Professional Documents
Culture Documents
Guidelines
of various hormones and neurogenic stimuli. Very occa- the age group 6574 years, and in women from 051%
sionally, spasm of the coronary arteries can occur in the to 1014%, respectively. After the age of 75 years the
presence of apparently normal coronary arteries, but prevalence is almost similar in men and women. On the
even in these circumstances minor plaques or damage to basis of these studies it may be estimated that in
the endothelium are frequently present. countries with high or relatively high coronary heart
Although the initiating stimulus causing an epi- disease rates the total prevalent number of persons with
sode of angina may be an increase in myocardial oxygen angina may be as high as 30 00040 000 per 1 million
demand or decrease in coronary blood flow due to total population. In more than one half of patients
vasoconstriction at the site of an atheromatous narrow- with angina the severity of symptoms seriously limits
ing, the subsequent sequence of events invariably lead to their everyday activities, often leading to premature
segmental dysfunction and/or left ventricular dilatation retirement in patients of working age[4,11].
causing a fall in coronary blood flow. Also the shortened Population-based information on the incidence
diastolic filling time due to the tachycardia that develops of angina pectoris is mainly based on prospective epi-
and various hormonal perturbations may lead to cor- demiological studies with repeated re-examinations of
onary vasoconstriction. At the same time, the increases study cohorts. During a 10-year follow-up of the Seven
in heart rate and blood pressure that usually follow the Countries Studies cohorts, the average annual incidence
development of myocardial ischaemia lead to a further of angina pectoris as the only manifestation of coronary
increase in myocardial oxygen demand. Finally, not only heart disease was in men aged 4059 years 01% in
may coronary tone alter but the heart can also adapt Japan, Greece and Croatia, 0204% in Italy, Serbia,
its metabolic demands. Chronic or recurrent episodes Netherlands and U.S.A., and 0611% in Finland[12].
of ischaemia may lead to an adaptive process in myo- These incidence rates showed a significant positive
cardial metabolism that can result in hibernating myo- correlation with coronary heart disease mortality rates
cardium, defined as chronic but reversible ischaemic left in the study cohorts. In the 20-year follow-up of the
ventricular dysfunction. Framingham Study cohort, the annual incidence of
Patients with coronary artery disease are at risk uncomplicated angina pectoris among men was 03% in
of developing plaque fissuring or rupture. Once plaque the age group 4554 years, 08% in the age group 5564
rupture occurs, this is usually followed by platelet aggre- years and 06% in the age group 6574 years[13]. Among
gation at the same site, which may lead to (further) women the corresponding age-specific incidence rates
impairment of coronary blood flow or even thrombotic were 02%, 06% and 06%. Angina pectoris was the
coronary occlusion. Furthermore, activated platelets at presenting manifestation less frequently in men than in
the site of plaque rupture may release a series of vascular women (37% vs 65%), but due to generally higher
active substances which will lead to increased vasomotor incidence rate of clinically manifest coronary heart dis-
tone or even spasm. The clinical syndrome associated ease in men there was a gap in the incidence of angina
with these events may be labelled either unstable angina between the sexes below the age of 65 years[12].
or evolving myocardial infarction. Half of those having their first myocardial infarc-
tion had angina following it, whereas only one fifth of
those having their first infarction had preceding an-
Epidemiology gina[14]. In the 5-year follow-up of the Israel Ischaemic
Heart Disease Study cohort of men over 40 years of age,
The diagnosis of angina pectoris has, until relatively the average annual incidence of uncomplicated angina
recently, depended largely upon obtaining a characteris- pectoris was 07%[15]. A study based on the experience of
tic history. Reliable estimates of incidence and preva- a general practitioner in London over 25 years[16] pro-
lence based upon such evidence have been difficult to duced annual incidence rates close to those observed in
obtain. The cardiovascular questionnaire developed by the Framingham and Israel studies. This was 05% in
Rose and Blackburn[3] has been widely used in studies persons above the age of 40 years, was higher in men
on the prevalence of angina pectoris in populations. A than in women and increased with age; the gap between
positive response to this questionnaire, however, over- men and women diminished with advancing age.
estimates the prevalence of angina pectoris in compari- Coronary heart disease mortality has been
son with a history taken by a physician, with particularly declining in a many industrialized, socio-economically
high proportions of false positives in younger women, well established countries in Europe and elsewhere. This
as shown in a population-based study carried out in decline has been most marked in younger middle-aged
Finland[4]. Similar or even higher proportions of false groups and it appears to be, in part, explained by a real
positives have been reported from other studies[5,6]. decline in the incidence of the disease and in part by an
Population-based studies using various data collection improvement in the prognosis of those who get it. These
methods in countries with high or relatively high cor- favourable trends are, however, accompanied with a
onary heart disease rates have shown that among shift of the main burden of clinically manifest coronary
middle-aged people angina is more than twice as com- heart disease, particulary its milder manifestations, to-
mon in men as it is in women[4,710]. In both sexes the wards older age groups[17], and in countries showing
prevalence of angina increases sharply with age: in men such trends the prevalence of angina pectoris can be
from 25% in the age group 4554 years to 1120% in predicted to increase in the older age groups. This has
recently been documented by morbidity statistics for In the evaluation of patients with chronic stable
England and Wales collected by the Royal College of angina it is important to identify those patients at
General Practitioners in 19811982 and 19911992[10]. increased risk whose outcome may be improved by
During the 10-year period the prevalence of angina revascularization. Information on long-term prognosis
pectoris increased in the age group 6574 years by 63% of patients with stable angina can be derived from the
in men and by 69% in women and in the age group 75 follow-up results of the large control groups of ran-
years and over by 79% in men and 92% in women. domized trials aimed at evaluating the effectiveness of
revascularization[2527]. In general, the outcome is worse
Natural history and prognosis (and the revascularizationrelated improvement greater)
in patients with worse left ventricular function, a greater
Chronic stable angina is compatible with a relatively number of diseased vessels, more proximal locations
good prognosis in the majority of patients. Several of coronary stenosis, greater severity of lesions, more
studies have shown that mortality on average is approxi- severe angina, more easily provoked angina or ischae-
mately 23% per annum and a further 23% each year mia, and greater age.
will sustain a non-fatal myocardial infarction[1820]. Ischaemic episodes in patients with angina pec-
There are, however, subgroups at higher risk: patients toris are often silent. Ambulatory silent ischaemia has
with significant impairment of left ventricular function, been reported to predict adverse coronary events in
especially if heart failure has occurred. Another small some studies but not in others[28,29] and there is conflict-
subgroup with a poor outlook are those with malignant ing evidence that the suppression of silent ischaemia in
coronary anatomy: patients with left main stem stenosis stable angina pectoris improves cardiac outcome[30]. The
or very proximal left anterior descending stenoses[21]. It significance and treatment of silent ischaemia in this
is important as part of management to identify patients context appears to be different from that of unstable and
at high risk so that appropriate therapy is targeted to post-infarction angina where it has been clearly shown
improve prognosis. that recurrent ischaemia predicts an adverse outcome[31].
