This is the current release of the guideline.

This guideline updates a previous version: Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM, Grunwald MA, Levy D, Lytle BW, O'Rourke RA, Schafer WP, Williams SV, Ritchie JL, Cheitlin MD, Eagle KA, Gardner TJ, Garson A Jr, Russell RO, Ryan TJ, Smith SC Jr. ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 1999 Jun;33(7):2092-197.

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Note from the National Guideline Clearinghouse (NGC): This guideline is an update of the 1999 guideline on chronic stable angina, which was published by the American College of Physicians (ACP) (then the American College of Physicians-American Society of Internal Medicine) and the American College of Cardiology/American Heart Association (ACC/AHA). In 2002, the ACC/AHA published an updated guideline, which the ACP recognized as a scientifically valid review of the evidence and background paper [ACC/AHA 2002 guideline update for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for the Management of Patients With Chronic Stable Angina)]. This ACP guideline summarizes the recommendations of the 2002 ACC/AHA updated guideline and underscores the recommendations most likely to be important to physicians seeing patients in the primary care setting. See the companion documents field for a complete reference to the ACC/AHA guideline.

The levels of evidence (A, B, C) are defined at the end of the "Major Recommendations" field.

 

 

Recommendation 1: In patients presenting with chest pain, the probability of CAD should be estimated on the basis of patient age, sex, cardiovascular risk factors, and pain characteristics (level of evidence: B). Patients with intermediate or high probability should undergo risk stratification through further testing. For patients with a low probability of CAD, the decision to pursue further testing should be based on a shared discussion between the patient and clinician.

Recommendation 2: The following patients who have chronic stable angina or are asymptomatic should have left ventricular function measured by resting echocardiography or resting radionuclide angiography: patients with a history of myocardial infarction (MI), patients with pathologic Q waves, patients with symptoms or signs suggestive of heart failure, and patients with complex ventricular arrhythmias (level of evidence for all patients: B).

 

 

Recommendation 3: Exercise electrocardiography (ECG), using the Bruce protocol and Duke treadmill score, should be the initial test for risk stratification in patients with symptomatic chronic stable angina who are able to exercise and are not taking digoxin (level of evidence: B). Exercise ECG testing is also recommended after a significant change in anginal pattern (level of evidence: C). Exercise ECG testing is not recommended when the following confounding factors are found on resting ECG: preexcitation (Wolff–Parkinson–White) syndrome, electronically paced ventricular rhythm, more than 1 mm of ST depression at rest, and complete left bundle-branch block (level of evidence for all factors: B).

 

 

Recommendation 4: For patients with chronic stable angina who are able to exercise, do not have left bundle-branch block or an electronically paced ventricular rhythm, and have abnormal results on resting ECG or are using digoxin, exercise perfusion imaging or exercise echocardiography is recommended as the initial test for risk stratification (level of evidence: B).

Recommendation 5: For patients who are unable to exercise and do not have left bundle-branch block or an electronically paced ventricular rhythm, dipyridamole or adenosine myocardial perfusion imaging (level of evidence: B) or dobutamine echocardiography (level of evidence: B) is recommended as the initial test for risk stratification.

Recommendation 6: For patients with left bundle-branch block or electronically paced ventricular rhythm, dipyridamole or adenosine myocardial perfusion imaging is recommended regardless of ability to exercise (level of evidence: B).

Recommendation 7: For patients with left bundle-branch block or electronically paced ventricular rhythm, exercise or dobutamine echocardiography (level of evidence: C) and exercise myocardial perfusion imaging (level of evidence: C) are not recommended.

 

 

Note:

The American College of Cardiology/American Heart Association (ACC/AHA+ recommends against "screening" asymptomatic outpatients for coronary disease. However, the American College of Physicians (ACP) recognizes the clinical reality that primary care physicians and subspecialists are being consulted by asymptomatic patients who may have been inappropriately screened and present with "abnormal" results on ambulatory ECG monitoring, electron-beam computed tomography, or other tests. Most of the recommendations in this section are based on level C evidence, which denotes expert opinion from the ACC/AHA guideline. As a matter of policy, the ACP seldom makes clinical policy recommendations on the basis of expert opinion. However, this clinical situation has become a particularly important problem for ACP membership. Therefore, in the absence of any high-grade evidence (level A or B), the ACP has chosen to endorse the following recommendations from the ACC/AHA document, which in this case were developed by using expert opinion.

