients with significant left main CAD who
are candidates for CABG. (Level of Evidence: B) initial medical management (RITA-II) included a majority of
patients with 1-vessel disease (60%) and some angina (only
Note: PTCA is used in these recommendations to 20% without angina) monitored over a 2.7-year median
indicate PTCA and/or other catheter-based techniques follow-up interval. There was a slightly greater risk of death
such as stents, atherectomy, and laser therapy. or MI for the PTCA group (P50.02), although those risks
Currently, there are 2 well-established revascularization were low for both groups. The PTCA patients had less angina
approaches to treatment of chronic stable angina caused by 3 months after randomization, although by 2 years, the
coronary atherosclerosis. One is CABG, in which segments differences between the 2 groups were small (7.6% more
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of autologous arteries and/or veins are used to reroute blood medically treated patients had angina).
around relatively long segments of the proximal coronary
artery. The second is PTCA, a technique that uses catheter- PTCA Versus CABG
borne mechanical or laser devices to open a (usually) short Multiple trials have compared the strategy of initial PTCA
area of stenosis from within the coronary artery. versus initial CABG for the treatment of multivessel CAD. In
general, the goal of these trials has been to try to answer the
CABG Versus Medical Management
question of whether or not there are subsets of patients who
The goals of coronary bypass surgery are to improve symp-
pay a penalty in terms of survival for initial treatment with
toms and prolong life expectancy. Early in the history of
PTCA. The 2 US trials of PTCA versus CABG are the
CABG, it became clear that successful bypass surgery re-
multicenter Bypass Angioplasty Revascularization Investiga-
lieved or improved angina. To investigate the question of
tion (BARI) Trial and the 1-center Emory Angioplasty versus
whether bypass surgery prolonged survival, 3 large multi-
Surgery Trial (EAST).
center randomized trials, the Veterans Administration Coop-
The results of both of these trials at an '5-year follow-up
erative Study (VA Study), the European Coronary Surgery interval have shown that early and late survival rates have
Study (ECSS), and the Coronary Artery Surgery Study been equivalent for the PTCA and CABG groups. In the
(CASS), were undertaken. These trials compared the strategy BARI trial, the subgroup of patients with treated diabetes had
of initial bypass surgery with that of initial medical manage- significantly better survival rates with CABG. That survival
ment in regard to long-term survival and symptom status for advantage for CABG was focused in the group of diabetic
patients with mild or moderate symptoms. patients with multiple severe lesions. In the EAST trial,
Recently, a meta-analysis of these 3 major randomized diabetics had equivalent survival rates with CABG or PTCA
trials of initial surgery versus medical management as well as at 3 years. Longer-term follow-up data from the BARI and
other smaller trials has confirmed the survival benefit EAST trials have not yet been published.
achieved by surgery at 10 postoperative years for patients
with 3-, 2-, or even 1-vessel disease that included a stenosis Recommendations for Revascularization for
of the proximal LAD coronary artery. The survival rate of Patients With Native-Vessel CAD
these patients was improved by surgery whether they had Advances have been made in medical therapy that reduce MI
normal or abnormal LV function. For patients without a and death and decrease the rate of progression of coronary
proximal LAD stenosis, bypass surgery improved the mortal- stenoses. However, there is still no evidence that medical
ity rate only for those with 3-vessel disease or left main treatment alone sufficiently improves the life expectancy of
stenosis. the high-risk subgroups defined by the trials of medical
treatment versus bypass surgery.
PTCA The randomized trials of initial medical treatment versus
PTCA for CAD was introduced in 1977 as balloon angio- initial surgery showed that patients with left main stenoses
plasty, a strategy in which a catheter-borne balloon was $70% and those with multivessel CAD with a proximal LAD
inflated at the point of coronary stenosis. Alternative mechan- stenosis $70% have a better late survival rate if they have
ical devices for percutaneous treatments have been developed coronary bypass surgery. Because the randomized trials of
and have included rotating blades or burrs designed to PTCA versus bypass surgery included an inadequate number
remove atheromatous material, lasers to achieve photoabla- of patients in these high-risk subsets, it cannot be assumed
tion of lesions, and metal intracoronary stents designed to that the alternative strategy of PTCA produces equivalent late
structurally maintain lumen size. survival in such patients.
 Gibbons et al June 1, 1999 2847