Nowadays, the natural history of stable angina
is affected by the complex and dynamic results of Diagnosis and assessment
anti-ischaemic, anti-thrombotic, anti-hypertensive and
lipid lowering therapy, as well as by revascularization Symptoms and signs
procedures which lead to a new managed history.
Intensive risk factor modification may radically change A carefully taken history is essential in the diagnosis and
the outcome of the disease. Reduction of lipid levels by management of angina pectoris. In the majority of cases,
diet, statins and other drugs, or ileal bypass have been it is possible to make a confident diagnosis on the basis
shown to reduce coronary events and the need for of the history alone, although physical examination and
revascularization. In stable angina pectoris patients, objective tests are necessary to determine its cause and
coronary atherosclerotic disease can progress subclini- assess its severity.
cally, but usually does so slowly. Angiographically com- The classic symptom has four cardinal features:
plex and smooth stenoses progress at different rates location; relationship to exercise; character, and dur-
within the same coronary tree, the former changing ation. Most patients can describe the first two charac-
more rapidly than the latter. Long-term progression of teristics without difficulty, but are less precise about the
disease may be slow and linear or episodic and rapid, or latter two.
a combination of both[22]. In patients with stable angina
who had been advised to undergo coronary angioplasty Location. Typically the discomfort is located in the
in whom the coronary angiogram was repeated 73 retrosternal region, and may radiate to both sides of
months apart, a similar proportion of target and non- the chest and the arms (more commonly the left) as far
target lesions progressed rapidly (9% and 8% respect- as the wrist, and to the neck and jaw. Less often, it may
ively), both contributing to the appearance of new radiate to the back. Quite frequently, the pain starts in
symptoms[23]. These observations indicate that in one of the other areas and only later spreads to the
patients with stable angina, coronary stenoses exist that central chest; sometimes it does not involve the sternal
may progress rapidly and that plaque events, rather than region at all.
slow linear progression, can take place at the site of
stenosis. These findings also indicate that progression of Relationship to exercise. In most cases, angina is pro-
disease leading to clinical symptoms or outcome may voked by increased myocardial oxygen consumption
not necessarily be related to the severity of the stenosis. during exercise (or other stress) and is quickly relieved
In many patients, smaller plaques are present in by rest. Some patients experience angina at rest; this
addition to those causing severe stenosis. The likelihood suggests either changes in coronary artery tone, arrhyth-
of instability or rupture of one of the many smaller mias, or unstable angina. However, emotion, a potent
plaques exceeds the risk of instability of the few areas provoking factor, may be responsible.
with a marked stenosis[24]. The most severe stenosis in a
vessel is not necessarily the one most likely to lead to Character. Although angina is often described as a pain,
infarction. patients may deny this but acknowledge a discomfort
which may be a feeling of pressure or a strangling sensa- so clear-cut and other diagnoses must be considered.
tion. The intensity of the symptoms varies greatly, from Chief amongst these are oesophageal reflux and spasm,
a slight localised discomfort to the most severe pain. peptic ulcer, gallstones, musculo-skeletal disorders and
non-specific chest pains, often associated with anxiety
Duration. Anginal pain provoked by physical exercise is states.
usually spontaneously relieved within 13 min after
discontinuation of exercise, but may last up to 10 min or Physical signs. There are no physical signs which are
even longer after very strenuous exercise. Anginal pain specific for angina, but those characteristic of an under-
provoked by emotion may be relieved more slowly than lying cause (such as aortic stenosis) may be present. The
that provoked by physical exercise. Anginal episodes patient often looks pale, distressed and sweaty during an
in patients with syndrome X are frequently longer and attack. Third or fourth heart sounds may be heard as
less consistent in their relation to exercise than those in well as a murmur of (temporary) mitral incompetence.
patients with atherosclerotic coronary artery stenosis.
The chest discomfort may be accompanied by or Evaluation for concomitant disorders. Co-existent meta-
even overshadowed by such symptoms as breathlessness, bolic and clinical disorders are common. A full lipid
fatigue and faintness. profile should be obtained, and the appropriate clinical
and laboratory examinations should be undertaken with
respect to anaemia, hypertension, diabetes and thyroid
Classification of angina function.
The Canadian Cardiovascular Society[32] has provided a
grading classification of angina:
ALGORITHM FOR THE DIAGNOSIS OF
Class I Ordinary physical activity does not cause ANGINA PECTORIS, THE CHOICE OF
angina such as walking or climbing stairs. INVESTIGATIONS
Angina with strenuous or rapid or prolonged
exertion at work or recreation. While history often suffices to establish the diagnosis of
Class II Slight limitation of ordinary activity angina pectoris, additional investigations are usually
walking or climbing stairs rapidly, walking needed to confirm the diagnosis, to assess prognosis and
uphill, walking or stair climbing after meals, to select the most appropriate therapy. Different strat-
in cold, or in wind, or when under emotional egies may be followed depending on the patients pre-
stress, or only during the few hours after vious history and the severity (frequency and intensity)
awakening. Walking more than two blocks* of their symptoms. In patients with new symptoms,
on the level and climbing more than one flight in whom the diagnosis of coronary artery disease has
of stairs at a normal pace and in normal not yet been established, the approach will differ in com-
conditions. parison with patients with known coronary artery dis-
Class III Marked limitation of ordinary physical ease, after previous coronary angiography or coronary
activity walking one or two blocks on intervention or after previous myocardial infarction.
the level and climbing one flight of stairs in Three diagnostic strategies can be distinguished:
normal conditions and at normal pace.
Class IV Inability to carry on any physical activity (1) It may be adequate to rely solely on the patients
without discomfort anginal syndrome may history, supplemented by physical examination
be present at rest. and a resting electrocardiogram. This approach of-
ten suffices in elderly patients with mild symptoms
The Canadian classification has proved popular responding promptly to medical therapy and in
and is widely used, but alternative, and prognostic- patients in whom coronary interventions are not
ally superior, instruments are available such as the considered a therapeutic option.
