Chronic stable angina risk stratification coronary angiography

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2]; Associate Editor-in-Chief: Lakshmi Gopalakrishnan, M.B.B.S.


In patients with chronic stable angina, the extent and severity of coronary artery disease (CAD)[1] 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.[2] In patients with single-vessel disease, coronary angiography and myocardial perfusion imaging provide similar results in assessing the severity of coronary stenosis[3][4][5] however, in patients with multi-vessel disease, nuclear imaging or echocardiography are more useful in evaluating the prognosis.[6][7]

Coronary Angiography

  • Number of stenoses: Patients with three-vessel disease have a higher mortality rate in comparison to patients with single vessel disease.[2]
  • Jeopardy score:[8] 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.
Jeopardy Score 5-year Survival (%)
2 97%
4 95%
6 85%
8 78%
10 75%
12 56%
  • Coronary artery disease prognostic index:[9] This index assessed the severity and the location of lesion and stratified the patients based on benefit from revascularization.[10][11] 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.
Extent of CAD Prognostic Weight (0-100) 5-year Mortality Rate (%)
(assuming medical treatment only)
1-vessel disease, 75% 23 7
>1-vessel disease, 50-74% 23 7
1-vessel disease, ≥ 95% 32 9
2-vessel disease 37 12
2-vessel disease, both ≥ 95% 42 14
1-vessel disease, ≥ 95% proximal LAD 48 17
2-vessel disease, ≥ 95% LAD 48 17
2-vessel disease, ≥ 95% proximal LAD 56 21
3-vessel disease 56 21
3-vessel disease, ≥ 95% in at least 1 63 27
3-vessel disease, 75% proximal LAD 67 33
3-vessel disease, ≥ 95% proximal LAD 74 41

ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina (DO NOT EDIT)[12]

Coronary Angiography and Left Ventriculography for Risk Stratification in Patients With Chronic Stable Angina (DO NOT EDIT)[12]

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 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)"
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)"

ESC Guidelines- Who With Stable Angina Should Undergo Risk Stratification by Coronary Arteriography (DO NOT EDIT)[13]

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)"


  1. Pryor DB, Bruce RA, Chaitman BR, Fisher L, Gajewski J, Hammermeister KE et al. (1989) Task Force I: Determination of prognosis in patients with ischemic heart disease. J Am Coll Cardiol 14 (4):1016-25. PMID: 2794262
  2. 2.0 2.1 Califf RM, Armstrong PW, Carver JR, D'Agostino RB, Strauss WE (1996)27th Bethesda Conference: matching the intensity 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 Cardiol27 (5):1007-19. PMID: 8609316
  3. Serruys PW, di Mario C, Piek J, Schroeder E, Vrints C, Probst P et al. (1997)Prognostic value of intracoronary flow velocity and diameter stenosis in assessing the short- and long-term outcomes of coronary balloon angioplasty: the DEBATE Study (Doppler Endpoints Balloon Angioplasty Trial Europe). Circulation 96 (10):3369-77. PMID:9396429
  4. Pijls NH, De Bruyne B, Peels K, Van Der Voort PH, Bonnier HJ, Bartunek J Koolen JJ et al. (1996) Measurement of fractional flow reserve to assess the functional severity of coronary-artery stenoses. N Engl J Med 334 (26):1703-8. [1] PMID: 8637515
  5. Kern MJ, Donohue TJ, Aguirre FV, Bach RG, Caracciolo EA, Wolford T et al. (1995) Clinical outcome of deferring angioplasty in patients with normal translesional pressure-flow velocity measurements. J Am Coll Cardiol 25 (1):178-87. PMID: 7798498
  6. Chamuleau SA, Tio RA, de Cock CC, de Muinck ED, Pijls NH, van Eck-Smit BL et al. (2002)Prognostic value of coronary blood flow velocity and myocardial perfusion in intermediate coronary narrowings and multivessel disease. J Am Coll Cardiol 39 (5):852-8. PMID: 11869852
  7. Miller DD (2002)Coronary flow studies for risk stratification in multivessel disease. A physiologic bridge too far? J Am Coll Cardiol 39 (5):859-63. PMID:11869853
  8. Califf RM, Phillips HR, Hindman MC, Mark DB, Lee KL, Behar VS et al. (1985) Prognostic value of a coronary artery jeopardy score. J Am Coll Cardiol 5 (5):1055-63. PMID: 3989116
  9. Mark DB, Nelson CL, Califf RM, Harrell FE, Lee KL, Jones RH et al. (1994) Continuing evolution of therapy for coronary artery disease. Initial results from the era of coronary angioplasty. Circulation 89 (5):2015-25. PMID: 8181125
  10. Yusuf S, Zucker D, Peduzzi P, Fisher LD, Takaro T, Kennedy JW et al. (1994) Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomised trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration. Lancet 344 (8922):563-70. PMID: 7914958
  11. Califf RM, Harrell FE, Lee KL, Rankin JS, Hlatky MA, Mark DB et al. (1989) The evolution of medical and surgical therapy for coronary artery disease. A 15-year perspective. JAMA 261 (14):2077-86. PMID: 2784512
  12. 12.0 12.1 Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999) ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina). Circulation 99 (21):2829-48. PMID: 10351980
  13. Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F; et al. (2006). "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. 27 (11): 1341–81. doi:10.1093/eurheartj/ehl001. PMID 16735367.

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