Chronic stable angina prognosis


 * Associate Editor-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S.

Overview
Reduced LV function, number and location of stenoses, workload in METs calculated using Duke score are the strongest predictors of survival in patients with chronic stable angina.

Mortality

 * The estimated annual mortality rate in patients with chronic stable angina ranges from 0.9% - 1.4%  with an annual incidence of non-fatal MI between 0.5% and 2.6%.


 * The Framingham Heart Study revealed the 2-year incidence rates of non-fatal MI and coronary heart disease death for men and women who initially presented with stable angina was 14.3% MI and 5.5% CAD death in men, and 6.2% MI and 3.8% CAD death in women.


 * Relative risk based on anginal characteristics in elderly associated with no comorbidities:

Factors that affect Long Term Prognosis in patients with Chronic Stable Angina

 * Reduced LV function (reduced ejection fraction; LV hypertrophy) remains the strongest predictor of survival in patients with chronic stable angina.


 * Location of stenosis (proximal stenosis involving the left main and proximal left anterior descending artery(LAD), are associated with poor outcomes and increased risk of ischemic events).


 * Number of stenoses (patients with three-vessel disease have a higher mortality rate in comparison to patients with single vessel disease).

Table 1:Coronary Artery Disease Prognostic Index 


 * Associated risk factors that contribute to poor outcomes are:
 * Smoking
 * Diabetes mellitus
 * Hypertension
 * Hypercholesterolemia
 * Low HDL-C.

==Duke Score (Exercise Treadmill Test) ==


 * Workload in METs assessed using the DUKE Score is an important factor in estimating the prognosis of patients with chronic stable angina.


 * Duke score = [(exercise duration in minutes) - (5 x ST segment deviation in millimeters) - (4 x treadmill angina index)]


 * Angina index:
 * 0 for no angina,
 * 1 for angina, and
 * 2 if angina is the reason for stopping the test.

==ESC Guidelines- Pharmacological therapy to improve prognosis in patients with stable angina (DO NOT EDIT) == {{cquote|

Class I
1. Aspirin 75 mg daily in all patients without speciﬁc contraindications (i.e. active GI bleeding, aspirin allergy, or previous aspirin intolerance). (Level of Evidence: A)

2. Statin therapy for all patients with coronary artery disease. (Level of Evidence: A)

3. ACE-inhibitor therapy in patients with coincident indications for ACE-inhibition, such as hypertension, heart failure, LV dysfunction, prior MI with LV dysfunction, or diabetes. (Level of Evidence: A)

4. Oral beta-blocker therapy in patients post-MI or with heart failure. (Level of Evidence: A)

Class IIa
1. ACE-inhibitor therapy in all patients with angina and proven coronary artery disease. (Level of Evidence: B)

2. Clopidogrel as an alternative antiplatelet agent in patients with stable angina who cannot take aspirin (e.g. aspirin allergic). (Level of Evidence: B)

3. High dose statin therapy in high-risk (0.2% annual CV mortality) patients with proven coronary artery disease. (Level of Evidence: B)

Class IIb
1. Fibrate therapy in patients with low HDL and high triglycerides who have diabetes or the metabolic syndrome. (Level of Evidence: B)

2. Fibrate or nicotinic acid as adjunctive therapy to statin in patients with low HDL and high triglycerides at high risk (0.2% annual CV mortality). (Level of Evidence: C)}}

==ESC Guidelines- Revascularization to improve prognosis in patients with stable angina (DO NOT EDIT) == {{cquote|

Class I
1. CABG for signiﬁcant left main CAD or its equivalent (i.e. severe stenosis of ostial/proximal segment of left descending and circumﬂex coronary arteries). (Level of Evidence: A)

2. CABG for signiﬁcant proximal stenosis of three major vessels, particularly in those patients with abnormal LV function or with early or extensive reversible ischaemia on functional testing. (Level of Evidence: A)

3. CABG for one- or two-vessel disease with high-grade stenosis of proximal LAD with reversible ischaemia on non-invasive testing. (Level of Evidence: A)

4. CABG for signiﬁcant disease with impaired LV function and viability demonstrated by non-invasive testing. (Level of Evidence: B)

Class IIa
1. CABG for one- or two-vessel CAD without signiﬁcant proximal LAD stenosis in patients who have survived sudden cardiac death or sustained ventricular tachycardia. (Level of Evidence: B)

2. CABG for signiﬁcant three-vessel disease in diabetics with reversible ischaemia on functional testing. (Level of Evidence: C)

3. PCI or CABG for patients with reversible ischaemia on functional testing and evidence of frequent episodes of ischaemia during daily activities. (Level of Evidence: C)}}

Related Chapters

 * Prognosis

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