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Preamble Guidelines and Expert Consensus Documents aim to present management recommendations based on all the relevant evidences on a particular subject in order to help physicians to select the best possible management strategies for the individual patient, suffering from a specific condition, not only taking into account the impact on outcome, but also the risk–benefit ratio of a particular diagnostic or therapeutic procedure. Numerous studies have demonstrated that patient outcomes improve when guideline recommendations, based on the rigorous assessment of evidence-based research, are applied in clinical practice. A great number of Guidelines and Expert Consensus Documents have been issued in recent years by the European Society of Cardiology (ESC) and also by other organizations or related societies. The profusion of documents can put at stake the authority and credibility of guidelines, particularly if discrepancies appear between different documents on the same issue, as this can lead to confusion in the minds of physicians. To avoid these pitfalls, the ESC and other organizations have issued recommendations for formulating and issuing the Guidelines and Expert Consensus Documents. The ESC recommendations for guidelines production can be found on the ESC website (www.escardio.org).

It is beyond the scope of this preamble to recall all but the basic rules. In brief, the ESC appoints experts in the field to carry out a comprehensive review of the literature, with a view to making a critical evaluation of the use of diagnostic and therapeutic procedures and assessing the risk–benefit ratio of the therapies recommended for the management and/or prevention of a given condition. Estimates of expected health outcomes are included, where data exist. The strength of evidence for or against particular procedures or treatments is weighed, according to the pre-defined scales for grading recommendations and levels of evidence, as outlined subsequently. The Task Force members of the writing panels, as well as the document reviewers, are asked to provide disclosure statements of all relationships they may have which might be perceived as real or potential conflicts of interest. These disclosure forms are kept on file at the European Heart House, Headquarters of the ESC and can be made available by written request to the ESC President.

Any changes in conflict of interest that arise during the writing period must be notified to the ESC. Guidelines and recommendations are presented in formats that are easy to interpret. They should help physicians to make clinical decisions in their daily routine by describing the range of generally acceptable approaches to diagnosis and treatment. However, the ultimate judgement regarding the care of an individual patient must be made by the physician in charge of his/her care. The ESC Committee for Practice Guidelines (CPG) supervises and coordinates the preparation of new Guidelines and Expert Consensus Documents produced by the Task Forces, expert groups, or consensus panels. The committee is also responsible for the endorsement of these Guidelines and Expert Consensus Documents or statements.

Once the document has been finalized and approved by all the experts involved in the Task Force, it is submitted to outside specialists for review. In some cases, the document can be presented to a panel of key opinion leaders in Europe, specialists in the relevant condition at hand, for discussion and critical review. If necessary, the document is revised once more and finally approved by the CPG and selected members of the Board of the ESC and subsequently published.

After publication, dissemination of the message is of paramount importance. Publication of executive summaries and the production of pocket-sized and PDA-downloadable versions of the recommendations are helpful.

However, surveys have shown that the intended end-users are often not aware of the existence of guidelines or simply don't put them into practice. Implementation programmes are thus necessary and form an important component of the dissemination of the knowledge. Meetings are organized by the ESC and directed towards its member National Societies and key opinion leaders in Europe.

Implementation meetings can also be undertaken at a national level, once the guidelines have been endorsed by the ESC member societies and translated into the local language, when necessary. Classes of recommendations. Class I Evidence and/or general agreement that a given diagnostic procedure/treatment is beneficial, useful, and effective Class II Conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of the treatment or procedure Class IIa Weight of evidence/opinion is in favour of usefulness/efficacy Class IIb Usefulness/efficacy is less well established by evidence/opinion; Class III Evidence or general agreement that the treatment or procedure is not useful/effective and in some cases may be harmful. Class I Evidence and/or general agreement that a given diagnostic procedure/treatment is beneficial, useful, and effective Class II Conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of the treatment or procedure Class IIa Weight of evidence/opinion is in favour of usefulness/efficacy Class IIb Usefulness/efficacy is less well established by evidence/opinion; Class III Evidence or general agreement that the treatment or procedure is not useful/effective and in some cases may be harmful. Altogether, the task of writing Guidelines or Expert Consensus Document covers not only the integration of the most recent research, but also the creation of educational tools and the implementation programmes for the recommendations. The loop between clinical research, writing of guidelines, and implementing them into clinical practice can only be completed if surveys and registries are organized to verify that actual clinical practice is in keeping with what is recommended in the guidelines.

