JONATHAN ABRAMS, MD, FACC JEFFREY L. ANDERSON, MD, FACC ERIC R. BATES, MD, FACC BRUCE R. BRODIE, MD, FACC* CINDY L. GRINES, MD, FACC PETER G. DANIAS, MD, PHD, FACC* GABRIEL GREGORATOS, MD, FACC* MARK A. HLATKY, MD, FACC JUDITH S. HOCHMAN, MD, FACC* SANJIV KAUL, MBBS, FACC ROBERT C. LICHTENBERG, MD, FACC JONATHAN R. LINDNER, MD, FACC ROBERT A. O’ROURKE, MD, FACC GERALD M. POHOST, MD, FACC RICHARD S. SCHOFIELD, MD, FACC SAMUEL J. SHUBROOKS, MD, FACC CYNTHIA M. TRACY, MD, FACC* WILLIAM L. WINTERS, JR, MD, MACC*

Jeffrey L. Anderson, MD, FACC, FAHA, Chair Jonathan L. Halperin, MD, FACC, FAHA, Chair-Elect Alice K. Jacobs, MD, FACC, FAHA, Immediate Past Chair 2009–2011 [§§][1] Sidney C. Smith, Jr, MD, FACC, FAHA, Past Chair 2006–2008 [§§][1] Cynthia D. Adams, MSN, APRN-BC, FAHA[§§][1] Nancy M

A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jacc.2012.07.013

A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jacc.2012.07.012

HomeCirculationVol. 116, No. 232007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUB2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable AnginaA 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. FrakerJr, 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 FergusonJr, MD, FACC, FAHA, Stephan D. Fihn, MD, MPH, FACP, Theodore D. FrakerJr, 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, Sidney C. SmithJr, TASK FORCE MEMBERS:, 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 and Clyde W. Yancy, MD, FACC Theodore D. FrakerJrTheodore D. FrakerJr , Stephan D. FihnStephan D. Fihn , Writing on behalf of the 2002 Chronic Stable Angina Writing Committee , 2002 WRITING COMMITTEE MEMBERS , Raymond J. GibbonsRaymond J. Gibbons , Jonathan AbramsJonathan Abrams , Kanu ChatterjeeKanu Chatterjee , Jennifer DaleyJennifer Daley , Prakash C. DeedwaniaPrakash C. Deedwania , John S. DouglasJohn S. Douglas , T. Bruce FergusonJrT. Bruce FergusonJr , Stephan D. FihnStephan D. Fihn , Theodore D. FrakerJrTheodore D. FrakerJr , Julius M. GardinJulius M. Gardin , Robert A. O'RourkeRobert A. O'Rourke , Richard C. PasternakRichard C. Pasternak , Sankey V. WilliamsSankey V. Williams , Sidney C. SmithJrSidney C. SmithJr , Alice K. JacobsAlice K. Jacobs , Cynthia D. AdamsCynthia D. Adams , Jeffrey L. AndersonJeffrey L. Anderson , Christopher E. BullerChristopher E. Buller , Mark A. CreagerMark A. Creager , Steven M. EttingerSteven M. Ettinger , Jonathan L. HalperinJonathan L. Halperin , Sharon A. HuntSharon A. Hunt , Harlan M. KrumholzHarlan M. Krumholz , Frederick G. KushnerFrederick G. Kushner , Bruce W. LytleBruce W. Lytle , Rick NishimuraRick Nishimura , Richard L. PageRichard L. Page , Barbara RiegelBarbara Riegel , Lynn G. TarkingtonLynn G. Tarkington and Clyde W. YancyClyde W. Yancy Originally published12 Nov 2007https://doi.org/10.1161/CIRCULATIONAHA.107.187930Circulation. 2007;116:2762–2772is corrected byCorrectionOther version(s) of this articleYou are viewing the most recent version of this article. Previous versions: November 12, 2007: Previous Version 1 Preamble…27631. Introduction…2764 1.1. Evidence Review…2764 1.2. Organization of Committee and Relationships With Industry…2765 1.3. Review and Approval…2765References…2769Appendix 1…2770Appendix 2…2770PreambleA 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 journalLarge, randomized, placebo-controlled trial(s)Nonrandomized data deemed important on the basis of results impacting current safety and efficacy assumptionsStrengths/weakness of research methodology and findingsLikelihood of additional studies influencing current findingsImpact 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 biasNumber of previous trials showing consistent resultsNeed for consistency with a new guideline or guideline revisionIn 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. Download figureDownload PowerPointTable 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.Table 2. Cardiovascular Risk Reduction for Patients With Chronic Angina2002 Chronic Angina Recommendations2007 Chronic Angina Recommendations2007 COR and LOECommentsContinued on next pageSmokingAssess tobacco use. Strongly encourage patient and family to stop smoking and to avoid second-hand smoke. Provide counseling, pharmacological therapy (including nicotine replacement and