Specific Activity Scale and the Duke Activity Status (2) Another approach is based on a functional assess-
Index[33-35]. ment of the presence or absence and extent of
In clinical practice it is important to describe myocardial ischaemia, which may include exercise
accurately the factors associated with angina pectoris in testing with electrocardiography, exercise (or other
each individual patient. This should include specific stress) myocardial perfusion imaging (thallium or
activities associated with angina, walking distance, one of the technetium-99 m labelled perfusion
frequency and duration of episodes. tracers), stress-echocardiography and, possibly, ex-
ercise radionuclide angiography. In patients with
Differential diagnosis of the symptoms. If all four cardi- significant functional abnormalities, this may be
nal features are present, or even only the first two if they followed by coronary angiography to assess whether
are quite typical, the diagnosis of chronic stable angina coronary intervention is indicated and which inter-
is virtually assured. Often, however, the picture is not vention would be most appropriate. The indications
for coronary angiography are discussed in more
*Equivalent to 100200 m. detail below.
Table 1(a) Pretest likelihood of coronary artery disease in symptomatic patients according to age and sex
Non-anginal
Age Typical angina Atypical angina
chest pain
(years)
Male Female Male Female Male Female
Table 1(b) Coronary artery disease post-test likelihood (%) based on age, sex, symptom classification and
exercise-induced electrocardiographic ST-segment depression
Non-anginal
Age ST depression Typical angina Atypical angina Asymptomatic
chest pain
(years) (mV)
Male Female Male Female Male Female Male Female
5059 000004 73 47 25 10 6 2 2 1
005009 91 78 57 31 20 8 9 3
010014 96 89 75 50 37 16 19 7
015019 98 94 86 67 53 28 31 12
020024 99 98 94 84 75 50 54 27
>025 >99 99 98 95 91 78 81 56
6069 000004 79 69 32 21 8 5 3 2
005009 94 90 65 52 26 17 11 7
010014 97 95 81 72 45 33 23 15
015019 99 98 89 83 62 49 37 25
020024 99 99 96 93 81 72 61 47
>025 >99 99 99 98 94 90 85 76
(3) A further option is to proceed immediately from not necessarily have a causal relation to any coronary
history, physical examination and ECG to coronary artery narrowings present. Thus, additional functional
angiography. This approach may be indicated par- assessment may be needed in patients with less typical
ticularly in patients with typical and severe symp- symptoms and moderately severe coronary artery
toms, including unstable angina, patients with early narrowings. Furthermore, such an assessment may help
post infarction angina, and in patients with early to establish the functional significance of abnormalities
recurrence of symptoms after previous coronary observed in the coronary angiogram[37]. For example, in
intervention[36]. a patient with both complete obstruction of one cor-
onary vessel (and possibly previous myo- cardial infarc-
In clinical practice, the second approach is fol- tion) and a moderately severe stenosis in another vessel,
lowed most frequently. In patients with frequent or perfusion scintigraphy may help to decide whether
severe stable angina, functional assessment is often symptoms are likely to be alleviated by percutaneous
useful prior to or in addition to angiography. It should intervention (PTCA) of the moderately severe lesion
be appreciated that symptoms resembling angina do only, or by surgical intervention of both vessels.
Detection of CAD
Sensitivity 5080% 6590% 6590%
Specificity 8095% 9095% 9095%
Greatest sensitivity Multi-vessel disease Single vessel disease Single and multi-vessel disease
Location of CAD 80% LAD No influence
60% RCA
Use in patients with Difficult interpretation Unhampered Unhampered
abnormal ST at rest
Recommended use First choice in most patients To provide additional data in First choice in patients unable to
some patients, particularly exercise. Limited value in patients
location of myocardial ishcaemia with poor echo quality
It should be appreciated that the diagnostic patients with such conditions as syndrome X, digitalis
approach to patients with chest pain of possible cardiac treatment and electrolyte abnormalities.
origin has changed since the introduction of effective In order to improve the specificity and sensitivity
measures for prevention of progression of coronary of exercise ECG to identify coronary artery disease the
artery disease. In addition to an advice to stop smoking test procedure should be standardized with the use of
and treatment of hypertension and diabetes, patients nomograms predicting the exercise response taking into
with known coronary artery disease may now require account age, gender and body size. The test may be
treatment with lipid lowering drugs, particularly choles- conducted in patients taking anti-ischaemic drugs. A
terol synthesis inhibitors (statins). It has been shown normal test in such patients does not rule out signifi-
unequivocally that these drugs reduce the rate of pro- cant coronary disease. Thus, a second test, with less or
gression of coronary disease[43,44] and reduce the inci- no medication, may be indicated, depending on the
dence of coronary events.[4547]. Since these drugs are clinical question to be answered[48].
costly, these should be prescribed for (secondary) pre- The evaluation of the exercise test demands
vention only in patients with documented coronary assessment of the pretest and post-test likelihood of
disease. Thus, it has become important to establish or coronary disease in the particular patient under investi-
rule out this diagnosis even in patients with mild symp- gation (Table 1 (a) and (b)). The ECG should be
toms in whom coronary intervention would not be continuously recorded with a print-out of signal aver-
considered. aged recordings at preselected intervals, mostly at each
minute during exercise, and 4 to 10 minutes of re-
covery after exercise. An exercise test is commonly
Non-invasive investigations regarded as positive if there is horizontal or downslop-
ing ST-segment depression 01 mV in any lead. Such a
Resting electrocardiogram (ECG) dichotomous approach (i.e. positive or negative) is to
be deplored. It is misleading because in assessing the
All patients with the suspicion of angina pectoris significance of the test, one should take into account not
based upon symptoms should have a resting 12-lead only the ECG changes but also the work load, heart rate
electrocardiogram (ECG) recorded. This will not iden- increase and blood pressure response, and the clinical
tify with certainty whether patients have coronary artery context. ST changes related to heart rate have been
disease or not; a normal resting ECG is not uncommon suggested to be more reliable, describing the slope of ST
even in patients with very severe angina. However, the segment changes over time[40,50]. Either the Bruce proto-
resting ECG may show signs of coronary artery disease col or one of its modifications on a treadmill or a bicycle
such as previous myocardial infarction or an abnormal ergometer can be employed. The bicycle work load is
repolarisation pattern. In addition, the ECG may show described in terms of Watts (W). Increments are of 20 W
other abnormalities such as left ventricular hypertrophy, per 1 minute stage starting from 20 to 50 W, but
bundle branch block, pre-excitation, arrhythmias or increments may be reduced to 10 W per stage in patients
conduction defects. Such information may be helpful in with heart failure or severe angina[48]. A standard pro-
defining the mechanisms responsible for chest pain or in tocol should be employed, since this may be used for
identifying patient subgroups with a higher risk of death future reference in the same patient. In addition to the
or myocardial infarction. diagnostic value of the exercise ECG, the stress test has
an important role in demonstrating silent ischaemia and
in predicting the prognosis of patients with chronic
stable angina pectoris and following the progress of the
ECG stress testing disease or the effect of treatment.
