Diagnosis and Management of Patients With Stable Ischemic Heart Disease

Publication Date: July 28, 2014
Last Updated: September 2, 2022

Diagnosis

Clinical Evaluation in the Initial Diagnosis of SIHD in Patients With Chest Pain

Patients with chest pain should receive a thorough history and physical examination to assess the probability of IHD before additional testing. (C, I)
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Patients who present with acute angina should be categorized as stable or unstable. Patients with unstable angina (UA) should be further categorized as being at high, moderate, or low risk ( C , I )
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A resting electrocardiogram (ECG) is recommended in patients without an obvious, noncardiac cause of chest pain. ( B , I )
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Stress Testing and Advanced Imaging for Initial Diagnosis in Patients With Suspected SIHD Who Require Noninvasive Testing

Able to Exercise

Standard exercise ECG testing is recommended for patients with an intermediate pretest probability of IHD who have an interpretable ECG and at least moderate physical functioning or no disabling comorbidity. ( A , I )
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Exercise stress with nuclear myocardial perfusion imaging (MPI) or echocardiography is recommended for patients with an intermediate to high pretest probability of IHD who have an uninterpretable ECG and at least moderate physical functioning or no disabling comorbidity. ( B , I )
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For patients with a low pretest probability of obstructive IHD who do require testing, standard exercise ECG testing can be useful, provided the patient has an interpretable ECG and at least moderate physical functioning or no disabling comorbidity. ( C , IIa )
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Exercise stress with nuclear MPI or echocardiography is reasonable for patients with an intermediate to high pretest probability of obstructive IHD who have an interpretable ECG and at least moderate physical functioning or no disabling comorbidity. ( B , IIa )
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Pharmacological stress with cardiac magnetic resonance (CMR) can be useful for patients with an intermediate to high pretest probability of obstructive IHD who have an uninterpretable ECG and at least moderate physical functioning or no disabling comorbidity. ( B , IIa )
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Coronary/cardiac computed tomography angiography (CCTA) might be reasonable for patients with an intermediate pretest probability of IHD who have at least moderate physical functioning or no disabling comorbidity. ( B , IIb )
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For patients with a low pretest probability of obstructive IHD who do require testing, standard exercise stress echocardiography might be reasonable, provided the patient has an interpretable ECG and at least moderate physical functioning or no disabling comorbidity (C, IIb)
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Pharmacological stress with nuclear MPI, echocardiography, or cardiac magnetic resonance (CMR) is NOT recommended for patients who have an interpretable ECG and at least moderate physical functioning or no disabling comorbidity. ( C , III (no benefit) )
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Exercise stress with nuclear MPI is NOT recommended as an initial test in low-risk patients who have an interpretable ECG and at least moderate physical functioning or no disabling comorbidity. ( C , III (no benefit) )
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Unable to Exercise

Pharmacological stress with nuclear MPI or echocardiography is recommended for patients with an intermediate to high pretest probability of IHD who are incapable of at least moderate physical functioning or have disabling comorbidity. ( B , I )
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Pharmacological stress echocardiography is reasonable for patients with a low pretest probability of IHD who require testing and are incapable of at least moderate physical functioning or have disabling comorbidity. ( C , IIa )
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CCTA is reasonable for patients with a low to intermediate pretest probability of IHD who are incapable of at least moderate physical functioning or have disabling comorbidity. ( B , IIa )
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Pharmacological stress CMR is reasonable for patients with an intermediate to high pretest probability of IHD who are incapable of at least moderate physical functioning or have disabling comorbidity. ( B , IIa )
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Standard exercise ECG testing is NOT recommended for patients who have an uninterpretable ECG or are incapable of at least moderate physical functioning or have disabling comorbidity. ( C , III (no benefit) )
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CCTA is reasonable for patients with an intermediate pretest probability of IHD who: ( C , IIa )
  • Have continued symptoms with prior normal test findings, or
  • Have inconclusive results from prior exercise or pharmacological stress testing, or
  • Are unable to undergo stress with nuclear MPI or echocardiography
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For patients with a low to intermediate pretest probability of obstructive IHD noncontrast cardiac computed tomography (CT) to determine the coronary artery calcium (CAC) score may be considered. ( C , IIb )
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Resting Imaging to Assess Cardiac Structure and Function

