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## Complete Summary

#### GUIDELINE TITLE

Evaluation of primary care patients with chronic stable angina:
guidelines from the American College of Physicians.

#### BIBLIOGRAPHIC SOURCE(S)

Snow V, Barry P, Fihn SD, Gibbons RJ, Owens DK, Williams SV, Weiss KB,
Mottur-Pilson C. Evaluation of primary care patients with chronic stable
angina: guidelines from the American College of Physicians. Ann Intern
Med 2004 Jul 6;141(1):57-64. \[36 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15238371)

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Gibbons RJ, Chatterjee K,
Daley J, Douglas JS, Fihn SD, Gardin JM, Grunwald MA, Levy D, Lytle BW,
O\'Rourke RA, Schafer WP, Williams SV, Ritchie JL, Cheitlin MD, Eagle
KA, Gardner TJ, Garson A Jr, Russell RO, Ryan TJ, Smith SC Jr.
ACC/AHA/ACP-ASIM guidelines 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. J Am Coll Cardiol
1999 Jun;33(7):2092-197.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Chronic stable angina

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Risk Assessment

#### CLINICAL SPECIALTY

Cardiology\
Family Practice\
Internal Medicine

#### INTENDED USERS

Physicians

#### GUIDELINE OBJECTIVE(S)

-   To update the 1999 guideline on chronic stable angina, which was
    published by the American College of Physicians (ACP) (then the
    American College of Physicians-American Society of Internal
    Medicine) and the American College of Cardiology/American Heart
    Association (ACC/AHA)

-   To summarize the recommendations of the 2002 American College of
    Cardiology/American Heart Association (ACC/AHA) updated guideline
    and underscore the recommendations most likely to be important to
    physicians seeing patients in the primary care setting

-   To provide guidance on the management of patients with chronic
    stable angina

#### TARGET POPULATION

-   All persons without known coronary disease whose symptoms suggest
    chronic stable angina

-   Patients who present with known chronic stable angina

-   Asymptomatic patients with evidence suggesting coronary disease on
    previous testing

**Note**: This guideline does not apply to patients with unstable angina
because they have a high to moderate short-term risk for an acute
coronary event.

*Unstable angina* is defined as angina that presents in 1 of 3 principal
ways: rest angina, severe new-onset angina, or increasing angina.

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Description of pain: quality, location, duration, and the presence
    of factors that trigger and relieve the pain

2.  Assessment of cardiovascular risk factors including smoking,
    hyperlipidemia, diabetes mellitus, hypertension, family history of
    premature coronary artery disease (CAD), and postmenopausal status
    in women

3.  Consideration of comorbid conditions that may precipitate
    \"functional\" angina

4.  Resting electrocardiography (ECG)

5.  Chest radiography

6.  Electron-beam computed tomography (CT) (not recommended)

7.  Resting echocardiography

8.  Resting radionuclide angiography

9.  Exercise ECG, using the Bruce protocol and Duke treadmill score

10. Exercise echocardiography

11. Exercise radionuclide angiography

12. Dipyridamole or adenosine myocardial perfusion imaging

13. Dobutamine echocardiography

#### MAJOR OUTCOMES CONSIDERED

-   Signs and symptoms of coronary artery disease (CAD)

-   Left ventricular function

-   Predictive value of diagnostic tests

-   Sensitivity and specificity of diagnostic tests

-   Survival

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Since this document is based on the American College of
Cardiology/American Heart Association (ACC/AHA) guidelines, the American
College of Physicians (ACP) has maintained the levels of evidence
designated by the ACC/AHA in the recommendation statements:

**Levels of Evidence**

**Level A** recommendation is based on evidence from multiple randomized
clinical trials with large numbers of patients.

**Level B** recommendation is based on evidence from a limited number of
randomized trials with small numbers of patients, careful analyses of
nonrandomized studies, or observational registries.

