Grading chronic angina pectoris (myocardial ischemia)

Abstract

Patients more or less define the chronicity or the instability of their symptoms of myocardial ischemia. Chronic stable angina (myocardial ischemia) is easily classified into four categories based on activity limitation due to symptoms; however it is not easily classified into clinical categories that are useful for specific decision-making.e.g. medical therapy, or medical therapy plus revascularization. Some patients are intolerant of one episode of mild myocardial ischemia per day and limit their activity to prevent that one episode, whereas others can tolerate multiple angina episodes and go on about their usual activities. Others can tolerate multiple angina episodes and go on about their usual activities. Using only the CCVS classification, the latter patient, who may be at high risk, may get a lower classification than the patient who is intolerant of any angina. Many patients have asymptomatic ischemic episodes in addition to symptomatic ones and can be misclassified as stable angina but may have unstablemyocardial ischemia.Approximatley,25% of patients in the ACIP trial had no symptoms, even during positive stress testing. For patients with chronic stable angina, I think it is appropriate to risk stratify them in a manner similar to the risk stratification schemes for acute coronary syndromes. This requires more than just noting how much the patient is limited by symptoms, since even patientswho reportmild angina can experiencemajor adverse cardiac events. One can ask the question, "What is clinically important cardiac ischemia?" The answer to that question is, "I don't think any myocardial ischemia is good for the individual patient and any amount of ischemia can be associated with a future cardiac event such asmyocardialinfarction, sustained VT, or sudden cardiac death." I am not sure whether a simple grading systemthat does not take into account the multiple variables listed in this editorial can be useful for clinical decision-making or useful to categorize patients entered into clinical trials. © 2010 Wiley Periodicals, Inc.