Chronic Stable Angina

The general population of patients with nondisabling chronic angina have a significant prevalence of advanced coronary disease. Douglas and Hurst reported that 11% of male patients with mild chronic angina evaluated angiographically had left main coronary disease, 28% had three-vessel disease, and 22% had two-vessel disease (17). The severity of symptoms does not correlate well with the severity of disease in nondiabetics, and this discrepancy is even more marked in diabetics. Diabetics not only have more advanced disease than nondiabetics, but, also are at higher risk for progression of disease and subsequent cardiac events. For these reasons, aggressive risk stratification is indicated with noninvasive testing (stress ECG, stress echocardiography, or perfusion SPECT) (13-15) or coronary angiography in patients who have angina, even if it is not disabling. Patients preferentially selected for coronary angiography include those with multiple coronary risk factors (Table 2), prior infarction, evidence of left ventricular dysfunction, symptoms of congestive heart failure, noninvasive testing results indicating high risk, and symptoms that are inadequately controlled with medical therapy. These recommendations comply with ACC/AHA/ACP-ASIM guidelines (16). In addition, diabetic patients with any evidence of ischemia on myocardial scans, shown by Kang et al. to have increased subsequent occurrence of hard cardiac endpoint events, should be offered angiographic evaluation (13).

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