The Canadian Cardiovascular Society grading of angina pectoris revisited 30 years later

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1 SPECIAL ARTICLE The Canadian Cardiovascular Society grading of angina pectoris revisited 30 years later Lucien Campeau MD FRCPC L Campeau. The Canadian Cardiovascular Society grading of angina pectoris revisited 30 years later. Can J Cardiol 2002; 18(4): BACKGROUND: The Canadian Cardiovascular Society (CCS) grading of angina pectoris was described in the medical literature in OBJECTIVES: To describe the origin of this grading, its worldwide acceptance, critiques, perceived limitations and alternative systems. METHODS: The present author, who chaired the CCS ad hoc committee that developed this grading system in 1972, used documentation based on personal correspondence, and information from MEDLINE and international citation indexes searches. RESULTS: The CCS committee s mandate was to standardize the definition of terms used in reporting studies of coronary artery disease and coronary artery bypass graft surgery. The committee defined a four-level system modelled on the New York Heart Association functional classification of patients with diseases of the heart, and the American Medical Association classes of organic heart diseases. Threshold activities that produced angina were detailed to assess reliably the severity of exertional angina by independent observers, and changes over time. The grading system has been cited over 650 times in the literature since its official publication in Although this grading system was found to be generally relevant and practical, several imperfections and potential limitations were reported, the most pertinent being the criterion anginal syndrome may be present at rest included in grade IV, which was found to be inappropriate and confusing. The prognostic significance of the grading system, despite the finding that this was not its primary goal, was also thought to be inadequate. CONCLUSION: Although this grading system of the severity of effort angina has been accepted throughout the world over the past 30 years, a revision is desirable considering its potential imperfections and inconsistencies with present day management of ischemic heart disease. Key Words: Angina; Health promotion; Ischemic heart disease Résumé à la page suivante The Canadian Cardiovascular Society, stimulated by this paper by Dr Campeau, has established a commitee to re-evaluate the CCS grading system for angina pectoris Research Centre, Montreal Heart Institute, Montreal, Quebec Correspondence and reprints: Dr Lucien Campeau, Montreal Heart Institute, 5000 Belanger Street East, Montreal, Quebec H1T 1C8. Telephone or , fax , Received for publication August 1, Accepted February 14, 2002 Can J Cardiol Vol 18 No 4 April

2 Campeau Classification de l angine de poitrine selon la Société canadienne de cardiologie : revue 30 ans plus tard CONTEXTE : La description de la classification de l angine de poitrine selon la Société canadienne de cardiologie (SCC) dans la documentation scientifique remonte à OBJECTIF : Décrire l origine du système de classification, son acceptation à l échelle mondiale, les critiques qu il suscite, ses faiblesses perçues et les solutions de rechange. MÉTHODE : L auteur du présent article, président du comité spécial de la SCC qui avait mis au point ce système de classification en 1972, s est appuyé sur de la correspondance personnelle, de l information tirée de MEDLINE et des index de citations à l échelle internationale. RÉSULTATS : Le comité de la SCC avait pour mandat de normaliser la définition des termes utilisés dans les études sur les coronaropathies et le pontage coronarien. Le comité a conçu un système à quatre niveaux, fondé sur la classification fonctionnelle des patients porteurs d une cardiopathie selon la New York Heart Association et sur la classification des cardiopathies organiques selon l American Medical Association. Les activités-seuils qui provoquent de l angine ont été décrites en détail pour permettre à des observateurs indépendants de procéder à une évaluation fiable du degré de gravité de l angine d effort et des changements observés au fil du temps. Le système de classification a été cité plus de 650 fois dans la documentation scientifique depuis sa publication officielle en Même si, dans l ensemble, le système est jugé pratique et pertinent, plusieurs faiblesses et limites potentielles ont été relevées, notamment le critère faisant référence à la présence possible du syndrome angineux au repos pour décrire le quatrième degré de gravité, qui s avère inapproprié et source de confusion. Autre point faible : la valeur pronostique du système de classification, mais il ne s agit pas là de son objet principal. CONCLUSION : Bien que le système de classification du degré de gravité de l angine de poitrine selon la SCC ait été accepté partout dans le monde au cours des 30 dernières années, il est souhaitable