The areas covered by this guideline are: investigation, risk factor identification and management, drug treatment, and referral.
All recommendations are for primary health care professionals and
apply to adult patients attending general practice with chronic stable angina.
The development group assumes that health care professionals will use general
medical knowledge and clinical judgement in applying the general practice
principles and specific recommendations of this document to the management of
individual patients. Recommendations may not be appropriate for use in all
circumstances. Decisions to adopt any particular recommendation must be made by
the practitioner in the light of available resources and circumstances presented
by individual patients.
Initial assessment
The guideline development group felt it important to state, as a general principle, that it is important to ensure clear communication and understanding at all stages in dealings between health care professionals and patients.
Norell et al. (1992) reviewed the case notes of 250 patients who had presented with recent onset chest pain to a "chest pain clinic"; of 109 patients with normal ECGs, 48% had non cardiac pain, 13% had an undetermined diagnosis and 39% had cardiac pain (half of these with unstable angina). Forty-one of these 109 patients had coronary arteriography and 37 showed significant coronary artery disease.
Mukerji et al. (1989) in a case control study reviewed the records of patients who had been investigated for chest pain; 15% of the patients with coronary artery disease had a normal ECG.
Mukerji, V., Alpert, M.A., Hewett, J.E. and Parker, B.M. (1989) Can patients with chest pain and normal coronary arteries be discriminated from those with coronary artery disease prior to coronary angiography? Angiology 40:276-282.
Norell, M., Lythall, D., Coghlan, G., Cheng, A., Jushwaha, S., Swan, J., Ilsley, C. and Mitchell, A. (1992) Limited value of the resting electrocardiogram in assessing patients with recent onset chest pain: lessons from a chest pain clinic. British Heart Journal 67:53-56.
Mirvis et al. (1990) looked at angiographically determined coronary anatomy in a cohort of patients. Comparing those with normal and those with abnormal 12 lead ECGs showed that ST/T abnormalities correlated with left ventricular contraction abnormalities, male sex, older age, left anterior descending artery stenosis, higher end systolic diameter and higher blood pressure.
Gregoire and Theroux (1990) followed a series of patients who presented with unstable angina and estimated the ability of the 12 lead ECG to predict the presence of coronary artery stenosis (demonstrated at subsequent angiography). A transient abnormality in the 12 lead ECG during pain had a 35% sensitivity and a 68% specificity. The corresponding figures if abnormalities occurred at any time were 65% and 63%.
France et al. (1990) looked at the ECG records of a cohort of 122 angiographed patients and found that QRS notching or slurring had 62.2% sensitivity and 93.8% specificity for the detection of ischaemic heart disease.
Berger et al. (1990) studied the ECGs of a cohort of 278 emergency department patients with chest pain and found that an abnormal ECG was 98% sensitive for coronary artery disease; ST/T abnormalities were 86% sensitive and 72.5% specific.
In a further cohort study, Miranda et al. (1991) looked at patients with resting ST depression, not due to left ventricular hypertrophy, conduction defects or drugs, assessed by exercise test or arteriography. They found that patients with ST segment depression or a previous myocardial infarction had a higher prevalence of severe coronary artery disease than those without.
Berger, J.P., Buclin, T., Haller, E., Van Melle, G. and Yersin, B. (1990) Right arm involvement and pain extension can help to differentiate coronary diseases from chest pain of other origin: a prospective emergency ward study of 278 consecutive patients admitted for chest pain. Journal of Internal Medicine 227:165-172.
France, R.J., Formolo, J.M. and Penney, D.G. (1990) Value of notching and slurring of the resting QRS complex in the detection of ischaemic heart disease. Clinical Cardiology 13:190-196.
Gregoire, J. and Theroux, P. (1990) Detection and assessment of unstable angina using myocardial perfusion imaging: comparison between technetium-99m sestamibi SPECT and 12-lead electrocardiogram. American Journal of Cardiology 66:42E-46E.
Miranda, C.P., Lehmann, K.G. and Froelicher, V.F. (1991) Correlation between resting ST segment depression, exercise testing, coronary angiography, and long-term prognosis. American Heart Journal 122:1617-1628.
Mirvis, D.M., El-Zeky, F., Vander Zwaag, R., Ramanathan, K.B., Crenshaw, J.H., Kroetz, F.W. and Sullivan, J.M. (1990) Clinical and pathophysiologic correlates of ST-T wave abnormalities in coronary artery disease. American Journal of Cardiology 66:699-704.
Madsen et al. (1987) followed a cohort of patients with suspected myocardial infarction for one year and found that patients with ST segment depression or elevation, T wave inversion or inter-ventricular conduction delay had a higher incidence of events at one year.