**Level C** recommendation is based on expert consensus.

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

The guidelines were approved by the American College of Physicians Board
of Regents in January 2004.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

*Note from the National Guideline Clearinghouse (NGC)*: This guideline
is an update of the 1999 guideline on chronic stable angina, which was
published by the American College of Physicians (ACP) (then the American
College of Physicians-American Society of Internal Medicine) and the
American College of Cardiology/American Heart Association (ACC/AHA). In
2002, the ACC/AHA published an updated guideline, which the ACP
recognized as a scientifically valid review of the evidence and
background paper \[ACC/AHA 2002 guideline update for the management of
patients with chronic stable angina: a report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines
(Committee to Update the 1999 Guidelines for the Management of Patients
With Chronic Stable Angina)\]. This ACP guideline summarizes the
recommendations of the 2002 ACC/AHA updated guideline and underscores
the recommendations most likely to be important to physicians seeing
patients in the primary care setting. See the companion documents field
for a complete reference to the ACC/AHA guideline.

The levels of evidence (A, B, C) are defined at the end of the \"Major
Recommendations\" field.

**Estimating the Probability of Significant Coronary Artery Disease
(CAD)**

***Recommendation 1***: In patients presenting with chest pain, the
probability of CAD should be estimated on the basis of patient age, sex,
cardiovascular risk factors, and pain characteristics (**level of
evidence: B**). Patients with intermediate or high probability should
undergo risk stratification through further testing. For patients with a
low probability of CAD, the decision to pursue further testing should be
based on a shared discussion between the patient and clinician.

**Estimating Prognosis on the Basis of Resting Left Ventricular
Function**

***Recommendation 2***: The following patients who have chronic stable
angina or are asymptomatic should have left ventricular function
measured by resting echocardiography or resting radionuclide
angiography: patients with a history of myocardial infarction (MI),
patients with pathologic Q waves, patients with symptoms or signs
suggestive of heart failure, and patients with complex ventricular
arrhythmias (**level of evidence for all patients: B**).

**Exercise Testing for Diagnosis and Risk Stratification in Symptomatic
Patients with Intermediate to High Probability of CAD**

***Recommendation 3***: Exercise electrocardiography (ECG), using the
Bruce protocol and Duke treadmill score, should be the initial test for
risk stratification in patients with symptomatic chronic stable angina
who are able to exercise and are not taking digoxin (**level of
evidence: B**). Exercise ECG testing is also recommended after a
significant change in anginal pattern (**level of evidence: C**).
Exercise ECG testing is not recommended when the following confounding
factors are found on resting ECG: preexcitation
(Wolff--Parkinson--White) syndrome, electronically paced ventricular
rhythm, more than 1 mm of ST depression at rest, and complete left
bundle-branch block (**level of evidence for all factors: B**).

**Risk Stratification with Stress Imaging Studies (Radionuclide
Angiography and Echocardiography) in Symptomatic Patients**

***Recommendation 4***: For patients with chronic stable angina who are
able to exercise, do not have left bundle-branch block or an
electronically paced ventricular rhythm, and have abnormal results on
resting ECG or are using digoxin, exercise perfusion imaging or exercise
echocardiography is recommended as the initial test for risk
stratification (**level of evidence: B**).

***Recommendation 5***: For patients who are unable to exercise and do
not have left bundle-branch block or an electronically paced ventricular
rhythm, dipyridamole or adenosine myocardial perfusion imaging (**level
of evidence: B**) or dobutamine echocardiography (**level of evidence:
B**) is recommended as the initial test for risk stratification.

***Recommendation 6***: For patients with left bundle-branch block or
electronically paced ventricular rhythm, dipyridamole or adenosine
myocardial perfusion imaging is recommended regardless of ability to
exercise (**level of evidence: B**).

***Recommendation 7***: For patients with left bundle-branch block or
electronically paced ventricular rhythm, exercise or dobutamine
echocardiography (**level of evidence: C**) and exercise myocardial
perfusion imaging (**level of evidence: C**) are not recommended.

**Risk Stratification in Asymptomatic Patients**

*Note*: The American College of Cardiology/American Heart Association
(ACC/AHA+ recommends against \"screening\" asymptomatic outpatients for
coronary disease. However, the American College of Physicians (ACP)
recognizes the clinical reality that primary care physicians and
subspecialists are being consulted by asymptomatic patients who may have
been inappropriately screened and present with \"abnormal\" results on
ambulatory ECG monitoring, electron-beam computed tomography, or other
tests. Most of the recommendations in this section are based on level C
evidence, which denotes expert opinion from the ACC/AHA guideline. As a
matter of policy, the ACP seldom makes clinical policy recommendations
on the basis of expert opinion. However, this clinical situation has
become a particularly important problem for ACP membership. Therefore,
in the absence of any high-grade evidence (level A or B), the ACP has
chosen to endorse the following recommendations from the ACC/AHA
document, which in this case were developed by using expert opinion.

