2. ACC/AHA 2002 Guideline for the Management of Patients With Chronic Stable Angina 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines

3. Definition Clinical syndrome characterized by discomfort in the chest, jaw, shoulder, back or arm Typically aggravated by exertion or emotional stress and relieved by nitroglycerin.

4. Canadian Cardiovascular Society Classification  Class I Ordinary physical activity does not cause angina, such as walking, climbing stairs.  Class II Slight limitation of ordinary activity. Angina on walking or climbing stairs rapidly, walking uphill, walking or stair climbing after meals  Class III Marked limitations of ordinary physical activity. Angina on walking one to two blocks on the level and climbing one flight of stairs  Class IV Inability to carry on any physical activity without discomfort—anginal symptoms at rest.

5. Purpose of diagnosis and assessment Confirmation of presence of ischemia in patients with suspected angina Identification associated conditions or precipitating factors Risk stratification To plan treatment options Evaluation of efficacy of treatment

6. Diagnosis

7. ACC/AHA Guidelines for Routine Clinical Testing in Patients with Chronic Stable Angina CLASSINDICATION LEVEL OF EVIDENCE* I (indicated) 1. Rest ECG in patients without obvious noncardiac cause of chest pain B 2. Rest ECG during an episode of chest painB 3. Chest radiograph in patients with signs or symptoms of congestive heart failure, valvular heart disease, pericardial disease, or aortic dissection or aneurysm B 4. HemoglobinC 5. Fasting glucoseC 6. Fasting lipid panelC

8. Exercise Electrocardiography Most valuable for diagnosis when the patient's other clinical data suggest an intermediate probability of coronary disease Uncertain value for patients with high or low pretest probability of coronary disease

9. CLASS INDICATION FOR EXERCICE ECG FOR DIAGNOSIS LEVEL OF EVIDENCE I (indicated) Patients with intermediate pretest probability of CAD based on age, gender, and symptoms, including those with complete RBBB or <1 mm of ST-segment depression at rest B IIa (good supportive evidence) Patients with suspected vasospastic anginaC

10. CLASSINDICATION FOR EXERCICE ECG FOR DIAGNOSIS LEVEL OF EVIDENCE III (not indicated) 1. Patients with the following baseline electrocardiographic abnormalities: a. Preexcitation (Wolff-Parkinson-White) syndromeB b. Electronically paced ventricular rhythmB c. >1 mm of ST-segment depression at restB d. Complete left bundle branch blockB 2. Patients with an established diagnosis of CAD because of prior MI or CAG; however, testing can assess functional capacity and prognosis

11. CLASSINDICATION FOR ECHO FOR DIAGNOSIS L EVEL OF EVIDENCE * I (indicated)1. Systolic murmur suggestive of aortic stenosis or HOCMC 2. Evaluation of extent (severity) of ischemia -LV segmental wall motion abnormality when obtained during pain or within 30 min after C III (not indicated) Normal ECG, no history of MI, and no signs or symptoms suggestive of heart failure, valvular heart disease, or HOCM C

12. CARDIAC STRESS IMAGING Exercise stress testing is preferable to pharmacologic stress testing when the patient can exercise Most useful for diagnosis in patients with an intermediate probability of disease. Dobutamine perfusion imaging has significant limitations because it does not provoke as great an increase in coronary flow Dobutamine is the agent of choice for pharmacologic stress echocardiography

13. CLASS INDICATION FOR CARDIAC STRESS IMAGING Who Are Able to Exercise FOR DIAGNOSIS LEVEL OF EVIDENCE I 1. Exercise myocardial perfusion imaging or exercise echo - intermediate pretest probability of CAD with baseline ECG abnormalities a. Preexcitation (Wolff-Parkinson-White) syndromeB b. >1 mm of ST-segment depression at restB 2. Exercise myocardial perfusion imaging or exercise echo - prior revascularization (either PCI or CABG) B 3. Adenosine or dipyridamole myocardial perfusion imaging - intermediate pretest probability of CAD & baseline ECG abnormalities: a. Electronically paced ventricular rhythmC b. Left bundle branch blockB

14. CLASSINDICATION CARDIAC STRESS IMAGING Who Are Unable to Exercise LEVEL OF EVIDENCE* I (indicated) 1. Adenosine or dipyridamole myocardial perfusion imaging or dobutamine echocardiography in patients with intermediate pretest probability of CAD B 2. Adenosine or dipyridamole myocardial perfusion imaging or dobutamine echocardiography in patients with prior revascularization (either PCI or CABG) B

