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CSAP full 2002

CSAP full 2002

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This document was approved by the American College of CardiologyFoundation Board of Trustees in October 2002,the American Heart AssociationScience Advisory and Coordinating Committee in October 2002,and theClinical Efficacy Assessment Subcommittee of the American College of Physicians-American Society of Internal Medicine in June 2002.When citing this document,please use the following citation format:GibbonsRJ,Abrams J,Chatterjee K,Daley J,Deedwania PC,Douglas JS,Ferguson TBJr.,Fihn SD,Fraker TD Jr.,Gardin JM,O’Rourke RA,Pasternak RC,WilliamsSV. ACC/AHA 2002 guideline update for the management of patients withchronic stable angina:a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Committee toUpdate the 1999 Guidelines for the Management of Patients with ChronicStable Angina). 2002. Available at www.acc.org/clinical/guidelines/stable/sta-ble.pdf.This document is available on the World Wide Web sites of the AmericanCollege of Cardiology (
www.acc.org
) and the American Heart Association(
www.americanheart.org
). Copies of this document are available by calling 1-800-253-4636 or writing the American College of Cardiology Foundation,Resource Center,at 9111 Old Georgetown Road,Bethesda,MD 20814-1699.Ask for reprint number 71-0243. To obtain a reprint of the Summary Articlepublished in the January 1,2003 issue of the
 Journal of the American Collegeof Cardiology
and the January 7/14,2003 issue of 
Circulation
,ask for reprintnumber 71-0244. To purchase bulk reprints (specify version and reprint num-ber):Up to 999 copies,call 1-800-611-6083 (US only) or fax 413-665-2671;1000 or more copies,call 214-706-1466,fax 214-691-6342,or e-mail pub-auth@heart.org.
 © 2002 by the American College of Cardiology Foundation and the American Heart Association, Inc.
ACC/AHA PRACTICE GUIDELINES—FULL TEXT
ACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina
A Report of the American College of Cardiology/American Heart AssociationTask Force on Practice Guidelines (Committee to Update the 1999 Guidelinesfor the Management of Patients With Chronic Stable Angina)
The Clinical Efficacy Assessment Subcommittee of the ACP-ASIM acknowledges the scientific validity of this product as a back-ground paper and as a review that captures the levels of evidence in the management of patients with chronic stable angina as of November 17,2002.
COMMITTEE MEMBERS
Raymond J. Gibbons,MD,FACC,FAHA,
Chair 
TASK FORCE MEMBERS
Raymond J. Gibbons,MD,FACC,FAHA,
Chair 
Elliott M. Antman,MD,FACC,FAHA,
Vice Chair 
Jonathan Abrams,MD,FACC,FAHAKanu Chatterjee,MB,FACCJennifer Daley,MD,FACPPrakash C. Deedwania,MD,FACC,FAHAJohn S. Douglas,MD,FACCT. Bruce Ferguson,Jr.,MDStephan D. Fihn,MD,MPH,FACPTheodore D. Fraker,Jr.,MD,FACCJulius M. Gardin,MD,FACC,FAHARobert A. O’Rourke,MD,FACC,FAHARichard C. Pasternak,MD,FACC,FAHASankey V. Williams,MD,MACPJoseph S. Alpert,MD,FACC,FAHADavid P. Faxon,MD,FACC,FAHAValentin Fuster,MD,PhD,FACC,FAHAGabriel Gregoratos,MD,FACC,FAHALoren F. Hiratzka,MD,FACC,FAHAAlice K. Jacobs,MD,FACC,FAHA
TABLE OF CONTENTS
Preamble ...................................................................................2I. Introduction and Overview................................................3A. Organization of Committee and Evidence Review.......3B. Scope of the Guidelines................................................4C. Overlap With Other Guidelines....................................5D. Magnitude of the Problem............................................5E. Organization of the Guidelines.....................................7II. Diagnosis...........................................................................7A. History and Physical.....................................................71. Definition of Angina..................................................72. Clinical Evaluation of Patients With Chest Pain.......73. Developing the Probability Estimate.......................104. Generalizability of the Predictive Models...............125. Applicability of Models to Primary-CarePractices..................................................................12B. Associated Conditions.................................................13C. Noninvasive Testing....................................................151. ECG/Chest X-Ray...................................................152. Exercise ECG for Diagnosis...................................163. Echocardiography....................................................214. Stress Imaging Studies:Echocardiographic andNuclear....................................................................22
Sidney C. Smith,Jr.,MD,FACC,FAHA
 