buproprion), and formal cessation programs as appropriate.Smoking cessation and avoidance of exposure to environmental tobacco smoke at work and home is recommended. Follow-up, referral to special programs, and/or pharmacotherapy (including nicotine replacement) is recommended, as is a stepwise strategy for smoking cessation (Ask, Advise, Assess, Assist, Arrange).I (B)Modified recommendation (changed text and COR LOE added)Blood Pressure ControlInitiate lifestyle modification (weight control, physical activity, alcohol moderation, moderate sodium restriction, and emphasis on fruits, vegetables, and low-fat dairy products) in all patients with blood pressure greater than or equal to 130 mm Hg systolic or 80 mm Hg diastolic. Add blood pressure medication, individualized to other patient requirements and characteristics (i.e., age, race, need for drugs with specific benefits) if blood pressure is not less than 140 mm Hg systolic or 90 mm Hg diastolic, or if blood pressure is not less than 130 mm Hg systolic or 85 mm Hg diastolic for individuals with heart failure or renal insufficiency (less than 80 mm Hg diastolic for individuals with diabetes).Patients should initiate and/or maintain lifestyle modifications—weight control; increased physical activity; moderation of alcohol consumption; limited sodium intake; and maintenance of a diet high in fresh fruits, vegetables, and low-fat dairy products.I (B)New recommendationBlood pressure control according to Joint National Conference VII guidelines is recommended (i.e., blood pressure less than 140/90 mm Hg or less than 130/80 mm Hg for patients with diabetes or chronic kidney disease) (11).I (A)Modified recommendation (changed text and COR LOE added)For hypertensive patients with well established coronary artery disease, it is useful to add blood pressure medication as tolerated, treating initially with beta blockers and/or ACE inhibitors, with addition of other drugs as needed to achieve target blood pressure.I (C)New recommendationLipid ManagementStart dietary therapy in all patients (less than 7% saturated fat and less than 200 mg per dL cholesterol) and promote physical activity and weight management. Encourage increased consumption of omega-3 fatty acids.Dietary therapy for all patients should include reduced intake of saturated fats (to less than 7% of total calories), trans-fatty acids, and cholesterol (to less than 200 mg per day).I (B)Modified recommendation (changed text and COR LOE added)Adding plant stanol/sterols (2 g per day) and/or viscous fiber (greater than 10 g per day) is reasonable to further lower LDL-C.IIa (A)New recommendationDaily physical activity and weight management are recommended for all patients.I (B)New recommendationConsider omega-3 fatty acids as adjunct for high TG.For all patients, encouraging consumption of omega-3 fatty acids in the form of fish* or in capsule form (1 g per day) for risk reduction may be reasonable. For treatment of elevated TG, higher doses are usually necessary for risk reduction.IIb (B)Modified recommendation (changed text and COR LOE added)Assess fasting lipid profile in all patients, and within 24 hours of hospitalization for those with an acute event. If patients are hospitalized, consider adding drug therapy on discharge. Add drug therapy according to the following guide:Recommended lipid management includes assessment of a fasting lipid profile.I (A)Modified recommendation (changed text and COR LOE added)LDL less than 100 mg per dL (baseline or on-treatment). Further LDL-lowering therapy not required. Consider fibrate or niacin (if low HDL or high TG).a. LDL-C should be less than 100 mg per dL andI (A)Modified recommendation (changed text and COR LOE added)b. Reduction of LDL-C to less than 70 mg per dL or high-dose statin therapy is reasonable.IIa (A)New recommendationLDL 100 to 129 mg per dL (baseline or on-treatment) Therapeutic options: Intensify LDL-lowering therapy (statin or resin†). Fibrate or niacin (if low HDL or high TG). Consider combined drug therapy (statin + fibrate or niacin) (if low HDL or high TG).c. If baseline LDL-C is greater than or equal to 100 mg per dL, LDL-lowering drug therapy should be initiated in addition to therapeutic lifestyle changes. When LDL-lowering medications are used in high-risk