Clinical Review ABC of interventional cardiology

Chronic stable angina: treatment options

BMJ 2003; 326 doi: http://dx.doi.org/10.1136/bmj.326.7400.1185 (Published 29 May 2003) Cite this as: BMJ 2003;326:1185
  1. Laurence O'Toole, consultant cardiologist and physician,
  2. Ever D Grech, consultant cardiologist, assistant professor
  1. Royal Hallamshire Hospital, Sheffield, Health Sciences Centre and St Boniface Hospital, Winnipeg, Manitoba, Canada, University of Manitoba, Winnipeg

    Introduction

    In patients with chronic stable angina, the factors influencing the choice of coronary revascularisation therapy (percutaneous coronary intervention or coronary artery bypass surgery) are varied and complex. The severity of symptoms, lifestyle, extent of objective ischaemia, and underlying risks must be weighed against the benefits of revascularisation and the patient's preference, as well as local availability and expertise. Evidence from randomised trials and large revascularisation registers can guide these decisions, but the past decade has seen rapid change in medical treatment, bypass surgery, and percutaneous intervention. Therefore, thought must be given to whether older data still apply to contemporary practice.

    View this table:

    Major factors influencing risks and benefits of coronary revascularisation

    Top: Diagrams of saphenous vein and left internal mammary artery grafts for coronary artery bypass surgery. Bottom: Three completed grafts—(1) left internal mammary artery (LIMA) to left anterior descending artery (LAD), and saphenous vein grafts (SVG) to (2) diagonal artery (DG) and (3) obtuse marginal artery (OM)

    Patients with chronic stable angina have an average annual mortality of 2-3%, only twice that of age matched controls, and this relatively benign prognosis is an important consideration when determining the merits of revascularisation treatment. Certain patients, however, are at much higher risk. Predictors include poor exercise capacity with easily inducible ischaemia or a poor haemodynamic response to exercise, angina of recent onset, previous myocardial infarction, impaired left ventricular function, and the number of coronary vessels with significant stenoses, especially when disease affects the left main stem or proximal left anterior descending artery. Although the potential benefits of revascularisation must be weighed against adverse factors, those most at risk may have the most to gain.

    Treatment strategies

    Medical treatment

    Anti-ischaemic drugs improve symptoms and quality of life, but have not been shown to reduce mortality or myocardial infarction. βblockers may improve survival in hypertension, in heart failure, and …

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