Such surveys and registries also make it possible to check the impact of strict implementation of the guidelines on patient outcome. Classes of recommendations.

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Introduction Stable angina pectoris is a common and sometimes disabling disorder. The development of new tools for the diagnostic and prognostic assessments of patients, along with the continually evolving evidence base for various treatment strategies, mandates that existing guidelines be revised and updated. Therefore, the Task Force has obtained opinions from a wide variety of experts and has tried to achieve agreement on the best contemporary approaches to the care of stable angina pectoris, bearing in mind not only the efficacy and safety of treatments, but also the cost and the availability of resources. The Task Force has taken the view that these guidelines should reflect the pathophysiology and management of angina pectoris caused by myocardial ischaemia due to coronary artery disease (CAD), usually macrovascular but also microvascular in some of the patients. Furthermore, this Task Force does not deal with primary prevention, which has already been covered in other recently published guidelines and has limited its discussion on secondary prevention. Recently published guidelines and consensus statements that overlap to a considerable extent with the remit of this document are listed in the complete version of the guidelines available on-line.

Definition and pathophysiology Stable angina is a clinical syndrome characterized by discomfort in the chest, jaw, shoulder, back, or arms, typically elicited by exertion or emotional stress and relieved by rest or nitroglycerin. Less typically, discomfort may occur in the epigastric area.

It is usual to confine the term to the cases in which the syndrome can be attributed to myocardial ischaemia, although essentially similar symptoms can be caused by disorders of the oesophagus, lungs, or chest wall. Although the most common cause of myocardial ischaemia is atherosclerotic CAD, demonstrable myocardial ischaemia may be induced by hypertrophic or dilated cardiomyopathy, aortic stenosis, or other rare cardiac conditions in the absence of obstructive atheromatous coronary disease, which are not considered in this document. Epidemiology The prevalence of angina increases sharply with age in both sexes from 0.1–1% in women aged 45–54 to 10–15% in women aged 65–74 and from 2–5% in men aged 45–54 to 10–20% in men aged 65–74. Therefore, it can be estimated that in most European countries, 20 000–40 000 individuals of the population per million suffer from angina. Natural history and prognosis Information on the prognosis associated with chronic stable angina is derived from long-term prospective population-based studies, clinical trials of anti-anginal therapy, and observational registries, with selection bias, an important factor to consider when evaluating and comparing the available data. Data from the Framingham Heart Study, showed that for men and women with an initial clinical presentation of stable angina, the 2-year incidence rates of non-fatal myocardial infarction and coronary heart disease (CHD) death were 14.3 and 5.5% in men and 6.2 and 3.8% in women, respectively.

More contemporary data from the clinical trials of anti-anginal therapy and/or revascularization estimate the annual mortality rate to range from 0.9 to 1.4% per annum, with an annual incidence of non-fatal MI between 0.5% (INVEST) and 2.6% (TIBET). These estimates are consistent with the observational registry data. However, within the population with stable angina, an individual's prognosis can vary considerably, up to 10-fold, depending on baseline clinical, functional, and anatomical factors, emphasizing the importance of careful risk stratification. Virtual Dj Dancehall Sound Effects Free Download. Diagnosis and assessment Diagnosis and assessment of angina involve clinical assessment, laboratory tests, and specific cardiac investigations. Clinical assessment related to diagnosis and basic laboratory investigations are dealt with in this section. Cardiac specific investigations may be non-invasive or invasive and may be used to confirm the diagnosis of ischaemia in patients with suspected stable angina, to identify or exclude associated conditions or precipitating factors for risk stratification and to evaluate the efficacy of treatment.

