- Home>
- Specialty Care>
- Cardiology>
- Clinical Practice Guideline Watch
Guidelines: Chronic Stable Angina
These revised guidelines for chronic stable angina outline how best to manage not only symptomatic -- but also asymptomatic -- patients with known or suspected coronary artery disease.
Sponsoring Organizations: the American College of Cardiology and the American Heart Association, assisted by the American College of Physicians/American Society of Internal Medicine
Background and Purpose: These guidelines, a revision of the 1999 document, apply primarily to adult patients with stable chest-pain syndromes and known or suspected coronary artery disease. However, the guidelines also include subsections on asymptomatic patients with known or suspected CAD; these subsections appear after the corresponding sections for symptomatic patients.
Key Points:
1. There is a new class-I indication for ACE inhibitors in patients who have significant documented CAD and who also have diabetes and/or LV systolic dysfunction. (Note that the guidelines call for ACE inhibitors as routine secondary prevention for most patients with known CAD.)
2. For patients with documented or suspected CAD and LDL levels of 100-129 mg/dL, several therapeutic options are now recommended (class IIa): lifestyle or drug therapies to lower LDL to <100 mg/dL; weight reduction and increased physical activity in people with the metabolic syndrome; and treatment of other lipid (high triglycerides, low HDL) or nonlipid risk factors.
3. For patients with documented or suspected CAD and triglyceride levels >200 mg/dL, a non-HDL-cholesterol treatment target of <130 mg/dL is now recommended (class IIa).
4. Vitamin C and E supplementation, coenzyme Q, and hormone replacement therapy (in postmenopausal women) are no longer recommended.
5. Surgical laser transmyocardial revascularization (TMR) is now listed as an alternative therapy for managing drug-refractory chronic stable angina (class IIa). However, in a recent single-blind, randomized trial not cited in the guidelines, percutaneous TMR conferred no more benefit than medical therapy in patients with severe angina due to chronic total occlusion (Journal Watch Cardiology Jul 12 2002).
6. The guidelines do not endorse noninvasive testing for diagnosing and risk-stratifying asymptomatic patients. However, because asymptomatic patients often present for evaluation after noninvasive tests have been performed, the authors have included recommendations for various presentation scenarios.
7. There is a new class-IIa recommendation for coronary angiography in asymptomatic patients whose noninvasive-test findings meet high-risk criteria and suggest ischemia. Angiography is not recommended for patients who simply prefer to avoid revascularization.
8. The guidelines now recommend aspirin, beta-blockers, lipid-lowering therapy, and ACE inhibitors to prevent MI and death in appropriate asymptomatic patients, as in symptomatic patients.
9. Recommendations regarding percutaneous coronary intervention and coronary artery bypass grafting are now identical for symptomatic and asymptomatic patients.
Comment: These guidelines suggest that management of patients with chronic stable angina should be similar to that of patients with unstable angina or non-ST-elevation MI who have already been treated successfully. Aspirin, beta-blockers, lipid-lowering therapy, and ACE inhibitors remain treatment cornerstones for appropriate patients with known or suspected CAD, symptomatic or asymptomatic. In asymptomatic patients, treatment cannot improve symptoms, so the principal goal is reducing rates of death and MI.
— Joel M. Gore, MD
Published in Journal Watch Cardiology January 24, 2003
Citation(s):
Abrams J et al. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for the Management of Patients with Chronic Stable Angina). http://www.acc.org/clinical/guidelines/stable/stable.pdf