15. CLASSINDICATION CARDIAC STRESS IMAGING Who Are Unable to Exercise LEVEL OF EVIDENCE* I (indicated) 1. Adenosine or dipyridamole myocardial perfusion imaging or dobutamine echocardiography in patients with intermediate pretest probability of CAD B 2. Adenosine or dipyridamole myocardial perfusion imaging or dobutamine echocardiography in patients with prior revascularization (either PCI or CABG) B

16. CLASSINDICATION FOR CORONARY ANGIOGRAPHY FOR DIAGNOSIS LEVEL OF EVIDENCE [ † I (indicated ) Patients with known or possible angina who have survived sudden cardiac arrrest B IIa (good supportive evidence) 1. Patients with an uncertain diagnosis after noninvasive testingC 2. Patients who cannot undergo noninvasive testing because of disability, illnessC 3. Patients with an occupational requirement for a definitive diagnosisC

17. CLASSINDICATION FOR CORONARY ANGIOGRAPHY FOR DIAGNOSIS LEVEL OF EVIDENCE [ † IIa 4. Young patients, with noninvasive imaging, or other clinical parameters are suspected of having a nonatherosclerotic cause for myocardial ischemia C 5. Patients in whom coronary artery spasm is suspected and provocative testing may be necessary C 6. Patients with high pretest probability of left main or triple-vessel CADC

18. CLASSINDICATION FOR CORONARY ANGIOGRAPHY LEVEL OF EVIDENCE [†] III (not indicated) 1. Patients with significant comorbidity in whom the risk of coronary arteriography outweighs the benefit of the procedure C 2. Patients with an overriding personal desire for a definitive diagnosis and a low probability of CAD C

19. S pecific Patient Subsets Treadmill electrocardiographic testing is less accurate for diagnosis in women than in men Imaging technologies is also compromised by technical issues (e.g., breast tissue) in women currently are insufficient data to justify replacing standard exercise testing with stress imaging in the initial evaluation of women.

20. RISK STRATIFICATION

21. EXERCISE TESTING for RISK ASSESSMENT AND PROGNOSIS in Intermediate or High Probability of CAD CLASS INDICATION LEVEL OF EVIDENCE I 1. Patients undergoing initial evaluation (exceptions are listed below in Classes IIb and III) B 2. Patients after a significant change in cardiac symptomsC IIb 1. Patients with the following electrocardiographic abnormalities: a. Preexcitation (Wolff-Parkinson-White) syndromeB b. Electronically paced ventricular rhythmB c. >1 mm of ST-segment depression at restB d. Complete left bundle branch blockB

22. EXERCISE TESTING for RISK ASSESSMENT AND PROGNOSIS in Intermediate or High Probability of CAD CLASS INDICATION LEVEL OF EVIDENCE III Patients with severe comorbidity likely to limit life expectancy or prevent revascularization C

23. Cardiac Stress Imaging as Initial Test for Risk Stratification of Patients with Chronic Stable Angina Who Are Able to Exercise CLASSINDICATION LEVEL OF EVIDENCE I 1. Exercise myocardial perfusion imaging or exercise echo to identify severity, and location of ischemia in patients with abnormal rest ECG or using digoxin B 2. Dipyridamole or adenosine myocardial perfusion imaging in patients with left bundle branch block or electronically paced ventricular rhythm B 3. Exercise myocardial perfusion imaging or exercise echocardiography to assess the functional significance of coronary lesions when planning PCI B

24. Cardiac Stress Imaging as Initial Test for Risk Stratification of Patients with Chronic Stable Angina Who Are Able to Exercise CLASS INDICATION LEVEL OF EVIDENCE III 1. Exercise myocardial perfusion imaging in patients with left bundle branch block C 2. In patients with severe comorbidity likely to limit life expectation or prevent revascularization C

25. Cardiac stress imaging as initial test for risk stratification of patients with chronic stable angina who are unable to exercise CLASSINDICATION LEVEL OF EVIDENCE I 1. Dipyridamole or adenosine myocardial perfusion imaging or dobutamine echocardiography to identify severity, and location of ischemia B 2. Dipyridamole or adenosine myocardial perfusion imaging in patients with left bundle branch block or electronically paced ventricular rhythm B 3. Dipyridamole or adenosine myocardial perfusion imaging or dobutamine echocardiography to assess the functional significance of coronary lesions when planning PCI B III Patients with severe comorbidity likely to limit life expectation or prevent revascularization C

26. ACC/AHA Guideline Criteria for Noninvasive Risk Stratification High Risk (>3% Annual Mortality Rate) 1 Severe resting left ventricular dysfunction (LVEF < 0.35) 2 High-risk treadmill score (score ≤ −11) 3 Severe exercise left ventricular dysfunction (exercise LVEF < 0.35) 4 Stress-induced large perfusion defect (particularly if anterior) 5 Stress-induced multiple perfusion defects of moderate size 6 Large, fixed perfusion defect with LV dilation or increased lung uptake 7 Stress-induced moderate perfusion defect with LV dilation or increased lung uptake 8 RWMA (involving more than two segments) developing at low dose of dobutamine or at low heart rate (<120 beats/min) 9 Stress echocardiographic evidence of extensive ischemia

