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(Circulation. 2007;116:2762-2772.)
© 2007 American Heart Association, Inc.

Chronic Angina Focused Update

2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina

A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to Develop the Focused Update of the 2002 Guidelines for the Management of Patients With Chronic Stable Angina

Theodore D. Fraker, Jr, MD, FACC, Chair; Stephan D. Fihn, MD, MPH, FACP; Writing on behalf of the 2002 Chronic Stable Angina Writing Committee; 2002 WRITING COMMITTEE MEMBERS; Raymond J. Gibbons, MD, FACC, FAHA^*; Jonathan Abrams, MD, FACC, FAHA; Kanu Chatterjee, MB, FACC; Jennifer Daley, MD, FACP; Prakash C. Deedwania, MD, FACC, FAHA; John S. Douglas, MD, FACC; T. Bruce Ferguson, Jr, MD, FACC, FAHA; Stephan D. Fihn, MD, MPH, FACP; Theodore D. Fraker, Jr, MD, FACC; Julius M. Gardin, MD, FACC, FAHA; Robert A. O’Rourke, MD, FACC, FAHA; Richard C. Pasternak, MD, FACC, FAHA; Sankey V. Williams, MD; TASK FORCE MEMBERS: Sidney C. Smith, Jr, MD, FACC, FAHA, Chair; Alice K. Jacobs, MD, FACC, FAHA, Vice-Chair; Cynthia D. Adams, MSN, PhD, FAHA; Jeffrey L. Anderson, MD, FACC, FAHA; Christopher E. Buller, MD, FACC; Mark A. Creager, MD, FACC, FAHA; Steven M. Ettinger, MD, FACC; Jonathan L. Halperin, MD, FACC, FAHA; Sharon A. Hunt, MD, FACC, FAHA; Harlan M. Krumholz, MD, FACC, FAHA; Frederick G. Kushner, MD, FACC, FAHA; Bruce W. Lytle, MD, FACC, FAHA; Rick Nishimura, MD, FACC, FAHA; Richard L. Page, MD, FACC, FAHA; Barbara Riegel, DNSc, RN, FAHA; Lynn G. Tarkington, RN; Clyde W. Yancy, MD, FACC

	Introduction

Top Introduction Preamble 1. Introduction Staff References

 

Preamble...2763

1. Introduction...2764

   1.1. Evidence Review...2764

   1.2. Organization of Committee and Relationships With Industry...2765

   1.3. Review and Approval...2765

References...2769

Appendix 1...2770

Appendix 2...2770

	Preamble

Top Introduction Preamble 1. Introduction Staff References

 
A primary challenge in the development of clinical practice guidelines is keeping pace with the stream of new data upon which recommendations are based. In an effort to respond more quickly to new evidence, the American College of Cardiology/American Heart Association (ACC/AHA) Task Force on Practice Guidelines has created a new "focused update" process to revise the existing guideline recommendations that are affected by the evolving data or opinion. Prior to the initiation of this focused approach, periodic updates and revisions of existing guidelines required up to 3 years to complete. Now, however, new evidence will be reviewed in an ongoing fashion to more efficiently respond to important science and treatment trends that could have a major impact on patient outcomes and quality of care. Evidence will be reviewed at least twice a year and updates will be initiated on an as-needed basis as quickly as possible, while maintaining the rigorous methodology that the ACC and AHA have developed during their more than 20 years of partnership.

These updated guideline recommendations reflect a consensus of expert opinion after a thorough review primarily of late-breaking clinical trials identified through a broad-based vetting process as being important to the relevant patient population, and of other new data deemed to have an impact on patient care (see Section 1.1 Evidence Review for details regarding this focused update). It is important to note that this focused update is not intended to represent an update based on a full literature review from the date of the previous guideline publication. Specific criteria/considerations for inclusion of new data include:

• Publication in a peer-reviewed journal
  
• Large, randomized, placebo-controlled trial(s)
  
• Nonrandomized data deemed important on the basis of results impacting current safety and efficacy assumptions
  
• Strengths/weakness of research methodology and findings
  
• Likelihood of additional studies influencing current findings
  
• Impact on current performance measure(s) and/or likelihood of need to develop new performance measure(s)
  
• Requests and requirements for review and update from the practice community, key stakeholders, and other sources free of relationships with industry or other potential bias
  