In practice, diagnostic and prognostic assessments are conducted in tandem rather than separately, and many of the investigations used for the diagnosis also offer prognostic information. For the purposes of description and presentation of the evidence, the individual investigative techniques are discussed subsequently with recommendations for diagnosis. Specific cardiac investigations routinely used for risk stratification purposes are discussed separately in the subsequent section. An algorithm for the initial evaluation of patients presenting with clinical symptoms suggestive of angina is depicted in Figure.

Algorithm for the initial evaluation of patients with clinical symptoms of angina. Symptoms and signs A careful history remains the cornerstone of the diagnosis of angina pectoris. In the majority of cases, it is possible to make a confident diagnosis on the basis of the history alone, although physical examination and objective tests are necessary to confirm the diagnosis and assess the severity of underlying disease. The characteristics of discomfort related to myocardial ischaemia (angina pectoris) have been extensively described and may be divided into four categories: location, character, duration and relation to exertion, and other exacerbating or relieving factors.

The discomfort caused by myocardial ischaemia is usually located in the chest, near the sternum, but may be felt anywhere from the epigastrium to the lower jaw or teeth, between the shoulder blades or in either arm to the wrist and fingers. The discomfort is usually described as pressure, tightness, or heaviness, sometimes strangling, constricting, or burning.

The severity of the discomfort varies greatly and is not related to the severity of the underlying coronary disease. Shortness of breath may accompany angina, and chest discomfort may also be accompanied by less specific symptoms such as fatigue or faintness, nausea, burping, restlessness, or a sense of impending doom. The duration of the discomfort is brief, not more than 10 min in the majority of cases, and more commonly even less. An important characteristic is the relation to exercise, specific activities, or emotional stress. Symptoms classically deteriorate with increased levels of exertion, such as walking up an incline or against a breeze, and rapidly disappear within a few minutes, when these causal factors abate. Exacerbations of symptoms after a heavy meal or first thing in the morning are classical features of angina. Buccal or sublingual nitrates rapidly relieve angina, and a similar rapid response may be observed with chewing nifedipine capsules.

Non-anginal pain lacks the characteristic qualities described, may involve only a small portion of the left hemithorax, and last for several hours or even days. It is usually not relieved by nitroglycerin (although it may be in the case of oesophageal spasm) and may be provoked by palpation. Non-cardiac causes of pain should be evaluated in such cases. Definitions of typical and atypical angina have been previously published and are summarized in Table. It is important when taking the history to identify those patients with unstable angina, which may be associated with plaque rupture, who are at significantly higher risk of an acute coronary event in the short-term. Unstable angina may present in one of three ways: (i) as rest angina, i.e.

Pain of characteristic nature and location, but occurring at rest and for prolonged periods, up to 20 min; (ii) rapidly increasing or crescendo angina, i.e. Previously stable angina, which progressively increases in severity, intensity, and at lower threshold over a short period of 4 weeks or less; or (iii) new onset angina, i.e. Recent onset of severe angina, such that the patient experiences marked limitation of ordinary activity within 2 months of initial presentation. The investigation and management of suspected unstable angina are dealt with in guidelines for the management of acute coronary syndromes. Physical examination of a patient with (suspected) angina pectoris is important to assess the presence of hypertension, valvular heart disease, or hypertrophic obstructive cardiomyopathy. Physical examination should include the assessment of body mass index (BMI) and waist circumference to assist evaluation of the metabolic syndrome,, evidence of non-coronary vascular disease which may be asymptomatic, and other signs of comorbid conditions.

During or immediately after an episode of myocardial ischaemia, a third or fourth heart beat may be heard and mitral insufficiency may also be apparent during ischaemia. Sculpture Palloncini Istruzioni Pdf Manuale. However, such signs are elusive and non-specific.

Laboratory tests Laboratory investigations may be loosely grouped into those that provide information related to possible causes of ischaemia, those that may be used to establish cardiovascular risk factors and associated conditions, and those that may be used to determine prognosis. Haemoglobin and, where there is a clinical suspicion of a thyroid disorder, thyroid hormones provide information related to possible causes of ischaemia. The full blood count incorporating total white cell count as well as haemoglobin may also add prognostic information. Serum creatinine is a simple if crude method to evaluate renal function and is recommended at initial evaluation in all patients with suspected angina. If there is a clinical suspicion of instability, biochemical markers of myocardial damage such as troponin or creatinine kinase myocardial band (measured by the mass assay) should be employed to exclude myocardial injury. If these markers are elevated, management should continue as for an acute coronary syndrome rather than stable angina.

