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2013 ESC Guidelines on the Management of Stable Coronary European Heart Journal Advance Access published August 30, 2013 European Heart Journal ESC GUIDELINES doi:10.1093/eurheartj/eht296 2013 ESC guidelines on the management of stable coronary artery disease The Task Force on the management of stable coronary artery disease of the European Society of Cardiology Task Force Members: Gilles Montalescot* (Chairperson) (France), Udo Sechtem* (Chairperson) (Germany), Stephan Achenbach (Germany), Felicita Andreotti (Italy), Chris Arden (UK), Andrzej Budaj (Poland), Raffaele Bugiardini (Italy), Filippo Crea Downloaded from (Italy), Thomas Cuisset (France), Carlo Di Mario (UK), J. Rafael Ferreira (Portugal), Bernard J. Gersh (USA), Anselm K. Gitt (Germany), Jean-Sebastien Hulot (France), Nikolaus Marx (Germany), Lionel H. Opie (South Africa), Matthias Pfisterer (Switzerland), Eva Prescott (Denmark), Frank Ruschitzka (Switzerland), Manel Sabate´ http://eurheartj.oxfordjournals.org/ (Spain), Roxy Senior (UK), David Paul Taggart (UK), Ernst E. van der Wall (Netherlands), Christiaan J.M. Vrints (Belgium). ESC Committee for Practice Guidelines (CPG): Jose Luis Zamorano (Chairperson) (Spain), Stephan Achenbach (Germany), Helmut Baumgartner (Germany), Jeroen J. Bax (Netherlands), He´ctor Bueno (Spain), Veronica Dean (France), Christi Deaton (UK), Cetin Erol (Turkey), Robert Fagard (Belgium), Roberto Ferrari (Italy), David Hasdai (Israel), Arno W. Hoes (Netherlands), Paulus Kirchhof (Germany/UK), Juhani Knuuti (Finland), Philippe Kolh (Belgium), Patrizio Lancellotti (Belgium), Ales Linhart (Czech Republic), Petros Nihoyannopoulos (UK), Massimo F. Piepoli (Italy), Piotr Ponikowski (Poland), Per Anton Sirnes (Norway), Juan Luis Tamargo (Spain), Michal Tendera (Poland), by guest on September 16, 2015 Adam Torbicki (Poland), William Wijns (Belgium), Stephan Windecker (Switzerland). Document Reviewers: Juhani Knuuti (CPG Review Coordinator) (Finland), Marco Valgimigli (Review Coordinator) (Italy), He´ctor Bueno (Spain), Marc J. Claeys (Belgium), Norbert Donner-Banzhoff (Germany), Cetin Erol (Turkey), Herbert Frank (Austria), Christian Funck-Brentano (France), Oliver Gaemperli (Switzerland), Jose´ R. Gonzalez-Juanatey (Spain), Michalis Hamilos (Greece), David Hasdai (Israel), Steen Husted (Denmark), Stefan K. James (Sweden), Kari Kervinen (Finland), Philippe Kolh (Belgium), Steen Dalby Kristensen (Denmark), Patrizio Lancellotti (Belgium), Aldo Pietro Maggioni (Italy), Massimo F. Piepoli (Italy), Axel R. Pries (Germany), * Corresponding authors. The two chairmen contributed equally to the documents. Chairman, France: Professor Gilles Montalescot, Institut de Cardiologie, Pitie-Salpetriere University Hospital, Bureau 2-236, 47-83 Boulevard de l’Hopital, 75013 Paris, France. Tel: +33 1 42 16 30 06, Fax: +33 1 42 16 29 31. Email: [email protected]. Chairman, Germany: Professor Udo Sechtem, Abteilung fu¨r Kardiologie, Robert Bosch Krankenhaus, Auerbachstr. 110, DE-70376 Stuttgart, Germany. Tel: +49 711 8101 3456, Fax: +49 711 8101 3795, Email: [email protected] Entities having participated in the development of this document: ESC Associations: Acute Cardiovascular Care Association (ACCA), European Association of Cardiovascular Imaging (EACVI), European Association for Cardiovascular Prevention & Rehabilitation (EACPR), European Association of Percutaneous Cardiovascular Interventions (EAPCI), Heart Failure Association (HFA) ESC Working Groups: Cardiovascular Pharmacology and Drug Therapy, Cardiovascular Surgery, Coronary Pathophysiology and Microcirculation, Nuclear Cardiology and Cardiac CT, Thrombosis, Cardiovascular Magnetic Resonance ESC Councils: Cardiology Practice, Primary Cardiovascular Care The content of these European Society of Cardiology (ESC) Guidelines has been published for personal and educational use only. No commercial use is authorized. No part of the ESC Guidelines may be translated or reproduced in any form without written permission from the ESC. Permission can be obtained upon submission of a written request to Oxford University Press, the publisher of the European Heart Journal and the party authorized to handle such permissions on behalf of the ESC. Disclaimer. The ESC Guidelines represent the views of the ESC and were arrived at after careful consideration of the available evidence at the time they were written. Health profes- sionals are encouraged to take them fully into account when exercising their clinical judgement. The Guidelines do not, however, override the individual responsibility of health profes- sionals to make appropriate decisions in the circumstances of the individual patients, in consultation with thatpatient and whereappropriate and necessary the patient’s guardian orcarer. It is also the health professional’s