• Number of previous trials showing consistent results
  
• Need for consistency with a new guideline or guideline revision
  

In analyzing the data and developing updated recommendations and supporting text, the Focused Update Writing Group used evidence-based methodologies developed by the ACC/AHA Task Force on Practice Guidelines that are described elsewhere ^(1,2). The schema for class of recommendation and level of evidence is summarized in Table 1, which also illustrates how the grading system provides an estimate of the size of the treatment effect and an estimate of the certainty of the treatment effect. Note that a recommendation with level of evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in guidelines do not lend themselves to clinical trials. Although randomized trials may not be available, there may be a very clear clinical consensus that a particular test or therapy is useful and effective. Both the class of recommendation and the level of evidence listed in the focused updates are based on consideration of the evidence reviewed in previous iterations of the guideline, as well as the focused update. Of note, the implications of older studies that have informed recommendations but have not been repeated in contemporary settings are carefully considered.

View larger version (70K): [in this window] [in a new window]   Table 1. Applying Classification of Recommendations and Level of Evidence *Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as gender, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use. A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Even though randomized trials are not available, there may be a very clear clinical consensus that a particular test or therapy is useful or effective. In 2003, the ACC/AHA Task Force on Practice Guidelines developed a list of suggested phrases to use when writing recommendations. All guideline recommendations have been written in full sentences that express a complete thought, such that a recommendation, even if separated and presented apart from the rest of the document (including headings above sets of recommendations), would still convey the full intent of the recommendation. It is hoped that this will increase readers’ comprehension of the guidelines and will allow queries at the individual recommendation level.

View this table: [in this window] [in a new window]   Table 2. Cardiovascular Risk Reduction for Patients With Chronic Angina

View this table: [in this window] [in a new window]   Table 2. Continued

View this table: [in this window] [in a new window]   Table 2. Continued

View this table: [in this window] [in a new window]   Table 2. Continued

The ACC/AHA practice guidelines address patient populations (and healthcare providers) residing in North America. As such, drugs that are not currently available in North America are discussed in the text without a specific class of recommendation. For studies performed in large numbers of subjects outside of North America, each writing committee reviews the potential impact of different practice patterns and patient populations on the treatment effect and on the relevance to the ACC/AHA target population to determine whether the findings should inform a specific recommendation.

The ACC/AHA practice guidelines are intended to assist healthcare providers in clinical decision making by describing a range of generally acceptable approaches for the diagnosis, management, and prevention of specific diseases or conditions. They attempt to define practices that meet the needs of most patients in most circumstances. The ultimate judgment regarding care of a particular patient must be made by the healthcare provider and patient in light of all the circumstances presented by that patient. Thus, there are circumstances in which deviations from these guidelines may be appropriate. Clinical decision making should consider the quality and availability of expertise in the area where care is provided. These guidelines may be used as the basis for regulatory or payer decisions, but the ultimate goal is quality of care and serving the patient’s best interests.

Prescribed courses of treatment in accordance with these recommendations are only effective if they are followed by the patient. Because lack of patient adherence may adversely affect treatment outcomes, healthcare providers should make every effort to engage the patient in active participation with prescribed treatment.

The ACC/AHA Task Force on Practice Guidelines makes every effort to avoid any actual, potential, or perceived conflict of interest arising from industry relationships or personal interests of a writing committee member. All writing committee members and peer reviewers were required to provide disclosure statements of all such relationships pertaining to the trials and other evidence under consideration (see Appendixes 1 and 2). Final recommendations were balloted to all writing committee members. Writing committee members with significant (greater than $10 000) relevant relationships with industry were required to recuse themselves from voting on that recommendation. Those writing committee members who did not participate are not listed as authors of this focused update.

With the exception of the recommendations presented here, the full guideline remains current. Only the recommendations from the affected sections of the full guideline are included in this focused update. For easy reference, all recommendations from any section of a guideline impacted by a change are presented with notation as to whether they remain current, are new, or have been modified. When evidence impacts recommendations in more than 1 guideline, those guidelines are updated concurrently.

The recommendations in this focused update will be considered current until they are superseded by another focused update or until the full-text guidelines are revised. This focused update is published in the December 4, 2007, issue of the Journal of the American College of Cardiology and the December 4, 2007, issue of Circulation as an update to the full-text guideline and is also posted on the ACC (www.acc.org) and AHA (my.americanheart.org) World Wide Web sites. Copies of the focused update are available from both organizations.

