Clinical Practice Guideline

The Diagnosis of Chronic Coronary Heart Disease

Dtsch Arztebl Int 2017; 114(42): 712-9; DOI: 10.3238/arztebl.2017.0712

Albus, C; Barkhausen, J; Fleck, E; Haasenritter, J; Lindner, O; Silber, S

Background: Chronic coronary heart disease (CHD) and acute myocardial infarction are endemic conditions. In Germany, an estimated 900 000 cardiac catheterizations were performed in the year 2014, and a percutaneous intervention was carried out in 40% of these procedures. It would be desirable to lessen the number of invasive diagnostic procedures while preserving the reliability of diagnosis. In this article, we present the updated recommendations of the German National Care Guideline for Chronic CHD with regard to diagnostic evaluation.

Methods: Updated recommendations for the diagnostic evaluation of chronic CHD were developed on the basis of existing guidelines and a systematic literature review and approved by a formal consensus process.

Results: 8–11% of patients with chest pain who present to a general practitioner and 20–25% of those who present to a cardiologist have chronic CHD. General practitioners should estimate the probability of CHD with the Marburg Heart Score. Specialists can use detailed tables for determining the pre-test probability of CHD; if this lies in the range of 15% to 85%, then non-invasive tests should be primarily used for evaluation and treatment planning. If the pre-test probability is less than 15%, other potential causes should be ruled out first. If it is over 85%, the presence of CHD should be presumed and treatment planning should be initiated. Coronary angiography is needed only if therapeutic implications are expected (revascularization). Psychosocial risk factors for the development and course of CHD and the patient’s quality of life should be regularly assessed as well.

Conclusion: Non-invasive testing and invasive coronary angiography should be used only if their findings are expected to have therapeutic implications. Psychosocial risk factors, the quality of life, and adherence to treatment are important components of these patients’ diagnostic evaluation and long-term care.

Chronic coronary heart disease (CHD) and myocardial infarction are widespread diseases (1). In Germany, 361 377 percutaneous coronary interventions (PCIs) were performed in 2014 during in total 906 843 cardiac catheterizations (extrapolated), corresponding to a rate of therapeutic interventions of 40% (2). To reduce the burden on the health system, it is desirable to decrease invasive in favor of non-invasive diagnostic testing without jeopardizing diagnostic and therapeutic safety. Therefore, the current „Diagnosis“ chapter of the German National Disease Management Guideline (NVL, Nationale VersorgungsLeitlinie) „Chronic CHD“ (3) recommends the use of rational diagnosis algorithms, based on validated clinical and non-invasive methods, prior to initiating invasive diagnostic procedures. In addition, the guideline makes recommendations on the different responsibilities on the primary care level (general practitioner, GP) and on the cardiology level in the differential diagnosis and further work-up of these patients.

The update of the NVL guideline contains several new elements, such as

  • the new validated „Marburg Heart Score“ to estimate the probability of CHD on the GP level,
  • current information about sensitivity and specificity of non-invasive tests,
  • updated recommendations on the relevance and significance of exercise ECG testing,
  • updated recommendations on the containment of the use of invasive coronary angiography,
  • updated recommendations on not using somatic testing in the follow-up of patients with asymptomatic CHD; and
  • for the first time recommendations on psychosocial aspects as an essential component of the diagnostic evaluation.

Methods

NVL guidelines are created based on the concepts of the Guidelines International Network (G-I-N), the evaluation criteria for guidelines of the German Medical Association (BÄK, Bundes­ärzte­kammer) and the National Association of Statutory Health Insurance Physicians (KBV, Kassenärztliche Bundesvereinigung) (e1), the guideline rules of the Association of the Scientific Medical Societies in Germany (AWMF, Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften) (e2), as well as the German Guideline Appraisal Instrument (DELBI, Deutsches Leitlinienbewertungsinstrument) (e3). The basic methodological approach is described in the general methods report (e4), the specific methodology in the guideline report for the NVL guideline (4). The creation of the 4th edition was organized by the German Agency for Quality in Medicine (ÄZQ, Ärztliches Zentrum für Qualität in der Medizin) from 2014 to 2016. The guideline group had a multidisciplinary membership (eBox). Potential conflicts of interest of all parties involved were recorded in a structured fashion according to AWMF specifications and published in the guideline report (4).

Editors and authors of NVL Chronic CHD, 4th edition
eBox
Editors and authors of NVL Chronic CHD, 4th edition

Evidence base

For the update, guideline databases were searched for relevant source and reference guidelines. Applicable guidelines with the highest relevance and applicability to the German healthcare situation were selected and appraised using the DELBI instrument (4).

The Medline database (via Pubmed) and the Cochrane database were searched for systematic reviews comparing the use of non-invasive methods with the reference standard, coronary angiography, in patients with (suspected) chronic CHD which were published between January 2007 and May 2014 (eTable 1). The hits identified were appraised in a two-step procedure (eFigure). Included studies were assessed, extracted and graded according to the system of the Scottish Intercollegiate Guidelines Network (e5) (4).

Diagnostic algorithm for suspected chronic CHD
Figure
Diagnostic algorithm for suspected chronic CHD
Flowchart of search on non-invasive techniques
eFigure
Flowchart of search on non-invasive techniques
Systematic literature search on the diagnostic value of imaging techniques
eTable 1
Systematic literature search on the diagnostic value of imaging techniques

A search for relevant guidelines on the use of invasive coronary angiography in the diagnosis of chronic CHD was performed in February 2015. These guidelines had to be not older than 5 years and published in German or English. The identified guidelines were appraised using the DELBI instrument and a guideline synopsis was created (4).

Pretest probability

Since no method of testing can achieve a sensitivity and specificity of 100%, inaccuracies of the results obtained, both false negative and false positive, are to be expected. Taking into account the probability of the presence of a finding prior to test application (pretest probability) reduces the risk of an inaccurate result and thus increases the chance of a correct result with regard to the detection or exclusion of CHD. The assumptions are based on statistical analyses of data from many controlled studies and take age, sex, risks, symptoms, and test results into account.

Grades of recommendation and consensus-based adoption of recommendations

Grades of recommendation take into account the strength of the underlying evidence, ethical obligations, clinical relevance of the effect measures of the studies, the applicability of the study results to the target patient group, patient preferences, as well as practicability in everyday clinical use and within the structures of the German healthcare system. Two arrow symbols (↑↑) indicate a strong recommendation („is recommended/indicated“), one arrow symbol (↑) a weak recommendation („should be considered“), and two arrow symbols directed downwards (↓↓) a negative recommendation („is not recommended“). The consensus-based adoption of the recommendations was achieved using a Delphi technique and the draft version of the guideline was posted on the publically accessible website www.versorgungsleitlinien.de in November 2015 for comments.

Results

The DEGAM (Deutsche Gesellschaft für Allgemein– und Familienmedizin, German College of General Practitioners and Family Physicians) guideline „Chest Pain“ was used as a source and reference guideline due to its high methodical quality (DELBI domain 3:0.86) (5). In addition, the ESC guidelines by Montalescot et al., rated lower with regard to methodology, (6) (DELBI domain 3: 0.43), and Perk et al. (7) (DELBI domain 3: 0.43) or their update by Piepoli et al. (8) were taken into consideration.

The diagnostic algorithm in patients with chronic CHD is depicted in the Figure. The basic assumption is that of patients with symptoms (angina pectoris) but no history of CHD who are assessed for potentially underlying obstructive CHD. The diagnostic process in patients with a history of CHD is basically similar.