27. ACC/AHA Guideline Criteria for Noninvasive Risk Stratification Intermediate Risk (1%-3% annual mortality rate) 1 Mild or moderate LV dysfunction (LVEF = 0.35-0.49) 2 Intermediate-risk treadmill score (−11 < score < 5) 3 Stress-induced moderate perfusion defect without LV dilation or increased lung intake 4 Limited stress echocardiographic ischemia with a wall motion abnormality only at higher doses of dobutamine involving two segments or less Low Risk (<1% Annual Mortality Rate) 1 Low-risk treadmill score (score ≥ 5) 2 Normal or small myocardial perfusion defect at rest or with stress* 3 Normal stress echocardiographic wall motion or no change of limited resting wall motion abnormalities during stress

28. Coronary Angiography for Risk Stratification in Chronic Stable Angina CLASS INDICATION LEVEL OF EVIDENCE I 1. Canadian Cardiovascular Society [CCS] Classes III and IV chronic stable angina despite medical therapy B 2. Patients with high-risk criteria on noninvasive testing regardless of anginal severity B 3. Patients with angina who have survived sudden cardiac death or serious ventricular arrhythmia B 4. Patients with angina and symptoms and signs of CHFC 5. Patients with clinical characteristics that indicate a high likelihood of severe CAD C

29. Coronary Angiography for Risk Stratification in Patients with Chronic Stable Angina IIa 1. Patients with significant LV dysfunction (ejection fraction > 0.45), CCS Class I or II angina, and demonstrable ischemia but no high-risk criteria on noninvasive testing C 2. Patients with inadequate prognostic information after noninvasive testingC III 1. Patients with CCS Class I or II angina who respond to medical therapy and who have no evidence of ischemia on noninvasive testing C 2. Patients who prefer to avoid revascularizationC

30. Pharmacotherapy for Chronic Stable Angina CLASS INDICATION LEVEL OF EVIDENCE I 1. Aspirin in the absence of contraindicationsA 2. Beta blockers as initial therapy in the absence of contraindications in patients with or without prior myocardial infarction A 3. ACE inhibitor in all patients with CAD who also have diabetes and/or LV systolic dysfunction A 4. Angiotensin receptor blockers -intolerant of ACE inhibitorsA 5. LDL-lowering therapy in patients with documented or suspected CAD and LDL-C > 130 mg/dL, with a target LDL < 100 mg/dL A

31. Pharmacotherapy for Chronic Stable Angina CLASS INDICATION LEVEL OF EVIDENCE I5. Sublingual nitroglycerin or nitroglycerin spray for the immediate relief of anginaB 6. Calcium antagonists or long-acting nitrates as initial therapy for reduction of symptoms when beta blockers are contraindicated B 7. Calcium antagonists or long-acting nitrates in combination with beta blockers when initial treatment with beta blockers is not successful B 8. Calcium antagonists and long-acting nitrates as a substitute for beta blockers if initial treatment with beta blockers leads to unacceptable side effects C 9. Aldosterone blockade - post-MI patients without significant renal dysfunction or hyperkalemia EF< 40%, with diabetes or heart failure A

32. Pharmacotherapy for Chronic Stable Angina CLASS INDICATION LEVEL OF EVIDENCE IIa 1. Clopidogrel when aspirin is absolutely contraindicatedB 2. Long-acting nondihydropyridine calcium antagonists instead of beta blockers as initial therapy B 3. ACE inhibitor in patients with CAD or other vascular diseaseB

33. Treatment of Risk Factors CLASS INDICATION LEVEL OF EVIDENCE I 1. Treatment of hypertension according to Joint National Conference VII guidelinesA 2. Smoking cessation therapyB 3. Management of diabetesC 4. Comprehensive cardiac rehabilitation program (including exercise)B 5. LDL-lowering therapy in patients with documented or suspected CAD and LDL- ≥ 130 mg/dL, with a target LDL < 100 mg/dL A 6. Weight reduction in obese patients in the presence of hypertension, hyperlipidemia, or diabetes mellitus C

34. Treatment of Risk Factors CLASS INDICATION LEVEL OF EVIDENCE IIa 1. In patients with documented or suspected CAD and LDL-C = 100- 129 mg/dL, several therapeutic options are available: B a. Lifestyle and/or drug therapies to lower LDL-C to <100 mg/dL; further reduction to below 70 mg/dL is reasonable B b. Weight reduction and increased physical activity in persons with the metabolic syndrome B c. Use of nicotinic acid or fibric acid for elevated triglyceride or low HDL cholesterol levels B

