Pre-test characteristics of unstable angina patients with obstructive coronary artery disease confirmed by coronary angiography (original) (raw)
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Anadolu kardiyoloji dergisi : AKD = the Anatolian journal of cardiology, 2007
In accordance with the AHA/ACC clinical practice guideline, the likelihood of acute ischemia caused by coronary artery disease (CAD) is to be determined as high, intermediate, or low for all patients presenting with chest discomfort. This study was conducted to estimate extent of significant CAD in patients with high and intermediate likelihood of unstable angina (UA) according to "AHA likelihood classification". Overall, 133 consecutive patients presented with symptoms or signs suggestive of UA, which was classified as of high or intermediate likelihood in Emergency Department (ED), and undergoing coronary angiography (CAG) within one week were enrolled into the study. The characteristics of the patients in either subgroup were compared in terms of the findings of the CAG. In patients with high likelihood of UA (n=89), CAG revealed that 62 had significant CAD, 7-moderate CAD, 20-mild CAD or normal coronary angiogram. In patients with intermediate likelihood of UA (n=19), ...
BMJ, 2006
Objectives To investigate the prognosis associated with stable angina in a contemporary population as seen in clinical practice, to identify the key prognostic features, and from this to construct a simple score to assist risk prediction. Design Prospective observational cohort study. Setting Pan-European survey in 156 outpatient cardiology clinics. Participants 3031 patients were included on the basis of a new clinical diagnosis by a cardiologist of stable angina with follow-up at one year. Main outcome measure Death or non-fatal myocardial infarction. Results The rate of death and non-fatal myocardial infarction in the first year was 2.3 per 100 patient years; the rate was 3.9 per 100 patient years in the subgroup (n = 994) with angiographic confirmation of coronary disease. The clinical and investigative factors most predictive of adverse outcome were comorbidity, diabetes, shorter duration of symptoms, increasing severity of symptoms, abnormal ventricular function, resting electrocardiogaphic changes, or not having any stress test done. Results of non-invasive stress tests did not significantly predict outcome in the population who had tests done. A score was constructed using the parameters predictive of outcome to estimate the probability of death or myocardial infarction within one year of presentation with stable angina. Conclusions A score based on the presence of simple, objective clinical and investigative variables makes it possible to discriminate effectively between very low risk and very high risk patients and to estimate the probability of death or non-fatal myocardial infarction over one year.
2010
We sought to determine whether clinical risk stratification correlates with the angiographic extent of coronary artery disease (CAD) in patient with unstable angina. BACKGROUND The Agency for Health Care Policy and Research (AHCPR) guidelines stratify patients with unstable angina according to short-term risk of myocardial infarction or death. Whether these guidelines are useful in predicting the extent of CAD is unknown. METHODS All residents of Olmsted County, Minnesota, undergoing emergency department evaluation from January 1, 1985 through December 31, 1992 for unstable angina without a history of prior coronary artery bypass grafting, and who underwent early angiography (within seven days of presentation) were classified into low, intermediate and high risk subgroups based on AHCPR criteria. RESULTS Seven hundred ninety-five patients underwent early angiography: 159 high risk, 572 intermediate risk and 64 low risk patients. Logistic regression analysis demonstrated that low risk patients had a greater likelihood of normal or mild CAD relative to intermediate risk (odds ratio [OR], 4.67; 95% confidence interval [CI], 2.70-8.06; p Ͻ 0.001) and high risk (OR, 11.1; 95% CI, 5.71-22.2; p Ͻ 0.001). Significant 1-, 2-, 3-vessel coronary disease or left main coronary disease was more likely in high relative to low risk (OR, 8.09; 95% CI, 4.22-15.5; p Ͻ 0.001), intermediate relative to low risk (OR, 4.11; 95% CI, 2.34-7.22; p Ͻ 0.001), and high relative to intermediate risk (OR, 1.97; 95% CI, 1.31-2.96; p ϭ 0.0012). CONCLUSIONS Among patients with unstable angina undergoing early coronary angiography, risk stratification according to the AHCPR guidelines correlates with the angiographic extent of CAD.
