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<p>European Heart Journal doi:10.1093/eurheartj/ehl002</p><p>ESC Guidelines</p><p>y</p><p>Guidelines on the management of stable angina pectoris: full text{The Task Force on the Management of Stable Angina Pectoris of the European Society of CardiologyAuthors/Task Force Members, Kim Fox, Chairperson, London (UK)*, Maria Angeles Alonso Garcia, Madrid (Spain), Diego Ardissino, Parma (Italy), Pawel Buszman, Katowice (Poland), Paolo G. Camici, London (UK), Filippo Crea, Roma (Italy), Caroline Daly, London (UK), Guy De Backer, Ghent Lopez-Sendon, Madrid (Spain), Jean Marco, (Belgium), Paul Hjemdahl, Stockholm (Sweden), Jose o Morais, Leiria (Portugal), John Pepper, London (UK), Udo Sechtem, Toulouse (France), Joa Stuttgart (Germany), Maarten Simoons, Rotterdam (The Netherlands), Kristian Thygesen, Aarhus (Denmark)ESC Committee for Practice Guidelines (CPG), Silvia G. Priori (Chairperson) (Italy), Jean-Jacques Blanc (France), Andrzej Budaj (Poland), John Camm (UK), Veronica Dean (France), Jaap Deckers (The Netherlands), Kenneth Dickstein o Morais (Portugal), Ady Osterspey (Norway), John Lekakis (Greece), Keith McGregor (France), Marco Metra (Italy), Joa L. Zamorano (Spain) (Germany), Juan Tamargo (Spain), Jose L. Zamorano (CPG Review Coordinator) (Spain), Felicita Andreotti (Italy), Harald Becher Document Reviewers, Jose (UK), Rainer Dietz (Germany), Alan Fraser (UK), Huon Gray (UK), Rosa Ana Hernandez Antolin (Spain), Kurt Huber (Austria), Dimitris T. Kremastinos (Greece), Attilio Maseri (Italy), Hans-Joachim Nesser (Austria), Tomasz Pasierski (Poland), Ulrich Sigwart (Switzerland), Marco Tubaro (Italy), Michael Weis (Germany)</p><p>Table of ContentsPreamble . . . . . . . . . . . . . . . . . . . . . . . Introduction . . . . . . . . . . . . . . . . . . . . . . Denition and pathophysiology . . . . . . . . . . . Epidemiology . . . . . . . . . . . . . . . . . . . . . Natural history and prognosis . . . . . . . . . . . . Diagnosis and assessment . . . . . . . . . . . . . . Symptoms and signs . . . . . . . . . . . . . . . Laboratory tests . . . . . . . . . . . . . . . . Chest X-ray . . . . . . . . . . . . . . . . . . . Non-invasive cardiac investigations . . . . . . Resting ECG . . . . . . . . . . . . . . . . . . ECG stress testing . . . . . . . . . . . . . . . Stress testing in combination with imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 . 3 . 3 . 5 . 5 . 6 . 6 . 7 . 8 . 8 . 8 . 9 . 11</p><p>Echocardiography at rest . . . . . . . . . . . . . Ambulatory ECG monitoring . . . . . . . . . . . . Non-invasive techniques to assess coronary calcication and coronary anatomy . . . . . . . Invasive techniques to assess coronary anatomy . . Coronary arteriography . . . . . . . . . . . . . . . Intravascular ultrasound . . . . . . . . . . . . . . Invasive assessment of functional severity of coronary lesions . . . . . . . . . . . . . . . . . . . Risk stratication . . . . . . . . . . . . . . . . . . . Risk stratication using clinical evaluation . . . Risk stratication using stress testing . . . . . . Risk stratication using ventricular function . . Risk stratication using coronary arteriography</p><p>. 13 . 13 . . . . . . . . . . 14 14 14 14 15 15 16 19 20 22</p><p>* Corresponding author. Chairperson: Kim Fox, Department of Cardiology, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK. Tel: 44 207 351 8626; fax: 44 207 351 8629. E-mail address:[email protected]</p><p>{ CME questions for this article are available at European Heart Journal online. This is the full text version of Eur Heart J doi:10.1093/eurheartj/ehl001.</p><p>The content of these European Society of Cardiology (ESC) Guidelines has been published for personal and educational use only. No commercial use is authorized. No part of the ESC Guidelines may be translated or reproduced in any form without written permission from the ESC. Permission can be obtained upon submission of a written request to Oxford University Press, the publisher of the European Heart Journal and the party authorized to handle such permissions on behalf of the ESC. Disclaimer. The ESC Guidelines represent the views of the ESC and were arrived at after careful consideration of the available evidence at the time they were written. Health professionals are encouraged to take them fully into account when exercising their clinical judgement. The guidelines do not, however, override the individual responsibility of health professionals to make appropriate decisions in the circumstances of the individual patients, in consultation with that patient, and where appropriate and necessary the patients guardian or carer. It is also the health professionals responsibility to verify the rules and regulations applicable to drugs and devices at the time of prescription.</p><p>& The European Society of Cardiology 2006. All rights reserved. For Permissions, please e-mail: [email protected]</p><p>2</p><p>ESC Guidelines</p><p>Special diagnostic considerations: angina with normal coronary arteries . . . . . . . . . . . . Syndrome X . . . . . . . . . . . . . . . . . . . . . . Vasospastic/variant angina . . . . . . . . . . . . . . Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . Aims of treatment . . . . . . . . . . . . . . . . . . . . General management . . . . . . . . . . . . . . . . . . Treatment of the acute attack . . . . . . . . . . . Smoking . . . . . . . . . . . . . . . . . . . . . . . . Diet and alcohol . . . . . . . . . . . . . . . . . . . . Omega-3 fatty acids . . . . . . . . . . . . . . . . . Vitamins and antioxidants . . . . . . . . . . . . . . Hypertension, diabetes, and other disorders . . . Physical activity . . . . . . . . . . . . . . . . . . . . Psychological factors . . . . . . . . . . . . . . . . . Car driving . . . . . . . . . . . . . . . . . . . . . . . Sexual intercourse . . . . . . . . . . . . . . . . . . Employment . . . . . . . . . . . . . . . . . . . . . . Pharmacological treatment of stable angina pectoris Pharmacological therapy to improve prognosis . . Pharmacological treatment of symptoms and ischaemia . . . . . . . . . . . . . . . . . . . . . . . Special therapeutic considerations: cardiac Syndrome X and vasospastic angina . . . . . . . . Myocardial revascularization . . . . . . . . . . . . . . Coronary artery bypass surgery . . . . . . . . . . . Percutaneous coronary intervention . . . . . . . . Revascularization vs. medical therapy . . . . . . . PCI vs. surgery . . . . . . . . . . . . . . . . . . . . . Specic patient and lesion subsets . . . . . . . . . Indications for revascularization . . . . . . . . . . Treatment of stable angina: multi-targeted treatment of a multi-faceted disease . . . . . . . Special subgroups . . . . . . . . . . . . . . . . . . . . Women . . . . . . . . . . . . . . . . . . . . . . . . . Diabetes mellitus . . . . . . . . . . . . . . . . . . . Elderly . . . . . . . . . . . . . . . . . . . . . . . . . Chronic refractory angina . . . . . . . . . . . . . . Conclusions and Recommendations . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . .</p><p>22 23 24 25 25 25 25 25 25 25 26 26 26 26 26 26 26 26 27 34 37 38 38 39 39 40 41 41 43 43 43 44 45 45 46 47</p><p>PreambleGuidelines and Expert Consensus documents aim to present management recommendations based on all of the relevant evidence on a particular subject in order to help physicians to select the best possible management strategies for the individual patient, suffering from a specic condition, taking into account the impact on outcome and also the riskbenet ratio of a particular diagnostic or therapeutic procedure. Numerous studies have demonstrated that patient outcomes improve when guideline recommendations, based on the rigorous assessment of evidence-based research, are applied in clinical practice. A great number of Guidelines and Expert Consensus Documents have been issued in recent years by the European Society of Cardiology (ESC) and also by other organizations or related societies. The profusion of documents can put at stake the authority and credibility of guidelines, particularly if discrepancies appear between different documents on the same issue, as this can lead to confusion in the mind of physicians. In order to avoid these pitfalls, the ESC</p><p>and other organizations have issued recommendations for formulating and issuing Guidelines and Expert Consensus Documents. The ESC recommendations for guidelines production can be found on the ESC website (Recommendations for ESC Guidelines Production at www.escardio.org). It is beyond the scope of this preamble to recall all but the basic rules. In brief, the ESC appoints experts in the eld to carry out a comprehensive review of the literature, with a view to making a critical evaluation of the use of diagnostic and therapeutic procedures and assessing the riskbenet ratio of the therapies recommended for management and/or prevention of a given condition. Estimates of the expected health outcomes are included, where data exist. The strength of evidence for or against particular procedures or treatments is weighed, according to predened scales for grading recommendations and levels of evidence, as outlined subsequently. The Task Force members of the writing panels, as well as the document reviewers, are asked to provide disclosure statements of all relationships they may have, which might be perceived as real or potential conicts of interest. These disclosure forms are kept on le at the European Heart House, headquarters of the ESC, and can be made available by written request to the ESC President. Any changes in conict of interest that arise during the writing period must be notied to the ESC. Guidelines and recommendations are presented in formats that are easy to interpret. They should help physicians to make clinical decisions in their daily routine practice, by describing the range of generally acceptable approaches to diagnosis and treatment. However, the ultimate judgment regarding the care of individual patients must be made by the physician in charge of their care. The ESC Committee for Practice Guidelines (CPG) supervises and coordinates the preparation of new Guidelines and Expert Consensus Documents produced by Task Forces, expert groups or consensus panels. The committee is also responsible for the endorsement of these Guidelines and Expert Consensus Documents or