Chronic stable angina risk stratification based upon rest left ventricular function

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Smita Kohli, M.D.; Lakshmi Gopalakrishnan, M.B.B.S.

Overview

Echocardiography is the best initial tool for obtaining an estimate of left ventricular function,^[1] both systolic and diastolic. In addition, echocardiography also provides information regarding associated valvular dysfunction and pulmonary artery pressures. This information can in turn be used to select or modify the treatment regimen for the patient.

Indications for Assessing Left Ventricular Function[1]

Indications for Assessing Left Ventricular Function^[1]

Patients with evidence of congestive heart failure
Patients with evidence of valvular dysfunction
Patients with documented MI
Patients with an ECG showing Q waves (suggestive of an old MI)

Mortality Based on Ejection Fraction

A resting or exercise LV ejection fraction (LVEF) of less than 35% is associated with a significantly higher mortality than a normal LVEF.

In patients with three-vessel coronary artery disease, the presence of an ejection fraction of less than 50% or clinical evidence of heart failure is associated with almost three times higher mortality than that in patients with normal left ventricular function and a similar extent of CAD.^[2]

ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina (DO NOT EDIT)[3]

ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina (DO NOT EDIT)^[3]

Rest LV Function (Echocardiographic/Radionuclide Imaging) (DO NOT EDIT)^[3]

Class I
“1. Echocardiography or radionuclide angiography (RNA) in patients with a history of prior MI, pathological Q waves, or symptoms or signs suggestive of heart failure to assess LV function. (Level of Evidence: B)”
“2. Echocardiography in patients with a systolic murmur suggesting mitral regurgitation to assess its severity and etiology. (Level of Evidence: C)”
“3. Echocardiography or radionuclide angiography in patients with complex ventricular arrhythmias to assess LV function. (Level of Evidence: B)”

Class III
“1. Routine periodic reassessment of stable patients for whom no new change in therapy is contemplated. (Level of Evidence: C)”
“2. Patients with a normal ECG, no history of MI, and no symptoms or signs suggestive of heart failure. (Level of Evidence: B)”

ESC Guidelines- Risk Stratiﬁcation by Echocardiographic evaluation of Ventricular Function (DO NOT EDIT)[4]

ESC Guidelines- Risk Stratiﬁcation by Echocardiographic evaluation of Ventricular Function (DO NOT EDIT)^[4]

Class I
“1. Resting echocardiography in patients with prior MI, symptoms or signs of heart failure, or resting ECG abnormalities. (Level of Evidence: B)”
“2. Resting echocardiography in patients with hypertension. (Level of Evidence: B)”
“3. Resting echocardiography in patients with diabetes. (Level of Evidence: C)”

Class IIa
“1. Resting echocardiography in patients with a normal resting ECG without prior MI who are not otherwise to be considered for coronary arteriography. (Level of Evidence: C)”

References

↑ ^1.0 ^1.1 Cheitlin MD, Alpert JS, Armstrong WF, Aurigemma GP, Beller GA, Bierman FZ et al. (1997) ACC/AHA Guidelines for the Clinical Application of Echocardiography. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Clinical Application of Echocardiography). Developed in collaboration with the American Society of Echocardiography. Circulation 95 (6):1686-744. PMID: 9118558
↑ Braunwald, Eugene. (2003). “25”. Primary Cardiology. Saunders. ISBN 0-7216-9444-6. Unknown parameter |coauthors= ignored (help); Unknown parameter |month= ignored (help)
↑ ^3.0 ^3.1 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.
↑ 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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[pmid9118558-1] 1.0 ^1.1 Cheitlin MD, Alpert JS, Armstrong WF, Aurigemma GP, Beller GA, Bierman FZ et al. (1997) ACC/AHA Guidelines for the Clinical Application of Echocardiography. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Clinical Application of Echocardiography). Developed in collaboration with the American Society of Echocardiography. Circulation 95 (6):1686-744. PMID: 9118558

[2] Braunwald, Eugene. (2003). “25”. Primary Cardiology. Saunders. ISBN 0-7216-9444-6. Unknown parameter |coauthors= ignored (help); Unknown parameter |month= ignored (help)

[pmid10351980-3] 3.0 ^3.1 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.

[pmid16735367-4] 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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