de procéder à sa révision compte tenu de ses faiblesses potentielles et des incohérences avec le traitement actuel des cardiopathies ischémiques. The Canadian Cardiovascular Society (CCS) grading scale of the severity of angina pectoris was first proposed to the CCS membership in 1972 and described in the literature in 1976 (1). It appears to have become the standard classification of patients with exertional angina. The purpose of the present paper is to describe its origin, its worldwide acceptance, critiques and perceived limitations, as well as alternative and competing systems. The literature was reviewed by using a MEDLINE search, and citation indexes of the International Science Index and the Web of Science Records. ORIGIN In October 1971, as recorded in the minutes of a meeting of the Council of the CCS chaired by Dr WG Bigelow, an ad hoc committee on nomenclature was set up to standardize the definition of terms used in reporting studies of coronary artery disease and coronary artery bypass graft (CABG) surgery. At the committee s first meeting on January 29, 1972, specific topics were assigned to members of this committee chaired by the author. These topics were the definition and grading of angina and other manifestations of ischemic heart disease (Lucien Campeau, Montreal, Quebec); objective, electrocardiogram and hemodynamic assessment (Simon JK Lee, Edmonton, Alberta); angiographic assessment (Jacques Lespérance, Montreal, Quebec); surgical observations and techniques (Alan S Trimble, Toronto, Ontario); and follow-up studies (WJ Keon, Ottawa, Ontario). Dr Bigelow also felt that a common nomenclature used by all Canadian centres performing cardiac surgery might be the first step toward a national registry on CABG surgery. Prospective data forms were prepared with the assistance of a computer expert (François Lustman, Montreal, Quebec). In October 1972, the proposed nomenclature, grading systems and computer data forms were presented at the annual CCS meeting held in Toronto, Ontario. This material was never published, except for the grading of the severity of effort angina (1). The purpose of defining a scale for the severity of exertional angina was to evaluate the efficacy of medical and surgical therapy by comparing the patient s status before and after therapeutic interventions. The scale needed to be simple, reproducible by independent observers and able to show little differences in the angina status over time (responsiveness). It was decided at the outset that exertional angina, rest angina and unstable angina would have separate classifications. It was also accepted that a grading of exertional angina would be limited to its severity, as part of a more complete assessment of the angina syndrome, that would include duration of the angina syndrome, duration and frequency of the angina attacks, and response to therapy and progression. All of these aspects were to be included in a computer card designed for the proposed national registry on CABG surgery. At that time, there were two classifications that dealt with the assessment of functional capacity of patients with heart diseases, the New York Heart Association (NYHA) functional classification and the American Medical Association (AMA) classes of organic heart diseases, as shown in Table 1 (2,3). The AMA classes of organic heart disease included symptoms and signs of heart failure, response to therapy and degree of functional impairment. It was considered to be too long and impractical for grading of the severity of exertional angina. The ad hoc committee chose to modify the NYHA classification, which was simpler and the most popular. However, activities and 372 Can J Cardiol Vol 18 No 4 April 2002

3 CCS functional classification of angina of effort Can J Cardiol Vol 18 No 4 April

4 Campeau Figure 1) The number of manuscripts that cited the publication of the Canadian Cardiovascular Society grading of angina pectoris (data from reference 1), based on the Current Index (1976 to 1979), the International Science Citation Index (1980 to 1997) and the Web Science Records (1998 to 2000) grading system (I to IV). It was expected that a four-grade instead of a three-grade system would result in a greater discriminative power that would insure better reproducibility. The inclusions of the criteria they are comfortable at rest in classes II and III of the NYHA classification and without symptoms at rest in classes I to III of the AMA systems that were justified for grading heart failure were thought to be inappropriate for the evaluation of effort angina because vasospastic angina could occur at all degrees of functional impairment. Nonetheless, the NYHA grade IV criterion anginal syndrome may be present at rest was retained for the CCS grade IV, except that it would not be binding, but only considered to be a combined descriptor of the utmost severity. Nonetheless, several members of the CCS felt that the inclusion in grade