*Exercise ECG*

Asymptomatic patients who are able to exercise can usually be evaluated
with exercise ECG. In this case, the recommendations for exercise stress
testing for risk stratification in asymptomatic patients would be the
same as for symptomatic patients and would depend on patients´ ability
to exercise and the presence of abnormalities on resting ECG (see
Recommendations 2 and 3 above).

*Stress Imaging Studies (Radionuclide Angiography and Echocardiography)*

The recommendations for the use of stress imaging (exercise or
pharmacologic) in asymptomatic patients with abnormalities on ambulatory
ECG monitoring or electron-beam computed tomography are the same as for
symptomatic patients. They depend on whether the patient is able to
exercise or whether abnormalities on resting ECG are present. In this
case, the ACP recommends, on the basis of the opinion of the ACC/AHA,
several options for further workup of asymptomatic patients.

Recommended options for cardiac stress imaging after exercise ECG for
risk stratification in asymptomatic patients are as follows. Exercise
myocardial perfusion imaging or exercise echocardiography may be
performed in asymptomatic patients with an intermediate-risk or
high-risk Duke treadmill score on exercise ECG (**level of evidence:
C**). Adenosine or dipyridamole myocardial perfusion imaging or
dobutamine echocardiography may be performed in asymptomatic patients
with a previously inadequate exercise ECG (**level of evidence: C**).
Asymptomatic patients with a low-risk Duke treadmill score on exercise
ECG should not have exercise myocardial perfusion imaging, exercise
echocardiography, adenosine or dipyridamole myocardial perfusion
imaging, or dobutamine echocardiography (**level of evidence: C**).

**[Definitions]{.underline}**

**Levels of Evidence**

**Level A** recommendation is based on evidence from multiple randomized
clinical trials with large numbers of patients.

**Level B** recommendation is based on evidence from a limited number of
randomized trials with small numbers of patients, careful analyses of
nonrandomized studies, or observational registries.

**Level C** recommendation is based on expert consensus.

#### CLINICAL ALGORITHM(S)

Two updated clinical algorithms are provided in the original American
College of Physicians guideline document for the evaluation of suspected
coronary artery disease (CAD) and for exercise electrocardiography (EEG)
and angiography.

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of evidence supporting the recommendations is identified and
graded in the \"Major Recommendations\" field.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Estimating the probability of significant coronary artery disease in
patients with stable angina will guide all further decisions about
additional testing and management.

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   The American College of Physicians (ACP) has traditionally developed
    evidence-based guidelines. The College bases guideline
    recommendations on the results of systematic reviews of high-quality
    evidence (multiple, well-designed randomized, controlled trials) and
    meta-analyses where appropriate. In the absence of good evidence
    from randomized trials, the ACP will not make recommendations but
    will underscore practices that are not supported by evidence.

-   *Asymptomatic* refers to patients with known or suspected coronary
    disease based on history or evidence on electrocardiography (ECG) of
    previous myocardial infarction (MI), coronary angiography, or
    abnormal results on noninvasive tests. This in no way constitutes an
    endorsement of noninvasive testing in asymptomatic patients for the
    purposes of \"screening\" but rather acknowledges the clinical
    reality that patients often present after having such an evaluation.

-   **Note**: Clinical practice guidelines are \"guides\" only and may
    not apply to all patients and all clinical situations. Thus, they
    are not intended to override clinicians´ judgment. All American
    College of Physicians (ACP) clinical practice guidelines are
    considered automatically withdrawn or invalid, 5 years after
    publication or once an update has been issued.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Clinical Algorithm\
Patient Resources

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Living with Illness

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Snow V, Barry P, Fihn SD, Gibbons RJ, Owens DK, Williams SV, Weiss KB,
Mottur-Pilson C. Evaluation of primary care patients with chronic stable
angina: guidelines from the American College of Physicians. Ann Intern
Med 2004 Jul 6;141(1):57-64. \[36 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15238371)

#### ADAPTATION

The guideline summarizes the recommendations of the 2002 American
College of Cardiology/American Heart Association (ACC/AHA) guideline
update for the management of patients with chronic stable angina: a
report of the ACA/AHA Task Force on Practice Guidelines (Committee to
Update the 1999 Guidelines for the Management of Patients with Chronic
Stable Angina).