or moderately high-risk persons, it is recommended that intensity of therapy be sufficient to achieve a 30% to 40% reduction in LDL-C levels.I (A)Modified recommendation (changed text and COR LOE added)LDL greater than or equal to 130 mg per dL (baseline or on-treatment). Intensify LDL-lowering therapy (statin or resin†). Add or increase drug therapy with lifestyle therapies.d. If on-treatment LDL-C is greater than or equal to 100 mg per dL, LDL-lowering drug therapy should be intensified.I (A)Modified recommendation (changed text and COR LOE added)e. If baseline LDL-C is 70 to 100 mg per dL, it is reasonable to treat LDL-C to less than 70 mg per dL.IIa (B)New recommendationTable 2. Continued2002 Chronic Angina Recommendations2007 Chronic Angina Recommendations2007 COR and LOECommentsContinued on next pageIf TG 200 to 499 mg per dL: Consider fibrate or niacin after LDL-lowering therapy.†f. If TG are 200 to 499 mg per dL, non–HDL-C‡ should be less than 130 mg per dL andI (B)Modified recommendation (changed text and COR LOE added)g. Further reduction of non–HDL-C‡ to less than 100 mg per dL is reasonable, if TG are greater than or equal to 200 to 499 mg per dL.IIa (B)New recommendationh. Therapeutic options to reduce non–HDL-C are: • Niacin can be useful as a therapeutic option to reduce non–HDL-C (after LDL-C–lowering therapy)§ or • Fibrate therapy as a therapeutic option can be useful to reduce non–HDL-C‡ (after LDL-C–lowering therapy).IIa (B)New recommendationIf TG greater than or equal to 500 mg per dL: Consider fibrate or niacin before LDL-lowering therapy.*i. If TG are greater than or equal to 500 mg per dL, therapeutic options to lower the TG to reduce the risk of pancreatitis are fibrate or niacin; these should be initiated before LDL-C lowering therapy. The goal is to achieve non–HDL-C‡ less than 130 mg per dL if possible.I (C)Modified recommendation (changed text and COR LOE added)The following lipid management strategies can be beneficial:IIa (C)a. If LDL-C less than 70 mg per dL is the chosen target, consider drug titration to achieve this level to minimize side effects and cost. When LDL-C less than 70 mg per dL is not achievable because of high baseline LDL-C levels, it generally is possible to achieve reductions of greater than 50% in LDL-C levels by either statins or LDL-C–lowering drug combinations. (12)If TG greater than or equal to 150 mg per dL or HDL less than 40 mg per dL: Emphasize weight management and physical activity. Advise smoking cessation.Deleted recommendationDrug combinations are beneficial for patients on lipid lowering therapy who are unable to achieve LDL-C less than 100 mg per dL.I (C)New recommendationPhysical ActivityAssess risk, preferably with exercise test, to guide prescription. Encourage minimum of 30 to 60 minutes of activity, preferably daily, or at least 3 or 4 times weekly (walking, jogging, cycling, or other aerobic activity) supplemented by an increase in daily lifestyle activities (e.g., walking breaks at work, gardening, household work).Physical activity of 30 to 60 minutes, 7 days per week (minimum 5 days per week) is recommended. All patients should be encouraged to obtain 30 to 60 minutes of moderate-intensity aerobic activity, such as brisk walking, on most, preferably all, days of the week, supplemented by an increase in daily activities (such as walking breaks at work, gardening, or household work).I (B)Modified recommendation (changed text and COR LOE added)The patient's risk should be assessed with a physical activity history. Where appropriate, an exercise test is useful to guide the exercise prescription (see Exercise Testing Guideline) (10).I (B)New recommendationAdvise medically supervised programs for moderate- to high-risk patients.Medically supervised programs (cardiac rehabilitation) are recommended for at-risk patients (e.g., recent acute coronary syndrome or revascularization, heart failure).I (B)Modified recommendation (changed text and COR LOE added)Expanding physical activity to include resistance training on 2 days per week may be reasonable.IIb (C)New recommendationTable 2. Continued2002 Chronic Angina Recommendations2007 Chronic Angina Recommendations2007 COR and LOECommentsContinued on next pageWeight ManagementCalculate BMI and measure waist