The reason for stopping the test and the symp-
For patients with stable angina pectoris, the first inves- toms at that time, including their severity, should always
tigation after clinical assessment and a resting ECG is be recorded. Time to the onset of ECG changes and/or
likely to be an exercise ECG. The exercise test should be symptoms, the overall exercise time, the blood pressure
carried out only after careful clinical evaluation of and heart rate response, and the post-exercise recovery
symptoms and a physical examination including resting pace of ECG changes should be assessed. The exercise
ECG. ECG changes during exercise are associated with stress test is terminated at the discretion of the physician
the presence of coronary artery disease with a sensitivity for one of the following reasons:
of around 70% and a specificity of approximately 90%.
The results of the ECG stress testing should be inter- (1) Symptom limitation, e.g. pain, fatigue, dyspnoea;
preted by trained clinicians[48,49]. In population studies for repeated exercise tests. The use of Borg scale is
with a low prevalence of ischaemic heart disease the recommended to allow comparisons[51].
proportion of false positive tests will be high. Further- (2) Combination of symptoms such as pain with signifi-
more, false positive exercise recordings are common in cant ST-changes.
women with a low prevalence of disease. ECG changes (3) Safety reasons such as marked ST-segment changes
during exercise suggesting myocardial ischaemia in the (particularly ST-segment elevation), arrhythmias, or
absence of coronary artery disease are also seen in a sustained fall in systolic blood pressure.
Radionuclide angiography during exercise with a ventriculogram in the left oblique projection. This
permits assessment of left ventricular function including
Radionuclide angiography using technetium labelled red wall motion abnormalities. The left coronary artery is
blood cells can be used to assess left ventricular function usually examined in five projections, to ensure optimal
(global ejection fraction and regional wall motion) at assessment of each specific coronary segment, and the
rest and during exercise. For these studies exercise is right coronary artery in at least two projections. Record-
conducted in the supine position with stepwise incre- ing of overlapping segments must be avoided and
ments in work load with a 3 to 5 min step duration. specific, steeply angulated caudal left and right anterior
Images are collected over 1 to 2 min on each exercise oblique projection must frequently be used. Interpret-
stage. Healthy subjects will show a normal ejection ation of the arteriogram includes description of the
fraction at rest which increases on exercise, while morphology and severity of coronary lesions, together
patients with coronary disease (or other types of left with the presence of collateral vessels.
ventricular dysfunction) often exhibit no increase or a Most angiographers tend to overestimate the
decrease of global ejection fraction as well as develop- degree of stenosis prior to intervention, and under-
ment of regional wall motion abnormalities during estimate the residual narrowing after treatment[63,64].
exercise[57,58]. Quantitative coronary angiography greatly improves the
accurate assessment of coronary stenoses. In clinical
practice, assessment and, even more, the treatment of a
Coronary angiography 5075% stenosis must be complemented by evaluation of
its physiological importance with the usual markers of
Coronary angiography has a pivotal position in the ischaemia. In a diffusely narrowed and/or small vessel,
management of patients with chronic stable angina it is preferable not to use the percentage of stenosis
pectoris. It is currently the most reliable tool to ascertain but to use the absolute value (mm) of the minimal
the anatomical severity of coronary artery disease. How- lumen diameter (MLD). In general, an MLD<1 mm in
ever, necropsy and ultrasound studies[61] have clearly a proximal vessel indicates a flow-limiting stenosis,
demonstrated that the extent of plaque mass is grossly regardless of the percentage diameter stenosis.
underestimated by this technique. It carries a small risk In conclusion, coronary angiography has
of mortality (<01%)[62] and often needs to be supple- evolved into a routine examination. It provides a con-
mented by functional tests. siderable body of information for establishing the diag-
nosis and assessing the prognosis of coronary artery
Indications. Taking into account the development of new disease. Nevertheless, the decision to perform this ex-
techniques of myocardial revascularization and the low amination must be based on the clinical and physiologi-
risk of complications of coronary angiography, it should cal findings derived from a careful review of the history
be considered in the following conditions: and evidence of myocardial ischaemia.
In selected patients, objective intravascular ultra-
(1) Severe stable angina (Class 3 of the Canadian Car-
sound may provide additional information regarding the
diovascular Society Classification (CCS)), particu-
status of plaques and the presence or absence of intra-
larly if the symptoms are inadequately responding to
coronary thrombosis. The measurement of fractional
medical treatment;
flow reserve[65] is a promising new technique for assess-
(2) Chronic stable angina (Class 1 to 2) if there is ment of the functional significance of stenoses. These
a history of myocardial infarction or evidence of methods are still under investigation.
myocardial ischaemia at a low work load;
(3) Chronic stable angina in patients with bundle
branch block if readily-induced ischaemia is demon-
strated by myocardial perfusion scintigraphy; TREATMENT
(4) Patients with stable angina who are being con-
sidered for major vascular surgery (repair of
aortic aneurysm, femoral bypass, or carotid artery Aims of treatment
surgery);
To improve prognosis by preventing myocardial
(5) Patients with serious ventricular arrhythmias;
infarction and death
(6) Patients previously treated by myocardial revascu- In order to achieve this end, attempts must be made
larization (PTCA or CABG) who develop recur- to induce regression or halt progression of coronary
rence of moderate or severe angina pectoris; atherosclerosis, and to prevent complications, especially
(7) When it is essential to establish the diagnosis for thrombosis. Lifestyle changes and drugs play a vital role
clinical or occupational reasons. in this, but the myocardium may also be protected if its
The performance and interpretation of coronary perfusion is enhanced by interventional techniques.
angiography must be irreproachable. A complete exami- To minimize or abolish symptoms
nation includes left ventricular cineangiography per- Lifestyle changes, drugs, and interventional techniques
formed in the right arterior oblique projection together all play a part.
reduction in vascular events[75,76]. It is recommended myocardial contractility; both these effects reduce
that aspirin is administered routinely in a dosage of myocardial oxygen demand and thereby the severity
75160 mg daily in the absence of contra-indications. of ischaemia. All -blockers when given in adequate
dosages help to prevent anginal attacks.