Assessment of resting left ventricular (LV) systolic and diastolic function and evaluation for abnormalities of myocardium, heart valves, or pericardium are recommended with the use of Doppler echocardiography in patients with known or suspected IHD and a prior myocardial infarction (MI), pathological Q waves, symptoms or signs suggestive of heart failure, complex ventricular arrhythmias, or an undiagnosed heart murmur. (B, I)
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Assessment of cardiac structure and function with resting echocardiography may be considered in patients with hypertension or diabetes mellitus and an abnormal ECG (C, IIb)
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Measurement of LV function with radionuclide imaging may be considered in patients with a prior MI or pathological Q waves, provided there is no need to evaluate symptoms or signs suggestive of heart failure, complex ventricular arrhythmias, or an undiagnosed heart murmur. ( C , IIb )
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Echocardiography, radionuclide imaging, CMR, and cardiac CT are NOT recommended for routine assessment of LV function in patients with a normal ECG, no history of MI, no symptoms or signs suggestive of heart failure, and no complex ventricular arrhythmias ( C , III (no benefit) )
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Routine reassessment (<1 year) of LV function with technologies such as echocardiography radionuclide imaging, CMR, or cardiac CT is NOT recommended in patients with no change in clinical status and for whom no change in therapy is contemplated. ( C , III (no benefit) )
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Stress Testing and Advanced Imaging in Patients With Known SIHD Who Require Noninvasive Testing for Risk Assessment

Risk Assessment in Patients Able to Exercise

Standard exercise ECG testing is recommended for risk assessment in patients with SIHD who are able to exercise to an adequate workload and have an interpretable ECG. ( B , I )
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The addition of either nuclear MPI or echocardiography to standard exercise ECG testing is recommended for risk assessment in patients with SIHD who are able to exercise to an adequate workload but have an uninterpretable ECG not due to left bundle-branch block (LBBB) or ventricular pacing. ( B , I )
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The addition of either nuclear MPI or echocardiography to standard exercise ECG testing is reasonable for risk assessment in patients with SIHD who are able to exercise to an adequate workload and have an interpretable ECG. ( B , IIa )
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CMR with pharmacological stress is reasonable for risk assessment in patients with SIHD who are able to exercise to an adequate workload but have an uninterpretable ECG. ( B , IIa )
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CCTA may be reasonable for risk assessment in patients with SIHD who are able to exercise to an adequate workload but have an uninterpretable ECG. ( B , IIb )
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Pharmacological stress imaging (nuclear MPI, echocardiography, or CMR) or CCTA is NOT recommended for risk assessment in patients with SIHD who are able to exercise to an adequate workload and have an interpretable ECG ( C , III (no benefit) )
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Risk Assessment In Patients Unable To Exercise

Pharmacological stress with either nuclear MPI or echocardiography is recommended for risk assessment in patients with SIHD who are unable to exercise to an adequate workload regardless of interpretability of ECG. ( B , I )
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Pharmacological stress CMR is reasonable for risk assessment in patients with SIHD who are unable to exercise to an adequate workload regardless of interpretability of ECG. ( B , IIa )
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CCTA can be useful as a first-line test for risk assessment in patients with SIHD who are unable to exercise to an adequate workload regardless of interpretability of ECG. ( C , IIa )
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Risk Assessment Regardless Of Patients’ Ability To Exercise

