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稳定型缺血性心脏病的诊断

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稳定型缺血性心脏病的诊断 Diagnosis of Stable Ischemic Heart Disease: Summary of a Clinical Practice Guideline From the American College of Physicians/American College of Cardiology Foundation/American Heart Association/ American Association for Thoracic Surgery/Preventive Cardiovascular Nu...
稳定型缺血性心脏病的诊断
Diagnosis of Stable Ischemic Heart Disease: Summary of a Clinical Practice Guideline From the American College of Physicians/American College of Cardiology Foundation/American Heart Association/ American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons Amir Qaseem, MD, PhD, MHA; Stephan D. Fihn, MD, MPH; Sankey Williams, MD; Paul Dallas, MD; Douglas K. Owens, MD, MS; and Paul Shekelle, MD, PhD, for the Clinical Guidelines Committee of the American College of Physicians* Description: The American College of Physicians (ACP) developed this guideline in collaboration with the American College of Cardi- ology Foundation (ACCF), American Heart Association (AHA), American Association for Thoracic Surgery, Preventive Cardiovascu- lar Nurses Association, and Society of Thoracic Surgeons to help clinicians diagnose known or suspected stable ischemic heart disease. Methods: Literature on this topic published before November 2011 was identified by using MEDLINE, Embase, Cochrane CENTRAL, PsychINFO, AMED, and SCOPUS. Searches were limited to human studies published in English. This guideline grades the evidence and recommendations according to a translation of the ACCF/AHA grading system into ACP’s clinical practice guidelines grading system. Recommendations: This guideline includes 28 recommendations that address the following issues: the initial diagnosis of the patient who might have stable ischemic heart disease, cardiac stress testing to assess the risk for death or myocardial infarction in patients diagnosed with stable ischemic heart disease, and coronary angiog- raphy for risk assessment. Ann Intern Med. 2012;157:729-734. www.annals.org For author affiliations, see end of text. EXECUTIVE SUMMARY This guideline presents the available evidence on the diagnosis of stable known or suspected ischemic heart dis- ease (IHD). This is the first of 2 guidelines addressing stable IHD; the second guideline addresses the manage- ment of patients with stable IHD (1). Internists and other primary care physicians are the target audiences for this guideline. The target population is all adult patients with stable known or suspected IHD. These recommendations are based on the joint American College of Cardiology Foundation (ACCF), American Heart Association (AHA), American College of Physicians (ACP), American Associa- tion for Thoracic Surgery (AATS), Preventive Cardiovas- cular Nurses Association (PCNA), Society for Cardiovas- cular Angiography and Interventions (SCAI), and Society of Thoracic Surgeons (STS) guideline for the diagnosis and management of patients with stable IHD published in 2012, which ACP recognized as a scientifically valid, high- quality review of the evidence (2). Full details about meth- ods and evidence are available in the Appendix at www .annals.org. Methods The databases used for the literature search included MEDLINE, Embase, Cochrane CENTRAL, PsychINFO, AMED, and SCOPUS for studies published up until No- vember 2011. The criteria for search included human partic- ipants and English-language articles. For more details on the methods, refer to the Appendix and the ACCF, AHA, ACP, AATS, PCNA, SCAI, and STS guideline for the diagnosis and management of patients with stable IHD (2). * This paper, written by Amir Qaseem, MD, PhD, MHA; Stephan D. Fihn, MD, MPH; Sankey Williams, MD; Paul Dallas, MD; Douglas K. Owens, MD, MS; and Paul Shekelle, MD, PhD, was developed for the Clinical Guidelines Committee of the American College of Physicians: Paul Shekelle, MD, PhD (Chair); Roger Chou, MD; Molly Cooke, MD; Paul Dallas, MD; Thomas D. Denberg, MD, PhD; Nick Fitterman, MD; Mary Ann Forciea, MD; Robert H. Hopkins Jr., MD; Linda L. Humphrey, MD, MPH; Tanveer P. Mir, MD; Holger J. Schu¨nemann, MD, PhD; Donna E. Sweet, MD; and Timothy Wilt, MD, MPH. Approved by the ACP Board of Regents on 16 April 2012. See also: Print Related article. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 735 Editorial comment. . . . . . . . . . . . . . . . . . . . . . . . . . 