Differential diagnoses

On the level of GP care, chronic CHD is the cause of the pain in 8–11% of chest pain patients (911). Relevant differential diagnoses include chest wall syndrome, psychogenic causes, respiratory tract infections, esophageal conditions, and acute coronary syndrome (911). On the level of cardiology care, a cardiac etiology can be assumed in 20–25% of patients with unclear chest pain. The differential diagnosis includes, apart from myocardial infarction, valvular disease (especially aortic valve stenosis), aortic dissection, pulmonary embolism, and inflammatory myocardial and/or pericardial conditions.

History and physical examination

Important aspects of history taking are the exact recording of symptoms (location, development over time, pain quality), the assessment of physical stress tolerance and the identification of risk factors (12). Psychological, somatic and social information are recommended to be collected simultaneously right from the start when the clinical history is taken to prevent early fixation on somatic causes (↑↑, expert consensus).

On the primary care level (GPs), the probability that a patient with chest pain has an underlying obstructive CHD shall be estimated using the Marburg Heart Score (Table 1) ([↑↑] [11, 13] according to [5]). A Marburg Heart Score ≤ 2 points indicates an underlying obstructive CHD with a mean probability of <5%. When interpreting these score results, it is important to take the overall clinical picture into account (statement [11, 13] according to [5]).

Marburg Heart Score to estimate probability of CHD and need for further diagnostic tests to be initiated on general practitioner care level—criteria and interpretation
Table 1
Marburg Heart Score to estimate probability of CHD and need for further diagnostic tests to be initiated on general practitioner care level—criteria and interpretation

On the cardiology care level, the data of the study by Genders et al. (14) are recommended to be used to determine pretest probability; the use of these data is also recommended by the ESC guideline (6) (Table 2) (↑↑, expert consensus based on [6, 14]). The combined presence of the following features defines typical angina pectoris if 3 of the features are present and atypical angina pectoris if 2 are present, while 1 or none of the features defines non-anginal chest pain:

  • squeezing pain experienced either retrosternally or in neck, shoulder, jaw or arm
  • aggravated by physical exercise or emotional stress
  • ameliorated by rest and/or nitroglycerin within 5 minutes ([14] according to [15, 16]).
Pretest probability of obstructive CHD in patients with stable chest pain to estimate the need for further diagnostic tests on the cardiology care level
Table 2
Pretest probability of obstructive CHD in patients with stable chest pain to estimate the need for further diagnostic tests on the cardiology care level

Basic evaluation

Patients with suspected CHD due to their clinical history and findings are recommended to have a 12-lead resting ECG recorded (↑↑, expert consensus based on [5, 17]). However, systematic reviews have found that the informative value of resting ECGs in patients with stable chest pain or its usefulness to identify stable CHD is generally low (18, 19). Of special importance was the finding that a normal ECG alone does not reliably exclude an underlying CHD. Nevertheless, abnormal Q-waves as a sign of previous myocardial infarction as well as ST-segment and T-wave changes may indicate the presence of CHD (17). This is especially helpful if the patient has no known history of CHD.

In patients with suspected CHD due to their history and findings, resting echocardiography should be considered (↑, expert consensus). Transthoracic echocardiography is a useful tool to assess global and regional myocardial function and can thus contribute to the diagnosis of CHD in patients with regional wall motion abnormalities (hypokinesia, akinesia, dyskinesia) while taking into account the differential diagnosis (6, 2022).

Non-invasive tests

Exercise ECG is a frequently and widely used diagnostic tool to detect myocardial ischemia as the cause of the corresponding symptoms (12). However, with regard to its diagnostic value in comparison with other testing methods, its lack of diagnostic power for the diagnosis of CHD as the cause of e.g. chest pain is problematic. Assuming a pretest probability of 30–50%, based on clinical history and findings, the posttest probability in case of negative exercise ECG results is between 15 and 30% (own calculations based on Likelihood Ratio [LR] information in Mant et al. [19]). Given a pretest probability of >30%, posttest probability in case of a negative exercise ECG result is on average still higher than 15%; thus, further tests are still required (statement, expert consensus based on [19, 23]). Consequently, a negative finding can only be of help if pretest probability is <30%.

Altogether 31 meta-analyses on the diagnostic value of imaging techniques were identified; of these, the 9 most recent ones with the highest methodological quality were selected for stress echocardiography (e6), myocardial perfusion SPECT (e6e9), stress-perfusion MRI (e6, e7), dobutamine stress MRI (e10), and CT coronary angiography (e9, e11e13) to be used as the basis for the recommendations (eTable 2). The results of the various analyses varied considerably. This was primarily due to differences in inclusion criteria, major clinical and methodological heterogeneity of the included primary studies, and rapid advances in the testing techniques.

Sensitivity and specificity of imaging techniques
eTable 2
Sensitivity and specificity of imaging techniques

Sensitivity and specificity considerations

In comparison with invasive coronary angiography, the sensitivity and specificity of most non-invasive techniques to detect obstructive CHD is about 85%. In patients with pretest probabilities of <15% and >85%, the tests have too many false positive or false negative results. This is illustrated by the following example:

In 1000 patients with 15% pretest probability (850 without CHD; 150 with CHD), a diagnostic test with 85% sensitivity and 85% specificity would generate in 850 patients correct results (850 × 0.85 + 150 × 0.85) and in 150 patients (850 × 0.15 + 150 × 0.15) incorrect results. However, if it is directly, i.e. without performing a test, assumed that all patients are healthy, this strategy is correct in 850 patients and incorrect in 150 patients. Thus, it has the same result as the diagnostic test. With decreasing pretest probability, the diagnostic test even performs worse. Only for pretest probabilities >15%, a diagnostic test with the criteria described above generates better results.

For pretest probabilities of 85%, a similar constellation is found. The assumption that all patients have the disease leads to results with an accuracy similar to that of a diagnostic test. If pretest probability increases further, the test performs progressively poorer in comparison with this assumption.

From these considerations it follows that in patients with low pretest probability (<15%) no diagnostic technique should be used to detect obstructive CHD. Instead, another cause of the symptoms should be considered (↑, expert consensus based on [e6–e13]). In patients with high pretest probability (>85%), obstructive CHD should be considered as the cause of the symptoms and treatment planning should be initiated (↑, expert consensus based on [e6–e13]). On patients with moderate pretest probability (15–85%), non-invasive techniques should be used for further work-up to rule out or confirm the suspected obstructive CHD (↑, [e6–e13]).

The non-invasive technique is recommended to be selected according to the pretest probability for obstructive CHD, the suitability of the patient for the respective test, test-related risks, locally available equipment, and local expertise (↑↑, expert consensus). Exercise ECG testing and CT coronary angiography are only recommended for certain pretest probabilities (Figure). Morphological techniques, such as CT coronary angiography, can, in case of a negative result, very reliably rule out CHD; however, these techniques have limitations in the assessment of obstructive versus non-obstructive CHD; thus, they are most helpful if pretest probability is between 15 and 50%. Suitability criteria for the various non-invasive techniques are listed in eTable 3.

Suitability criteria for the various non-invasive techniques
eTable 3
Suitability criteria for the various non-invasive techniques

In patients with known CHD and clinically suspected disease progression, functional non-invasive imaging techniques should preferentially be used for further work-up (↑, expert consensus). If a previous examination performed with one of these techniques is available, the same technique should be used again, whenever possible, to ensure the findings can be compared (↑, expert consensus).

Invasive coronary angiography

Altogether 9 guidelines making statements with regard to the use of coronary angiography for CHD diagnosis were identified and appraised using the DELBI tool (4). As basis for the recommendations (Table 3), the best rated and most relevant guidelines were used (6, 24, 25). In the context of treatment planning, coronary angiography shall only be offered, if it can be expected that as a result of its findings the patient will undergo a revascularization procedure (Table 3). As detailed in the Revascularization Therapy chapter of the NVL guideline Chronic CHD (3), patients should receive advice based on the patient information brochure „Suspected coronary heart disease: Do I need to undergo cardiac catheterization?“.

