Chronic stable angina risk stratification coronary angiography


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

Overview
In patients with chronic stable angina, the extent and severity of coronary artery disease (CAD) and left ventricular dysfunction remain the strongest predictors of long-term prognosis. Hence, patients identified as high risk for underlying CAD based on non-invasive testing, patients with CCS class III or IV angina and patients who are non-responsive to medical therapy, coronary angiography would be a preferred modality for risk stratification. Coronary angiography is primarily used to assess the number and location of stenoses, of which triple-vessel disease and proximal stenoses involving the left main and proximal LAD are associated with increased mortality. In patients with single-vessel disease, coronary angiography and myocardial perfusion imaging provide similar results in assessing the severity of coronary stenosis  however, in patients with multi-vessel disease, nuclear imaging or echocardiography are more useful in evaluating the prognosis.

Coronary Angiography

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


 * Jeopardy score : The jeopardy score assessed the location of coronary artery stenosis to provide prognostic information than the number of diseased coronary arteries. Higher jeopardy scores were associated with lower left ventricular ejection fraction and hence poorer clinical outcomes. Proximal stenosis involving the left main and proximal left anterior descending artery (LAD), were associated with higher scores and hence increased risk of ischemic events.


 * Coronary artery disease Prognostic Index : This index assessed the severity and the location of lesion and stratified the patients based on benefit from revascularization . In medically treated patients, this classification specifically analyzed the relationship between the lesion location and the risk of subsequent acute coronary event that caused death.

==ACC / AHA Guidelines- Who With Angina Should Undergo Coronary Angiography and Left Ventriculography for Risk Stratification (DO NOT EDIT) == {{cquote|

Class I
1. Patients with disabling (CCS classes III and IV) chronic stable angina despite medical therapy. (Level of Evidence: B)

2. Patients with high-risk criteria on noninvasive testing regardless of anginal severity. (Level of Evidence: B)

3. Patients with angina who have survived sudden cardiac death or serious ventricular arrhythmia. (Level of Evidence: B)

4. Patients with angina and symptoms and signs of congestive heart failure. (Level of Evidence: C)

5. Patients with clinical characteristics that indicate a high likelihood of severe CAD. (Level of Evidence: C)

Class IIa
1. Patients with significant LV dysfunction (ejection fraction less than 45%), CCS class I or II angina, and demonstrable ischemia but less than high-risk criteria on noninvasive testing. (Level of Evidence: C)

2. Patients with inadequate prognostic information after noninvasive testing. (Level of Evidence: C)

Class IIb
1. Patients with CCS class I or II angina, preserved LV function (ejection fraction more than 45%), and less than high-risk criteria on noninvasive testing. (Level of Evidence: C)

Class III
1. Patients with CCS class I or II angina who respond to medical therapy and have no evidence of ischemia on noninvasive testing. (Level of Evidence: C)

2. Patients who prefer to avoid revascularization. (Level of Evidence: C)}}

==ESC Guidelines- Who With Stable Angina Should Undergo Risk Stratification by Coronary Arteriography (DO NOT EDIT) == {{cquote|

Class I
1. Patients determined to be at high risk for adverse outcome on the basis of non-invasive testing even if they present with mild or moderate symptoms of angina. (Level of Evidence: B)

2. Severe stable angina (CCS class III, particularly if the symptoms are inadequately responding to medical treatment. (Level of Evidence: B)

3. Stable angina in patients who are being considered for major non-cardiac surgery, especially vascular surgery (repair of aortic aneurysm, femoral bypass, carotid endarterectomy) with intermediate or high risk features on non-invasive testing. (Level of Evidence: B)

Class IIa
1. Patients with an inconclusive diagnosis on non-invasive testing, or conﬂicting results from different noninvasive modalities. (Level of Evidence: C)

2. Patients with a high risk of restenosis after PCI if PCI has been performed in a prognostically important site. (Level of Evidence: C)}}

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

Guidelines Resources

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


 * 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 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