IV of the criterion angina at rest may be present was irrelevant for a scale of the severity of exertional angina. More importantly, it was felt that patients who should be classified with grades I to III might be wrongly considered to be in class IV when rest angina is present (personal communication, Gerald E Klassen and John O Parker). modifiers that were described in the AMA classes, such as walking and stair climbing, hurrying and prolonged exertion, were included in the CCS system. Class I of the NYHA classification was found to be ambiguous. It included patients with cardiac disease but without resulting limitations of physical activity. The added statement ordinary activity does not cause undue fatigue, palpitations, dyspnea or anginal pain suggested that severe exertion might provoke these symptoms. In the CCS grade I, the committee included patients in whom ordinary activity does not cause angina, but who clearly have angina with strenuous or rapid or prolonged exertion at work or recreation (Table 1). This became equivalent to class II of the AMA classification, which clearly states prolonged exertion, emotional stress, hurrying, hill climbing, recreation or similar activities produce symptoms, whereas they do not in class 1. CCS grades II and III include detailed descriptions of activity thresholds that were only broadly defined in the NYHA classification as resulting in slight and marked limitations of ordinary physical activity. The CCS grading system specified the number of city blocks and the number of flights of stairs walked at normal or rapid pace, walking on the level or uphill, walking in normal (usual) conditions or after meals, in the cold, wind or under emotional stress, or during the few hours after awakening. This detailed description was expected to separate reliably patients with slight limitation (grade II) from those who were markedly incapacitated (grade III). CCS grades II and III were somewhat equivalent to AMA class III. In fact, the AMA and the NYHA systems clearly separated symptomatic patients into only three classes (II to IV) instead of four as in the CCS WORLDWIDE ACCEPTANCE It appears that the CCS grading system of the severity of effort angina has been universally adopted, based on the numerous and increasingly more frequent reference to its original description (Figure 1). Of the 656 manuscripts citing this grading system, 87% were written in English, 28% in German, 27% in Russian, 22% in French, 2% each in Scandinavian and Spanish, and 1% in Japanese (from Current Index 1976 to 1979, International Science Index Citation 1980 to 1997 and Web of Science Records 1998 to 2000). The CCS grading system has been described in at least 18 textbooks that deal with pathophysiology, internal medicine, anesthesiology, nursing and, of course, books in cardiology. This number of textbooks may be underestimated since it includes only those for which permission was given by the author to reproduce Table 1 (1). As mentioned by Cox et al (4) the popularity of the CCS scale reflects its ease of use and clinical relevance, but its general adoption was also hastened by serendipity, having been accepted by the Coronary Artery Surgery Study (CASS) of the National Heart, Lung and Blood Institute in the United States. Dr Martial G Bourassa, who was the principal investigator of CASS at the Montreal Heart Institute (MHI), and the author of the present article, persuaded members of the steering committee to adopt the CCS grading scale instead of the other existing systems at that time, including the newly described American Heart Association (AHA) grading of chest pain, described below (alternative and competing systems) (5). The first reference by CASS was in 1980 (6), several years after the CCS classification had been adopted by authors from the MHI and from other centres in North America (7-9). It is interesting to note that, of the 24 references to the CCS grading during the first four years after its official publica- 374 Can J Cardiol Vol 18 No 4 April 2002

5 CCS functional classification of angina of effort tion, 14 (58%) were from the MHI, eight (33%) were from other centres in the United States and only two (8%) were from CASS. The system was later adopted by the European coronary surgery study group (10). In 1982, the CCS classification was selected by the National Heart, Lung and Blood Institute for its registry on percutaneous transluminal coronary angioplasty (11). It was subsequently included in the American College of Cardiology (ACC)/AHA) task force report on guidelines and indications for CABG surgery (12), and for coronary angiography (13). It was also included in the guidelines for the management of patients with chronic stable angina of the ACC/AHA/American College of Physicians- American Society of Internal Medicine (14). CRITIQUES AND LIMITATIONS Proudfit noted several limitations (15,16). He thought that the term prolonged exertion in grade I was too