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There is general agreement that otherwise healthy patients in the following groups should undergo revascularization: (1) Patients with unacceptable symptoms despite medical therapy to its tolerable limits (2) Patients with left main coronary artery stenosis greater than 50% with or without symptoms (3) Patients with three-vessel disease with LV dysfunction (EF < 50% or previous transmural infarction) (4) Patients with unstable angina who after symptom control by medical therapy continue to exhibit ischemia on exercise testing or monitoring (5) Post-myocardial infarction patients with continuing angina or severe ischemia on noninvasive testing (See sections on Acute Coronary Syndromes and Myocardial Infarction) In addition, many cardiologists have believed that patients with less severe symptoms should be revascularized if they have two-vessel disease associated with underlying LV dysfunction, anatomically critical lesions (> 90% proximal stenoses, especially of the proximal left anterior descending artery), or physiologic evidence of severe ischemia (early positive exercise tests, large exercise-induced thallium scintigraphic defects, or frequent episodes of ischemia on ambulatory monitoring) While this trend toward aggressive intervention has accelerated as a result of the growing use of coronary angioplasty and stenting, two sources of data have tempered some of the enthusiasm for coronary intervention for stable angina Drug-eluting stents, widely used because of their benefits in preventing restenosis, have been associated with higher rates of late stent thrombosis In addition, data from the COURAGE trial has shown that for most patients with chronic angina, percutaneous coronary intervention (PCI) offers limited benefits beyond excellent medical therapy

5 % amount of depression (in mm) = ____________________

Annual Mortality 025% 125% 525%

11 Mechanical extracorporeal counterpulsation Extracorporeal counterpulsation (ECP) entails repetitive inflation of a high-pressure chamber surrounding the lower half of the body during the diastolic phase of the cardiac cycle for daily 1-hour sessions over a period of 7 weeks Randomized trials have shown that ECP reduces angina, improves exercise tolerance, and can reduce symptoms of heart failure 12 Neuromodulation Spinal cord stimulation has been used for many years to relieve various pain syndromes, including chronic refractory angina Modern spinal cord stimulators are entirely subcutaneously implantable via a minimally invasive procedure under local anesthesia

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The prognosis of angina pectoris has improved with development of therapies aimed at secondary prevention Mortality rates vary depending on the number of vessels diseased, the severity of obstruction, the status of LV function, and the presence of complex arrhythmias The outlook in individual patients is unpredictable, and nearly half of the deaths are sudden Therefore, risk stratification is often attempted Patients with accelerating symptoms have a poorer outlook Among stable patients, those whose exercise tolerance is severely limited by ischemia (less than 6 minutes on the Bruce treadmill protocol) and those with extensive ischemia by exercise ECG or scintigraphy have more severe anatomic disease and a poorer prognosis The Duke Treadmill Score, based on a standard Bruce protocol exercise treadmill test, provides an estimate of risk of death at 1 year The score uses time on the treadmill, amount of ST-segment depression, and presence of angina (Table 10 3)

3:

Chaitman BR et al; Combination Assessment of Ranolazine In Stable Angina (CARISA) Investigators Effects of ranolazine with atenolol, amlodipine, or diltiazem on exercise tolerance and angina frequency in patients with severe chronic angina: a randomized controlled trial JAMA 2004 Jan 21;291(3): 309 16 [PMID: 14734593] Gibbons RJ et al ACC/AHA 2002 guideline update for the management of patients with chronic stable angina summary article: a report of the American College of Cardiology/ American Heart Association Task Force on practice guidelines (Committee on the Management of Patients With Chronic Stable Angina) J Am Coll Cardiol 2003 Jan 1;41(1): 159 68 [PMID: 12570960]

Coronary artery bypass grafting (CABG) can be accomplished with a very low mortality rate (1 3%) in otherwise healthy patients with preserved cardiac function However, the mortality rate of this procedure rises to 4 8% in older individuals and in patients who have had a prior CABG Increasingly, younger individuals with focal lesions of one or several vessels are undergoing coronary angioplasty as the initial revascularization procedure Grafts using one or both internal mammary arteries (usually to the left anterior descending artery or its branches) provide the best long-term results in terms of patency and flow Segments of the saphenous vein (or, less optimally, other veins) or the radial artery interposed between the aorta and the coronary arteries distal to the obstructions are also used One to five distal anastomoses are commonly performed After successful surgery, symptoms generally abate The need for antianginal medications diminishes, and LV function may improve Minimally invasive surgical techniques utilize different approaches to the heart than standard sternotomy and

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