Hormone replacement therapy (HRT). Epidemiological Selective -blockers are generally to be preferred
evidence strongly suggests a beneficial effect of HRT in in patients suffering from asthma, peripheral vascular
patients without manifest coronary disease. Although disease and insulin-dependent diabetes, although they
there is little information on the benefits and safety of are not entirely safe in these contexts. Some more
HRT in anginal patients, there is no reason not to use recently developed agents cause peripheral vasodi-
these drugs where indicated in patients with coronary latation and may be more useful in cases of peripheral
artery disease. vascular disease. Major adverse effects include severe
bradycardia, hypotension, brochospasm and, rarely,
Anti-oxidants. The theoretical benefits of anti-oxidant heart failure, but these are uncommon if patients are
therapy have not yet been confirmed in adequate trials. appropriately selected. More subtle side-effects, which
Further studies are needed before this therapy can be may go unrecognised unless sought, include fatigue,
recommended for angina patients. lassitude, nightmares, and cold extremities.
The effect of -blockers on the prognosis of
Drugs for symptom relief stable angina has not been specifically studied in a large
Three main classes of drugs are used to control symp- trial. A history of angina has, however, been present in
toms in chronic stable angina:nitrates, beta-blockers and about one-third of the patients recruited into post-
calcium antagonists[77]. Given in appropriate regimens, infarction studies of these agents. The Beta-Blocker
all these agents can be effective in this context, but there Pooling Project[80] reported a highly significant reduc-
is a considerable and, to a large extent, unpredictable tion in mortality in this sub-group, and it seems reason-
variation in response and adverse effects. The aim of able to assume that -blockers have the potential to
anti-anginal treatment is to reduce the myocardial oxy- prevent death, especially sudden death, and the develop-
gen requirements or to increase myocardial perfusion. ment of myocardial infarction even when there has been
Often, it may be possible to achieve both aims. no prior infarction.
-blockers are indicated for most patients with
Nitrates. Sublingual nitrates work rapidly, i.e. within more than the mildest angina, in the absence of contra-
minutes, and the effect lasts for about 3045 min. indications. They are particularly indicated in the post-
Profound relief of symptoms is the result of venodi- infarction patient.
latation, afterload reduction and coronary dilatation.
Many nitrate delivery systems have been developed for Calcium antagonists. Calcium antagonists cause cor-
chronic prophylactic use. It has become clear, however, onary and peripheral vasodilation. Furthermore, smooth
that patients can develop at least partial tolerance to muscle relaxation and reduction of afterload together
this therapy. The use of nitrate-free interval between with the negative inotropic effects of some of the agents
dosing is an effective means of overcoming the devel- will reduce myocardial oxygen consumption. While
opment of tolerance, although in some cases a rebound various formulations of the two prototype papaverine-
of symptoms may occur at this time. This can be like and benzothiazepine-like calcium antagonists
obviated by the concomitant use of another class of verapamil and diltiazem are widely available, most
anti-anginal agent. Nitrates did not influence morbidity current development involves analogues of the
or mortality in the 46 weeks after myocardial infarc- nifedipine-like dihydropyridine class. The calcium antag-
tion in the ISIS-4[78] and GISSI-3[79] trials. There have onists are a structurally heterogeneous group of com-
been no long-term trials of nitrates in patients with pounds with important differences in pharmacological
chronic stable angina. action.
The main adverse effect of nitrates is headache, Verapamil slows conduction through the atrio-
which may be troublesome but tends to diminish with ventricular node and has important negative inotropic
continued use. Other side-effects include flushing and effects as well as causing smooth muscle relaxation
syncope. Nitrates are particularly indicated for the which leads to an increase in coronary blood flow and a
prompt relief or prevention of angina and are also of reduction in afterload. The dihydropyridines, such as
value long-term in patients with heart failure or with nifedipine and amlodipine, also cause smooth muscle
contra-indications to beta-blockers. They are often (but relaxation but have no effect on cardiac pacemaker
not always) effective in patients with vasospastic angina tissue which may result in a reflex increase in the heart
and in syndrome X. rate. In common with other calcium antagonists, these
drugs have negative inotropic effects, which are, how-
-blockers. -blockers act mainly by blocking the ever, less marked than those of verapamil. The effect of
1 receptor. Non-selective -blockers also block the 2 diltiazem is similar to those of verapamil though it has a
receptor but even selective -blockers have some effect less potent effect of left ventricular function.
upon this receptor, especially at higher dosages. Block- The calcium antagonists in general should be
ade of the 1 receptor slows the heart rate and reduces used with caution in patients in heart failure or with
poor left ventricular function, although some long acting vascular selective long-acting dihydropiridines can also
dihydropyridines, such as amlodipine, may be safer in be given cautiously in such circumstances. Patients with
this context. asthma and peripheral vascular disease may be best
Unlike -blockers, calcium antagonists have not treated with a long acting nitrate or a calcium antagon-
been shown to reduce mortality after myocardial infarc- ist, although selective -blockers may be given with
tion, although there is some evidence that verapamil caution. As mentioned above, various combinations of
and diltiazem may reduce the risk of reinfarction[81,82]. -blockers, nitrates and calcium antagonists have been
Concerns have been expressed about the safety of cal- shown to be useful where a single agent is ineffective, but
cium antagonists, particularly the short-acting prep- it is probably best to evaluate an alternative single drug
arations[83]. Calcium antagonists should be considered if before starting combination treatment.
beta-blockers are contra-indicated or ineffective. They
are specifically indicated for vasospastic angina.
