Chronic stable angina risk stratification


 * Associate Editor(s)-in-Chief: ; Smita Kohli, M.D.; Lakshmi Gopalakrishnan, M.B.B.S.

Overview
The average mortality in patients with stable angina ranges from 1-3%. However, the prognosis varies widely depending on various factors such as: the duration and severity of symptoms, resting ECG abnormalities, abnormal left ventricular function and associated comorbidities.

Risk stratification based on different factors

 * Risk stratification is based on anatomic factors:
 * Left ventricular function, indicated as the strongest predictor of long term survival
 * Extent of atherosclerosis in the coronary arteries (single vessel disease vs multivessel disease)
 * Evidence of a recent coronary plaque rupture (acute coronary syndrome)
 * Overall health and presence of other co-morbidities


 * Risk stratification based on clinical factors: An initial scoring system was proposed by the Framingham Heart Study group to predict 10 year risk for patients with CAD based upon:
 * Patient's age and sex
 * Total cholesterol
 * Presence of hypertension
 * History of smoking and diabetes
 * Presence of other peripheral vascular diseases


 * Risk stratification categories and appropriate management:
 * Patients at low risk have an annual mortality rate of less than 1% and can be managed medically.
 * Patients at intermediate risk have an annual mortality rate of 1%–3% and may require additional imaging studies such as exercise imaging for further risk assessment.
 * Patients at high risk have an annual mortality rate of more than 3% and require coronary angiography

Risk Stratification of Chronic Stable Angina in Symptomatic patients

 * The next step after establishing the clinical probability of angina is to assess the risk of underlying coronary artery disease based on initial rest ECG and the patients ability to exercise.
 * If the rest ECG is abnormal, the next step is to conduct a stress imaging test.
 * If the patient is unable to exercise then pharmacological stress test is used to stratify the risk underlying the atherosclerotic state.
 * For patients with CCS class III or IV angina, patients with poor LVEF or non responsive to medical therapy there may be benefit to perform coronary angiography.


 * For a full discussion on individual risk stratifying topics, visit the microchapters below:
 * Electrocardiogram / Chest X-Ray
 * Assessment of Resting LV Function
 * Exercise testing for Risk Stratification and Prognosis:
 * Exercise Treadmill Test
 * In patients Who Are Able To Exercise
 * In patients Who Are Unable To Exercise
 * Coronary Angiography and Left Ventriculography

Risk Stratification of Chronic Stable Angina in Asymptomatic Patients

 * Risk Stratification by Noninvasive Testing
 * Coronary Angiography in Asymptomatic Patients

Related Chapters

 * T Wave Alternans for Risk Stratification during Exercise Stress Testing

Vote on and Suggest Revisions to the Current Guidelines

 * The Chronic Stable Angina Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines

Guideline Resources

 * Guidelines on the management of stable angina pectoris: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology


 * The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina


 * TheACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina


 * The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina