The diagnostic and treatment guideline of chronic stable angina

Ischemic heart disease (IHD) is the leading cause of death in the U.S. The most common manifestation of this disease is chronic stable angina (CSA). CSA is the initial feature of IHD in approximately one half of patients. Large epidemiological study of IHD in Taiwan showed increasing prevalence. Report of Mortality Statistics in Taiwan shows the cardiac death was the 4th top from 1989 to 1999, and became the 3rd from 2000 to 2002. The majority of cardiac death is IHD. Patients with a ≧ 10% pretest probability of CSA by history taking based on combined Diamond/Forrester and coronary artery surgery study data are recommended to do treadmill test without imaging modality. Thallum-201 dipyridamole myocardial perfusion scan (TI-scan) is recommended for patients with the following baseline electrocardiographic abnormalities: Wolff-Parkinson-White syndrome, electronically paced ventricular rhythm, ST depression ≧ 1 mm at rest and complete left bundle branch block. Coronary angiography (CAG) is recommended for patients with high-risk indicators on noninvasive tests (NIT): high-risk Duke treadmill score (Duke score ≦ -11 if Bruce protocol or predicted annual mortality by nomogram ≧ 3% if non-Bruce protocol), left ventricular ejection fraction (EF) at rest < 35% on echocardiography in patients with confirmed CSA, high-risk TI-scan. A composite graph is used for estimating the probability of severe CSA. Patients with a ≧ 35% pretest probability of severe CSA are recommended for CAG without NIT. Coronary artery bypassing grafting is Class I regimen in: left main disease (≧ 50% stenosis), three-vessel disease especially in EF < 50%, two-vessel disease with proximal left anterior descending (p-LAD) involvement and one of the following findings: EF < 50%, ischemia on NIT or diabetes mellitus, one- or two- vessel disease without p-LAD involvement who has survived sudden cardiac death or sustained ventricular tachycardia.