International Journal of Cardiology, 2005
Clinical and ECG prognostic markers, ischemic threshold (IT) and extent of coronary disease were analyzed in 383 patients with unstable angina (UA) and correlated with long-term events. Patients > 74 years or those with severe heart failure or previous revascularization procedures were excluded. There were 369 events in 245 patients: 87 deaths, 96 myocardial infarction (MI), 111 coronary artery bypass grafting (CABG), and 75 angioplasty procedures (PTCA). Follow-up was obtained in 367 hospital survivors (99%, 114 (44) months) and ST depression on admission ECG, a modest enzyme rise, refractory angina (>2 episodes), two to three vessel coronary disease and a reduced IT (V 130 beats/min) were each associated with cardiac events. A multivariate analysis, however, showed refractory angina (p < 0.001) and multivessel disease (p < 0.001) as most significant predictors. After their exclusion, IT was most relevant predictor (p < 0.001). However, the predictive value of these markers was essentially centered on first-year events (249, 67%). Moreover, refractory angina, minor enzyme rise and admission ST depression were each highly correlated with a reduced IT (p < 0.006) and with multivessel disease (p < 0.0001). Therefore, these findings underscore that the prognostic value of conventional clinical markers in patients with UA is limited to first-year events and that their remarkable correlation with extensive coronary disease and reduced coronary reserve reveal the anatomical substrate of this prognostic significance.
European Heart Journal, 2005
See page 949 for the editorial comment on this article (doi:10.1093/eurheartj/ehi294) Aims The Euro Heart Survey of Stable Angina set out to prospectively study the presentation and management of patients with stable angina as first seen by a cardiologist in Europe, with particular reference to adherence to existing guidelines and regional variability in patient presentation and initial assessment. Methods and results Consecutive outpatients with a clinical diagnosis by a cardiologist of stable angina were enrolled in the study and 3779 patients were included in the analysis. The average age was 61 years and 58% were male. The majority of patients (88%) had mild to moderate angina, CCS class I or II. Despite a high prevalence of recognized risk factors, 27% did not have cholesterol and 33% did not have glucose measured within 4 weeks of assessment. The resting ECG was abnormal in 41% of patients. An exercise ECG was performed or planned as part of initial investigation in 76% of patients and 18% had a stress imaging test such as perfusion scanning or stress echo. A coronary angiogram was performed or planned in 41%, and 64% had an echo. The time from assessment to investigation varied widely, particularly for angiography. One in 10 patients had neither any form of stress test nor angiography, with marked regional variation. Availability of invasive facilities increased the likelihood of both non-invasive and invasive investigations. Those with more severe symptoms or longer duration of symptoms or a positive non-invasive test were more likely to have angiography. In multivariable analysis, a positive stress test was the strongest predictor of the use of angiography, associated with a six-fold increase in the likelihood of invasive investigation. However, gender and availability of facilities were also predictive. Conclusion Considerable variation in features at presentation and use of investigations has been identified in the stable angina population in Europe. The evaluation of biochemical cardiovascular risk factors was suboptimal. Overall rates of non-invasive investigation for angina and the clinical appropriateness of factors predictive of the use of invasive investigation were broadly in line with guidelines. However, the influence of access to facilities, and marked international variation in rates and timing of investigation suggest that factors unrelated to clinical need are also influential in the management of patients with stable angina.
Journal of the American College of Cardiology, 2001
We sought to determine whether clinical risk stratification correlates with the angiographic extent of coronary artery disease (CAD) in patient with unstable angina. BACKGROUND The Agency for Health Care Policy and Research (AHCPR) guidelines stratify patients with unstable angina according to short-term risk of myocardial infarction or death. Whether these guidelines are useful in predicting the extent of CAD is unknown.
The value of routine non-invasive tests to predict clinical outcome in stable angina
European Heart Journal, 2003
Background Chronic stable angina is a common condition, but considerable differences exist in the likelihood of acute coronary events such as CHD death, non-fatal myocardial infarction (MI) and unstable angina between individual patients. Effective risk prediction is necessary for optimum management. The aim of this study was to identify clinical features and non-invasive test parameters associated with high risk of these coronary events in stable angina and compose a clinically useful model to predict adverse outcomes in this population. Methods Six hundred and eighty-two patients with stable angina and a positive exercise test (1 mm ST depression) from the Total Ischaemic Burden European Trial (TIBET) study, were studied. Resting ECG, exercise tolerance testing and echocardiography were performed at baseline, off anti-anginal therapy. The patients were then randomised to treatment with atenolol, nifedipine or a combination of both. Clinical follow up continued for an average of 2 years (range 1-3 years). Results and conclusions Prior MI or prior CABG were the clinical parameters associated with adverse outcome in patients with stable angina and a positive exercise test. On the ECG, left ventricular hypertrophy was predictive, and on echocardiogram, increased left ventricular dimensions were predictive of adverse events. When combined with time to ischaemia on exercise testing in a simple clinically applicable table these factors could be used to predict of 2 year probability of events for an individual patient.