vague, and that the phrase inability to carry on any physical activity without discomfort in grade IV was not a realistic criterion because such a severe incapacity was so rarely observed. He suggested that only walking be included as the ordinary activity, and that 100 yards or metres be equivalent to one city block. He then suggested that activity thresholds of grades II and III be distributed more evenly throughout all four grades: grade I would include walking after meals, into a cold wind, ascending an incline or carrying ; grade II would be defined by walking more than one block instead of more than two blocks ; grade III would include walking one block instead of one to two blocks ; and, finally, grade IV walking less than one block, associated with rest pain. Proudfit thought that such a modified version, similar to what had been used in a study on the natural history of obstructive coronary artery disease would improve its prognostic significance (17). He also thought that the duration and timing of the angina attack (whether it occurred at the beginning of an exertion as opposed to a walked through or after a warm-up period) should be somehow incorporated in the scale. However, he finally concluded that this grading scale was an enormous improvement over the NYHA functional classification of diseases of the heart. Ho Ping Kong et al (18) and Cox et al (4,19) also reported several potential limitations of the CCS grading system. One study directly addressed its validity content according to the science of clinimetrics for the assessment of health indexes and scales (18). It was based on a sample size of only 41 patients with stable angina admitted at a tertiary centre for coronary angiography. A closed-end questionnaire included numbers of blocks walked on the level and flights of stairs climbed before the onset of chest pain, frequency of chest pain, presence of rest pain and influence of modifiers included in grade II of the CCS grading system, such as walking rapidly, uphill, after meals, etc. Ho Ping Kong et al (18) and Cox et al (4,19) stated, based on individual crossmatching, that the equivalence of walking and stair climbing were at best equivocal. They claimed that this weak agreement between stairclimbing and walking tolerance might, in part, explain the ambiguous identification of patients with grades II to III. However, compared with the distance walked on level ground under normal conditions, distances walked uphill, into the wind, in the cold and after meals were found to be shorter before onset of chest pain in a significant majority of patients. However, angina in the first few hours after awakening was inconsistently affected. The incidence of rest angina was not correlated with the severity of angina as judged by the CCS grading; thus, the authors questioned its inclusion as a criterion for grade IV angina. Also, they noted that the CCS grading system did not, unfortunately, consider the confounding roles of drug therapy, particularly sublingual nitrates, before exertion, and personal warm-up, such as starting the activity slowly. They nonetheless recognized that the CCS grading was relevant, popular and practical, but believed that refinements were needed according to explicit measurement goals. Although they thought that the CCS scale was used for appraising symptomatic change, they also thought that it might have a diagnostic and prognostic significance on the assumption that symptoms are a surrogate for ischemic jeopardy (4,18). Cox et al (19) were concerned because it was potentially difficult to work through the full permutations of symptoms and qualifiers of the scale for each patient. They suggested that a measure of symptom burden could be obtained more expediently by asking the patient to rate their degree of functional limitation in performing their daily activities. They described such a disability score as no, mild, moderate and severe limitation of desired activities. A good agreement was found (Spearman r=0.73) between this patient-perceived disability score and a modified CCS scale that included the standard CCS grades I to III and unstable angina as grade IV. This modified CCS scale, it was suggested, might have a greater prognostic relevance. ALTERNATIVE AND COMPETING SYSTEMS Specifically designed systems to assess the severity of exertional angina include the AHA grading of severity of chest pain (angina) and a clinical taxonomy for rating change in functional activities of patients with angina pectoris (5,20). The AHA grading of severity of chest pain has three grades (5): Mild equals mild chest pain: ordinary physical or emotional stress (ie, the level of physical or emotional stress that can be considered to be usual and typical of everyday activity for that individual patient) does not cause chest pain. Chest pain can be elicited by effort that is greater than ordinary efforts, eg, running for a bus, pushing a car Can J Cardiol Vol 18 No 4 April