35. Specific Goals for Risk Reduction in Chronic Stable Angina RISK FACTOR OR STRATEGY GOAL Smoking Complete cessation Blood pressure 140/90 mm Hg Lipid management Primary goal: LDL < 100 mg/dL; further reduction of LDL-C to <70 mg/dL is reasonable (Class IIa) Secondary goal: If triglycerides ≥ 200 mg/dL, then non–HDL-C should be <130 mg/dL TG≥ 500 – fibrate +niacin – before LDL lowering Physical activity Minimum goal: 30 min daily Weight management BMI: 18.5-24.9 kg/m 2 Diabetes management HbA1c < 7%

36. Specific Goals for Risk Reduction Strategies in Chronic Stable Angina Antiplatelet agents, anticoagulants All patients—indefinite use of aspirin 75-162mg/day Consider clopidogrel as an alternative Warfarin -in patients after MI when clinically indicated or for those not able to take aspirin or clopidogrel INR = 2.0-3.0 ACE inhibitors Start and continue indefinitely -LVEF ≤ 40% and in those with hypertension, diabetes, or chronic kidney disease -- - unless contraindicated. Beta blockers Start in all postmyocardial infarction and acute patients (arrhythmia, inducible ischemia). Continue for 6 mo minimum. Observe usual contraindications. Use as needed to manage angina, rhythm, or blood pressure in all patients

37. Revascularization with Percutaneous Coronary Intervention and Coronary Artery Bypass Grafting in Stable Angina CLASS INDICATION LEVEL OF EVIDENCE I 1. CABG for patients with significant left main coronary diseaseA 2. CABG for patients with triple-vessel disease. The survival benefit is greater in patients with abnormal LV function (LVEF < 0.50). A 3. CABG for patients with double-vessel disease with significant proximal LAD CAD and either abnormal LV function (ejection fraction <50%) or demonstrable ischemia on noninvasive testing A 4. PCI for patients with double- or triple-vessel disease with significant proximal LAD CAD, who have anatomy suitable for catheter-based therapy and normal LV function and who do not have treated diabetes B

38. Revascularization with PCI or CABG in Stable Angina CLASS INDICATION LEVEL OF EVIDENCE I 5. PCI or CABG for patients with single- or double-vessel CAD without significant proximal LAD CAD but with a large area of viable myocardium and high-risk criteria on noninvasive testing B 6. CABG for patients with single- or double-vessel CAD without significant proximal LAD CAD who survived sudden cardiac death or sustained VT C 7. In patients with prior PCI-- CABG, or PCI for recurrent stenosis associated with a large area of viable myocardium or high-risk criteria on noninvasive testing C 8. PCI or CABG for patients who have not been successfully treated by medical therapy and can undergo revascularization with acceptable risk B

39. Revascularization with PCI or CABG in Stable Angina CLASS INDICATION LEVEL OF EVIDENCE IIa 1. Repeat CABG for patients with multiple saphenous vein graft stenoses, especially with significant stenosis of a graft supplying the LAD; PCI for focal saphenous vein graft lesions or multiple stenoses in poor candidates for reoperative surgery. C 2. PCI or CABG for patients with single- or double-vessel CAD without significant proximal LAD disease but with a moderate area of viable myocardium and demonstrable ischemia on noninvasive testing B 3. Use of PCI or CABG for patients with single-vessel disease with significant proximal LAD disease B

40. Patient Follow-up CLASS INDICATION LEVEL OF EVIDENCE I 1.LVEF and RWMA by echocardiography or radionuclide imaging with new or worsening CHF or evidence of intervening MI C 2 Echocardiography for new or worsening valvular heart diseaseC 3 Treadmill exercise test for patients without prior revascularization who have a significant change in clinical status, are able to exercise C

41. Patient Follow-up I 5. Stress radionuclide imaging or stress echocardiography for pts with significant change in clinical status and are unable to exercise or have one of the following electrocardiographic abnormalities : C a. Preexcitation (Wolff-Parkinson-White) syndrome b. Electronically paced ventricular rhythm c. >1 mm of ST-segment depression at rest d. Complete left bundle branch block

42. Patient Follow-up I 6. Stress radionuclide imaging or stress echocardiography procedures for patients who have a significant change in clinical status and required a stress imaging procedure on their initial evaluation C 7. Stress radionuclide imaging or stress echocardiography procedures for patients with prior revascularization who have a significant change in clinical status C 8. Coronary angiography in patients with marked limitation of ordinary activity (CCS Class III) despite maximal medical therapy C