Recommendations for coronary angiography
Table 3
Recommendations for coronary angiography

Psychosocial evaluation

The aspects discussed in the following are not related to differential diagnosis, but to support a comprehensive biopsychosocial simultaneous diagnosis. Low social status, lack of social support, job-related and family-related stress, depression, anxiety, post-traumatic stress disorder, schizophrenia, bipolar disorder, or certain personality patterns, especially hostility and the so-called Type-D pattern (habitual tendency to experience negative emotions in combination with social inhibition) can have a negative impact on development and course of CHD as well as the quality of life of the patient (7, 8, 2628). The best prognostic evidence is available for depressive disorder after acute coronary syndrome (29, e14). In addition, treatment options are available for depressed CHD patients which are effective in relieving symptoms of depression (e15). Thus, for the detection of a depressive disorder, a strong recommendation (↑↑, expert consensus based on [e14, e15, 29, 30]), for the detection of other relevant psychological disorders and psychosocial risk constellations a weak recommendation (↑, expert consensus based on [e16-e31, 31–33]) was issued. An overview of suitable medical history questions or questionnaires is provided in eTable 4. In case of positive screening for psychological problems/mental disorder, a clinical diagnosis with explicit exploration of all primary and secondary symptoms according to ICD-10 is recommended to be pursued (↑↑, expert consensus).

Overview of suitable questions and instruments for psychosocial evaluation
eTable 4
Overview of suitable questions and instruments for psychosocial evaluation

Routine follow-up of patients with confirmed obstructive CHD

The GP is responsible for the regular long-term follow-up care of patients with chronic CHD. The corresponding recommendations (Table 4) are based on expert consensus due to the lack of studies evaluating follow-up care.

Recommendations for routine follow-up in patients with chronic CHD
Table 4
Recommendations for routine follow-up in patients with chronic CHD

Apart from a good prognosis, management of chronic CHD aims at achieving a high quality of life for the patient, another key parameter of treatment. For application in clinical practice, an indicative assessment of quality of life using the items of the EuroQoL (EQ-5D) sheet (34) is recommended. The recommendations on quality of life and treatment adherence (Table 4) are based on the ESC guideline (7, 8) and a current position paper of the German Cardiac Society (26).

Acknowledgement
The group of authors would like to thank Dr. Susanne Schorr for the excellent methodological support and coordination during the preparation of the manuscript. We would also like to thank Prof. Dr. Frank Bengel, Prof. Dr. Matthias Gutberlet und Prof. Dr. Christoph Herrmann-Lingen for their very helpful comments on the manuscript.

Conflict of interest statement

Prof. Lindner has received lecture fees from GE Healthcare, Casionpharm and Mediso.

Prof. Albus is receiving honoraria for an authorship related to the topic from Elsevier-Verlag, Deutscher Ärzteverlag and Schattauer-Verlag. He has received fees for scientific lectures from Daiichi-Sankyo, WebMD Germany, KelCON GmbH, PCO Tyrol Kongress, and MSD.

Prof. Barkhausen has received lecture fees from Bayer and Philips.

Prof. Silber, Prof. Fleck and Dr. Hasenritter declare no conflict of interest.

Manuscript received on 29 March 2017; revised version accepted on 10 August 2017

Translated from the original German by Ralf Thoene, MD

Corresponding author
Prof. Dr. med. Christian Albus
Klinik und Poliklinik für Psychosomatik und Psychotherapie
Universitätsklinikum Köln
Kerpener Str. 62
50937 Köln, Germany
Christian.albus@uk-koeln.de