Pharmacological stress with either nuclear MPI or echocardiography is recommended for risk assessment in patients with SIHD who have LBBB on ECG, regardless of ability to exercise to an adequate workload. ( B , I )
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Either exercise or pharmacological stress with imaging (nuclear MPI, echocardiography, or CMR) is recommended for risk assessment in patients with SIHD who are being considered for revascularization of known coronary stenosis of unclear physiological significance. ( B , I )
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CCTA can be useful for risk assessment in patients with SIHD who have an indeterminate result from functional testing. ( C , IIa )
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CCTA might be considered for risk assessment in patients with SIHD unable to undergo stress imaging or as an alternative to invasive coronary angiography when functional testing indicates a moderate-to high-risk result and angiographic coronary anatomy is unknown. ( C , IIb )
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A request to perform either a) more than 1 stress imaging study or b) a stress imaging study and a CCTA at the same time is NOT recommended for risk assessment in patients with SIHD ( C , III (no benefit) )
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Coronary Angiography as an Initial Testing Strategy to Assess Risk

Patients with SIHD who have survived sudden cardiac death or potentially life-threatening ventricular arrhythmia should undergo coronary angiography to assess cardiac risk ( B , I )
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Patients with SIHD who develop symptoms and signs of heart failure should be evaluated to determine whether coronary angiography should be performed for risk assessment. ( B , I )
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Coronary Angiography to Assess Risk After Initial Workup With Noninvasive Testing

Coronary arteriography is recommended for patients with SIHD whose clinical characteristics and results of noninvasive testing indicate a high likelihood of severe IHD and when the benefits are deemed to exceed risk. ( C , I )
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Coronary angiography is reasonable to further assess risk in patients with SIHD who have depressed LV function (ejection fraction [EF] <50%) and moderate risk criteria on noninvasive testing with demonstrable ischemia. ( C , IIa )
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Coronary angiography is reasonable to further assess risk in patients with SIHD and inconclusive prognostic information after noninvasive testing or in patients for whom noninvasive testing is contraindicated or inadequate. ( C , IIa )
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Coronary angiography for risk assessment is reasonable for patients with SIHD who have unsatisfactory quality of life due to angina, have preserved LV function (EF >50%), and have intermediate risk criteria on noninvasive testing. ( C , IIa )
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Coronary angiography for risk assessment is NOT recommended in patients with SIHD who elect not to undergo revascularization or who are not candidates for revascularization because of comorbidities or individual preferences. ( B , III (no benefit) )
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Coronary angiography is NOT recommended to further assess risk in patients with SIHD who have preserved LV function (EF >50%) and low-risk criteria on noninvasive testing. ( B , III (no benefit) )
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Coronary angiography is NOT recommended to assess risk in patients who are at low risk according to clinical criteria and who have not undergone noninvasive risk testing ( C , III (no benefit) )
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Coronary angiography is NOT recommended to assess risk in asymptomatic patients with no evidence of ischemia on noninvasive testing ( C , III (no benefit) )
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Invasive Testing for Diagnosis of Coronary Artery Disease in Patients With Suspected SIHD (New in 2014)

Coronary angiography is useful in patients with presumed SIHD who have unacceptable ischemic symptoms despite guideline-directed medical therapy (GDMT) and who are amenable to, and candidates for, coronary revascularization. ( C , I )
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Coronary angiography is reasonable to define the extent and severity of CAD in patients with suspected SIHD whose clinical characteristics and results of noninvasive testing (exclusive of stress testing) indicate a high likelihood of severe IHD and who are amenable to, and candidates for, coronary revascularization ( C , IIa )
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Coronary angiography is reasonable in patients with suspected symptomatic SIHD who cannot undergo diagnostic stress testing, or have indeterminate or nondiagnostic stress tests, when there is a high likelihood that the findings will result in important changes to therapy. ( C , IIa )
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Coronary angiography might be considered in patients with stress test results of acceptable quality that do not suggest the presence of CAD when clinical suspicion of CAD remains high and there is a high likelihood that the findings will result in important changes to therapy. ( C , IIb )
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Treatment

Patient Education

Patients with SIHD should have an individualized education plan to optimize care and promote wellness, including:

Education on the importance of medication adherence for managing symptoms and retarding disease progression ( C , I )
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An explanation of medication management and cardiovascular risk reduction strategies in a manner that respects the patient’s level of understanding, reading comprehension, and ethnicity ( B , I )
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A comprehensive review of all therapeutic options ( B , I )
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A description of appropriate levels of exercise, with encouragement to maintain recommended levels of daily physical activity. ( C , I )
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Introduction to self-monitoring skills ( C , I )
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Information on how to recognize worsening cardiovascular symptoms and take appropriate action. ( C , I )
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Patients with SIHD should be educated about the following lifestyle elements that could influence prognosis: 