6 Campeau Moderate equals moderately severe chest pain: ordinary physical or emotional stress typical of everyday activity for the individual can cause chest pain, eg, climbing stairs, playing golf with a cart, walking briskly uphill Severe equals severe chest pain: in addition to being severely limited in the physical activity that can be performed, the patient has angina at rest (either decubitus or nocturnal), synonymous with NYHA class IV functional status Mild chest pain is equivalent to CCS grade I. Moderate chest pain encompasses CCS grades II and III. This category is so broad, including the majority of patients with effort angina, that small changes over time may not be discernible. The severe chest pain category is equivalent to CCS grade IV, except that it requires that the patient has angina at rest, which is a criterion that may create a problem in classifying severely limited patients without rest angina. Emotional, stress-induced angina, which was also included in the AMA classes II and III (3), is classified separately in the CCS grading system because it was thought that exertion- and stress-provoked angina are not always present to the same degree (1). A clinical taxonomy for rating change in functional activities of patients with angina pectoris was developed for a clinical trial on the role of beta-blocking agents in the management of hypertension and angina pectoris (20). The authors thought that the NYHA functional classification of diseases of the heart did not refer to a sufficiently large number of activities, and that the four categories of the scale were too coarse to show small changes that can occur while the patient retains the same rating. This system, based on an extensive open-ended questionnaire, solicited detailed data about three activity categories, ordinary activities (walking and stair climbing), and occupational and sporadic activities such as gardening and recreation. A summary rating indicated change in the patient s status as a result of therapy for each category: 0 equals much worse; 1 equals worse; 2 equals no change; 3 equals slight or moderate improvement; 4 equals major improvement. Finally, a global rating was based on a judgmental evaluation of the total information. The Web of Science Records reports only 27 citations since its publication. Systems for the assessment of the functional capacity of patients with heart diseases include the NYHA classification and the AMA classes of organic heart diseases (2,3). They were not found to be suitable for grading the severity of exertional angina, as discussed above (see section on Origin ). Systems developed for the assessment of the functional capacity of patients in general include the new Specific Activity Scale (SAS) and the Duke Activity Status Index (DASI) (21,22). 376 The SAS is a four-level scale based on estimated metabolic costs (Mets) of a variety of personal care, housework, occupational and recreational activities (21). Class I includes asymptomatic patients who can perform to completion any activity requiring 7 Mets, including recreational activities and outdoor work such as shovelling snow or spading soil. It is equivalent to the unofficial and frequently used CCS grade 0. Class II, equivalent to CCS grade I, is defined as unable to perform any activity requiring 7 Mets. Class III, equivalent to CCS grade III, includes cannot perform to completion any activities requiring 5 Mets such as walking at a four-mile per hour rate on level ground. Class IV, equivalent to CCS grade IV, specifies patients who cannot perform activities requiring 2 Mets, such as showering or dressing without stopping. The SAS has no CCS grade II equivalent. The DASI is a self-administered questionnaire that includes 12 major spheres of activity, such as personal care, ambulation, household tasks, and sexual and recreational functions (22). The scoring results are continuous measurements rather than the traditional four functional classes. It was thought by the authors to be well suited for large population studies as a tool to evaluate therapeutic interventions. According to the Mets of the activities described in their proposal, CCS grade I would include limitation of activities requiring 7.5 to 8 Mets, such as heavy work around the house ( scrubbing floors or lifting or moving heavy furniture ) and strenuous sports ( singles tennis or skiing ). CCS grade II would include limitation of activities requiring 5.5 Mets, such as walking uphill, and grade III would include limitation of activities requiring 2.75 Mets (walking a block or two on level ground). Finally, CCS grade IV includes limitation of activities requiring 1.75 to 2.75 Mets ( take care of yourself, eating, dressing, bathing or using the toilet, walk indoors around the house ). Hlatky et al (22) concluded that their method is probably better suited for a clinical investigation than for its use in routine medical practice. Both systems based