Supplementary material
eReferences:
www.aerzteblatt-international.de/ref4217

eFigure, eTables, eBox:
www.aerzteblatt-international.de/17m0712

1.
Gosswald A, Schienkiewitz A, Nowossadeck E, Busch MA: Prävalenz von Herzinfarkt und koronarer Herzkrankheit bei Erwachsenen im Alter von 40 bis 79 Jahren in Deutschland. Ergebnisse der Studie zur Gesundheit Erwachsener in Deutschland (DEGS1). Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2013; 56: 650–5 CrossRef CrossRef MEDLINE
2.
Deutsche Herzstiftung: Deutscher Herzbericht 2016. 28. Sektorenübergreifende Versorgungsanalyse zur Kardiologie und Herzchirurgie in Deutschland. Frankfurt/Main: Deutsche Herzstiftung 2016.
3.
Bundes­ärzte­kammer (BÄK), Kassenärztliche Bundesvereinigung (KBV), Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF): Nationale VersorgungsLeitlinie Chronische KHK – Langfassung, 4. Auflage. Version 1. http://doi.org/10.6101/AZQ/000267 (last accessed on 26 June 2017).
4.
Bundes­ärzte­kammer (BÄK), Kassenärztliche Bundesvereinigung (KBV), Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF): Nationale VersorgungsLeitlinie Chronische KHK – Leitlinienreport, 4. Auflage. Version 1. http://doi.org/10.6101/AZQ/000264 (last accessed on 26 June 2017).
5.
Deutsche Gesellschaft für Allgemeinmedizin und Familienmedizin (DEGAM), Haasenritter J, Bösner S, Klug J, Ledig T, Donner-Banzhoff N: Brustschmerz. DEGAM-Leitlinie Nr. 15. Düsseldorf: Omikron Publ. 2011.
6.
Montalescot G, Sechtem U, Achenbach S, et al.: 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the Management of Stable Coronary Artery Disease of the European Society of Cardiology. Eur Heart J 2013; 34: 2949–3003 CrossRef MEDLINE
7.
Perk J, De Backer G, Gohlke H, et al.: European Guidelines on cardiovascular disease prevention in clinical practice (version 2012): The Fifth Joint Task Force of the European Society of Cardiology and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of nine societies and by invited experts).Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J 2012; 33: 1635–701 CrossRef MEDLINE
8.
European Association for Cardiovascular Prevention & Rehabilitation (EACPR), Piepoli MF, Hoes AW, et al.: 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of 10 societies and by invited experts): Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J 2016; 37: 2315–81 CrossRef MEDLINE PubMed Central
9.
Verdon F, Herzig L, Burnand B, et al.: Chest pain in daily practice: occurrence, causes and management. Swiss Med Wkly 2008; 138: 340–7 MEDLINE
10.
Bosner S, Becker A, Haasenritter J, et al.: Chest pain in primary care: epidemiology and pre-work-up probabilities. Eur J Gen Pract 2009; 15: 141–6 CrossRef MEDLINE
11.
Haasenritter J, Bosner S, Vaucher P, et al.: Ruling out coronary heart disease in primary care: external validation of a clinical prediction rule. Br J Gen Pract 2012; 62: e415–21 CrossRef MEDLINE PubMed Central
12.
Cooper A, Calvert N, Skinner J, et al.: Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin. London: National Clinical Guideline Centre for Acute and Chronic Conditions 2010.
13.
Bosner S, Haasenritter J, Becker A, et al.: Ruling out coronary artery disease in primary care: development and validation of a simple prediction rule. CMAJ 2010; 182: 1295–300 CrossRef MEDLINE PubMed Central
14.
Genders TS, Steyerberg EW, Alkadhi H, et al.: A clinical prediction rule for the diagnosis of coronary artery disease: validation, updating, and extension. Eur Heart J 2011; 32: 1316–30 CrossRef MEDLINE
15.
Diamond GA, Staniloff HM, Forrester JS, Pollock BH, Swan HJ: Computer-assisted diagnosis in the noninvasive evaluation of patients with suspected coronary artery disease. J Am Coll Cardiol 1983; 1: 444–55 CrossRef
16.
American College of Cardiology Foundation, American College of Radiology, Society of Cardiovascular Computed Tomography (SCCT), et al.: ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 appropriateness criteria for cardiac computed tomography and cardiac magnetic resonance imaging. J Am Coll Cardiol 2006; 48: 1475–97 MEDLINE
17.
Skinner JS, Smeeth L, Kendall JM, Adams PC, Timmis A, Chest Pain Guideline Development Group: NICE guidance. Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin. Heart 2010; 96: 974–8 CrossRef MEDLINE
18.
Chun AA, McGee SR: Bedside diagnosis of coronary artery disease: a systematic review. Am J Med 2004; 117: 334–43 CrossRef MEDLINE
19.
Mant J, McManus RJ, Oakes RA, et al.: Systematic review and modelling of the investigation of acute and chronic chest pain presenting in primary care.
Health Technol Assess 2004; 8: iii1–58 CrossRef
20.
Cheitlin MD, Alpert JS, Armstrong WF, et al.: ACC/AHA guidelines for the clinical application of echocardiography. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Clinical Application of Echocardiography). Developed in colloboration with the American Society of Echocardiography. Circulation 1997; 95: 1686–744 CrossRef MEDLINE
21.
Cheitlin MD, Armstrong WF, Aurigemma GP, et al.: ACC/AHA/ASE 2003 guideline update for the clinical application of echocardiography: summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE Committee to Update the 1997 Guidelines for the Clinical Application of Echocardiography). J Am Soc Echocardiogr 2003; 16: 1091–110 CrossRef CrossRef MEDLINE
22.
American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography (ASE), American Society of Nuclear Cardiology (ASNC), et al.: ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography. J Am Coll Cardiol 2011; 57: 1126–66 CrossRef MEDLINE
23.
Banerjee A, Newman DR, Van den Bruel A, Heneghan C: Diagnostic accuracy of exercise stress testing for coronary artery disease: a systematic review and meta-analysis of prospective studies. Int J Clin Pract 2012; 66: 477–92 CrossRef MEDLINE
24.
Fihn SD, Blankenship JC, Alexander KP, et al.: 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2014; 130: 1749–67 CrossRef MEDLINE
25.
National Institute for Health and Clinical Excellence (NICE): Management of stable angina. Last modified: December 2012. London: NICE 2011.
26.
Ladwig KH, Lederbogen F, Albus C, et al.: Positionspapier zur Bedeutung psychosozialer Faktoren in der Kardiologie. Update 2013. Kardiologe 2013; 7: 7–27 CrossRef
27.
Gohlke H, Albus C, Bönner G, et al.: CME Zertifizierte Fortbildung. Empfehlungen der Projektgruppe Prävention der DGK zur risikoadjustierten Prävention von Herz- und Kreislauferkrankungen. Teil 4: Thrombozytenfunktionshemmer, Hormonersatztherapie, Verhaltensänderung und psychosoziale Risikofaktoren. Kardiologe 2013; 7: 297–306 CrossRef
28.
Albus C, Ladwig KH, Herrmann-Lingen C: Psychokardiologie: praxisrelevante Erkenntnisse und Handlungsempfehlungen. Dtsch Med Wochenschr 2014; 139: 596–601 CrossRef MEDLINE
29.
Lichtman JH, Froelicher ES, Blumenthal JA, et al.: Depression as a risk factor for poor prognosis among patients with acute coronary syndrome: systematic review and recommendations: a scientific statement from the American Heart Association. Circulation 2014; 129: 1350–69 CrossRef MEDLINE
30.
Deutsche Gesellschaft für Psychiatrie, Psychotherapie und Nervenheilkunde (DGPPN), Bundes­ärzte­kammer (BÄK), Kassenärztliche Bundesvereinigung (KBV), Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF): S3-Leitlinie/Nationale VersorgungsLeitlinie Unipolare Depression – Langfassung, 2. Auflage. Version 5. http://doi.org/10.6101/AZQ/000364 (last accessed on 26 June 2017).
31.
Bandelow B, Wiltink J, Alpers GW, et al.: S3-Leitlinie Behandlung von Angststörungen. Kurzversion. www.awmf.org/uploads/tx_szleitlinien/051–028k_S3_Angstst%C3%B6rungen_2014–05_1.pdf (last accessed on 26 June 2017).