 

Asymptomatic patients who are able to exercise can usually be evaluated with exercise ECG. In this case, the recommendations for exercise stress testing for risk stratification in asymptomatic patients would be the same as for symptomatic patients and would depend on patients’ ability to exercise and the presence of abnormalities on resting ECG (see Recommendations 2 and 3 above).

 

The recommendations for the use of stress imaging (exercise or pharmacologic) in asymptomatic patients with abnormalities on ambulatory ECG monitoring or electron-beam computed tomography are the same as for symptomatic patients. They depend on whether the patient is able to exercise or whether abnormalities on resting ECG are present. In this case, the ACP recommends, on the basis of the opinion of the ACC/AHA, several options for further workup of asymptomatic patients.

Recommended options for cardiac stress imaging after exercise ECG for risk stratification in asymptomatic patients are as follows. Exercise myocardial perfusion imaging or exercise echocardiography may be performed in asymptomatic patients with an intermediate-risk or high-risk Duke treadmill score on exercise ECG (level of evidence: C).

Adenosine or dipyridamole myocardial perfusion imaging or dobutamine echocardiography may be performed in asymptomatic patients with a previously inadequate exercise ECG (level of evidence: C). Asymptomatic patients with a low-risk Duke treadmill score on exercise ECG should not have exercise myocardial perfusion imaging, exercise echocardiography, adenosine or dipyridamole myocardial perfusion imaging, or dobutamine echocardiography (level of evidence: C).

 

Two updated clinical algorithms are provided in the original American College of Physicians guideline document for the evaluation of suspected coronary artery disease (CAD) and for exercise electrocardiography (EEG) and angiography.

The type of evidence supporting the recommendations is identified and graded in the "Major Recommendations" field.

 

The guideline summarizes the recommendations of the 2002 American College of Cardiology/American Heart Association (ACC/AHA) guideline update for the management of patients with chronic stable angina: a report of the ACA/AHA Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for the Management of Patients with Chronic Stable Angina).

2004 Jul 6

American College of Physicians - Medical Specialty Society

American College of Physicians (ACP)

Clinical Efficacy Assessment Subcommittee of the American College of Physicians (ACP)

Authors: Vincenza Snow, MD; Patricia Barry, MD, MPH; Stephan D. Fihn, MD, MPH; Raymond J. Gibbons, MD; Douglas K. Owens, MD; Sankey V. Williams, MD; Kevin B. Weiss, MD, MPH; Christel Mottur-Pilson, PhD

Clinical Efficacy Assessment Subcommittee of the American College of Physicians (ACP) Members: Kevin B. Weiss, MD (Chair); Mark Aronson, MD; Patricia Barry, MD; Thomas Cross Jr., MD, MPH; Nick Fitterman, MD; E. Rodney Hornbake, MD; Douglas K. Owens, MD; Katherine D. Sherif, MD

Potential Financial Conflicts of Interest: Employment: P. Barry (Merck Institute of Aging and Health); Consultancies: R.J. Gibbons (CV Therapeutics, DOV Pharmaceuticals, King Pharm, Medicure, Boehringer Ingelheim, Hawaii Biotech, GlaxoSmithKline, TargeGen); Stock ownership or options (other than mutual funds): P. Barry (Merck & Co., Inc.); Grants received: P. Barry (Merck Company Foundation), R.J. Gibbons (Medtronic, King Pharm, Wyeth-Ayerst, Radiant Medical, Alsius Corp., TherOx, Innercool Therapies, Boston Scientific), S.V. Williams; Grants pending: R.J. Gibbons (Boehringer Ingelheim)

This is the current release of the guideline.

This guideline updates a previous version: Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM, Grunwald MA, Levy D, Lytle BW, O'Rourke RA, Schafer WP, Williams SV, Ritchie JL, Cheitlin MD, Eagle KA, Gardner TJ, Garson A Jr, Russell RO, Ryan TJ, Smith SC Jr. ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 1999 Jun;33(7):2092-197.

Electronic copies: Available from the American College of Physicians (ACP) Web site:

Print copies: Available from the American College of Physicians (ACP), 190 N. Independence Mall West, Philadelphia PA 19106-1572.

None available

The following is available:

Electronic copies: Available from the American College of Physicians (ACP) Web site:

Print copies: Available from the American College of Physicians (ACP), 190 N. Independence Mall West, Philadelphia PA 19106-1572.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

This NGC summary was completed by ECRI on August 16, 2004. The information was verified by the guideline developer on August 19, 2004.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.