on Mets of daily activities (SAS and DASI) have gained popularity. The Web of Science Records reports 249 citations 18 years after the first publication for SAS, and 136 citations at 10 years for DASI. However, both were designed to assess the functional capacity and health-related quality of life of patients in general. A review of the titles of the manuscript that have cited these systems during the past three years revealed that no more than 20% appear to be related to ischemic heart disease. Alonso et al (23) suggested that a reduced version of DASI may be considered for the routine clinical evaluation of chronic coronary patients. These systems, however, seem to be best suited for large population studies and, in addition, being generic instruments, they are not really competing with the CCS grading of effort angina, which is a more specific tool. Goldman et al (21) compared the reproducibility of the specific activity scale (SAS) with that of the NYHA func- Can J Cardiol Vol 18 No 4 April 2002

7 CCS functional classification of angina of effort tional classification of diseases of the heart and of the CCS grading of angina pectoris in a study of 75 patients scheduled for an electrocardiogram stress test. The CCS system had a reproducibility of 73%, equal to that of the SAS, and was significantly greater than the NYHA functional classification (56%). Goldman et al (21) believed that the higher reproducibility of the CCS system compared with the NYHA classification was related to the greater details included in its definitions, but that further details in their SAS could not improve on the high degree of reproducibility attained by the CCS criteria. The criterion-related validity that evaluates the scale performance against a gold standard has been studied by several groups. It is postulated that the severity of angina should correlate with objective assessment of the ischemic burden or the extent of coronary artery disease as evaluated by exercise testing and coronary arteriography. In a study of 75 patients, Goldman et al (21) found agreement with treadmill performance in 59% for the CCS grading compared with 68% for their SAS (P<0.05). Unfortunately, this study did not specifically assess the severity of angina, because chest pain was present in only 75% of the study cohort and, more importantly, the exercise test was stopped because of chest pain or asymptomatic electrocardiogram abnormalities in only 35% of the cases. Hlatky et al (22) reported a significant correlation of the CCS grading and peak oxygen uptake. They submitted to 50 subjects undergoing an exercise test a self-administered questionnaire that measured functional status, the DASI, described above. Correlations of the peak oxygen uptake with DASI were higher (P=0.0001) than the correlations with alternative measures, CCS grading (P=0.004) and the SAS, also described above (P=0.04) Permanyer-Miralda et al (24), in a study of 93 patients with stable coronary artery disease, correlated the CCS grading system with electrocardiogram exercise test performance. The test was considered to be positive when typical angina or ST segment depression 1 mm or more occurred. Permanyer-Miralda et al (24) found that there was a significant relationship between the CCS scale and the duration of the exercise test in the total cohort (P<0.05), but not when only symptomatic patients were evaluated, the overall positive correlation being due to a significant difference between asymptomatic (29% of the cohort) and symptomatic patients. DISCUSSION Proudfit (15,16) agreed that the CCS grading system was: an enormous improvement over the NYHA functional classification of diseases of the heart by its restriction to grading effort angina and its definition of specific amounts of exercise characteristic of each grade It was considered to be simple and user-friendly as a dayto-day tool in clinical practice. It has also been accepted as a worthwhile instrument in clinical research because of sufficiently detailed thresholds of activities and its stepwise logic. The CCS grading system was based on clinical experience and intuition, before the advent of the science of clinimetrics for the assessment of health indexes and functional scales described by Ho Ping Kong et al (18). In a study based on a limited number of patients, they concluded that the content-related validity (equivalence in activities within grades) may not be adequate; thus, it may result in various gradings for the same patient by different observers. For example, a patient who has angina and climbs one flight of stairs (grade III) but also walks more than two city blocks (grade II) might be classified with grade II or III, or grade II-III angina. However, because of the expected stepwise logic, the highest grade should be selected, namely, grade III. A single activity, as suggested by Proudfit (15), would prevent this ambiguity related to the unequal equivalence in activities within