32.
Deutschsprachige Gesellschaft für Psychotraumatologie (DeGPT), Deutsche Gesellschaft für Psychotherapeutische Medizin und ärztliche Psychotherapie (DGPM), Deutsches Kollegium für Psychosomatische Medizin (DKPM), Deutsche Gesellschaft für Psychologie (DGPs), Deutsche Gesellschaft für Psychoanalyse, Psychotherapie, Psychosomatik und Tiefenpsychologie (DGPT), Deutsche Gesellschaft für Psychiatrie, Psychotherapie und Nervenheilkunde (DGPPN): S3-Leitlinie. Posttraumatische Belastungsstörung. ICD 10: F 43.1.www.awmf.org/uploads/tx_szleitlinien/051–010l_S3_Posttraumatische_Belastungsstoerung_ 2012–03.pdf (last accessed on 26 June 2017).
33.
Deutsche Gesellschaft für Psychiatrie, Psychotherapie und Nervenheilkunde (DGPPN): Behandlungsleitlinie Schizophrenie. Darmstadt: Steinkopff 2006.
34.
EuroQol Group: EuroQol – a new facility for the measurement of health-related quality of life. Health Policy 1990; 16: 199–208 CrossRef
35.
Ho PM, Bryson CL, Rumsfeld JS: Medication adherence: its importance in cardiovascular outcomes. Circulation 2009; 119: 3028–35 CrossRef MEDLINE
36.
Osterberg L, Blaschke T: Adherence to medication. N Engl J Med 2005; 353: 487–97 CrossRef MEDLINE
37.
Kripalani S, Yao X, Haynes RB: Interventions to enhance medication adherence in chronic medical conditions: a systematic review. Arch Intern Med 2007; 167: 540–50 CrossRef MEDLINE
e1.
Bundes­ärzte­kammer (BÄK), Kassenärztliche Bundesvereinigung (KBV): Beurteilungskriterien für Leitlinien in der medizinischen Versorgung – Beschlüsse der Vorstände der Bundes­ärzte­kammer und Kassenärztlicher Bundesvereinigung, Juni 1997. Dtsch Arztebl 1997; 94: A-2154–5.
e2.
Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF): Das AWMF-Regelwerk Leitlinien. München: Zuckschwerdt 2012.
e3.
Ärztliches Zentrum für Qualität in der Medizin (ÄZQ), Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF): Deutsches Instrument zur methodischen Leitlinien-Bewertung (DELBI). Fassung 2005/2006 + Domäne 8. www.leitlinien.de/mdb/edocs/pdf/literatur/delbi-fassung-2005–2006-domaene-8–2008.pdf (last accessed on 26 June 2017).
e4.
Bundes­ärzte­kammer (BÄK), Kassenärztliche Bundesvereinigung (KBV), Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF): Nationales Programm für Versorgungs
Leitlinien. Methoden-Report 4th edition www.leitlinien.de/mdb/downloads/nvl/methodik/mr-aufl-4-version-1.pdf (last accessed on 26 June 2017).
e5.
Harbour R, Miller J: A new system for grading recommendations in evidence based guidelines. BMJ 2001; 323: 334–6 CrossRef
e6.
de Jong MC, Genders TS, van Geuns RJ, Moelker A, Hunink MG: Diagnostic performance of stress myocardial perfusion imaging for coronary artery disease: a systematic review and meta-analysis. Eur Radiol 2012; 22: 1881–95 CrossRef MEDLINE PubMed Central
e7.
Chen L, Wang X, Bao J, Geng C, Xia Y, Wang J: Direct comparison of cardiovascular magnetic resonance and single-photon emission computed tomography for detection of coronary artery disease: a meta-analysis. PLoS One 2014; 9: e88402.
e8.
Parker MW, Iskandar A, Limone B, et al.: Diagnostic accuracy of cardiac positron emission tomography versus single photon emission computed tomography for coronary artery disease: a bivariate meta-analysis. Circ Cardiovasc Imaging 2012; 5: 700–7 CrossRef MEDLINE
e9.
e9. Nielsen LH, Ortner N, Norgaard BL, Achenbach S, Leipsic J, Abdulla J: The diagnostic accuracy and outcomes after coronary computed tomography angiography vs. conventional functional testing in patients with stable angina pectoris: a systematic review and meta-analysis. Eur Heart J Cardiovasc Imaging 2014; 15: 961–71 CrossRef MEDLINE
e10.
Nandalur KR, Dwamena BA, Choudhri AF, Nandalur MR, Carlos RC: Diagnostic performance of stress cardiac magnetic resonance imaging in the detection of coronary artery disease: a meta-analysis. J Am Coll Cardiol 2007; 50: 1343–53 CrossRef MEDLINE
e11.
Li S, Ni Q, Wu H, et al.: Diagnostic accuracy of 320-slice computed tomography angiography for detection of coronary artery stenosis: meta-analysis. Int J Cardiol 2013; 168: 2699–705 CrossRef MEDLINE
e12.
Powell H, Cosson P: Comparison of 64-slice computed tomography angiography and coronary angiography for the detection and assessment of coronary artery disease in patients with angina: a systematic review. Radiogr 2013; 19: 168–75 CrossRef
e13.
Gorenoi V, Schonermark MP, Hagen A: CT coronary angiography vs. invasive coronary angiography in CHD. GMS Health Technol Assess 2012; 8: Doc02.
e14.
Nicholson A, Kuper H, Hemingway H: Depression as an aetiologic and prognostic factor in coronary heart disease: a meta-analysis of 6362 events among 146 538 participants in 54 observational studies. Eur Heart J 2006; 27: 2763–74 CrossRef MEDLINE
e15.
Rutledge T, Redwine LS, Linke SE, Mills PJ: A meta-analysis of mental health treatments and cardiac rehabilitation for improving clinical outcomes and depression among patients with coronary heart disease. Psychosom Med 2013; 75: 335–49 CrossRef MEDLINE
e16.
Tonne C, Schwartz J, Mittleman M, Melly S, Suh H, Goldberg R: Long-term survival after acute myocardial infarction is lower in more deprived neighborhoods. Circulation 2005; 111: 3063–70 CrossRef MEDLINE
e17.
Stringhini S, Sabia S, Shipley M, et al.: Association of socioeconomic position with health behaviors and mortality. JAMA 2010; 303: 1159–66 CrossRef MEDLINE PubMed Central
e18.
Alter DA, Franklin B, Ko DT, et al.: Socioeconomic status, functional recovery, and long-term mortality among patients surviving acute myocardial infarction. PLoS One 2014; 8: e65130.
e19.
Barth J, Schneider S, von Känel R: Lack of social support in the etiology and the prognosis of coronary heart disease: a systematic review and meta-analysis. Psychosom Med 2010; 72: 229–38 CrossRef MEDLINE
e20.
Richardson S, Shaffer JA, Falzon L, Krupka D, Davidson KW, Edmondson D: Meta-analysis of perceived stress and its association with incident coronary heart disease. Am J Cardiol 2012; 110: 1711–6 CrossRef MEDLINE PubMed Central
e21.
Virtanen M, Ferrie JE, Singh-Manoux A, et al.: Overtime work and incident coronary heart disease: the Whitehall II prospective cohort study. Eur Heart J 2010; 31: 1737–44 CrossRef MEDLINE PubMed Central
e22.
Eller NH, Netterstrom B, Gyntelberg F, et al.: Work-related psychosocial factors and the development of ischemic heart disease: a systematic review. Cardiol Rev 2009; 17: 83–97 CrossRef MEDLINE
e23.
Orth-Gomer K, Wamala SP, Horsten M, Schenck-Gustafsson K, Schneiderman N, Mittleman MA: Marital stress worsens prognosis in women with coronary heart disease: the Stockholm Female Coronary Risk Study. JAMA 2000; 284: 3008–14 CrossRef
e24.
Roest AM, Martens EJ, de Jonge P, Denollet J: Anxiety and risk of incident coronary heart disease: a meta-analysis. J Am Coll Cardiol 2010; 56: 38–46 CrossRef MEDLINE
e25.
Roest AM, Martens EJ, Denollet J, de Jonge P: Prognostic association of anxiety post myocardial infarction with mortality and new cardiac events: a meta-analysis. Psychosom Med 2010; 72: 563–9 CrossRef MEDLINE
e26.
Edmondson D, Kronish IM, Shaffer JA, Falzon L, Burg MM: Posttraumatic stress disorder and risk for coronary heart disease: a meta-analytic review. Am Heart J 2013; 166: 806–14 CrossRef MEDLINE PubMed Central
e27.
Edmondson D, Richardson S, Falzon L, Davidson KW, Mills MA, Neria Y: Posttraumatic stress disorder prevalence and risk of recurrence in acute coronary syndrome patients: a meta-analytic review. PLoS One 2012; 7: e38915.
e28.