circumferences as part of evaluation. Monitor response of BMI and waist circumference to therapy. Start weight management and physical activity as appropriate. Desirable BMI range is 18.5 to 24.9 kg/m2.BMI and waist circumference should be assessed regularly. On each patient visit, it is useful to consistently encourage weight maintenance/reduction through an appropriate balance of physical activity, caloric intake, and formal behavioral programs when indicated to achieve and maintain a BMI between 18.5 and 24.9 kg/m2.I (B)Modified recommendation (changed text and COR LOE added)When BMI greater than or equal to 25 kg/m2, goal for waist circumference is less than or equal to 40 inches (102 cm) in men and less than or equal to 35 inches (89 cm) in women.If waist circumference is greater than or equal to 35 inches (89 cm) in women or greater than or equal to 40 inches (102 cm) in men, it is beneficial to initiate lifestyle changes and consider treatment strategies for metabolic syndrome as indicated. Some male patients can develop multiple metabolic risk factors when the waist circumference is only marginally increased (e.g., 37 to 40 inches [94 to 102 cm]). Such persons may have a strong genetic contribution to insulin resistance. They should benefit from changes in life habits, similarly to men with categorical increases in waist circumference.I (B)Modified recommendation (changed text and COR LOE added)Start weight management and physical activity as appropriate. Desirable BMI range is 18.5 to 24.9 kg/m2.The initial goal of weight loss therapy should be to gradually reduce body weight by approximately 10% from baseline. With success, further weight loss can be attempted if indicated through further assessment.I (B)Modified recommendation (changed text and COR LOE added)Diabetes ManagementAppropriate hypoglycemic therapy to achieve near-normal fasting plasma glucose, as indicated by HbA1c.Diabetes management should include lifestyle and pharmacotherapy measures to achieve a near-normal HbA1c.I (B)Modified recommendation (changed text and COR LOE added)Treatment of other risks (e.g., physical activity, weight management, blood pressure, and cholesterol management).Vigorous modification of other risk factors (e.g., physical activity, weight management, blood pressure control, and cholesterol management) as recommended should be initiated and maintained.I (B)Modified recommendation (changed text and COR LOE added)Antiplatelet Agents/AnticoagulantsStart and continue indefinitely aspirin 75 to 325 mg per day if not contraindicated. Consider clopidogrel as an alternative if aspirin contraindicated.Aspirin should be started at 75 to 162 mg per day and continued indefinitely in all patients unless contraindicated.I (A)Modified recommendation (changed text and COR LOE added)Manage warfarin to international normalized ratio = 2.0 to 3.0 in post-MI patients when clinically indicated or for those not able to take aspirin or clopidogrel.Use of warfarin in conjunction with aspirin and/or clopidogrel is associated with an increased risk of bleeding and should be monitored closely.I (B)Modified recommendation (changed text and COR LOE added)Renin-Angiotensin-Aldosterone System BlockersACE InhibitorsACE inhibitors should be started and continued indefinitely in all patients with left ventricular ejection fraction less than or equal to 40% and in those with hypertension, diabetes, or chronic kidney disease unless contraindicated.I (A)Modified recommendation (changed text and COR LOE added)Treat all patients indefinitely post-MI; start early in stable high-risk patients (anterior MI, previous MI, Killip class II [S3, gallop, rales, radiographic CHF]). Consider chronic therapy for all other patients with coronary or other vascular disease unless contraindicated.Use as needed to manage blood pressure or symptoms in all other patients.ACE inhibitors should be started and continued indefinitely in patients who are not lower risk (lower risk defined as those with normal left ventricular ejection fraction in whom cardiovascular risk factors are well controlled and revascularization has been performed), unless contraindicated.I (B)Modified recommendation (changed text and COR LOE added)It is reasonable to use ACE inhibitors among lower-risk patients with mildly reduced or normal left ventricular ejection fraction in whom cardiovascular risk factors are well controlled and revascularization has been performed.IIa (B)New recommendationTable 2. Continued2002 Chronic Angina Recommendations2007 Chronic Angina Recommendations2007 COR and LOEComments*Pregnant and lactating women should limit their intake of fish to minimize exposure to methylmercury.