Class I activities include chopping wood, climbing hills, cycling, aerobic ballet, ballroom (fast) or square dancing, jogging a 10-minute mile, rope skipping, skating, skiing, playing tennis or squash, and walking 5 miles per hour. Class I is defined by angina that occurs with strenuous or rapid or prolonged exertion at work or recreation, but not with ordinary physical activity. Infrequently, patients with normal coronary arteries may experience angina related to coronary spasm or endothelial dysfunction (Gibbons et al., 2002a).Īngina is classified using the Canadian Cardiovascular Society (CCS) scheme, which grades angina or an anginal equivalent (e.g., exertional dyspnea) based on a description of the level of activity that causes symptoms ( Table 7-1). Angina usually occurs in patients with CHD, but also can occur in individuals with valvular disease, hypertrophic cardiomyopathy, and uncontrolled hypertension. This is a clinical syndrome characterized by discomfort in the chest, jaw, shoulder, back, or arms that is typically aggravated by exertion or emotional stress and relieved promptly with rest or by taking nitroglycerin. The discomfort experienced when the heart muscle is deprived of adequate oxygen is called angina pectoris. They are most likely to occur during exercise or emotional stress, when the demand for the oxygen carried by the blood increases. However, as the atherosclerosis progresses, especially if left untreated, symptoms may occur. Most people with early (less than 50 percent narrowing) CHD do not experience symptoms or limitation of blood flow. When the blood flow to the heart muscle is completely blocked, the heart muscle cells die, which is termed a heart attack or myocardial infarction (MI). Although the narrowing can be caused by a blood clot or by constriction of the blood vessel, most often it is caused by buildup of plaque, called atherosclerosis. Ischemic heart disease, also called coronary heart disease (CHD) or coronary artery disease, is the term given to heart problems caused by narrowed heart (coronary) arteries that supply blood to the heart muscle. Ischemic means that an organ (e.g., the heart) is not getting enough blood and oxygen. Ischemia is defined as inadequate blood supply (circulation) to a local area due to blockage of the blood vessels supplying the area. These updated criteria now provide a significantly enhanced and evidence-based approach for making disability determinations based on anatomic and functional criteria in patients with severe angina. Additionally, the criteria by which angiographic CHD meet a listing have been specified, and severe CHD is defined by greater than or equal to 50 percent left main stenosis and/or greater than or equal to 70 percent proximal/mid stenoses in greater than or equal to two native arteries or bypass grafts.

Because many patients with ischemic heart disease are unable to exercise, standard stress electrocar diographic criteria for ischemia (the sole determinant of objective ischemia assessment in prior cardiovascular disability listings) have been expanded significantly to encompass nonexercise modalities (including nuclear imaging and echocardiography provoked by pharmacologic vasodilator stress) to assess the presence of se vere inducible ischemia that, when combined with severe angina (Canadian Cardiovascular Society Class III or IV) would meet a cardiovascular disability listing. A flow diagram has been introduced that depicts five pathways to meet listings, including clinical, standard exercise testing, stress imaging, and angiographic anatomic criteria, with one pathway specific for patients with prior coronary artery by pass graft and severe CHD. A fundamental premise in establishing new listing criteria for ischemic heart disease disability is the linking of anatomic or structural evidence of coronary heart disease (CHD) with both functional impairment and severe anginal symptoms. In particular, several clinical trials have documented the benefits of revascularization in patients with acute ischemic syndromes as well as the efficacy of medical therapy, including lifestyle modification in patients with stable coronary disease. This chapter describes the evaluation and management of ischemic heart disease, which has evolved significantly over the past decade.

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