How is prognosis assessed in patients with angina?

Prognosis of patients with angina is most easily assessed by an exercise stress test. Performance on an exercise test is strongly dependent on left ventricular function and the severity of CAD. Exercise duration or capacity during exercise testing is independently predictive of survival. Patients who exercise to stage 4 of a Bruce protocol have an 8-year survival rate of 93%, compared to a survival of only 45% in those who stop in stage 1. Exercise-induced hypotension correlates with left main or multivessel CAD and indicates a threefold increase in risk for subsequent death or myocardial infarction. Likewise, early-onset ST-segment depression during exercise is associated with a worse outcome. Patients with multivessel disease and impaired left ventricular function have a poor prognosis with medical therapy and strongly benefit from coronary artery bypass surgery. Multiple thallium-201 redistribution defects are also highly predictive of multivessel or left main artery disease and therefore predictive of a worse prognosis.

How effective is risk factor modification in improving the prognosis of patients with angina?

Risk factor modification is effective in reducing risk for cardiac events in patients who are asymptomatic or do not carry a diagnosis of CAD. Once symptoms of angina have appeared, there are still benefits of risk factor modification are less. Risk factor modification is a vital part of the management of patients with angina.

Control of hyperlipidemia in patients with CAD and prior myocardial infarction can reduce the risk of nonfatal myocardial infarction by 27% and fatal infarction by 15%.

Smoking increases the relative risk for myocardial infarction 2.8-fold, and this risk is substantially reduced after patients quit smoking. Cessation of smoking after coronary artery bypass grafting also improves graft patency and prognosis.

How effective blood pressure control is on preventing subsequent cardiac mortality in patients with known CAD has not been well studied. Hypertension is a well-established major risk factor for the development of CAD, but numerous trials have indicated a lack of effect of antihypertensives on CAD mortality, which may reflect the adverse effects of certain drugs on glucose tolerance, lipid levels, and insulin resistance.

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