grades. Furthermore, grading the severity of exertional angina based on the same activity for everybody, such as walking, might result in a more homogeneous evaluation of large populations. Qualifiers of walking or stair climbing after meal or in cold or in wind were found to decrease the angina threshold (18). Their influence on the angina threshold has since been well documented (25-27). Despite potential imperfections, a satisfactory reproducibility of the CCS system of 73% was documented by Goldman et al (21). It was equal to that found for their scale (SAS), and significantly better than that of the NYHA functional classification, which was only 56%. Several critics were concerned by the paucity of characteristics and circumstances related to the anginal attack, such as its duration and frequency, the influence of medication and of the warm-up phenomenon (4,15,18). The CCS committee had felt that the grading system should be simple and concise, particularly as a day-to-day tool in clinical practice, but also as a research instrument. The committee had decided that other pertinent information would be recorded separately as part of a global evaluation in addition to the assessment of the ischemic burden by objective means. The most frequent and, according to the author, definitely justified critique is the inappropriate definition of grade IV, which has been found to be confusing (4,15,19), as suspected at the outset by several CCS members (see section on Origin ). In fact, although the statement anginal syndrome may be present at rest was not binding (1), it might be mistakenly considered to be a required criterion. More importantly, it might falsely identify patient s with grade I to III angina as grade IV because rest pain may occur in all other grades as a manifestation of vasospastic angina. Thus, it is agreed that the criteria for grade IV need to be modified. Perhaps the following definition would be suitable: severe limitations of ordinary activity angina occurs while walking less than one block in normal conditions and at a normal pace, or while walking in the house, or doing light chores or Can J Cardiol Vol 18 No 4 April

8 Campeau personal care such as dressing and showering. In fact, patients with angina walking outside less than one block cannot be correctly classified using the present CCS grading. The review of the literature showed that most workers have used classification and class instead of the official CCS nomenclature of grading and grade. A footnote indicating that the distance of one city block is equivalent to 100 yards or 100 metres, as suggested by Proudfit (15), would also be useful. Validity studies that evaluate the scale performance against objective measurements of the ischemic burden or the extent of coronary obstructive disease do not appear to be warranted because the primary goal of this grading system is the assessment of the severity of angina, and its change over time. The ischemic burden can be assessed more reliably by objective means such as stress testing, left ventricular ejection fraction and coronary angiography (28-30). Likewise, prognosis may be better evaluated by combining effort angina CCS grades I to III and unstable angina (19,31). Several critics (4,15,19) have suggested that there be a revision of this grading system. The AHA functional classification of diseases of the heart has been updated nine times since its introduction in 1928 (32). CONCLUSIONS The author proposes a new definition for grade IV, replacing inability to carry on any physical activity without discomfort by a set of detailed activities, and deleting anginal syndrome may be present at rest. A revision of this grading system appears to be indicated considering its potential imperfections and inconsistencies with present day management of effort angina and ischemic heart disease, which has changed considerably during the past 30 years. None of the alternative systems specifically designed to assess the severity of effort angina or the functional capacity of patients with heart disease was shown to be superior to the CCS system. However, systems based on Mets of daily activity (SAS and DASI) have gained popularity as generic tools with which to evaluate the functional capacity and health-related quality of life in general, particularly for large population studies. ACKNOWLEDGEMENTS: The author thanks for their assistance Dr Gilles Dupuis PhD and Ngo Phong Liem RN of the Montreal Heart Institute, Montreal, and Mrs Monique Bond, librarian at the University of Montreal, Montreal, Quebec. REFERENCES 1. Campeau L. Grading of angina pectoris. Circulation 1976;54: (Lett). 2. The Criteria Committee of the New York Heart Association, Inc. (Kossman CE, chairman). Nomenclature and criteria for diagnosis. In: Diseases of the Heart and Blood Vessels, 6th edn. Boston: Little, Brown & Company, 1964: American Medical Association. 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