Meta-analysis of the randomized trials of medical manage- Class IIb

ment versus CABG have further indicated that patients Annual treadmill exercise testing in patients who have no
without severe symptoms but with a proximal left anterior change in clinical status, can exercise, have none of the ECG
descending artery lesion have a better survival rate with abnormalities listed in number 5 above, and have an esti-
surgery, even if they have normal LV function and only mated annual mortality of >1%. (Level of Evidence: C)
1-vessel disease. For these patients, data from the PTCA
Class III
versus CABG trials appear to show that, at least for the first
5 years, the alternative revascularization strategy of PTCA 1. Echocardiography or radionuclide imaging for as-
does not compromise survival for patients who are good sessment of LV ejection fraction and segmental wall
angiographic candidates for PTCA. motion in patients with a normal ECG, no history of
Caution should be used in treating diabetic patients with MI, and no evidence of congestive heart failure.
PTCA, particularly in the setting of multivessel, multilesion, (Level of Evidence: C)
2. Repeat treadmill exercise testing in <3 years in
severe CAD.
patients who have no change in clinical status and an
estimated annual mortality <1% on their initial
V. Patient Follow-Up: Monitoring of evaluation as demonstrated by 1 of the following:
Symptoms and Antianginal Therapy a. Low-risk Duke treadmill score (without imaging).
(Level of Evidence: C)
Recommendations for Echocardiography, b. Low-risk Duke treadmill score with negative
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Treadmill Exercise Testing, Stress Imaging imaging. (Level of Evidence: C)

Studies, and Coronary Angiography During c. Normal LV function and a normal coronary
Patient Follow-Up angiogram. (Level of Evidence: C)
d. Normal LV function and insignificant CAD. (Lev-
Class I el of Evidence: C)
3. Stress imaging procedures for patients who have no
1. Chest x-ray for patients with evidence of new or change in clinical status and a normal rest ECG, are
worsening congestive heart failure. (Level of Evi- not taking digoxin, are able to exercise, and did not
dence: C) require a stress imaging procedure on their initial
2. Assessment of LV ejection fraction and segmental evaluation because of equivocal or intermediate-risk
wall motion in patients with new or worsening treadmill results. (Level of Evidence: C)
congestive heart failure or evidence of intervening 4. Repeat coronary angiography in patients with no
MI by history or ECG. (Level of Evidence: C) change in clinical status, no change on repeat exer-
3. Echocardiography for evidence of new or worsening cise testing or stress imaging, and insignificant CAD
valvular heart disease. (Level of Evidence: C) on initial evaluation. (Level of Evidence: C)
4. Treadmill exercise test for patients without prior
revascularization who have a significant change in The committee believes that the patient with successfully
clinical status, are able to exercise, and do not have treated chronic stable angina should have a follow-up evalu-
any of the ECG abnormalities listed below in num- ation every 4 to 12 months. A more precise interval cannot be
ber 5. (Level of Evidence: C) recommended because many factors influence the length of
5. Stress imaging procedures for patients without prior the follow-up period. During the first year of therapy,
revascularization who have a significant change in evaluations every 4 to 6 months are recommended. After the
clinical status and are unable to exercise or have 1 of first year of therapy, annual evaluations are recommended if
the following ECG abnormalities: the patient is stable and reliable enough to call or make an
a. Preexcitation (Wolff-Parkinson-White) syn- appointment when anginal symptoms become worse or other
symptoms occur. Patients who are comanaged by their
drome. (Level of Evidence: C)
primary-care physician and cardiologist may alternate these
b. Electronically paced ventricular rhythm. (Level
visits, provided that communication among physicians is
of Evidence: C)
excellent and all appropriate issues are addressed at each
c. More than 1 mm of rest ST depression. (Level of
visit. Annual office visits can be supplemented by telephone
Evidence: C) or other types of contact between the patient and the physi-
d. Complete left bundle-branch block. (Level of cians caring for him or her. Patients who cannot reliably
Evidence: C) identify and report changes in their status or who need more
6. Stress imaging procedures for patients who have a support with their treatment or risk factor reduction should be
significant change in clinical status and required a seen more frequently.
stress imaging procedure on their initial evaluation Five questions must be answered regularly during the
because of equivocal or intermediate-risk treadmill follow-up of the patient who is receiving treatment for
results. (Level of Evidence: C) chronic stable angina:
7. Stress imaging procedures for patients with prior
revascularization who have a significant change in 1. Has the patient decreased the level of physical activity
clinical status. (Level of Evidence: C) since the last visit?
8. Coronary angiography in patients with marked lim- 2. Have the patients anginal symptoms increased in fre-
itation of ordinary activity (CCS class III) despite quency and become more severe since the last visit? If
maximal medical therapy. (Level of Evidence: C) the symptoms have worsened or the patient has de-
 2848 ACC/AHA/ACPASIM Practice Guidelines: Executive Summary