2
ACC - www.acc.orgAHA- www.americanheart.org
Gibbons
et al.
2002ACC/AHAPractice Guidelines
7. Other Proposed Therapies That Have Not BeenShown to Reduce Risk for Coronary DiseaseEvents......................................................................758. Asymptomatic Patients............................................77E. Revascularization for Chronic Stable Angina.............771. Coronary Artery Bypass Surgery............................782. Coronary Artery Bypass Grafting Versus MedicalManagement............................................................783. Percutaneous Coronary Intervention.......................794. Patients With Previous Bypass Surgery..................895. Asymptomatic Patients............................................90V. Patient Follow-up:Monitoring of Symptoms andAntianginal Therapy.........................................................91A. Patients Not Addressed in This Section of theGuidelines....................................................................921. Follow-up of patients in the following categoriesis not addressed by this section of the guidelines...922. Level of Evidence for Recommendations onFollow-up of Patients With ChronicStable Angina...........................................................92Appendix 1 .............................................................................94References ..............................................................................95
PREAMBLE
It is important that the medical profession play a significantrole in critically evaluating the use of diagnostic proceduresand therapies in the management or prevention of diseasestates. Rigorous and expert analysis of the available datadocumenting relative benefits and risks of those proceduresand therapies can produce helpful guidelines that improvethe effectiveness of care,optimize patient outcomes,andhave a favorable impact on the overall cost of care by focus-ing resources on the most effective strategies.The American College of Cardiology (ACC) and theAmerican Heart Association (AHA) have jointly engaged inthe production of such guidelines in the area of cardiovascu-lar disease since 1980. This effort is directed by theACC/AHA Task Force on Practice Guidelines,whose chargeis to develop and revise practice guidelines for importantcardiovascular diseases and procedures. Experts in the sub- ject under consideration are selected from both organiza-tions to examine subject-specific data and write guidelines.The process includes additional representatives from othermedical practitioner and specialty groups where appropriate.Writing groups are specifically charged to perform a formalliterature review,weigh the strength of evidence for oragainst a particular treatment or procedure,and include esti-mates of expected health outcomes where data exist. Patient-specific modifiers,comorbidities,and issues of patient pref-erence that might influence the choice of particular tests ortherapies are considered,as well as frequency of follow-upand cost-effectiveness.The ACC/AHA Task Force on Practice Guidelines makesevery effort to avoid any actual or potential conflicts of inter-est that might arise as a result of an outside relationship orpersonal interest of a member of the writing panel.Specifically,all members of the writing panel are asked to
D. Invasive Testing:Value of Coronary Angiography.....29E. Indications For Coronary Angiography.......................301. Women.....................................................................302. The Elderly..............................................................303. Coronary Spasm......................................................314. Coronary Anomaly..................................................315. Resuscitation From Ventricular Fibrillation orSustained Ventricular Tachycardia..........................31III. Risk Stratification.............................................................31A. Clinical Assessment....................................................311. Prognosis of CAD for Death or Nonfatal MI:General Considerations...........................................312. Risk Stratification With Clinical Parameters..........31B. ECG/Chest X-Ray.......................................................33C. Noninvasive Testing....................................................331. Resting LV Function (Echocardiographic/ Radionuclide Imaging)............................................332. Exercise Testing for Risk Stratification andPrognosis.................................................................343. Stress Imaging Studies (Radionuclide andEchocardiography)...................................................38D. Coronary Angiography and Left Ventriculography....441. Coronary Angiography for Risk Stratification inPatients With Chronic Stable Angina......................442. Risk Stratification With Coronary Angiography.....453. Patients With Previous CABG................................464. Asymptomatic Patients............................................47IV. Treatment..........................................................................47A. Pharmacologic Therapy..............................................471. Overview of Treatment...........................................482. Measurement of Health Status and Quality of Lifein Patients With Stable Angina................................483. Pharmacotherapy to Prevent MI and Death............494. Choice of Pharmacologic Therapy in ChronicStable Angina...........................................................58B. Definition of Successful Treatment and Initiation of Treatment.....................................................................591. Successful Treatment..............................................592. Initial Treatment......................................................593. Asymptomatic Patients............................................61C. Education of Patients With Chronic StableAngina.........................................................................611. Principles of Patient Education...............................622. Information for Patients..........................................63D. Coronary Disease Risk Factors and Evidence ThatTreatment Can Reduce the Risk for Coronary DiseaseEvents..........................................................................631. Categorization of Coronary Disease Risk Factors..642. Risk Factors for Which Interventions Have BeenShown to Reduce the Incidence of CoronaryDisease Events.........................................................643. Risk Factors for Which Interventions Are Likelyto Reduce the Incidence of Coronary DiseaseEvents......................................................................694. Effects of Exercise Training on Exercise Tolerance,Symptoms,and Psychological Well-Being.............715. Risk Factors for Which Interventions Might Reducethe Incidence of Coronary Disease Events..............746. Risk Factors Associated With Increased Risk butThat Cannot Be Modified or the Modification of Which Would Be Unlikely to Change the Incidenceof Coronary Disease Events....................................75
 