Percutaneous transluminal coronary
Other agents. Molsidomine belongs to a newly discov- angioplasty
ered class of sydnonimines, which resemble nitroglycerin
in their mode of action. Molsidomine appears to act Percutaneous transluminal coronary angioplasty
more slowly than nitrates, but its effect lasts longer. (PTCA) is widely used in the treatment of stable angina
Nicorandil, a potassium channel activator, also pos- pectoris. Introduced in 1977 by Grntzig, the number of
sesses nitrate-like activity. It relaxes vascular smooth procedures has increased exponentially and angioplasty
muscle; and does not appear to cause tolerance with has surpassed the frequency of coronary bypass graft
chronic dosing. Metabolic agents, such as trimetazidine, surgery (CABG). This dramatic increase is largely the
may also be useful. result of major changes in the technique, the materials,
and lesion selection criteria. The introduction of better
Combination treatment. Many but by no means all imaging systems has also contributed to the great
studies have demonstrated additional beneficial anti- improvements in results that have been seen. In the
anginal effects when a beta-blocker is used in combi- majority of cases, the procedure is achieved with a
nation with a calcium antagonist or a long-acting nitrate balloon tracking over a guide wire. Alternative methods
preparation. Care needs, to be taken however, with the may be preferred for particular types of lesions. Large
combination of a -blocker and verapamil or diltiazem, bulky, eccentric lesions are good indications for direc-
especially if there is evidence of conduction disturbance tional atherectomy. Ablation with a Rotablator is most
or left ventricular dysfunction. Furthermore, calcium effective in the treatment of hard, fibrocalcific lesions,
antagonists may be combined with long-acting nitrates. ostial lesions, and diffuse disease. Earlier enthusiasm for
The effects of combining drugs may be due to an laser therapy has declined because of the frequent need
additional reduction in the rate-pressure product both at for adjunctive balloon angioplasty and a high rate of
rest and on exercise, but the IMAGE study[84] suggests restenosis. By contrast, stents are used more and more
that the benefit of adding a new agent may be due to the frequently in coronary interventional cardiology. Better
recruitment of new reponders than to combination per deployment and new management after stent implan-
se. In addition, synergy between two classes of drug may tation have increased the safety of coronary stenting and
abolish the potentially detrimental effects of each. There led to a low risk of subacute thrombosis and vascular
is little evidence to support the current vogue of using complications[86]. Stents have markedly decreased the
triple therapy. Indeed as Tolins et al.[85] have empha- need for emergency CABG, the rate of post procedure
sized, maximal therapy is not necessarily optimal myocardial infarction, and restenosis.
therapy.
Success and risks. In stable angina pectoris, a procedural
Choice of anti-anginal agent. All patients should be success in anatomically suitable patients is achieved in
offered short-acting nitrates either sublingually or by 95% of cases[87]. The mortality rate is less than 02% in
spray. These drugs may be used not only to treat an patients with single vessel disease and 05% in case of
acute episode but are particuarly valuable taken prophy- multivessel disease. The need for emergency bypass
lactically when an attack is anticipated, for example surgery is currently less than 1% since the advent of
prior to exercise. stents. The rate of myocardial infarction, as recognised
Choice of first line treatment for prophylaxis by developments of new Q waves, is now less than 1%.
depends on the underlying predominant pathophysi- These results can be achieved within a short
ological process, left ventricular function, and associated period of hospitalisation. Furthermore, the use of small
conditions. Patients with very clear-cut effort-related (6 F) catheters allow simple lesions to be treated on a
angina should be offered a beta-blocker as should those day case basis. The return to work is rapid.
with a prior myocardial infarction. Diltiazem and vera-
pamil are also useful in such circumstances though they Restenosis. Restenosis remains a major concern. It
should be avoided in the presence of significant left occurs in 35 to 40% of cases with angiographic control.
ventricular dysfunction. Nitrates are of value where In some cases, restenosis is detected by the recurrence of
there is left ventricular dysfunction; -blockers and some symptoms but it can be completely silent and detected
only by systematic angiography. Non-invasive tests are preferred because their long-term patency is superior to
not very predictive (predictive value 50% if positive) but that of saphenous vein graft. The left internal mammary
have a good negative predictive value (93%). artery is incorporated in almost all bypass procedures of
There are two principal mechanisms of re- the left coronary artery. The right internal mammary
stenosis: chronic recoil of the artery (remodelling)[88] and artery, may also be used. Other conduits, such as the
neo-intimal proliferation (healing process). In more than right gastro-epiploic artery and inferior epigastric artery
50 randomised multicentre trials, drugs have failed to may also be considered. Endarterectomy is most often
prevent neo-intimal proliferation perhaps because they reserved for vessels with distal disease not satisfactory
attacked only one (relatively limited) of the mechanisms. for distal grafts. This method is most commonly applied
Recently, trials with c73E3 Gp IIb/IIIa receptor block- to the right coronary artery at and beyond the crux.
ade have indicated a reduction in death and myocardial It has been shown that endarterectomy is associated
infarction after PTCA[89]. The remodelling process can with a higher perioperative mortality and myocardial
be prevented by stent implantation which significantly infarction whilst a lower long-term graft patency is
decreases the rate of restenosis in patients with stable frequently observed.
angina and vessels with diameters between 26 and
34 mm. The combination of stent implantation and a Risks and complications. The in-hospital major compli-
drug locally or generally delivered could lead in the near cations largely depend on the extent of vessel disease,
future to a marked reduction in the rate of restenosis. left ventricular function and associated diseases (renal or
When the patient experiences recurrence of chest pain respiratory insufficiency). The in-hospital mortality rate
and significant restenosis, a repeat PTCA with or with- is 1% in single vessel disease and increases up to 4 to 5%
out stent implantation can be performed. The risk of this in multivessel disease with poor left ventricular function.
reintervention is low and the success rate high. Perioperative myocardial infarction characterized by the
occurrence of new Q waves may be observed in 4 to 5%
Comparisons of PTCA and drug treatment. There is, as of cases[92].
yet, no convincing evidence that PTCA is superior to
medical treatment with regard to the risk of myocardial Patency of the conduits. The patency rate of saphenous
infarction or death in patients with chronic stable vein grafts is quite variable but 10 to 20% of grafts are
angina. The decision whether to undertake PTCA in occluded within one week of surgery from thrombosis.
such patients depends, therefore, on the anticipated By 3 to 5 years after operation, 6070% of vein grafts
benefit to be obtained in respect of angina. Few com- have evidence of atherosclerotic narrowing[93]. This new
parative trials have been undertaken to address this disease is characterized by very soft, friable material
issue. In the ACME trial[90,91], a randomized study which is very prone to embolize to the distal part of the
comparing PTCA vs medical therapy in single LAD vessels. By contrast, 90% of the internal mammary
disease, PTCA decreased the incidence of symptomatic artery grafts anastomosed to the left anterior coronary
ischaemia and was associated with more normal tread- artery are patent 10 years after operation[94]. The risk of
mill exercise tests. However, 48% of the medically re-operation is high, the 5 to 11% mortality rate depend-
treated patients were rendered free of angina compared ing mainly on the LV function.