749 Summary for Patients. . . . . . . . . . . . . . . . . . . . . . . I-42 Web-Only Appendix: Full Guideline Summary CME quiz (preview on page I-34) Clinical Guideline © 2012 American College of Physicians 729 Downloaded From: http://annals.org/ on 11/19/2012 医 脉 通 ww w. me dl iv e. cn Because this document is based on the joint guideline, ACP translated the ACCF/AHA evidence and recommen- dation grades into ACP’s guideline grading system (3) (Tables 1 and 2). We included only class I and class III statements from the joint guideline because the evidence for these statements very clearly demonstrates the tradeoff between benefits and harms (Table 2). For details on other recommendations, refer to the ACCF, AHA, ACP, AATS, PCNA, SCAI, and STS guideline for the diagnosis and management of patients with stable IHD (2). The objective of this guideline is to synthesize the ev- idence for the following key questions: 1: How should a clinician evaluate a patient with chest pain that is consistent with IHD? 2: What is the role of noninvasive testing in the diag- nosis of stable IHD? Recommendations In interpreting these recommendations, it is important to distinguish between the probability of having IHD and the probability (risk) of death or myocardial infarction once the diagnosis of IHD is established. Initial Cardiac Testing to Establish Diagnosis of IHD Recommendation 1: The organizations recommend that patients with chest pain should receive a thorough history and physical examination to assess the probability of IHD prior to additional testing (Grade: strong recommendation; low- quality evidence). Recommendation 2: The organizations recommend that choices regarding diagnostic and therapeutic options should be made through a process of shared decision making involving the patient and provider, explaining information about risks, benefits, and costs to the patient (Grade: strong recommenda- tion; low-quality evidence). Recommendation 3: The organizations recommend that patients who present with acute angina must be categorized as stable or unstable; patients with unstable angina should be further categorized as high, moderate, or low risk (Grade: strong recommendation; low-quality evidence). Recommendation 4: The organizations recommend a rest- ing electrocardiography (ECG) in patients without an obvious noncardiac cause of chest pain for risk assessment (Grade: strong recommendation; moderate-quality evidence). Recommendation 5: The organizations recommend stan- dard exercise ECG for initial diagnosis in patients with an intermediate pretest probability of IHD who have an inter- pretable ECG and at least moderate physical functioning or no disabling comorbidity (Grade: strong recommendation; high- quality evidence). Recommendation 6: The organizations recommend that exercise stress with radionuclide myocardial perfusion imaging or echocardiography should be used for patients with an inter- mediate to high pretest probability of IHD that have an un- interpretable ECG and at least moderate physical functioning or no disabling comorbidity (Grade: strong recommendation; moderate-quality evidence). Recommendation 7: The organizations recommend that pharmacologic stress with radionuclide myocardial perfusion imaging, echocardiography, or cardiac magnetic resonance im- aging should not be used for patients who have an interpreta- ble ECG and at least moderate physical functioning or no Table 1. The American College of Physicians’ Guideline Grading System* Quality of Evidence Strength of Recommendation Benefits Clearly Outweigh Risks and Burden or Risks and Burden Clearly Outweigh Benefits Benefits Finely Balanced With Risks and Burden High Strong Weak Moderate Strong Weak Low Strong Weak Insufficient evidence to determine net benefits or risks * Adopted from the classification developed by the GRADE (Grading of Recom- mendations Assessment, Development, and Evaluation) workgroup. Table 2. Comparison of Grading Systems From the ACP and ACCF/AHA ACP’s Grading System ACCF/AHA’s Grading System (Size vs. Certainty) Description Grade (For or Against Intervention) Grade Class Recommendation Evidence For Against Benefits clearly outweigh risks and burden or vice versa Strong High-quality A I III Benefits clearly outweigh risks and burden or vice versa Strong Moderate-quality B I III Benefits clearly outweigh risks and burden or vice versa Strong Low-quality C I III Benefits closely balanced with risks and burden Weak High-quality A IIa, IIb NER Benefits closely balanced with risks and burden Weak Moderate-quality B IIa, IIb NER Uncertainty, benefits may be closely balanced with risks and burden Weak Low-quality C IIa, IIb NER ACCF � American College of Cardiology Foundation; ACP � American College of Physicians; AHA � American Heart Association; NER � no equivalent rating. Clinical Guideline Diagnosis of Stable Ischemic Heart Disease 730 20 November 2012 Annals of Internal Medicine Volume 157 • Number 10 www.annals.org Downloaded From: http://annals.org/ on 11/19/2012 医 脉 通 ww w. me dl iv e. cn disabling comorbidity (Grade: strong recommendation; low- quality evidence). Recommendation 8: The organizations recommend that exercise stress with nuclear myocardial perfusion imaging should not be used as an initial test in low-risk patients who have an interpretable ECG and at least moderate physical functioning or no disabling comorbidity (Grade: strong recom- mendation; low-quality evidence). Recommendation 9: The organizations recommend phar- macologic stress with radionuclide myocardial perfusion imag- ing or echocardiography for patients with an intermediate