Weight control – maintenance of a body mass index (BMI2 ) of 18.5-24.9 kg/mand maintenance of a waist circumference <102 cm (40 inches) in men and <88 cm (35 inches) in women (less for certain racial groups)
  • Lipid management
  • Blood pressure (BP) control
  • Smoking cessation and avoidance of exposure to secondhand smoke
  • Individualized medical, nutrition, and lifestyle changes for patients with diabetes mellitus to supplement diabetes treatment goals and education.
( C , I )
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It is reasonable to educate patients with SIHD about:

Adherence to a diet that is low in saturated fat, cholesterol, and trans fat; high in fresh fruits, whole grains, and vegetables; and reduced in sodium intake, with cultural and ethnic preferences incorporated ( B , IIa )
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Common symptoms of stress and depression to minimize stress-related angina symptoms ( C , IIa )
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Comprehensive behavioral approaches for the management of stress and depression ( C , IIa )
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Evaluation and treatment of major depressive disorder when indicated. ( B , IIa )
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Risk Factor Modification

Lipid Management

Lifestyle modifications, including daily physical activity and weight management, are strongly recommended for all patients with SIHD. ( B , I )
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Dietary therapy for all patients should include reduced intake of saturated fats (to <7% of total calories), trans fatty acids (to <1% of total calories), and cholesterol (to <200 mg/d). ( B , I )
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In addition to therapeutic lifestyle changes, a moderate or high dose of a statin therapy should be prescribed in the absence of contraindications or documented adverse effects. ( A , I )
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For patients who do not tolerate statins, low-density lipoprotein cholesterol (LDL-Ca)–lowering therapy with bile acid sequestrants, niacin,b or both is reasonable. ( B , IIa )
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a The use of bile acid sequestrant is relatively contraindicated when triglycerides are ≥200 mg/dL and is contraindicated when triglycerides are ≥500 mg/dL.

b Dietary supplement niacin must not be used as a substitute for prescription niacin.

Blood Pressure Management

All patients should be counseled about the need for lifestyle modification: weight control; increased physical activity; alcohol moderation; sodium reduction; and emphasis on increased consumption of fresh fruits, vegetables, and low-fat dairy products. ( A , I )
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In patients with SIHD with BP ≥140/90 mm Hg, antihypertensive drug therapy should be instituted in addition to or after a trial of lifestyle modifications. ( A , I )
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The specific medications used for treatment of high BP should be based on specific patient characteristics and may include angiotensin-converting enzyme (ACE) inhibitors and/or beta blockers with the addition of other drugs, such as thiazide diuretics or calcium channel blockers, if needed to achieve a goal BP of <140/90 mm Hg. ( B , I )
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Diabetes Management

For selected individual patients, such as those with a short duration of diabetes mellitus and a long life expectancy, a goal hemoglobin A1c (HbA1c) of ≤7% is reasonable. ( B , IIa )
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A goal HbA1c between 7% and 9% is reasonable for certain patients according to age, history of hypoglycemia, presence of microvascular or macrovascular complications, or presence of coexisting medical conditions. ( C , IIa )
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Initiation of pharmacotherapy interventions to achieve target HbA1c might be reasonable. ( A , IIb )
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Therapy with rosiglitazone should NOT be initiated in patients with SIHD. ( C , III (harm) )
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Physical Activity

For all patients, the clinician should encourage 30-60 minutes of moderate-intensity aerobic activity, such as brisk walking, at least 5 days and preferably 7 days per week, supplemented by an increase in daily lifestyle activities (eg, walking breaks at work, gardening, household work) to improve cardiorespiratory fitness and move patients out of the least-fit, least-active, high-risk cohort (bottom 20%). ( B , I )
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For all patients, risk assessment with a physical activity history and/or an exercise test is recommended to guide prognosis and prescription. ( B , I )
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Medically supervised programs (cardiac rehabilitation) and physician-directed, home-based programs are recommended for at-risk patients at first diagnosis. ( B , I )
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It is reasonable for the clinician to recommend complementary resistance training at least 2 days per week. ( C , IIa )
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Weight Management