statements. Once the document has been nalized and approved by all the experts involved in the Task Force, it is submitted to outside specialists for review. In some cases, the document can be presented to a panel of key opinion leaders in Europe, specialists in the relevant condition at hand, for discussion and critical review. If necessary, the document is revised once more and, nally, approved by the CPG and selected members of the board of the ESC and subsequently published. After publication, dissemination of the message is of paramount importance. Publication of executive summaries and the production of pocket-sized and PDA-downloadable versions of the recommendations are helpful. However, surveys have shown that the intended end-users are often not aware of the existence of guidelines or simply do not put them into practice. Implementation programmes are thus necessary and form an important component of the dissemination of knowledge. Meetings are organized by the ESC and directed towards its member National Societies and key opinion leaders in Europe. Implementation meetings can also be undertaken at a national level, once the guidelines have been endorsed by the ESC member</p><p>ESC Guidelines</p><p>3</p><p>societies and translated into the local language, when necessary. All in all, the task of writing Guidelines or Expert Consensus Document covers not only the integration of the most recent research but also the creation of educational tools and implementation programmes for the recommendations. The loop between clinical research, writing of guidelines, and implementing them into clinical practice can then only be completed if surveys and registries are organized to verify that actual clinical practice is in keeping with what is recommended in the guidelines. Such surveys and registries also make it possible to check the impact of strict implementation of the guidelines on patient outcome. Classes of Recommendations</p><p>also the cost and the availability of resources. The Task Force has taken the view that these guidelines should reect the pathophysiology and management of angina pectoris, namely myocardial ischaemia due to coronary artery disease (CAD), usually macrovascular, i.e. involving large coronary arteries, but also microvascular in some of the patients. Furthermore, this Task Force does not deal with primary prevention, which has already been covered in other recently published guidelines1 and has limited its discussion on secondary prevention. Recently published guidelines and consensus statements that overlap to a considerable extent with the remit of this document are listed in Table 1.</p><p>Denition and pathophysiologyStable angina is a clinical syndrome characterized by discomfort in the chest, jaw, shoulder, back, or arms, typically elicited by exertion or emotional stress and relieved by rest or nitroglycerin. Less typically, discomfort may occur in the epigastric area. William Heberden rst introduced the term angina pectoris in 17722 to characterize a syndrome in which there was a sense of strangling and anxiety in the chest, especially associated with exercise, although its pathological aetiology was not recognized until some years later.3 It is now usual to conne the term to cases in which the syndrome can be attributed to myocardial ischaemia, although essentially similar symptoms can be caused by disorders of the oesophagus, lungs, or chest wall. Although the most common cause of myocardial ischaemia is atherosclerotic CAD, demonstrable myocardial ischaemia may be induced in the abscence by hypertrophic or dilated cardiomyopathy, aortic stenosis, or other rare cardiac conditions in the absence of obstructive atheromatous coronary disease, which are not considered in this document. Myocardial ischaemia is caused by an imbalance between myocardial oxygen supply and myocardial oxygen consumption. Myocardial oxygen supply is determined by arterial oxygen saturation and myocardial oxygen extraction, which are relatively xed under normal circumstances, and coronary ow, which is dependent on the luminal crosssectional area of the coronary artery and coronary arteriolar tone. Both cross-sectional area and arterioloar tone may be dramatically altered by the presence of atherosclerotic plaque within the vessel wall, leading to imbalance between supply and demand when myocardial oxygen demands increase, as during exertion, related to increases in heart rate, myocardial contractility, and wall stress. Ischaemia-induced sympathetic activation can further increase the severity of ischaemia throu...</p>
The purpose of this chapter is to give the medical student and resident a broad overview of the diseases of the colon, rectum, and anus. Because of the breadth of material covered, this chapter is neither all inclusive nor in depth. For more extensive review, the reader is directed to the reference. Guidelines on the management of stable angina pectoris: full text{. Trials of stable coronary disease or angina: CAMELOT,467 PEACE,252 ACTION,493. Atenolol versus amlodipine versus isosorbide-5-mononitrate on anginal. Chevalier P, Dacosta A, Defaye P, Chalvidan T, Bonnefoy E, Kirkorian G et al.