A new clinical classification for hospital prognosis of unstable angina pectoris
The American Journal of Cardiology, 1995
Unstable angina represents a heterogeneous spectrum of clinical entities between chronic stable angina and acute myocardial infarction. To facilitate prognostication of in-hos ital outcome, we prospectively tested an a P riori unsta iI le an P ina classification scheme based on in ormation availab e at the time of acute presentation. Prospective database enrollment at the time of emergency room presentation was were classified into 1 of the fol owing categories: class P erformed and patients IA, acceleration of previous exertional angina without electrocardiographic (ECG) changes; class IB, acceleration of previous exertional angina with ECG changes; class II, new-onset exertional angina; class Ill, newonset rest angina; class IV, protracted rest angina with ECG changes. The study consisted of 1,387 consecutive patients with unstable angina. Baseline demographics and aggregate in-hospital major cardiac event rates U nstable angina is responsible for 750,000 admissions annually in the United States.' It has evolved into a broadly inclusionary term denoting a phase of coronary disease intermediate between chronic stable angina and acute myocardial infarction. Superimposition of thrombus on a ruptured atherosclerotic plaque is generally invoked as the pathogenesis of this syndrome.2-7 A surfeit of recent reports indicate that the likelihood for an adverse in-hospital prognosis is related to the severity of symptoms and the clinical presentation.*p1° No prospective studies of these interrelations have been reported in the modern era in large groups of patients. Given the emergence in the last decade of newer treatment strategies demonstrated to alter the prognosis in this disease, 1l it is imperative to reexamine the relation between symptoms and outcome in unstable angina.
Angina in Patients with Non-obstructive Coronary Angiograms: Six-years Follow-up
International Cardiovascular Forum Journal, 2017
Background About one third of patients undergoing coronary angiography for angina have non-obstructive coronary artery disease (CAD). Until recent years the prognosis has been thought to be favourable and no treatment were recommended. More recently, an increased risk of cardiovascular (CV) events has been documented in these patients compared with a general population. We aimed to evaluate the long term persistence of angina and the occurrence of major CV events in patients with stable angina and nonobstructive CAD. Methods We retrospectively evaluated all patients with effort angina referred to the cardiac catheterization laboratory of the Cardiovascular Unit, University of Catania, Sicily, between 1st July 2008 and 31st December 2009, because of a clinical suspicion of myocardial ischemia, without obstructive CAD, defined as <50% stenosis of left main stem or <70% in any epicardial coronary artery. Results Among 2574 patients (2025 men and 549 women) referred for diagnostic coronary angiography, 151 (5.8%) had non-obstructive coronary angiograms. Six-years follow-up was available in 127 patients (63 men and 64 women). Persistence of angina was reported in 20.4%. Four patients (3.1%) had acute myocardial infarction and two (1.6%) had stroke. Conclusions During a six-years follow-up, persistence of angina and occurrence of acute major CV events were found in a significant proportion of patients with stable angina and non-obstructive coronary angiograms.
European Heart Journal, 2018
Aims We hypothesized that the modified Diamond–Forrester (D-F) prediction model overestimates probability of coronary artery disease (CAD). The aim of this study was to update the prediction model based on pre-test information and assess the model’s performance in predicting prognosis in an unselected, contemporary population suspected of angina. Methods and results We included 3903 consecutive patients free of CAD and heart failure and suspected of angina, who were referred to a single centre for assessment in 2012–15. Obstructive CAD was defined from invasive angiography as lesion requiring revascularization, >70% stenosis or fractional flow reserve <0.8. Patients were followed (mean follow-up 33 months) for myocardial infarction, unstable angina, heart failure, stroke, and death. The updated D-F prediction model overestimated probability considerably: mean pre-test probability was 31.4%, while only 274 (7%) were diagnosed with obstructive CAD. A basic prediction model with ...