with 64% of the PTCA group, and PTCA was associated
with a higher frequency of complications and greater Comparison of CABG with medical therapy. Yusuf
expense. et al.[95] have undertaken a systematic review of the
outcomes of 2649 patients randomly assigned to receive
CABG or medical management for coronary artery
Coronary bypass graft surgery disease in seven individual trials conducted between
1972 and 1984. This meta-analysis demonstrated that
Coronary bypass graft surgery has been recognised as a CABG reduced mortality in patients with left main
very effective method of myocardial revascularisation disease and others at relatively high risk, such as those
for more than 25 years. Coronary artery surgery is now with three vessel disease associated with impaired left
a reproducible and technically precise procedure. Patient ventricular function.
survival and freedom from events are dependent to an
important degree on attention to technical details. The Comparison of PTCA vs CABG. Five major randomised
coronary bypass operation is usually performed with trials have compared these two forms of intervention,
cardiopulmonary bypass using the pump oxygenator, mainly in patients with multiple vessel disease. Three
although less invasive techniques are being increasingly were conducted in Europe (RITA[96], GABI[97] and
employed. A number of methods of minimising peri- CABRI[98] and two in U.S.A. (EAST[99] and BARI[100].
operative ischaemia and numerous strategies for Only one (RITA)[96] compared the results of PTCA and
myocardial management are in use. CABG in patients with single vessel disease.
The results of these trials are uniform and con-
Conduits for coronary bypass graft surgery. Several sistent: both methods of myocardial revascularization
autogenous conduits are available. The long saphenous were associated with a similar risk of death and non-
vein is still widely used, but if possible, arterial grafts are fatal myocardial infarction, although the trials were
coronary artery disease is assumed to be less likely, symptoms should be evaluated and managed in the same
chronic stable angina pectoris may be underdiagnosed. way as younger ones. With increasing age, however,
Symptoms of chest pain in women are often atypical and many patients are willing to accept a less well proven
therefore dismissed, particularly if the woman is young. diagnosis of chronic stable angina pectoris and to start
Furthermore, because the prevalence of coronary artery treatment for evaluation of its efficacy. This means that
disease in younger women is low, the exercise test is not all elderly patients need be referred for exercise stress
more likely to be falsely positive. This explains the more testing, especially when noncardiac factors might limit
frequent prevalence of chest pain with normal coronary the test.
arteries in women (five times that of men) and therefore Changes in drug bioavailability, elimination and
the better prognosis for women with angina who have sensitivity mean that dose modification is essential when
been evaluated without angiography as a baseline[103]. prescribing cardiovascular drugs to elderly patients[111].
The diagnostic value of exercise stress testing is lower in Further issues which should be taken into account when
women[104], primarily because of the lower prevalence of prescribing for the elderly include risk of drug inter-
coronary artery disease. Women who can exercise to actions, polypharmacy and compliance problems.
stage III of the Bruce protocol or who have ST-segment Although evidence suggests that doctors may be reluc-
normalisation within 4 min postexercise are unlikely to tant to treat angina aggressively in very old patients, the
have coronary artery disease[105]. Microvascular disease usual antianginal medications are as efficacious in this
(syndrome X) may provoke chest pain in women due to patient population as in the young. On the other hand,
myocardial ischaemia despite angiographically normal elderly patients have a higher incidence of contraindi-
arteries[106]. Women are less likely to be referred for cations, complications and therapy withdrawals. Con-
coronary angiography than men and women referred for sidering symptoms as well as prognosis, elderly patients
chest pain who subsequently underwent coronary angi- have the same benefit from medical therapy, angioplasty
ography are found to have normal coronary arteries and bypass surgery as younger patients[112,113,114].
more often than men[107]. Due to the high frequency of
false positive exercise ECG tests, myocardial perfusion Syndrome X
scintigraphy or stress echocardiography should more
often be considered. Women with typical angina symp- A significant proportion of patients undergoing diagnos-
toms on effort with positive exercise ECG or myo- tic coronary angiography for chest pain show normal or
cardial perfusion defects should have access to coronary near normal coronary arteries. It has been reported that
angiography. 6 to 30% of the patients fall into this category[115,116].
There is no justification for treating men and The term syndrome X is often used if patients with
women differently after coronary artery disease is diag- normal angiograms have angina-like chest pain and a
nosed. Women have a higher morbidity and mortality positive exercise stress test[115]. Angina with a normal
when suffering myocardial infarction than men after coronary angiogram is clearly a heterogeneous condition
taking into account known adverse factors and cor- and a noncardiac cause, e.g. oesophageal disease is
recting for age. There are suggestions that treatment of probably common[117]. In subsets of patients, myocar-
myocardial infarction is less vigorous in women than in dial ischaemia can clearly be provoked and a reduced
men and that survival chances are reduced in women coronary vasodilator reserve has been demonstrated in
discharged after myocardial infarction because they do these patients. There are observations suggesting that
not have the same therapeutic interventions as men[108]. patients with syndrome X may have an endothelial
There is a need to improve detection and treatment of dysfunction[118].
coronary artery disease in women; when diagnosed Patients with angina pectoris and normal cor-
they have the same benefits from medical therapy and onary arteries have a good prognosis regarding mor-
revascularization. tality[119]. This is important information for the patient
who often has severe chest pain, functional limitation
and psychological distress. Patients with syndrome X are
The elderly considered to respond poorly to conventional pharma-
cological treatment. Sublingual nitrates are reported to
After the age of 75 years there is an equal prevalence of relieve chest pain in only about 50% of the patients[115].
coronary artery disease in men and women[109]. The Conventional anti-ischaemic treatments have less con-
disease is more likely to be diffuse and severe; left main sistent benefits. Since there is a female predominance in
coronary artery stenosis and triple vessel disease are angina with normal coronary arteries and the symptoms
more prevalent in older patients, as is depressed left commonly start after menopause, a pathogenetic role of
ventricular function[110]. Coexistent illness or a sedentary oestrogen deficiency has been suggested[120]. Hormone
lifestyle may limit the usefulness of exertional chest pain replacement therapy may be useful[121].