After initial assessment, these tests are not recommended as routine investigations during each subsequent evaluation. Fasting plasma glucose and fasting lipid profile including total cholesterol (TC), high density lipoprotein (HDL) and low density lipoprotein (LDL) cholesterol, and triglycerides should be evaluated in all patients with suspected ischaemic disease, including stable angina, to establish the patient's risk profile and ascertain the need for treatment.

Lipid profile and glycaemic status should be re-assessed periodically to determine efficacy of treatment, and in non-diabetic patients, to detect new development of diabetes. There is no evidence to support recommendations for how regularly re-assessment should take place. Consensus suggests annual measurement. Patients with very high levels of lipids or glucose, in whom the progress of any intervention needs to be monitored, should have measurements more frequently.

Elevations of fasting or post-glucose challenge glycaemia and HbA1c have also been shown to predict adverse outcome independently of conventional risk factors. Obesity and, in particular, evidence of the metabolic syndrome are predictive of adverse cardiovascular outcome in patients with established disease as well as in asymptomatic populations. The presence of the metabolic syndrome can be determined from the assessment of waist circumference (or BMI), blood pressure, HDL, and triglycerides and fasting glucose levels and offers additional prognostic information to that obtained from the conventional Framingham risk scores without major additional cost in terms of laboratory investigation. Further laboratory testing, including cholesterol subfractions (ApoA and ApoB) homocysteine, lipoprotein (a) (Lpa), haemostatic abnormalities and markers of inflammation such as hs C-reactive protein, has been the subject of much interest as methods to improve current risk prediction., However, markers of inflammation fluctuate over time and may not be a reliable estimator of risk in the long-term.

More recently, NT-BNP has been shown to be an important predictor of long-term mortality independent of age ventricular ejection fraction (EF) and conventional risk factors. As yet, there is no adequate information regarding how modification of these biochemical indices can significantly improve on current treatment strategies to recommend their use in all patients, particularly given the constraints of cost and availability. Nevertheless, these measurements have a role in selected patients, for example, testing for haemostatic abnormalities in those with prior MI without conventional risk factors, or a strong family history of coronary disease, or where resources are not limited. Further research regarding their use is welcome. The exercise stress test is terminated for one of the following reasons: 1.

Symptom limitation, e.g. Pain, fatigue, dyspnoea, and claudication; 2. Combination of symptoms such as pain with significant ST-changes; 3. Safety reasons such as a. Marked ST-depression (>2 mm ST-depression can be taken as a relative indication for termination and ≥4 mm as an absolute indication to stop the test), b. ST-elevation ≥1 mm, c. Significant arrhythmia, d.

Sustained fall in systolic blood pressure >10 mmHg, e. Marked hypertension (>250 mmHg systolic or >115 mmHg diastolic); 4.

Achievement of maximum predicted heart rate may also be a reason to terminate the test in patients with excellent exercise tolerance who are not tired and at the discretion of the supervising physician. The exercise stress test is terminated for one of the following reasons: 1. Symptom limitation, e.g. Pain, fatigue, dyspnoea, and claudication; 2. Combination of symptoms such as pain with significant ST-changes; 3. Safety reasons such as a.

Marked ST-depression (>2 mm ST-depression can be taken as a relative indication for termination and ≥4 mm as an absolute indication to stop the test), b. ST-elevation ≥1 mm, c. Significant arrhythmia, d. Sustained fall in systolic blood pressure >10 mmHg, e. Marked hypertension (>250 mmHg systolic or >115 mmHg diastolic); 4. Achievement of maximum predicted heart rate may also be a reason to terminate the test in patients with excellent exercise tolerance who are not tired and at the discretion of the supervising physician.