[Chronic stable angina pectoris. A comparison of diagnostic pathways]

Against the background of a variety of international guidelines and a national disease management program for patients with coronary heart disease, a national health-care guideline for the management of patients with chronic ischemic heart disease ("Nationale VersorgungsLeitlinie Chronische KHK [NVL KHK]") was first published in Germany in 2006. This guideline is an interdisciplinary initiative of several German health-care authorities and medical societies. Because of the limited diagnostic sensitivity of about 70% only, and a high percentage of patients, who are unable to exercise, a negative stress ECG can definitely not exclude hemodynamically significant coronary heart disease. Therefore, the well-known evidence-based algorithms of the American College of Cardiology/American Heart Association (ACC/AHA) guidelines for noninvasive stress testing and complementary stress imaging were newly adopted by the NVL KHK. In flow charts for patients with suspected or already known chronic ischemic heart disease, the essential importance of stress imaging is depicted on different levels of decision. Stress imaging methods considered comparable and interchangeable are: stress echocardiography combined with physical or pharmacological stress testing, myocardial perfusion imaging with physical or pharmacological stress testing, dobutamine stress magnetic resonance imaging (DSMR), or myocardial perfusion magnetic resonance tomography (MRT). Basically, no stress imaging method is definitely superior to the others, each method has its own advantages and disadvantages that should be considered and adjusted to the individual patient. Moreover, the NVL KHK gives the recommendation that with the decision for one method also the local availability and institutional expertise of diagnostic centers should be taken into account. However, according to the Bayes theorem, stress imaging combined with physical or pharmacological stress testing is only indicated in patients with an intermediate pretest probability for chronic ischemic heart disease between 10% and 90%. However, the assessment of the pretest probability is difficult or impossible in totally asymptomatic patients with suspected chronic ischemic heart disease. This is exemplified by a typical case report.