Sidney C. Smith, Jr, MD, FACC, FAHA Chair, ACC/AHA Task Force on Practice Guidelines

Alice K. Jacobs, MD, FACC, FAHA Vice-Chair, ACC/AHA Task Force on Practice Guidelines

	1. Introduction

Top Introduction Preamble 1. Introduction Staff References

 
1.1. Evidence Review
Late-breaking clinical trials presented at the 2005 and 2006 annual scientific meetings of the ACC, AHA, and European Society of Cardiology, as well as selected other data published during the same time period, were reviewed by the standing guideline writing committee along with the parent Task Force and other experts to identify those trials and other key data that might impact guideline recommendations. On the basis of the criteria/considerations noted above, recent trial data and other clinical information were considered when deciding whether there was evidence important enough to prompt a focused update of the 2002 ACC/AHA Guidelines for the Management of Patients With Chronic Stable Angina ^(3–9). After consideration and evaluation of the criteria, the 2006 AHA Guidelines for Secondary Prevention for Patients With Coronary and Other Atherosclerotic Vascular Disease ⁽⁸⁾ were considered important enough to prompt this focused update.

This focused update of the ACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina spotlights the 2006 AHA/ACC Guidelines for Secondary Prevention for Patients With Coronary and Other Atherosclerotic Vascular Disease. Only recommendations related to secondary prevention in patients with chronic angina have been revised. In September 2007, the ACC/AHA Task Force on Practice Guidelines convened a writing committee to revise the full guideline for the management of patients with stable ischemic heart disease. This writing committee will consider all the recent evidence, including late-breaking clinical trials recently presented.

Consult the full-text version or executive summary of the ACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina for policy on clinical areas not covered by the focused update ⁽¹⁰⁾. Individual recommendations updated in this focused update will be incorporated into future revisions and/or updates of the full-text guidelines.

1.2. Organization of Committee and Relationships With Industry
For this focused update, all members of the 2002 Chronic Angina Writing Committee were invited to participate; those who agreed (referred to as the 2007 Focused Update Writing Group) were required to disclose all relationships with industry relevant to the data under consideration ⁽²⁾. Focused Update Writing Group members who had no significant relevant relationships with industry authored the first draft of the focused update; the draft was then reviewed and revised by the full writing group. Each recommendation required a confidential vote by the writing group members prior to external review of the document. Any writing committee member with a significant (greater than $10 000) relationship with industry relevant to the recommendation was recused from voting on that recommendation.

1.3. Review and Approval
This document was reviewed by 2 official reviewers nominated by the ACC and 2 official reviewers nominated by the AHA, as well as 1 reviewer from the ACC Cardiac Catheterization and Intervention Committee and 16 content reviewers. All reviewer relationship with industry information was collected and distributed to the Writing Committee and is published in this document (see Appendix 2 for details).

This document was approved for publication by the governing bodies of the American College of Cardiology Foundation and the AHA.

	Staff

Top Introduction Preamble 1. Introduction Staff References

 
American College of Cardiology Foundation

John C. Lewin, MD, Chief Executive Officer

Charlene May, Director, Clinical Policy and Documents

Lisa Bradfield, Associate Director, Practice Guidelines

Mark D. Stewart, MPH, Associate Director, Evidence-Based Medicine

Sue Keller, BSN, MPH, Senior Specialist, Evidence-Based Medicine

Vita Washington, MSA, Specialist, Practice Guidelines

Erin A. Barrett, Senior Specialist, Clinical Policy and Documents

American Heart Association

M. Cass Wheeler, Chief Executive Officer

Rose Marie Robertson, MD, FACC, FAHA, Chief Science Officer

Kathryn A. Taubert, PhD, FAHA, Senior Scientist

View this table: [in this window] [in a new window]   Appendix 1. Author Relationships With Industry—Writing Group to Develop the 2007 Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina

View this table: [in this window] [in a new window]   Appendix 2. Peer Reviewer Relationships With Industry—2007 Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina

View this table: [in this window] [in a new window]   Appendix 2. Continued.

View this table: [in this window] [in a new window]   Appendix 2. Continued.

	Footnotes

 
*2002 Chronic Stable Angina Chair.

Former Task Force member during this writing effort.

This document is a limited update to the 2002 guideline update and is based on a review of certain evidence, not a full literature review.