Fan Z, Wu Y, Shen J, Ji T, Zhan R: Schizophrenia and the risk of cardiovascular diseases: a meta-analysis of thirteen cohort studies. J Psychiatr Res 2013; 47: 1549–56 CrossRef MEDLINE
e29.
Walker ER, McGee RE, Druss BG: Mortality in mental disorders and global disease burden implications: A systematic review and meta-analysis. JAMA Psychiatry 2015; 72: 334–41 CrossRef MEDLINE PubMed Central
e30.
Chida Y, Steptoe A: The association of anger and hostility with future coronary heart disease: a meta-analytic review of prospective evidence. J Am Coll Cardiol 2009; 53: 936–46 CrossRef MEDLINE
e31.
Grande G, Romppel M, Barth J: Association between type D personality and prognosis in patients with cardiovascular diseases: a systematic review and meta-analysis. Ann Behav Med 2012; 43: 299–310 CrossRef MEDLINE
e32.
Deutsche Gesellschaft für Kardiologie (DGK): Infarkt-bedingter kardiogener Schock – Diagnose, Monitoring und Therapie. Langfassung. www.awmf.org/uploads/tx_szleitlinien/019–013l_S3_Infarkt-bedingter_kardiogener_Schock_Diagnose_Monitoring_Therapie_2010-abgelaufen.pdf (last accessed on 26 June 2017).
e33.
European Society of Cardiology (ESC), Hamm CW, Bassand JP, et al.: ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The Task Force for the Management of Acute Coronary Syndromes (ACS) in Patients Presenting without Persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2011; 32: 2999–3054 CrossRef MEDLINE
e34.
Amsterdam EA, Wenger NK, Brindis RG, et al.: 2014 AHA/ACC Guideline for the management of patients with non-ST-elevation acute coronary syndromes: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 130: e344–426.
e35.
O’Gara PT, Kushner FG, Ascheim DD, et al.: 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2013; 127: e362–e425.
e36.
Scottish Intercollegiate Guidelines Network (SIGN): Acute coronary syndromes. A national clinical guideline. Updated February 2013. Edinburgh: SIGN 2013.
e37.
Steg PG, James SK, Atar D, et al.: ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J 2012; 33: 2569–619 CrossRef MEDLINE
e38.
Bundesamt für Strahlenschutz (BfS): Bekanntmachung der aktualisierten diagnostischen Referenzwerte für diagnostische und interventionelle Röntgenuntersuchungen. www.bfs.de/SharedDocs/Downloads/BfS/DE/fachinfo/ion/drw-roentgen.pdf?__blob=publicationFile&v=1 (last accessed on 26 June 2017).
e39.
Bundesamt für Strahlenschutz (BfS): Bekanntmachung der aktualisierten diagnostischen Referenzwerte für nuklearmedizinische Untersuchungen. www.laekb.de/files/1456FC3088F/Referenzwerte_Nuklearmedizin.pdf (last accessed on 26 June 2017).
Department of Psychosomatics and Psychotherapy, University Hospital Cologne, Cologne, Germany: Prof. Dr. med. Albus
Department of Radiology and Nuclear Medicine, Schleswig-Holstein University Hospital (UK-SH), Campus Lübeck, Lübeck, Germany: Prof. Dr. med. Barkhausen
Internal Medicine/Cardiology, German Society of Cardiology (DGK), DGK Capital Office, Berlin, Germany:
Prof. Dr. med. Fleck
Philipps University Marburg, Department of General Medicine, Preventive and Rehabilitative Medicine, Marburg, Germany: Dr. rer. medic. Haasenritter, M. Sc. N., Dipl. Pflegewirt (FH)
Institute of Radiology, Nuclear Medicine and Molecular Imaging, Heart and Diabetes Center NRW, Bad Oeynhausen, Germany: Prof. Dr. med. Lindner
Cardiology Practice, Munich, Germany: Prof. Dr. med. Silber
Diagnostic algorithm for suspected chronic CHD
Figure
Diagnostic algorithm for suspected chronic CHD
Key messages
Marburg Heart Score to estimate probability of CHD and need for further diagnostic tests to be initiated on general practitioner care level—criteria and interpretation
Table 1
Marburg Heart Score to estimate probability of CHD and need for further diagnostic tests to be initiated on general practitioner care level—criteria and interpretation
Pretest probability of obstructive CHD in patients with stable chest pain to estimate the need for further diagnostic tests on the cardiology care level
Table 2
Pretest probability of obstructive CHD in patients with stable chest pain to estimate the need for further diagnostic tests on the cardiology care level
Recommendations for coronary angiography
Table 3
Recommendations for coronary angiography
Recommendations for routine follow-up in patients with chronic CHD
Table 4
Recommendations for routine follow-up in patients with chronic CHD
Editors and authors of NVL Chronic CHD, 4th edition
eBox
Editors and authors of NVL Chronic CHD, 4th edition
Flowchart of search on non-invasive techniques
eFigure
Flowchart of search on non-invasive techniques
Systematic literature search on the diagnostic value of imaging techniques
eTable 1
Systematic literature search on the diagnostic value of imaging techniques
Sensitivity and specificity of imaging techniques
eTable 2
Sensitivity and specificity of imaging techniques
Suitability criteria for the various non-invasive techniques
eTable 3
Suitability criteria for the various non-invasive techniques
Overview of suitable questions and instruments for psychosocial evaluation
eTable 4
Overview of suitable questions and instruments for psychosocial evaluation
1. Gosswald A, Schienkiewitz A, Nowossadeck E, Busch MA: Prävalenz von Herzinfarkt und koronarer Herzkrankheit bei Erwachsenen im Alter von 40 bis 79 Jahren in Deutschland. Ergebnisse der Studie zur Gesundheit Erwachsener in Deutschland (DEGS1). Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2013; 56: 650–5 CrossRef CrossRef MEDLINE
2. Deutsche Herzstiftung: Deutscher Herzbericht 2016. 28. Sektorenübergreifende Versorgungsanalyse zur Kardiologie und Herzchirurgie in Deutschland. Frankfurt/Main: Deutsche Herzstiftung 2016.
3. Bundes­ärzte­kammer (BÄK), Kassenärztliche Bundesvereinigung (KBV), Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF): Nationale VersorgungsLeitlinie Chronische KHK – Langfassung, 4. Auflage. Version 1. http://doi.org/10.6101/AZQ/000267 (last accessed on 26 June 2017).
4. Bundes­ärzte­kammer (BÄK), Kassenärztliche Bundesvereinigung (KBV), Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF): Nationale VersorgungsLeitlinie Chronische KHK – Leitlinienreport, 4. Auflage. Version 1. http://doi.org/10.6101/AZQ/000264 (last accessed on 26 June 2017).
5. Deutsche Gesellschaft für Allgemeinmedizin und Familienmedizin (DEGAM), Haasenritter J, Bösner S, Klug J, Ledig T, Donner-Banzhoff N: Brustschmerz. DEGAM-Leitlinie Nr. 15. Düsseldorf: Omikron Publ. 2011.
6. Montalescot G, Sechtem U, Achenbach S, et al.: 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the Management of Stable Coronary Artery Disease of the European Society of Cardiology. Eur Heart J 2013; 34: 2949–3003 CrossRef MEDLINE
7. Perk J, De Backer G, Gohlke H, et al.: European Guidelines on cardiovascular disease prevention in clinical practice (version 2012): The Fifth Joint Task Force of the European Society of Cardiology and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of nine societies and by invited experts).Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J 2012; 33: 1635–701 CrossRef MEDLINE
8. European Association for Cardiovascular Prevention & Rehabilitation (EACPR), Piepoli MF, Hoes AW, et al.: 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of 10 societies and by invited experts): Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J 2016; 37: 2315–81 CrossRef MEDLINE PubMed Central
9. Verdon F, Herzig L, Burnand B, et al.: Chest pain in daily practice: occurrence, causes and management. Swiss Med Wkly 2008; 138: 340–7 MEDLINE