criteria outlined in the individual sections. The recommen-dations were based primarily on these published data. Theweight of the evidence was ranked high (A) if the data werederived from multiple randomized clinical trials with largenumbers of patients and intermediate (B) if the data werederived from a limited number of randomized trials withsmall numbers of patients,careful analyses of nonrandom-ized studies,or observational registries. A low rank (C) wasgiven when expert consensus was the primary basis for therecommendation. A recommendation with Level of Evidence B or C does not imply that the recommendation isweak. Many important clinical questions addressed in theguidelines do not lend themselves to clinical trials. Eventhough randomized trials are not available,there may be avery clear clinical consensus that a particular test or therapyis useful and effective.The customary ACC/AHA classifications I,II,and III areused in tables that summarize both the evidence and expertopinion and provide final recommendations for both patientevaluation and therapy:
Class I:Conditions for which there is evidence or gen-eral agreement that a given procedure ortreatment is useful and effective.Class II:Conditions for which there is conflicting evi-dence or a divergence of opinion about theusefulness/efficacy of a procedure or treat-ment.Class IIa:Weight of evidence/opinion is infavor of usefulness/efficacy.Class IIb:Usefulness/efficacy is less wellestablished by evidence/opinion.Class III:Conditions for which there is evidence and/orgeneral agreement that the procedure/treat-ment is not useful/effective and in some casesmay be harmful.
A complete list of many publications on various aspects of this subject is beyond the scope of these guidelines; onlyselected references are included. The committee consisted of acknowledged experts in general internal medicine from theACP-ASIM,and general cardiology,as well as persons withrecognized expertise in more specialized areas,includingnoninvasive testing,preventive cardiology,coronary inter-vention,and cardiovascular surgery. Both the academic andprivate practice sectors were represented. Methodologic sup-port was provided by the University of California,SanFrancisco-Stanford (UCSF-Stanford) Evidence BasedPractice Center (EPC). This document was reviewed by twooutside reviewers nominated by the ACC,two outsidereviewers nominated by the AHA,and two outside reviewersnominated by the ACP-ASIM. This document was approvedfor publication by the governing bodies of the ACC,AHA,and the Clinical Efficacy Assessment Subcommittee of theACP-ASIM. The task force will review these guidelines 1provide disclosure statements of all such relationships thatmight be perceived as real or potential conflicts of interest.These statements are reviewed by the parent task force,reported orally to all members of the writing panel at the firstmeeting,and updated as changes occur. (See Appendix 1 forconflict of interest information for writing committee mem-bers.)These practice guidelines are intended to assist physiciansin clinical decision making by describing a range of gener-ally acceptable approaches for the diagnosis,management,and prevention of specific diseases or conditions. Theseguidelines attempt to define practices that meet the needs of most patients in most circumstances. The ultimate judgmentregarding care of a particular patient must be made by thephysician and patient in light of all of the circumstances pre-sented by that patient. There are circumstances where devi-ations from these guidelines are appropriate.The Summary Article is published in the January 1,2003issue of the
 Journal of the American College of Cardiology
and the January 7/14,2003 issue of 
Circulation
. The full-text guideline is posted on the ACC and AHA World WideWeb sites. Copies of the full text and summary article areavailable from both organizations.
 Raymond J. Gibbons,MD,FACC,FAHAChair,ACC/AHA Task Force on Practice Guidelines Elliott M. Antman,MD,FACC,FAHAVice Chair,ACC/AHA Task Force on Practice Guidelines
I. INTRODUCTION AND OVERVIEW
 A. Organization of Committee and Evidence Review
The ACC/AHA Task Force on Practice Guidelines wasformed to make recommendations regarding the diagnosisand treatment of patients with known or suspected cardio-vascular disease. Ischemic heart disease is the single leadingcause of death in the United States. The most common man-ifestation of this disease is chronic stable angina.Recognizing the importance of the management of thiscommon entity and the absence of national clinical practiceguidelines in this area,the task force formed the currentcommittee to develop guidelines for the management of patients with stable angina. Because this problem is fre-quently encountered in the practice of internal medicine,thetask force invited the American College of Physicians-American Society of Internal Medicine (ACP-ASIM) toserve as a partner in this effort by naming general interniststo serve on the committee.The committee reviewed and compiled published reports(excluding abstracts) through a series of computerized liter-ature searches of the English language research literaturesince 1975 and a manual search of selected final articles.Details of the specific searches conducted for particular sec-tions are provided as appropriate. Detailed evidence tableswere developed whenever necessary on the basis of specific
3
Gibbons
et al.
2002ACC/AHAPractice Guidelines
ACC - www.acc.orgAHA- www.americanheart.org

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