to high pretest probability of IHD who are incapable of at least moderate physical functioning or with disabling comorbidity (Grade: strong recommendation; moderate-quality evidence). Recommendation 10: The organizations recommend that standard exercise ECG testing should not be used for patients that have an uninterpretable ECG or are incapable of at least moderate physical functioning or with disabling comorbidity (Grade: strong recommendation; low-quality evidence). Recommendation 11: The organizations recommend as- sessing resting left ventricular systolic and diastolic ventricular function and evaluating for abnormalities of myocardium, heart valves, or pericardium using Doppler echocardiography in patients with known or suspected IHD and a prior myo- cardial infarction, pathologic Q waves, symptoms or signs sug- gestive of heart failure, complex ventricular arrhythmias, or an undiagnosed heart murmur (Grade: strong recommendation; moderate-quality evidence). Recommendation 12: The organizations recommend that echocardiography, radionuclide imaging, cardiac magnetic res- onance imaging, or cardiac computed tomography should not be used for routine assessment of left ventricular function in patients with a normal ECG, no history of myocardial infarc- tion, no symptoms or signs suggestive of heart failure, and no complex ventricular arrhythmias (Grade: strong recommenda- tion; low-quality evidence). Recommendation 13: The organizations recommend that routine reassessment (�1 year) of left ventricular function using technologies such as echocardiography radionuclide im- aging, cardiac magnetic resonance imaging, or cardiac com- puted tomography should not be used in patients with no change in clinical status and for whom no change in therapy is contemplated (Grade: strong recommendation; low-quality evidence). Cardiac Stress Testing to Assess Risk in Patients With Known Stable IHD Who Are Able to Exercise Recommendation 14: The organizations recommend standard exercise ECG testing for risk assessment in patients who are able to exercise to an adequate workload and have an ECG that can be interpreted during exercise (Grade: strong recommendation; moderate-quality evidence). Recommendation 15: The organizations recommend the addition of either radionuclide myocardial perfusion imaging or echocardiography to standard exercise ECG testing for risk assessment, in patients with stable IHD who are able to exer- cise to an adequate workload but have an uninterpretable ECG not due to left bundle branch block or ventricular pacing (Grade: strong recommendation; moderate-quality evidence). Recommendation 16: The organizations recommend that pharmacologic stress imaging (radionuclide myocardial perfu- sion imaging, echocardiography, cardiac magnetic resonance imaging) or cardiac computed tomography angiography should not be used for risk assessment in patients with stable IHD who are able to exercise to an adequate workload and have an interpretable ECG (Grade: strong recommendation; low- quality evidence). Cardiac Stress Testing to Assess Risk in Patients With Known Stable IHD Who Are Unable to Exercise Recommendation 17: The organizations recommend pharmacologic stress with either radionuclide myocardial per- fusion imaging or echocardiography for risk assessment in pa- tients who are unable to exercise to an adequate workload regardless of interpretability of ECG (Grade: strong recom- mendation; moderate-quality evidence). Cardiac Stress Testing to Assess Risk in Patients With Stable IHD Regardless of Ability to Exercise Recommendation 18: The organizations recommend pharmacologic stress with either radionuclide myocardial perfusion imaging or echocardiography for risk assessment in patients with stable IHD who have left bundle branch block on ECG, regardless of ability to exercise to an ade- quate workload (Grade: strong recommendation; moderate- quality evidence). Recommendation 19: The organizations recommend ei- ther exercise or pharmacological stress with imaging (radionu- clide myocardial perfusion imaging, echocardiography, or car- diac magnetic resonance) for risk assessment in patients being considered for revascularization of known coronary stenosis of unclear physiologic significance (Grade: strong recommenda- tion; moderate-quality evidence). Recommendation 20: The organizations recommend that a) more than 1 stress imaging study or b) a stress imaging study and cardiac computed tomography angiography at the same time should not be used for risk assessment in patients with stable IHD (Grade: strong recommendation; low-quality evidence). Coronary Angiography as an Initial Testing Strategy to Assess Risk in Patients With Stable IHD Recommendation 21: The organizations recommend that patients with stable IHD who have survived sudden cardiac death or potentially life-threatening ventricular arrhythmia undergo coronary angiography to assess cardiac risk (Grade: strong recommendation; moderate quality-evidence). Recommendation 22: The organizations recommend that patients with stable IHD who develop symptoms and signs of heart failure should be evaluated to determine whether coro- Clinical GuidelineDiagnosis of Stable Ischemic Heart Disease www.annals.org 20 November 2012 Annals of Internal Medicine Volume 157 • Number 10 731 Downloaded From: http://annals.org/ on 11/19/2012 医 脉 通 ww w. me dl iv e. cn Figure 1. Diagnosis of patients suspected of having ischemic heart disease. Symptoms or finding suggest high-risk lesion(s)† OR Prior sudden death or serious ventricular arrhythmia OR Prior stent in unprotected left main coronary artery Suspected ischemic heart disease (or change in clinical status in a patient with known IHD) Intermediate- or high-risk UA?