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A systematic search of the medical literature was performed in January 2008. The search, limited to human subjects and English language journals, included the National Guideline Clearinghouse, the Cochrane database, PubMed, UpToDate®, and PIER. The current American College of Cardiology (ACC)/American Heart Association (AHA) 2007 Chronic Angina Focused Update of the 2002 Guidelines for the Management of Patients with Chronic Stable Angina can be found at www.acc.org.

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Ischemic heart disease remains a major health problem. Chronic stable angina is the first manifestation of ischemic heart disease in approximately 50% of patients.1–3 The reported yearly incidence of angina is 213 per 100000, in the population that comprise more than 30 years of age.4 The prevalence of angina can also be determined by extrapolating from the number of myocardial infarctions (MIs) in the United States.5 Thus, the number of patients with stable angina can be calculated as 30 × 550000 or 16.5 million.2,3 This approximation does not include patients who fail to seek medical attention for their chest pain, or who are shown to have a noncardiac cause of chest discomfort.2,3

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Despite a recent reduction in cardiovascular deaths, ischemic heart disease is still the leading cause of mortality in the United States and causes one of every 4.8 deaths.6 Many patients are hospitalized for the assessment and treatment of stable chest pain syndromes and many patients with chronic stable angina are unable to perform normal activities for varying periods of hours or days, and thus have a diminished quality of life. The economic costs of chronic coronary heart disease (CHD) are enormous with direct costs of hospitalization exceeding $15 billion a year.7

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The main objective of this chapter is to discuss the usefulness of noninvasive tests for the cost-effective diagnosis and risk stratification of patients with suspected or definite CHD, emphasizing the role of various imaging modalities for both diagnosis and risk stratification, the difference between the two often being arbitrary.

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It must be emphasized that not every patient needs every test and that a markedly positive low-level electrocardiogram (ECG) exercise test precludes the need for additional more costly imaging studies prior to coronary angiography and likely myocardial revascularization. The use of additional noninvasive imaging tests in this situation is usually financially driven. The management of patients with symptomatic and asymptomatic CHD will be discussed in detail. In general, when myocardial ischemia is produced, an ischemic cascade occurs. Regional diastolic and systolic dysfunction precede global diastolic and then systolic dysfunction, which in turn often occurs prior to changes in ECG and before the symptoms of angina pectoris (Fig. 3-1). Noninvasive testing is often useful in detecting ischemia. The detection of left-ventricular (LV) diastolic dysfunction by Doppler mitral valve recording or by diastolic filling curves using radionuclide ventriculography has many limitations. The prevalence of MI, unstable angina, variant angina, and silent ischemia ...

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