The clinical diagnosis of stable coronary artery disease
Authors:
Slavomíra Filipová
Authors‘ workplace:
Klinika kardiológie a angiológie, LF SZU, NÚSCH, a. s., Bratislava, prednosta prof. MUDr. Róbert Hatala, CSc.
Published in:
Forum Diab 2015; 4(1): 22-32
Category:
Topic
Overview
Chronic (stable) forms have an important role in diagnosis of coronary artery disease (CAD) in outpatients or hospitalized patients at departments of internal medicine/cardiology. Stable angina pectoris is one of the most common diagnosed cardiac conditions. Early detection of symptomatology in coronary disease accelerates the correct and complete diagnosis and initiation of treatment.
Diagnostic and differential diagnostic approach is focused on: (1) confirmation of the diagnosis of myocardial ischemia in patients with suspected coronary artery disease, (2) identify or rule out co-morbidities and accelerating factors, (3) stratification of global cardiovascular risk, (4) evaluation of efficacy of treatment in confirmed CAD.
Decision algorithm in patients with suspected stable coronary disease is carried out in three steps. Step 1 is to determine the pretest probability of the presence of CAD. In patients with moderate pre-test probability is performed step 2: non-invasive functional testing for diagnosis of stable coronary artery disease, including non-obstructive forms. Step 3 in patients with moderate pre-test probability consists of pretest risk stratification for the available non-invasive examination and execution of functional stress test(s) and therapeutic procedure is set according to the result.
Article focuses on interpretation and informative value of functional testing in diagnosis of chronic CAD: assessment of pretest probability of CAD and post-test scoring by Duke Treadmill Score. Completion of the non-invasive diagnosis of chronic CAD is followed by determination of prognosis of CAD. This is the basis for the application of lege artis (correct, according to evidence-based medicine) decision algorithm of subsequent therapy: (1) non-interventional (non-pharmacological and pharmacological and/or (2) interventional (percutaneous or cardiac revascularization).
Key words:
angina pectoris – coronary artery disease – myocardial perfusion stress testing – risk stratification of events
Sources
1. Allender S, Sharbotough P, Peto V et al. European Cardiovascular Disease Statistics 2008 Edition. British Heart Foundation: London 2008. Dostupné z WWW: <http://www.herzstiftung.ch/uploads/media/European_cardiovascular_disease_statistics_2008.pdf>.
2. Abrams J. Clinical practice. Chronic stable angina. Engl J Med. 2005; 352(24): 2524–2533.
3. Montalescot G, Sechtem U, Achenbach S et al. 2013 ESC guidelines on the management of stable coronary artery disease. The Task Force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J 2013; 34(38): 2949–3003.
4. Greenland P, Alpert JS, Beller GA et al. 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: a report of the American College of Cardiolo-gy Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2010; 56(25): e50–e103. Dostupné z DOI: <http://doi: 10.1016/j.jacc.2010.09.001>.
5. Fox K, Garcia MA, Ardissino D et al. Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. Eur Heart J 2006; 27(11): 1341–1381.
6. Staněk V, Bultas V, Škvařilová M et al. Chronická ischemická choroba srdeční. In: Aschermann M (ed). Kardiologie. Galén: Praha 2004: 596–649. ISBN 8072622900.
7. Filipová S, Hatala R, Dukát A, Fridrich V et al. Komentár expertnej skupiny Slovenskej kardiologickej spoločnosti pre manažment stabilnej angíny pektoris k Súhrnu odporúčaní Európskej kardiologickej spoločnosti pre manažment stabilnej angíny pektoris. Cardiol 2007; 16(2): 104–108.
8. Ong P, Athanasiadis A, Borgulya G et al. High prevalence of a pathological response to acetylcholine testing in patients with stable angina pectoris and unobstructed coronary arteries. The ACOVA Study (Abnormal COronary VAsomotion in patients with stable angina and unobstructed coronary arteries). J Am Coll Cardiol 2012; 59(7): 655–662.