creased physical activity to avoid precipitating angina, whose prognosis can be improved is inappropriate when the
then he or she should be evaluated and treated according patients estimated annual mortality rate is #1%. In contrast,
to either the unstable angina or chronic stable angina patients with a survival advantage with CABG, such as those
guidelines, as appropriate. with 3-vessel disease, have an annual mortality rate $3%.
3. How well is the patient tolerating therapy? Follow-up testing is more appropriate in patients whose risk
4. How successful has the patient been in reducing mod-
is in this range. The strategy for performance of additional
ifiable risk factors and improving knowledge about
ischemic heart disease? testing at any point during a patients follow-up is analogous
5. Has the patient developed any new comorbid illnesses to the strategy for performance of angiography after initial
or has the severity or treatment of known comorbid treadmill testing. It is appropriate in high-risk situations, a
illnesses worsened the patients angina? matter of clinical judgment in intermediate-risk situations,
and not required in low-risk situations.
In patients who have been successfully treated as previ- The choice of stress test to be used in patient follow-up
ously defined and who have had no change in clinical status, testing should be dictated by considerations similar to those
the rationale for follow-up noninvasive stress testing is to outlined earlier for the initial evaluation of the patient. In
identify patients in whom further evaluation and revascular- patients with interpretable exercise ECGs who are capable of
ization might be appropriate to improve prognosis. Such a exercise, treadmill exercise testing remains the first choice.
strategy can only be successful if the patients prognosis on Whenever possible, follow-up testing should be done using
medical therapy is sufficiently poor that it can potentially be the same stress and imaging techniques to permit the most
improved. Previous experience in the randomized trials of valid comparison to the original study. When different modes
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coronary artery bypass surgery demonstrated that patients of stress and imaging are used, it is much more difficult to
randomized to initial CABG had a lower mortality rate than judge whether an apparent change in results is due to
those treated with medical therapy only if they were at differences in the modality or a change in the patients
substantial risk. Low-risk patients who did not have a lower underlying status.
mortality with CABG had a 5-year survival rate with medical
therapy of '95%. This is equivalent to an annual mortality KEY WORDS: AHA Scientific Statements n angina n coronary artery disease
rate of 1%. As a result, follow-up testing to identify patients n myocardial infarction
 ACC/AHA/ACPASIM 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)
Raymond J. Gibbons, Kanu Chatterjee, Jennifer Daley, John S. Douglas, Stephan D. Fihn, Julius
M. Gardin, Mark A. Grunwald, Daniel Levy, Bruce W. Lytle, Robert A. O'Rourke, William P.
Schafer, Sankey V. Williams, James L. Ritchie, Raymond J. Gibbons, Melvin D. Cheitlin, Kim
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A. Eagle, Timothy J. Gardner, Arthur Garson, Jr, Richard O. Russell, Thomas J. Ryan and
Sidney C. Smith, Jr
Committee MembersTask Force Members

Circulation. 1999;99:2829-2848
doi: 10.1161/01.CIR.99.21.2829
Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright 1999 American Heart Association, Inc. All rights reserved.
Print ISSN: 0009-7322. Online ISSN: 1524-4539

The online version of this article, along with updated information and services, is located on the
World Wide Web at:
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