10. Bosner S, Becker A, Haasenritter J, et al.: Chest pain in primary care: epidemiology and pre-work-up probabilities. Eur J Gen Pract 2009; 15: 141–6 CrossRef MEDLINE
11. Haasenritter J, Bosner S, Vaucher P, et al.: Ruling out coronary heart disease in primary care: external validation of a clinical prediction rule. Br J Gen Pract 2012; 62: e415–21 CrossRef MEDLINE PubMed Central
12. Cooper A, Calvert N, Skinner J, et al.: Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin. London: National Clinical Guideline Centre for Acute and Chronic Conditions 2010.
13. Bosner S, Haasenritter J, Becker A, et al.: Ruling out coronary artery disease in primary care: development and validation of a simple prediction rule. CMAJ 2010; 182: 1295–300 CrossRef MEDLINE PubMed Central
14. Genders TS, Steyerberg EW, Alkadhi H, et al.: A clinical prediction rule for the diagnosis of coronary artery disease: validation, updating, and extension. Eur Heart J 2011; 32: 1316–30 CrossRef MEDLINE
15. Diamond GA, Staniloff HM, Forrester JS, Pollock BH, Swan HJ: Computer-assisted diagnosis in the noninvasive evaluation of patients with suspected coronary artery disease. J Am Coll Cardiol 1983; 1: 444–55 CrossRef
16. American College of Cardiology Foundation, American College of Radiology, Society of Cardiovascular Computed Tomography (SCCT), et al.: ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 appropriateness criteria for cardiac computed tomography and cardiac magnetic resonance imaging. J Am Coll Cardiol 2006; 48: 1475–97 MEDLINE
17. Skinner JS, Smeeth L, Kendall JM, Adams PC, Timmis A, Chest Pain Guideline Development Group: NICE guidance. Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin. Heart 2010; 96: 974–8 CrossRef MEDLINE
18. Chun AA, McGee SR: Bedside diagnosis of coronary artery disease: a systematic review. Am J Med 2004; 117: 334–43 CrossRef MEDLINE
19. Mant J, McManus RJ, Oakes RA, et al.: Systematic review and modelling of the investigation of acute and chronic chest pain presenting in primary care.
Health Technol Assess 2004; 8: iii1–58 CrossRef
20. Cheitlin MD, Alpert JS, Armstrong WF, et al.: ACC/AHA guidelines for the clinical application of echocardiography. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Clinical Application of Echocardiography). Developed in colloboration with the American Society of Echocardiography. Circulation 1997; 95: 1686–744 CrossRef MEDLINE
21. Cheitlin MD, Armstrong WF, Aurigemma GP, et al.: ACC/AHA/ASE 2003 guideline update for the clinical application of echocardiography: summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE Committee to Update the 1997 Guidelines for the Clinical Application of Echocardiography). J Am Soc Echocardiogr 2003; 16: 1091–110 CrossRef CrossRef MEDLINE
22. American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography (ASE), American Society of Nuclear Cardiology (ASNC), et al.: ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography. J Am Coll Cardiol 2011; 57: 1126–66 CrossRef MEDLINE
23. Banerjee A, Newman DR, Van den Bruel A, Heneghan C: Diagnostic accuracy of exercise stress testing for coronary artery disease: a systematic review and meta-analysis of prospective studies. Int J Clin Pract 2012; 66: 477–92 CrossRef MEDLINE
24. Fihn SD, Blankenship JC, Alexander KP, et al.: 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2014; 130: 1749–67 CrossRef MEDLINE
25. National Institute for Health and Clinical Excellence (NICE): Management of stable angina. Last modified: December 2012. London: NICE 2011.
26. Ladwig KH, Lederbogen F, Albus C, et al.: Positionspapier zur Bedeutung psychosozialer Faktoren in der Kardiologie. Update 2013. Kardiologe 2013; 7: 7–27 CrossRef
27. Gohlke H, Albus C, Bönner G, et al.: CME Zertifizierte Fortbildung. Empfehlungen der Projektgruppe Prävention der DGK zur risikoadjustierten Prävention von Herz- und Kreislauferkrankungen. Teil 4: Thrombozytenfunktionshemmer, Hormonersatztherapie, Verhaltensänderung und psychosoziale Risikofaktoren. Kardiologe 2013; 7: 297–306 CrossRef
28. Albus C, Ladwig KH, Herrmann-Lingen C: Psychokardiologie: praxisrelevante Erkenntnisse und Handlungsempfehlungen. Dtsch Med Wochenschr 2014; 139: 596–601 CrossRef MEDLINE
29. Lichtman JH, Froelicher ES, Blumenthal JA, et al.: Depression as a risk factor for poor prognosis among patients with acute coronary syndrome: systematic review and recommendations: a scientific statement from the American Heart Association. Circulation 2014; 129: 1350–69 CrossRef MEDLINE
30. Deutsche Gesellschaft für Psychiatrie, Psychotherapie und Nervenheilkunde (DGPPN), Bundes­ärzte­kammer (BÄK), Kassenärztliche Bundesvereinigung (KBV), Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF): S3-Leitlinie/Nationale VersorgungsLeitlinie Unipolare Depression – Langfassung, 2. Auflage. Version 5. http://doi.org/10.6101/AZQ/000364 (last accessed on 26 June 2017).
31. Bandelow B, Wiltink J, Alpers GW, et al.: S3-Leitlinie Behandlung von Angststörungen. Kurzversion. www.awmf.org/uploads/tx_szleitlinien/051–028k_S3_Angstst%C3%B6rungen_2014–05_1.pdf (last accessed on 26 June 2017).
32. Deutschsprachige Gesellschaft für Psychotraumatologie (DeGPT), Deutsche Gesellschaft für Psychotherapeutische Medizin und ärztliche Psychotherapie (DGPM), Deutsches Kollegium für Psychosomatische Medizin (DKPM), Deutsche Gesellschaft für Psychologie (DGPs), Deutsche Gesellschaft für Psychoanalyse, Psychotherapie, Psychosomatik und Tiefenpsychologie (DGPT), Deutsche Gesellschaft für Psychiatrie, Psychotherapie und Nervenheilkunde (DGPPN): S3-Leitlinie. Posttraumatische Belastungsstörung. ICD 10: F 43.1.www.awmf.org/uploads/tx_szleitlinien/051–010l_S3_Posttraumatische_Belastungsstoerung_ 2012–03.pdf (last accessed on 26 June 2017).
33. Deutsche Gesellschaft für Psychiatrie, Psychotherapie und Nervenheilkunde (DGPPN): Behandlungsleitlinie Schizophrenie. Darmstadt: Steinkopff 2006.
34.EuroQol Group: EuroQol – a new facility for the measurement of health-related quality of life. Health Policy 1990; 16: 199–208 CrossRef
35. Ho PM, Bryson CL, Rumsfeld JS: Medication adherence: its importance in cardiovascular outcomes. Circulation 2009; 119: 3028–35 CrossRef MEDLINE
36. Osterberg L, Blaschke T: Adherence to medication. N Engl J Med 2005; 353: 487–97 CrossRef MEDLINE
37. Kripalani S, Yao X, Haynes RB: Interventions to enhance medication adherence in chronic medical conditions: a systematic review. Arch Intern Med 2007; 167: 540–50 CrossRef MEDLINE
e1.Bundes­ärzte­kammer (BÄK), Kassenärztliche Bundesvereinigung (KBV): Beurteilungskriterien für Leitlinien in der medizinischen Versorgung – Beschlüsse der Vorstände der Bundes­ärzte­kammer und Kassenärztlicher Bundesvereinigung, Juni 1997. Dtsch Arztebl 1997; 94: A-2154–5.
e2. Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF): Das AWMF-Regelwerk Leitlinien. München: Zuckschwerdt 2012.
e3. Ärztliches Zentrum für Qualität in der Medizin (ÄZQ), Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF): Deutsches Instrument zur methodischen Leitlinien-Bewertung (DELBI). Fassung 2005/2006 + Domäne 8. www.leitlinien.de/mdb/edocs/pdf/literatur/delbi-fassung-2005–2006-domaene-8–2008.pdf (last accessed on 26 June 2017).
e4. Bundes­ärzte­kammer (BÄK), Kassenärztliche Bundesvereinigung (KBV), Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF): Nationales Programm für Versorgungs
Leitlinien. Methoden-Report 4th edition www.leitlinien.de/mdb/downloads/nvl/methodik/mr-aufl-4-version-1.pdf (last accessed on 26 June 2017).
e5.Harbour R, Miller J: A new system for grading recommendations in evidence based guidelines. BMJ 2001; 323: 334–6 CrossRef