as a diagnostic finding and exercise testing is less often of
diagnostic value for technical reasons. Due to the diffuse Logistics of care
distribution of coronary artery disease, there is a higher
likelihood of non-specific ECG changes during the The organisation of medical care varies greatly from one
stress test[48]. In general, elderly patients with anginal country to another, and no uniform role can therefore
be assigned to the generalist or specialist respectively. In (3) It is essential in interpreting the findings of the
those countries in which general practitioners or other exercise test, that the demographic and clinical fea-
generalists play a major role, it is important to recognise tures of the individual are taken into account, as
both their potential contribution and their limitations in well as the workload achieved and the blood pres-
the management of angina. Because of their usually sure and heart rate responses. While of great value
better knowledge of the patient and his or her personal in many cases, however, this test may provide
circumstances, they are often best placed to assess the equivocal or misleading information in some. Alter-
whole individual and to advise on and supervise lifestyle native investigations are needed when the diagnosis
modifications, as well as compliance with therapy. How- remains uncertain or functional assessment is inad-
ever, specialist assessment is virtually always necessary equate, especially when there are electrocardio-
with regard to establishing the diagnosis and assessing graphic features which are difficult or impossible to
severity and prognosis. Chest pain clinics which can interpret. Myocardial perfusion imaging and stress
review patients without delay are of considerable value, echocardiography are of particular value in demon-
particularly in patients with recent onset or suspected strating the extent and localisation of myocardial
unstable angina. ischaemia. Echocardiography and radionuclide an-
giography are helpful in evaluating ventricular
function.
Conclusions and recommendations (4) The interpretation of chest pain is particularly
difficult in young and middle-aged women. The
(1) Stable angina pectoris due to coronary atheroscler- classical symptom complex of chronic stable an-
osis is a common and disabling disorder. While gina, which is a reliable indicator of myocardial
compatible with longevity, there is a substantial ischaemia in men is not so in younger women. This
risk of progression to myocardial infarction, and/or problem is compounded by the relatively high
death. With proper management, the symptoms prevalence of syndrome X in women, and by the
can usually be controlled and the prognosis sub- frequency of false positive exercise tests.
stantially improved. In practice, it seems probable (5) The general management of the patient is of para-
that there is both widespread underdiagnosis and mount importance. This must include a strategy
overdiagnosis, and that optimal management strat- tailored to personal circumstances, an explanation
egies are often not implemented. of the nature of the condition and its treatment,
(2) Every patient with suspected stable angina requires and attention to lifestyle issues. Aspirin should be
prompt and appropriate cardiological investigation administered unless contra-indicated, and lipid-
to ensure that the diagnosis is correct and that the lowering drugs should be considered if dietary
prognosis is evaluated. As a minimum, each patient measures fail to reduce total serum cholesterol
should have a carefully taken history and physical below 50 mmol . l "1.
examination, an assessment of risk factors and a (6) Nitrates, -blockers and calcium antagonists, alone
resting electrocardiogram. Ready access to diag- or in combination, are effective in controlling the
nostic facilities should be available to general prac- symptoms of angina in most cases. Because there is
titioners. Cardiology Departments should ensure considerable variation in the response of patients to
that such patients are attended to without delay; each class of drug, and the side-effects are unpre-
some hospitals now provide a special Chest Pain dictable, the choice of agent should be determined
clinic for this purpose. on an individual basis. -blockers are particularly
Three diagnostic strategies may be followed de- indicated in those who experience angina after a
pending upon patient characteristics and the severity of myocardial infarction as they reduce the risk of
symptoms: reinfarction and death. The costs of the various
(a) The minimal assessment, as described above, drug regimens needs to be taken into account.
without additional investigations. This may suffice, par- (7) Coronary angiography should be undertaken when
ticularly in elderly patients with readily controlled symp- symptoms are not satisfactorily controlled by medi-
toms, or in those disabled or seriously ill for other cal means, when non-invasive investigations sug-
reasons. gest that the prognosis could be improved by
(b) An initial non-invasive strategy which is angioplasty or coronary artery bypass surgery, and
appropriate for most patients. This allows an assessment when it is considered essential to establish the
of the likelihood of and the severity of coronary heart diagnosis.
disease in patients with mild to moderate symptoms e.g. (8) Percutaneous transluminal coronary angioplasty
exercise testing with or without perfusion scintigraphy (PTCA) is an effective treatment for stable angina
or stress echocardiography. In many patients, this may pectoris, and is indicated for patients with angina
lead to coronary angiography. not satisfactorily controlled by medical treatment
(c) Coronary angiography without prior func- when there are anatomically suitable lesions. Re-
tional testing. This may be an option for patients with stenosis continues to be a problem, which is dimin-
uncontrolled severe symptoms in whom revascularisa- ished but not abolished by stenting. There is, as yet,
tion seems indicated urgently. no evidence that PTCA reduces the risk of death.
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Heart Failure
After further revision, it was submitted for
Appendix approval to the Committee for Scientific and Clinical
Initiatives of the Society. It was also sent to Dr F. L.
Procedure of the Task Force Ritchie of Seattle and Dr B. Gersch of Washington who
kindly commented on it. The report was finalised for
The Task Force on the Management of Stable Angina publication in November 1996.
Pectoris was created by the Committee for Scientific The Task Force wishes to thank Mrs W. Thieme
and Clinical Initiatives of the European Society of for her invaluable assistance.
Cardiology in September 1995 and asked to report to
the Congress of the Society in August 1996. Financial Support
The members of the Task Force were Prof. D. G.
Julian (Chairman) U.K., Prof. M. E. Bertrand (France), The Task Force wishes to express its appreciation of
Prof. . Hjalmarson (Sweden), Dr K. Fox (U.K.), the financial support provided by Astra Hssle AB,
Prof. M. L. Simoons (The Netherlands), Prof. L. Behringwerke AG, Institut de Recherches Inter-
Ceremuzynski (Poland), Prof. A. Maseri (Italy), Prof. T. nationales Servier, Knoll AG, Laboratoires Searle,
Meinertz (Germany), Prof. J. Meyer (Germany), Prof. Merck, Sharp and Dohme, Pfizer Ltd and Synthlabo.
K. Pyrl (Finland), Ass. Prof. N. Rehnqvist (Sweden), The Task Force report was developed without any
Prof. L. Tavazzi (Italy), Prof. P. Toutouzas (Greece), involvement of the pharmaceutical companies that
Prof. T. Treasure (U.K.) provided financial support.