BMI and/or waist circumference should be assessed at every visit, and the clinician should consistently encourage weight maintenance or reduction through an appropriate balance of lifestyle physical activity, structured exercise, caloric intake, and formal behavioral programs when indicated to maintain or achieve a BMI2 between 18.5 and 24.9 kg/m and a waist circumference <102 cm (40 inches) in men and <88 cm (35 inches) in women (less for certain racial groups). ( B , I )
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The initial goal of weight loss therapy should be to reduce body weight by ~5% to 10% from baseline. With success, further weight loss can be attempted if indicated. ( C , I )
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Smoking Cessation Counseling

Smoking cessation and avoidance of exposure to environmental tobacco smoke at work and home should be encouraged for all patients with SIHD. Follow-up, referral to special programs, and pharmacotherapy are recommended, as is a stepwise strategy for smoking cessation (Ask, Advise, Assess, Assist, Arrange, Avoid). ( B , I )
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Management Of Psychological Factors

It is reasonable to consider screening SIHD patients for depression and to refer or treat when indicated. ( B , IIa )
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Treatment of depression has not been shown to improve cardiovascular disease outcomes but might be reasonable for its other clinical benefits. ( C , IIb )
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Alcohol Consumption

In patients with SIHD who use alcohol, it might be reasonable for nonpregnant women to have 1 drink (4 ounces of wine, 12 ounces of beer, or 1 ounce of spirits) a day and for men to have 1 or 2 drinks a day, unless alcohol is contraindicated (such as in patients with a history of alcohol abuse or dependence or with liver disease). ( C , IIb )
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Avoiding Exposure To Air Pollution

It is reasonable for patients with SIHD to avoid exposure to increased air pollution to reduce the risk of cardiovascular events. ( C , IIa )
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Antiplatelet Therapy

Treatment with aspirin 75-162 mg daily should be continued indefinitely in the absence of contraindications in patients with SIHD. ( A , I )
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Treatment with clopidogrel is reasonable when aspirin is contraindicated in patients with SIHD. ( B , I )
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Treatment with aspirin 75-162 mg daily and clopidogrel 75 mg daily might be reasonable in certain high-risk patients with SIHD. ( B , IIb )
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Dipyridamole is NOT recommended as antiplatelet therapy for patients with SIHD. ( B , III (no benefit) )
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Beta-Blocker Therapy

Beta-blocker therapy should be started and continued for 3 years in all patients with normal LV function after MI or ACS. ( B , I )
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Beta-blocker therapy should be used in all patients with LV systolic dysfunction (EF ≤40%) with heart failure or prior MI, unless contraindicated. (Use should be limited to carvedilol, metoprolol succinate, or bisoprolol which have been shown to reduce risk of death.) ( A , I )
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Beta blockers may be considered as chronic therapy for all other patients with coronary or other vascular disease. ( C , IIb )
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Renin-Angiotensin-Aldosterone Blocker Therapy

ACE inhibitors should be prescribed in all patients with SIHD who also have hypertension, diabetes mellitus, LVEF ≤40%, or chronic kidney disease (CKD), unless contraindicated. ( A , I )
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Angiotensin-receptor blockers (ARBs) are recommended for patients with SIHD who have hypertension, diabetes mellitus, LV systolic dysfunction, or CKD and have indications for, but are intolerant of, ACE inhibitors. ( A , I )
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Treatment with an ACE inhibitor is reasonable in patients with both SIHD and other vascular disease. ( B , IIa )
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It is reasonable to use ARBs in other patients who are ACE inhibitor intolerant. ( C , IIa )
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Chelation Therapy (Updated in 2014)

The usefulness of chelation therapy is uncertain for reducing cardiovascular events in patients with SIHD. ( B , IIb )
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Influenza Vaccination