e6.de Jong MC, Genders TS, van Geuns RJ, Moelker A, Hunink MG: Diagnostic performance of stress myocardial perfusion imaging for coronary artery disease: a systematic review and meta-analysis. Eur Radiol 2012; 22: 1881–95 CrossRef MEDLINE PubMed Central
e7.Chen L, Wang X, Bao J, Geng C, Xia Y, Wang J: Direct comparison of cardiovascular magnetic resonance and single-photon emission computed tomography for detection of coronary artery disease: a meta-analysis. PLoS One 2014; 9: e88402.
e8.Parker MW, Iskandar A, Limone B, et al.: Diagnostic accuracy of cardiac positron emission tomography versus single photon emission computed tomography for coronary artery disease: a bivariate meta-analysis. Circ Cardiovasc Imaging 2012; 5: 700–7 CrossRef MEDLINE
e9.e9. Nielsen LH, Ortner N, Norgaard BL, Achenbach S, Leipsic J, Abdulla J: The diagnostic accuracy and outcomes after coronary computed tomography angiography vs. conventional functional testing in patients with stable angina pectoris: a systematic review and meta-analysis. Eur Heart J Cardiovasc Imaging 2014; 15: 961–71 CrossRef MEDLINE
e10.Nandalur KR, Dwamena BA, Choudhri AF, Nandalur MR, Carlos RC: Diagnostic performance of stress cardiac magnetic resonance imaging in the detection of coronary artery disease: a meta-analysis. J Am Coll Cardiol 2007; 50: 1343–53 CrossRef MEDLINE
e11. Li S, Ni Q, Wu H, et al.: Diagnostic accuracy of 320-slice computed tomography angiography for detection of coronary artery stenosis: meta-analysis. Int J Cardiol 2013; 168: 2699–705 CrossRef MEDLINE
e12.Powell H, Cosson P: Comparison of 64-slice computed tomography angiography and coronary angiography for the detection and assessment of coronary artery disease in patients with angina: a systematic review. Radiogr 2013; 19: 168–75 CrossRef
e13.Gorenoi V, Schonermark MP, Hagen A: CT coronary angiography vs. invasive coronary angiography in CHD. GMS Health Technol Assess 2012; 8: Doc02.
e14.Nicholson A, Kuper H, Hemingway H: Depression as an aetiologic and prognostic factor in coronary heart disease: a meta-analysis of 6362 events among 146 538 participants in 54 observational studies. Eur Heart J 2006; 27: 2763–74 CrossRef MEDLINE
e15.Rutledge T, Redwine LS, Linke SE, Mills PJ: A meta-analysis of mental health treatments and cardiac rehabilitation for improving clinical outcomes and depression among patients with coronary heart disease. Psychosom Med 2013; 75: 335–49 CrossRef MEDLINE
e16.Tonne C, Schwartz J, Mittleman M, Melly S, Suh H, Goldberg R: Long-term survival after acute myocardial infarction is lower in more deprived neighborhoods. Circulation 2005; 111: 3063–70 CrossRef MEDLINE
e17.Stringhini S, Sabia S, Shipley M, et al.: Association of socioeconomic position with health behaviors and mortality. JAMA 2010; 303: 1159–66 CrossRef MEDLINE PubMed Central
e18.Alter DA, Franklin B, Ko DT, et al.: Socioeconomic status, functional recovery, and long-term mortality among patients surviving acute myocardial infarction. PLoS One 2014; 8: e65130.
e19.Barth J, Schneider S, von Känel R: Lack of social support in the etiology and the prognosis of coronary heart disease: a systematic review and meta-analysis. Psychosom Med 2010; 72: 229–38 CrossRef MEDLINE
e20.Richardson S, Shaffer JA, Falzon L, Krupka D, Davidson KW, Edmondson D: Meta-analysis of perceived stress and its association with incident coronary heart disease. Am J Cardiol 2012; 110: 1711–6 CrossRef MEDLINE PubMed Central
e21.Virtanen M, Ferrie JE, Singh-Manoux A, et al.: Overtime work and incident coronary heart disease: the Whitehall II prospective cohort study. Eur Heart J 2010; 31: 1737–44 CrossRef MEDLINE PubMed Central
e22.Eller NH, Netterstrom B, Gyntelberg F, et al.: Work-related psychosocial factors and the development of ischemic heart disease: a systematic review. Cardiol Rev 2009; 17: 83–97 CrossRef MEDLINE
e23.Orth-Gomer K, Wamala SP, Horsten M, Schenck-Gustafsson K, Schneiderman N, Mittleman MA: Marital stress worsens prognosis in women with coronary heart disease: the Stockholm Female Coronary Risk Study. JAMA 2000; 284: 3008–14 CrossRef
e24.Roest AM, Martens EJ, de Jonge P, Denollet J: Anxiety and risk of incident coronary heart disease: a meta-analysis. J Am Coll Cardiol 2010; 56: 38–46 CrossRef MEDLINE
e25.Roest AM, Martens EJ, Denollet J, de Jonge P: Prognostic association of anxiety post myocardial infarction with mortality and new cardiac events: a meta-analysis. Psychosom Med 2010; 72: 563–9 CrossRef MEDLINE
e26.Edmondson D, Kronish IM, Shaffer JA, Falzon L, Burg MM: Posttraumatic stress disorder and risk for coronary heart disease: a meta-analytic review. Am Heart J 2013; 166: 806–14 CrossRef MEDLINE PubMed Central
e27.Edmondson D, Richardson S, Falzon L, Davidson KW, Mills MA, Neria Y: Posttraumatic stress disorder prevalence and risk of recurrence in acute coronary syndrome patients: a meta-analytic review. PLoS One 2012; 7: e38915.
e28.Fan Z, Wu Y, Shen J, Ji T, Zhan R: Schizophrenia and the risk of cardiovascular diseases: a meta-analysis of thirteen cohort studies. J Psychiatr Res 2013; 47: 1549–56 CrossRef MEDLINE
e29.Walker ER, McGee RE, Druss BG: Mortality in mental disorders and global disease burden implications: A systematic review and meta-analysis. JAMA Psychiatry 2015; 72: 334–41 CrossRef MEDLINE PubMed Central
e30.Chida Y, Steptoe A: The association of anger and hostility with future coronary heart disease: a meta-analytic review of prospective evidence. J Am Coll Cardiol 2009; 53: 936–46 CrossRef MEDLINE
e31.Grande G, Romppel M, Barth J: Association between type D personality and prognosis in patients with cardiovascular diseases: a systematic review and meta-analysis. Ann Behav Med 2012; 43: 299–310 CrossRef MEDLINE
e32.Deutsche Gesellschaft für Kardiologie (DGK): Infarkt-bedingter kardiogener Schock – Diagnose, Monitoring und Therapie. Langfassung. www.awmf.org/uploads/tx_szleitlinien/019–013l_S3_Infarkt-bedingter_kardiogener_Schock_Diagnose_Monitoring_Therapie_2010-abgelaufen.pdf (last accessed on 26 June 2017).
e33.European Society of Cardiology (ESC), Hamm CW, Bassand JP, et al.: ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The Task Force for the Management of Acute Coronary Syndromes (ACS) in Patients Presenting without Persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2011; 32: 2999–3054 CrossRef MEDLINE
e34.Amsterdam EA, Wenger NK, Brindis RG, et al.: 2014 AHA/ACC Guideline for the management of patients with non-ST-elevation acute coronary syndromes: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 130: e344–426.
e35.O’Gara PT, Kushner FG, Ascheim DD, et al.: 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2013; 127: e362–e425.
e36.Scottish Intercollegiate Guidelines Network (SIGN): Acute coronary syndromes. A national clinical guideline. Updated February 2013. Edinburgh: SIGN 2013.
e37.Steg PG, James SK, Atar D, et al.: ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J 2012; 33: 2569–619 CrossRef MEDLINE
e38.Bundesamt für Strahlenschutz (BfS): Bekanntmachung der aktualisierten diagnostischen Referenzwerte für diagnostische und interventionelle Röntgenuntersuchungen. www.bfs.de/SharedDocs/Downloads/BfS/DE/fachinfo/ion/drw-roentgen.pdf?__blob=publicationFile&v=1 (last accessed on 26 June 2017).
e39.Bundesamt für Strahlenschutz (BfS): Bekanntmachung der aktualisierten diagnostischen Referenzwerte für nuklearmedizinische Untersuchungen. www.laekb.de/files/1456FC3088F/Referenzwerte_Nuklearmedizin.pdf (last accessed on 26 June 2017).

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