9. Gulati M, Cooper-DeHoff RM, McClure C et al. Adverse cardiovascular outcomes in women with nonobstructive coronary artery disease: a report from the Women’s Ische-mia Syndrome Evaluation Study and the St James Women Take Heart Project. Arch Intern Med 2009; 169(9): 843–850.
10. Jespersen L, Hvelplund A, Abildstrom SZ et al. Stable angina pectoris with no obstructive coronary artery disease is associated with increased risks of major adverse cardiovascular events. Eur Heart J 2012; 33(6): 734–744.
11. Daly CA, De Stavola B, Sendon JL et al. Predicting prognosis in stable angina: results from the Euro heart survey of stable angina: prospective observational study. BMJ 2006; 332(7536): 262–267.
12. Morbidity & Mortality: 2012 Chart Book on Cardiovascular, Lung, and Blood Diseases. National Heart, Lung, and Blood Institute: 2012. Dostupné z WWW: <https://www.nhlbi.nih.gov/files/docs/research/2012_ChartBook_508.pdf>.
13. Kronmal RA, McClelland RL, Detrano R et al. Risk factors for the progression of coronary artery calcification in asymptomatic subjects: results from the Multi-Ethnic Study of Atherosclerosis (MESA). Circulation 2007; 115(21): 2722–2730.
14. Pekkanen J, Linn S, Heiss G, et al. Ten-year mortality from cardiovascular disease in relation to cholesterol level among men with and without preexisting cardiovascular disease. N Eng J Med 1990; 322(24): 1700–1707.
15. Bayturan O, Tuzcu EM, Uno K et al. Comparison of rates of progression of coronary atherosclerosis in patients with diabetes mellitus versus those with the metabolic syndrome. Am J Cardiol 2010; 105(12): 1735–1739.
16. Boesner S, Haasenritter J, Becker A et al. Ruling out coronary artery disease in primary care: development and validation of a simple prediction rule. CMAJ 2010; 182(12): 1295–1300.
17. Genders TS, Steyerberg EW, Alkadhi H et al. A clinical prediction rule for the diagnosis of coronary artery disease: validation, updating, and extension. Eur Heart J 2011; 32(11): 1316–1330.
18. Gibbons RJ, Balady GJ, Beasley JW et al. ACC/AHA 2002 guideline update for exercise testing: summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). J Am Coll Cardiol 2002; 40(8): 1531–1540.
19. Emond M, Mock MB, Davis KB et al. Long-term survival of medically treated patients in the Coronary Artery Surgery Study (CASS) Registry. Circulation 1994; 90(6): 2645–2657.
20. Raymond I, Pedersen F, Steensgaard-Hansen F et al. Prevalence of impaired left ventricular systolic function and heart failure in a middle aged and elderly urban population segment of Copenhagen. Heart 2003; 89(12): 1422–1429.
21. Ostrom MP, Gopal A, Ahmadi N et al. Mortality incidence and the severity of coronary atherosclerosis assessed by computed tomography angiography. J Am Coll Cardiol 2008; 52(16): 1335–1343.
22. Califf RM, Armstrong PW, Carver JR et al. 27th Bethesda Conference: matching the in-tensity of risk factor management with the hazard for coronary disease events. Task Force 5. Stratification of patients into high, medium and low risk subgroups for purposes of risk factor management. J Am Coll Cardiol 1996; 27(5): 1007–1019.
23. Bartnik M, Ryden L, Ferrari R et al. The prevalence of abnormal glucose regulation in patients with coronary artery disease across Europe. The Euro Heart Survey on diabetes and the heart. Eur Heart J 2004; 25(21): 1880–1890.
24. Ryden L, Grant PJ, Anker SD et al. ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD: the Task Force on diabetes, pre-diabetes, and cardiovascular diseases of the European Society of Cardiology (ESC) and developed in collaboration with the European Association for the Study of Diabetes (EASD. )Eur Heart J 2013; 34(39): 3035–3087.
25. Lenzen M, Ryden L, Ohrvik J et al. Diabetes known or newly detected, but not impaired glucose regulation, has a negative influence on 1-year outcome in patients with coronary artery disease: a report from the Euro Heart Survey on diabetes and the heart. Eur Heart J 2006; 27(24): 2969–2974.
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