This document was approved by the American College of Cardiology Board of Trustees in July 2007 and by the American Heart Association Science Advisory and Coordinating Committee in August 2007. The American College of Cardiology Foundation and American Heart Association request that this document be cited as follows: Fraker TD Jr, Fihn SD, writing on behalf of the 2002 Chronic Stable Angina Writing Committee. 2007 chronic angina focused update of the ACC/AHA 2002 guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to Develop the Focused Update of the 2002 guidelines for the management of patients with chronic stable angina. Circulation. 2007;116:2762–2772.

This article has been copublished in the December 4, 2007, issue of the Journal of the American College of Cardiology.

Copies: This document is available on the World Wide Web sites of the American College of Cardiology (www.acc.org) and American Heart Association (my.americanheart.org). To purchase Circulation reprints, call 843-216-2533 or e-mail kelle.ramsay@wolterskluwer.com.

Permissions: Multiple copies, modification, alteration, enhancement and/or distribution of this document are not permitted without the express permission of the American Heart Association. Instructions for obtaining permission are located at http://www.americanheart.org/presenter.jhtml?identifier=4431. A link to the "Permission Request Form" appears on the right side of the page.

	References

Top Introduction Preamble 1. Introduction Staff References

 
1. Gibbons RJ, Smith S, Antman EM. American College of Cardiology/American Heart Association clinical practice guidelines: Part I: where do they come from? Circulation. 107: 2003; 2979–86.[Free Full Text]

2. Antman EM. Methodology Manual for ACC/AHA Guideline Writing Committees: Methodologies and Policies from the ACC/AHA Task Force on Practice Guidelines. 2006. Available at: http://www.acc.org/qualityandscience/clinical/manual/pdfs/Methodology.pdf.

3. Keeley EC. Abciximab following clopidogrel reduces post-PCI complications in patients with acute coronary syndromes. Nat Clin Pract Cardiovasc Med. 3: 2006; 650–1.[CrossRef][Medline] [Order article via Infotrieve]

4. Gershlick AH, Stephens-Lloyd A, Hughes S, et al. Rescue angioplasty after failed thrombolytic therapy for acute myocardial infarction. N Engl J Med. 353: 2005; 2758–68.[Abstract/Free Full Text]

5. Hochman JS, Lamas GA, Buller CE, et al. Coronary intervention for persistent occlusion after myocardial infarction. N Engl J Med. 355: 2006; 2395–407.[Abstract/Free Full Text]

6. Dzavik V, Buller CE, Lamas GA, et al. Randomized trial of percutaneous coronary intervention for subacute infarct-related coronary artery occlusion to achieve long-term patency and improve ventricular function: the Total Occlusion Study of Canada (TOSCA)-2 trial. Circulation. 114: 2006; 2449–57.[Abstract/Free Full Text]

7. Sabatine MS, Morrow DA, McCabe CH, Antman EM, Gibson CM, Cannon CP. Combination of quantitative ST deviation and troponin elevation provides independent prognostic and therapeutic information in unstable angina and non-ST-elevation myocardial infarction. Am Heart J. 151: 2006; 25–31.[CrossRef][Medline] [Order article via Infotrieve]

8. Smith SC Jr., Allen J, Blair SN, et al. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update: endorsed by the National Heart, Lung, and Blood Institute. Circulation. 113: 2006; 2363–72.[Free Full Text]

9. Pfisterer M, Brunner-La Rocca HP, Buser PT, et al. Late clinical events after clopidogrel discontinuation may limit the benefit of drug-eluting stents: an observational study of drug-eluting versus bare-metal stents. J Am Coll Cardiol. 48: 2006; 2584–91.[Abstract/Free Full Text]

10. Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 guideline update for exercise testing: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing). J Am Coll Cardiol. 40: 2002; 1531–40.[Free Full Text]

11. Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 42: 2003; 1206–52.[Abstract/Free Full Text]

12. Grundy SM, Cleeman JI, Merz CN, et al. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation. 110: 2004; 227–39.[Abstract/Free Full Text]

Related Internet Resources:

AHA/ACC Guidelines for Secondary Prevention for Patients With Coronary and Other Atherosclerotic Vascular Disease: 2006 Update

ACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina

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This Article Free upon publication Extract Full Text (PDF) All Versions of this Article: 116/23/2762    most recent CIRCULATIONAHA.107.187930v1 Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Fraker, T. D. Articles by Yancy, C. W. Search for Related Content PubMed PubMed Citation Articles by Fraker, T. D., Jr Articles by Yancy, C. W. Pubmed/NCBI databases Medline Plus Health Information Angina Related Collections AHA Statements and Guidelines Related Internet Resources