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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 ...