responsibility to verify the rules and regulations applicable to drugs and devices at the time of prescription. & The European Society of Cardiology 2013. All rights reserved. For permissions please email: [email protected] Page 2 of 62 ESC Guidelines Francesco Romeo (Italy), Lars Ryde´n (Sweden), Maarten L. Simoons (Netherlands), Per Anton Sirnes (Norway), Ph. Gabriel Steg (France), Adam Timmis (UK), William Wijns (Belgium), Stephan Windecker (Switzerland), Aylin Yildirir (Turkey), Jose Luis Zamorano (Spain). The disclosure forms of the authors and reviewers are available on the ESC website www.escardio.org/guidelines ------------------------------------------------------------------------------------------------------------------------------------------------------ Keywords Guidelines † Angina pectoris † Myocardial ischaemia † Stable coronary artery disease † Risk factors † anti-ischaemic drugs † Coronary revascularization Table of Contents 1. Preamble . 6 6.4.4 Event risk stratification using coronary anatomy . 23 2. Introduction . 7 6.4.4.1 Coronary computed tomography angiography . 23 3. Definitions and pathophysiology (see web addenda) . 7 6.4.4.2 Invasive coronary angiography . 23 Downloaded from 4. Epidemiology . 8 6.5 Diagnostic aspects in the asymptomatic individual without 5. Natural history and prognosis . 8 known coronary artery disease (see web addenda) . 24 6. Diagnosis and assessment (see web addenda) . 9 6.6 Management aspects in the patient with known coronary 6.1 Symptoms and signs (see web addenda) . 9 artery disease . 25 6.2 Non-invasive cardiac investigations . 10 6.7 Special diagnostic considerations: angina with ‘normal’ http://eurheartj.oxfordjournals.org/ 6.2.1 Basic testing . 10 coronary arteries (see web addenda) . 25 6.2.1.1 Biochemical tests (see web addenda) . 10 6.7.1 Microvascular angina . 26 6.2.1.2 Resting electrocardiogram . 12 6.7.1.1 Clinical picture (see web addenda) . 26 6.2.1.3 Echocardiography at rest (see web addenda) . 12 6.7.1.2 Pathogenesis and prognosis (see web addenda) . 26 6.2.1.4 Cardiac magnetic resonance at rest . 12 6.7.1.3 Diagnosis and management of coronary 6.2.1.5 Ambulatory electrocardiogram monitoring . 13 microvascular disease (see web addenda) . 26 6.2.1.6 Chest X-ray . 13 6.7.2 Vasospastic angina . 26 6.2.2 Three major steps used for decision-making . 13 6.7.2.1 Clinical picture . 26 6.2.3 Principles of diagnostic testing . 13 6.7.2.2 Pathogenesis and prognosis (see web addenda ) . 26 by guest on September 16, 2015 6.2.4 Stress testing for diagnosing ischaemia . 15 6.7.2.3 Diagnosis of vasospastic angina . 26 6.2.4.1 Electrocardiogram exercise testing . 15 6.7.2.3.1 Electrocardiography . 26 6.2.4.2 Stress imaging (see web addenda) . 17 6.7.2.3.2 Coronary arteriography . 27 6.2.4.2.1 Stress echocardiography . 17 7. Lifestyle and pharmacological management . 27 6.2.4.2.2 Myocardial perfusion scintigraphy (single 7.1 Risk factors and ischaemia management . 27 photon emission computed tomography and positron 7.1.1 Generalmanagement of stable coronaryartery disease emission tomography) . 18 patients . 27 6.2.4.2.3 Stress cardiac magnetic resonance . 18 7.1.2 Lifestyle modifications and control of risk factors . 27 6.2.4.2.4 Hybrid techniques . 18 7.1.2.1 Smoking . 27 6.2.5 Non-invasive techniques to assess coronary anatomy 18 7.1.2.2 Diet (Table 25)........................ 27 6.2.5.1 Computed tomography . 18 7.1.2.3 Physical activity . 28 6.2.5.1.1 Calcium scoring . 18 7.1.2.4 Sexual activity . 28 6.2.5.1.2 Coronary computed tomography angiography 18 7.1.2.5 Weight management . 28 6.2.5.2 Magnetic resonance coronary angiography . 19 7.1.2.6 Lipid management . 28 6.3 Invasive coronary angiography (see web addenda) . 19 7.1.2.7 Arterial Hypertension . 28 6.4 Stratification for risk of events (see web addenda) . 20 7.1.2.8 Diabetes and other disorders . 29 6.4.1 Event risk stratification using clinical evaluation . 21 7.1.2.9 Psychosocial factors . 29 6.4.2 Event risk stratification using ventricular function . 21 7.1.2.10 Cardiac rehabilitation . 29 6.4.3 Event risk stratification using stress testing . 22 7.1.2.11 Influenza vaccination . 29 6.4.3.1 Electrocardiogram stress testing . 22 7.1.2.12 Hormone replacement therapy . 29 6.4.3.2 Stress echocardiography . 22 7.1.3 Pharmacological management of stable coronary 6.4.3.3 Stress perfusion scintigraphy (single photon emission artery disease patients . 29 computed tomography and positron emission tomography) . 23 7.1.3.1 Aims of treatment . 29 6.4.3.4 Stress cardiac magnetic resonance . 23 7.1.3.2 Drugs . 30 ESC Guidelines Page 3 of 62 7.1.3.3 Anti-ischaemic drugs . 30 9. Special groups or considerations . 46 7.1.3.3.1 Nitrates . 30 9.1 Women (see web addenda) . 46 7.1.3.3.2 b-Blockers . 30 9.2 Patients with diabetes (see web addenda)
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