†The use of resin is relatively contraindicated when TG are lower than 200 mg per dL.‡Non-HDL cholesterol = total cholesterol minus HDL cholesterol.§The combination of high-dose statin and fibrate can increase risk for severe myopathy. Statin doses should be kept relatively low with this combination. Dietary supplement niacin must not be used as a substitute for prescription niacin.¶Creatinine should be less than 2.5 mg per dL in men and less than 2.0 mg per dL in women.∥Potassium should be less than 5.0 mEq per L.ACE indicates angiotensin-converting enzyme; BMI, body mass index; CHF, congestive heart failure; COR, classification of recommendation; HbA1c, hemoglobin A1c; HDL, high-density lipoprotein; HDL-C, high-density lipoprotein cholesterol; LDL, low-density lipoprotein; LDL-C, low-density lipoprotein cholesterol; LOE, level of evidence; MI, myocardial infarction; and TG, triglycerides.Renin-Angiotensin-Aldosterone System Blockers (Continued)Angiotensin receptor blockers are recommended for patients who have hypertension, have indications for but are intolerant of ACE inhibitors, have heart failure, or have had a myocardial infarction with left ventricular ejection fraction less than or equal to 40%.I (A)New recommendationAngiotensin receptor blockers may be considered in combination with ACE inhibitors for heart failure due to left ventricular systolic dysfunction.IIb (B)New recommendationAldosterone blockade is recommended for use in post-MI patients without significant renal dysfunction¶ or hyperkalemia∥ who are already receiving therapeutic doses of an ACE inhibitor and a beta blocker, have a left ventricular ejection fraction less than or equal to 40%, and have either diabetes or heart failure.I (A)New recommendationBeta BlockersStart in all post-MI and acute patients (arrhythmia, LV dysfunction, inducible ischemia) at 5 to 28 days. Continue 6 months minimum. Observe usual contraindications. Use as needed to manage angina, rhythm, or blood pressure in all other patients.It is beneficial to start and continue beta-blocker therapy indefinitely in all patients who have had MI, acute coronary syndrome, or left ventricular dysfunction with or without heart failure symptoms, unless contraindicated.I (A)Modified recommendation (changed text and COR LOE added)Influenza VaccinationAn annual influenza vaccination is recommended for patients with cardiovascular disease.I (B)New recommendationChelation TherapyChelation therapy (intravenous infusions of ethylenediamine tetraacetic acid or EDTA) is not recommended for the treatment of chronic angina or arteriosclerotic cardiovascular disease and may be harmful because of its potential to cause hypocalcemia.III (C)New recommendationThe 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 GuidelinesAlice K. Jacobs, MD, FACC, FAHA Vice-Chair, ACC/AHA Task Force on Practice Guidelines1. Introduction1.1. Evidence ReviewLate-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 200

on Coronary Artery Calcium Scoring by Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCF/AHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) Developed in Collaboration With the Society of Atherosclerosis Imaging and Prevention and the Society of Cardiovascular Computed Tomography

Ranolazine (Ranexa; Cardiovascular Therapeutics) was approved by the US FDA for the treatment of chronic angina in January 2006. It is the first drug in a new class for treating this condition to be approved in the United States in more than 20 years.

Nature Reviews Drug Discovery 5, 453–454 (2006) On page 453, information summarizing the efficacy of ranolazine in the ERICA trial was reported incorrectly. The correct information is: Statistically significant decreases in angina attack frequency and nitroglycerin use were observed in the ranolazine group compared with the placebo group (mean number of attacks/week = 3.