#### DATE RELEASED

2004 Jul 6

#### GUIDELINE DEVELOPER(S)

American College of Physicians - Medical Specialty Society

#### SOURCE(S) OF FUNDING

American College of Physicians (ACP)

#### GUIDELINE COMMITTEE

Clinical Efficacy Assessment Subcommittee of the American College of
Physicians (ACP)

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Authors*: Vincenza Snow, MD; Patricia Barry, MD, MPH; Stephan D. Fihn,
MD, MPH; Raymond J. Gibbons, MD; Douglas K. Owens, MD; Sankey V.
Williams, MD; Kevin B. Weiss, MD, MPH; Christel Mottur-Pilson, PhD

*Clinical Efficacy Assessment Subcommittee of the American College of
Physicians (ACP) Members*: Kevin B. Weiss, MD (Chair); Mark Aronson, MD;
Patricia Barry, MD; Thomas Cross Jr., MD, MPH; Nick Fitterman, MD; E.
Rodney Hornbake, MD; Douglas K. Owens, MD; Katherine D. Sherif, MD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

**Potential Financial Conflicts of Interest**: *Employment*: P. Barry
(Merck Institute of Aging and Health); *Consultancies*: R.J. Gibbons (CV
Therapeutics, DOV Pharmaceuticals, King Pharm, Medicure, Boehringer
Ingelheim, Hawaii Biotech, GlaxoSmithKline, TargeGen); *Stock ownership
or options (other than mutual funds)*: P. Barry (Merck & Co., Inc.);
*Grants received*: P. Barry (Merck Company Foundation), R.J. Gibbons
(Medtronic, King Pharm, Wyeth-Ayerst, Radiant Medical, Alsius Corp.,
TherOx, Innercool Therapies, Boston Scientific), S.V. Williams; *Grants
pending*: R.J. Gibbons (Boehringer Ingelheim)

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Gibbons RJ, Chatterjee K,
Daley J, Douglas JS, Fihn SD, Gardin JM, Grunwald MA, Levy D, Lytle BW,
O\'Rourke RA, Schafer WP, Williams SV, Ritchie JL, Cheitlin MD, Eagle
KA, Gardner TJ, Garson A Jr, Russell RO, Ryan TJ, Smith SC Jr.
ACC/AHA/ACP-ASIM guidelines 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. J Am Coll Cardiol
1999 Jun;33(7):2092-197.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the American College of Physicians
(ACP) Web site:

-   [HTML Format](http://www.annals.org/cgi/content/full/141/1/57)

-   [Portable Document Format
    (PDF)](http://www.annals.org/cgi/reprint/141/1/57.pdf)

Print copies: Available from the American College of Physicians (ACP),
190 N. Independence Mall West, Philadelphia PA 19106-1572.

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

The following is available:

-   Summaries for patients. Diagnosis and Evaluation of Patients with
    Chronic Stable Angina: Recommendations from the American College of
    Physicians.

Electronic copies: Available from the American College of Physicians
(ACP) Web site:

-   [HTML Format](http://www.annals.org/cgi/content/summary/141/1/57)

-   [Portable Document Format
    (PDF)](http://www.annals.org/cgi/summary_pdf/141/1/57.pdf)

Print copies: Available from the American College of Physicians (ACP),
190 N. Independence Mall West, Philadelphia PA 19106-1572.

Please note: This patient information is intended to provide health
professionals with information to share with their patients to help them
better understand their health and their diagnosed disorders. By
providing access to this patient information, it is not the intention of
NGC to provide specific medical advice for particular patients. Rather
we urge patients and their representatives to review this material and
then to consult with a licensed health professional for evaluation of
treatment options suitable for them as well as for diagnosis and answers
to their personal medical questions. This patient information has been
derived and prepared from a guideline for health care professionals
included on NGC by the authors or publishers of that original guideline.
The patient information is not reviewed by NGC to establish whether or
not it accurately reflects the original guideline\'s content.

#### NGC STATUS

This NGC summary was completed by ECRI on August 16, 2004. The
information was verified by the guideline developer on August 19, 2004.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

#### NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce,
approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced
under the auspices of medical specialty societies, relevant professional
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Guidelines represented on the NGC Web site are submitted by guideline
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<http://www.guideline.gov/about/inclusion.aspx> .

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008