* Recent exercise or cardiac imaging studyTechnically adequate? See ACCF/AHA UA/NSTEMI guideline Pharmacologic stress echo Pharmacologic stress MPI or echo Pharmacologic CMR or CCTA MPI or echo with exercise or pharmacologic CMR Initiate guideline- directed medical therapy See Figure 1 of reference 1 Consider coronary revascularization to improve symptoms See Figure 3 of reference 1 Initiate guideline- directed medical therapy Consider coronary revascularization to improve survival See Figure 1 of reference 1 Regular monitoring MPI or echo with exercise Resting ECG interpretable? Standard exercise ECG Standard exercise ECG CCTA Comprehensive clinical assessment of risk, including personal characteristics, coexisting cardiac and medical conditions, and health status No No Contraindications to stress testing? No Patient able to exercise? Yes Yes Previous coronary revascularization? No No Yes Yes No Yes Yes No Successful treatment? Yes Low- likelihood IHD Test results suggest high-risk coronary lesion(s)? Intermediate- likelihood IHD Intermediate- to high- likelihood IHD Yes Yes OR OR No No No Yes Low- likelihood IHD Intermediate- to high- likelihood IHD CCTA � computed coronary tomography angiography; CMR � cardiac magnetic resonance; ECG � electrocardiogram; echo � echocardiography; IHD � ischemic heart disease; MPI � myocardial perfusion imaging; UA � unstable angina; UA/NSTEMI � unstable angina/non–ST-segment elevation myocardial infarction. * See Table 2 of reference 2 for short-term risk of death or nonfatal myocardial infarction in patients with UA/NSTEMI. † CCTA is reasonable only for patients with intermediate probability of IHD. Clinical Guideline Diagnosis of Stable Ischemic Heart Disease 732 20 November 2012 Annals of Internal Medicine Volume 157 • Number 10 www.annals.org Downloaded From: http://annals.org/ on 11/19/2012 医 脉 通 ww w. me dl iv e. cn nary angiography should be performed for risk assessment (Grade: strong recommendation; moderate quality-evidence). Recommendation 23: The organizations recommend that patients with stable IHD and clinical characteristics that in- dicate a high likelihood of severe IHD should undergo coro- nary angiography to assess cardiac risk (Grade: strong recom- mendation; low-quality evidence). Coronary Angiography to Assess Risk After Initial Workup With Noninvasive Testing Recommendation 24: The organizations recommend that coronary arteriography should be used for risk assess- ment in patients with stable IHD whose clinical character- istics and results of noninvasive testing indicate a high likelihood of severe IHD and when the benefits are deemed to exceed risk (Grade: strong recommendation; low-quality evidence). Recommendation 25: The organizations recommend that coronary angiography for risk assessment should not be utilized for stable IHD patients who elect not to undergo revascular- ization or who are not candidates for revascularization based on comorbidities or individual preferences (Grade: strong rec- ommendation; moderate-quality evidence). Recommendation 26: The organizations recommend that coronary angiography should not be used to further assess risk in patients with stable IHD who have preserved left ventric- Figure 2. Risk assessment of patients with stable ischemic heart disease. Yes Known ischemic heart disease Patient able to exercise? Resting ECG interpretable? Pharmacologic stress CMR or CCTA Pharmacologic stress MPI or echo YesNo OROR OR Consider coronary revascularization to improve survival See Figur e 2 of reference 1 Observe response to guideline- directed medical therapy See Figure 1 of reference 1 Consider coronary revascularization to improve symptoms See Figur e 3 of reference 1 NoYes Pharmacologic stress CMR Standard exercise text MPI or echo with exercise Regular monitoring Pharmacologic MPI, echo, CCTA, or CMR MPI or echo with exercise MPI or echo with exercise Special circumstances (irrespective of ability to exercise) Test results suggest high-risk coronary lesion(s)? LBBB on ECG? Indeterminate result from functional testing Known stenosis of unclear significance being considered for revascularization No No No Yes Yes Yes Yes No CCTA Successful treatment? CCTA � coronary computed tomography angiography; CMR � cardi
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