Aronow (1989) looked at a cohort of elderly chronic sick patients and found that the amount of ST segment depression correlated with an increased incidence of new cardiac events; >1 mm depression had 3.1 times greater risk; >0.5 mm and <1 mm had 1.9 times greater risk.
Lichtlen et al. (1990) studied the ECGs of a cohort of patients with unstable angina over a period of three days in hospital and found that patients with ECGs showing T wave inversion, ST segment elevation, ST segment depression or ST segment elevation and ST segment depression had a higher incidence of myocardial infarction and serious coronary disease at one year compared to patients without these changes.
Miranda et al. (1991) cited above is also predictive.
Aronow, W.S. (1989) Correlation of ischaemic ST-segment depression on the resting electrocardiogram with new cardiac events in 1,106 patients over 62 years of age. American Journal of Cardiology 64:232-233.
Lichtlen, P.R., Hugenholtz, P.G., Rafflenbeul, W., Hecker, H., Jost, S. and Deckers, J.W. (1990) Retardation of angiographic progression of coronary artery disease by nifedipine. Results of the International Nifedipine Trial on Antiatherosclerotic Therapy (INTACT). INTACT Group Investigators [see comments]. Lancet 335:1109-1113.
Madsen, J.K., Hommel, E. and Hansen, J.F. (1987) Prognostic value of an electrocardiogram at rest and exercise test in patients admitted with suspected acute myocardial infarction, in whom the diagnosis is not confirmed. European Heart Journal 8:717-724.
Referral for exercise testing will be influenced by whether or not open access facilities are available locally. If they are not then referral for exercise testing will have to be via a cardiologist (see section on referral to a cardiologist).
Weiner et al. (1984) analysed 30 variables as predictors of mortality in a cohort of 4,083 patients and found that while left ventricular contraction pattern and the number of diseased coronary arteries were most important, in patients with three vessel disease and preserved left ventricular function four year survival was 100% if stage V reached and 53% if only Bruce stage • reached.
Bonow et al. (1984) studied 106 male and 11 female patients with no angiographically demonstrable left main stem coronary artery disease and no symptoms, or mild stable angina on treatment. They were investigated with exercise testing and gated blood pool scan. All the deaths in four years (11%) were in a group with four factors: ST segment depression >1 mm, a decreased ejection fraction during exercise, exercise tolerance <120 watts and three vessel disease. The presence of three vessel disease alone equated with a good prognosis.
Sato et al. (1992) compared three cohorts of Japanese men who had typical angina, atypical angina or non-angina chest pain. They found that the exercise test was predictive of cardiac events; even in those patients with atypical angina and non-angina chest pain.
Mark et al. (1987) followed a cohort of 2,842 patients (70% males) for up to 10 years after an angiogram and exercise test. The results were analysed using the treadmill score (ST segment deviation, exercise time and angina index). This score allowed discrimination of high, moderate and low risk groups. Five year survival in the groups were 72%, 91% and 97% respectively; event free survival was 63%, 86% and 93% respectively.
Mark, D.B., Hlatky, M.A., Harrell, F.E., Jr., Lee, K.L., Califf, R.M. and Pryor, D.B. (1987) Exercise treadmill score for predicting prognosis in coronary artery disease. Annals of Internal Medicine 106:793-800.
Sato, I., Nishijima, H., Matsumura, N., Nishida, M., Okita, K. and Yasuda, H. (1992) The incidence of cardiac events in Japanese men with atypical or non-anginal chest pain: a prospective study on the significance of exercise testing. American Heart Journal 123:1510-1515.
Weiner, D.A., Ryan, T.J., McCabe, C.H., Chaitman, B.R., Sheffield, L.T., Ferguson, J.C., Fisher, L.D. and Tristani, F. (1984) Prognostic importance of a clinical profile and exercise test in medically treated patients with coronary artery disease. Journal of the American College of Cardiology 3(3):772-779.
Detry et al. (1985) looked at the computer-assisted exercise test evaluating ST segment changes, maximum heart rate, blood pressure, workload and onset of angina in 387 men. They found that ST segment changes alone were barely better than clinical history. When using all five variables, however, there was 83% correct classification. They also concluded that with a typical history an exercise test is not needed for diagnosis but is for prognosis.
Detrano et al. (1989) carried out a meta-analysis of diagnostic accuracy of exercise tests. They looked at 147 reports and concluded that 1 mm of ST segment depression had mean sensitivity for left main stem and triple vessel disease of 86%.
Mark et al. (1989) looked at cases of positive exercise tests with no pain. One thousand six hundred and ninety eight patients were split into three groups: no ST deviation; painless ST segment deviation; and painful ST segment deviation. The five year survival rate was similar in patients with painless and no ST segment deviation and better than those with pain and ST segment deviation.
Richardson et al. (1992) looked at angiography and exercise tolerance testing in 1,138 patients in order to determine the predictive power of ten exercise tolerance test parameters. Of the ten, exercise ECG, maximum rate pressure product and exercise chest pain gave predictive information.
Pratt et al. (1989) angiogrammed 200 women with chest pain compatible with angina and >1 mm ST segment depression on exercise testing. Four variables were associated with an increased likelihood of coronary artery disease: absence of mitral valve prolapse; exercise duration <5 minutes; inability to reach target heart rate; time to ST normalisation > 6 minutes. False positives were associated with the ability to reach stage III of Bruce protocol and <4 minutes to ST normalisation.
Weiner et al. (1987) followed up 2,982 patients. They categorised them into four groups: those with ST segment depression and no angina; those with angina and no ST segment depression; those with ST segment depression and angina; and those with no ST segment depression and no angina. The absence of pain did not negate other positive results; the seven year survival was similar whether ischaemia was silent or not.
Detry, J.M.R., Robert, A., Luwaert, R.J., Rousseau, M.F., Brasseur, L.A., Melin, J.A. and Brohet, C.R. (1985) Diagnostic value of computerised exercise testing in men without previous myocardial infarction. A multivariate, compartmental and probabilistic approach. European Heart Journal 6:227-238.
Mark, D.B., Hlatky, M.A., Califf, R.M, Morris, J.J., Jr., Sisson, S.D., McCants, C.B. et al. (1989) Painless exercise ST deviation on the treadmill: long-term prognosis. Journal of the American College of Cardiology 14:885-892.
Pratt, C.M., Francis, M.J., Divine, G.W. and Young, J.B. (1989) Exercise testing in women with chest pain. Are there additional exercise characteristics that predict true positive results? Chest 95:139-144.
Richardson, M.T., Holly, R.G., Amsterdam, E.A. and Miller, M.F. (1992) The value of chest pain during the exercise tolerance test in predicting coronary artery disease. Cardiology 81:164-171.
Weiner, D.A., Ryan, T.J., McCabe, C.H., Luk, S., Chaitman, B.R., Sheffield, L.T., Tristani, F. and Fisher, L.D. (1987). Significance of silent myocardial ischaemia during exercise testing in patients with coronary artery disease. American Journal of Cardiology 59:725-729.
Weiner et al. (1979) in the CASS study looked at 1,465 men and 580 women. Pre-test prevalence of coronary disease was 7-87%. The false positive rate was 12% in males and 53% in females. Therefore they concluded that the value of the test in identifying patients with coronary heart disease is limited in a heterogeneous population.
Diamond and Forrester (1979) looked for the features that influence the pre-test likelihood of coronary heart disease and concluded that exercise testing is most useful in the mid range of uncertainty when coronary disease is neither very unlikely nor very likely.
Weiner, D.A., Ryan, T.J., McCabe, C.H., Kennedy, J.W., Schloss, M., Tristani, F., Chaitman, B.R. and Fisher, L.D. (1979) Exercise stress testing. Correlations among history of angina, ST-segment response and prevalence of coronary artery disease in the coronary artery surgery study. New England Journal of Medicine 301:230-235.
Sulke et al. (1991) looked at 110 GP referrals for exercise tests, comparing patient characteristics and test results before and after guidelines. After the introduction of the guideline 67% of the referrals were judged to be appropriate compared to 46% before; more referrals were for prognosis and fewer for diagnosis or with non cardiac pain. There were also fewer with low probability of coronary heart disease and more with moderate risk.
Lim et al. (1994) studied 84 patients with typical angina or a past history of definite myocardial infarction and mild symptoms. An exercise test, radionucloetide ventriculography and angiography all performed on or off treatment were performed, and it was concluded that the exercise test should be performed on treatment to optimise identification of prognostically important disease and avoid angiography in those well controlled on treatment.
Morise et al. (1993) studied 326 male and 234 female patients, looking at the exercise test and subsequent coronary angiogram results. When assessing the result of the exercise tests along with other parameters, inclusion of women's oestrogen status, defined by menopause or oral oestrogens, resulted in the diagnostic accuracy of exercise tests becoming similar in men and women.
Ranjadayalan et al. (1990) compared exercise tests in 32 patients with diabetes and 36 without and found that there was no correlation between having diabetes and time to ST segment depression or exercise capacity but there was prolongation of the angina perceptual threshold in patients with diabetes.