An annual influenza vaccine is recommended for patients with SIHD. ( B , I )
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Medical Therapy for Relief of Symptoms

Use Of Antiischemic Medications

Beta blockers should be prescribed as initial therapy for relief of symptoms in patients with SIHD. ( B , I )
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Calcium channel blockers or long-acting nitrates should be prescribed for relief of symptoms when beta blockers are contraindicated or cause unacceptable side effects in patients with SIHD. ( B , I )
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Calcium channel blockers or long-acting nitrates, in combination with beta blockers, should be prescribed for relief of symptoms when initial treatment with beta blockers is unsuccessful in patients with SIHD. ( B , I )
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Sublingual nitroglycerin or nitroglycerin spray is recommended for immediate relief of angina in patients with SIHD. ( B , I )
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Treatment with a long-acting nondihydropyridine calcium channel blocker (verapamil or diltiazem) instead of a beta blocker as initial therapy for relief of symptoms is reasonable in patients with SIHD. ( B , IIa )
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Ranolazine can be useful when prescribed as a substitute for beta blockers for relief of symptoms in patients with SIHD if initial treatment with beta blockers leads to unacceptable side effects or is ineffective or if initial treatment with beta blockers is contraindicated. ( B , IIa )
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Ranolazine in combination with beta blockers can be useful when prescribed for relief of symptoms when initial treatment with beta blockers is not successful in patients with SIHD. ( A , IIa )
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Additional Therapy to Reduce Risk of MI And Death

NOT recommended with the intent of reducing cardiovascular risk or improving clinical outcomes:
Estrogen therapy ( A , III (no benefit) )
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Vitamin C, vitamin E, and beta-carotene supplementation. ( A , III (no benefit) )
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Treatment of elevated homocysteine with folate or vitamins B6 and B12. ( A , III (no benefit) )
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Chelation therapy. ( C , III (no benefit) )
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Garlic, coenzyme Q10, selenium, and chromium. ( C , III (no benefit) )
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Revascularization

A Heart Team approach to revascularization is recommended in patients with unprotected left main or complex CAD. ( C , I )
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Calculation of the STS (http://riskcalc.sts.org/STSWebRiskCalc273/de.aspx) and SYNTAX (http://www.syntaxscore.com/calculator/start.htm) scores is reasonable in patients with unprotected left main and complex CAD. (B)
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Table 12. Revascularization to Improve Survival Compared with Medical Therapy

Anatomic Setting
Unprotected Left Main (UPLM) or complex CAD
CABG and PCI
Heart Team approach recommended ( C , I )
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Calculation of STS and SYNTAX scores ( B , IIa )
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UPLM
CABG
- ( B , I )
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PCI
For SIHD when both of the following are present:

Anatomic conditions associated with a low risk of PCI procedural complications and a high likelihood of good long-term outcome (eg, a low SYNTAX score of ≤22, ostial or trunk left main CAD)
Clinical characteristics that predict a significantly increased risk of adverse surgical outcomes (eg, STS-predicted risk of operative mortality ≥5%) ( B , IIa )
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For UA/NSTEMI if not a CABG candidate ( B , IIa )
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For STEMI when distal coronary flow is TIMI flow grade <3 and PCI can be performed more rapidly and safely than CABG ( C , IIa )
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For SIHD when both of the following are present:

Anatomic conditions associated with a low to intermediate risk of PCI procedural complications and an intermediate to high likelihood of good long-term outcome (eg, low-intermediate SYNTAX score of <33, bifurcation left main CAD)
Clinical characteristics that predict an increased risk of adverse surgical outcomes (eg, moderate-severe COPD, disability from prior stroke, or prior cardiac surgery; STS-predicted operative mortality >2%) ( B , IIb )
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For SIHD in patients (versus performing CABG) with unfavorable anatomy for PCI and who are good candidates for CABG ( B , III (harm) )
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3-vessel disease with or without proximal LAD artery disease*
CABG
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It is reasonable to choose CABG over PCI in patients with complex 3-vessel CAD (eg, SYNTAX score >22) who are good candidates for CABG ( B , IIa )
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PCI
Of uncertain benefit ( B , IIb )
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2-vessel disease with proximal LAD artery disease*
CABG
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PCI
Of uncertain benefit ( B , IIb )
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2-vessel disease without proximal LAD artery disease
CABG
With extensive ischemia ( B , IIa )
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Of uncertain benefit without extensive ischemia ( C , IIb )
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PCI
Of uncertain benefit ( B , IIb )
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1-vessel proximal LAD artery disease
CABG
With LIMA for long-term benefit ( B , IIa )
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PCI
Of uncertain benefit ( B , IIb )
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1-vessel disease without proximal LAD artery involvement
CABG
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PCI
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LV dysfunction
CABG
EF 35%-50% ( B , IIa )
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EF <35% without significant left main CAD ( B , IIb )
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PCI
Insufficient data
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Survivors of sudden cardiac death with presumed ischemia-mediated VT
CABG
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PCI
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No anatomic or physiological criteria for revascularization
CABG
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PCI
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* CABG (particularly with LIMA graft to LAD) is generally recommended in preference to PCI to improve survival in patients with diabetes mellitus and 3-vessel CAD or complex 2-vessel CAD involving the proximal LAD. ( B , I )
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Table 13. Revascularization to Improve Symptoms With Significant Anatomic (≥50% Left Main or ≥70% Non–Left Main CAD) or Physiological (Fractional Flow Reserve [FFR] ≤0.80) Coronary Artery Stenoses

1—CABG (A)
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1—PCI ( A , )
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IIa—CABG
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IIa—PCI (C)
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IIa—PCI (C)
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IIb—CABG (, )
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Complex 3-vessel CAD (eg, SYNTAX score >22) with or without involvement of the proximal LAD artery and a good candidate for CABG
IIa—CABG preferred over PCI (B)
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Viable ischemic myocardium that is perfused by coronary arteries that are not amenable to grafting
IIb—TMR as an adjunct to CABG (B)
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No anatomic or physiological criteria for revascularization
III: Harm—CABG (C)
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III: Harm—PCI
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Revascularization to Improve Survival

Left Main CAD Revascularization

Coronary artery bypass graft (CABG) to improve survival is recommended for patients with significant (≥50% diameter stenosis) left main coronary artery stenosis. ( B , I )
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Percutaneous coronary intervention (PCI) to improve survival is reasonable as an alternative to CABG in selected stable patients with significant (≥50% diameter stenosis) unprotected left main CAD with: ( B , IIa )
  • Anatomic conditions associated with a low risk of PCI procedural complications and a high likelihood of good long-term outcome (eg, a low SYNTAX score [≤22], ostial or trunk left main CAD); and
  • Clinical characteristics that predict a significantly increased risk of adverse surgical outcomes (eg, STS-predicted risk of operative mortality ≥5%).
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PCI to improve survival is reasonable in patients with unstable angina/non–ST-elevation myocardial infarction (UA/NSTEMI) when an unprotected left main coronary artery is the culprit lesion and the patient is not a candidate for CABG. ( B , IIa )
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PCI to improve survival is reasonable in patients with acute ST-elevation myocardial infarction (STEMI) when an unprotected left main coronary artery is the culprit lesion, distal coronary flow is less than TIMI (Thrombolysis In Myocardial Infarction) grade 3, and PCI can be performed more rapidly and safely than CABG. ( C , IIa )
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PCI to improve survival may be reasonable as an alternative to CABG in selected stable patients with significant (≥50% diameter stenosis) unprotected left main CAD with: ( B , IIb )
  • anatomic conditions associated with a low to intermediate risk of PCI procedural complications and an intermediate to high likelihood of good long-term outcome (eg, low-intermediate SYNTAX score of <33, bifurcation left main CAD); and
  • clinical characteristics that predict an increased risk of adverse surgical outcomes (eg, moderate-severe chronic obstructive pulmonary disease, disability from previous stroke, or previous cardiac surgery; STS-predicted risk of operative mortality >2%).
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PCI to improve survival should NOT be performed in stable patients with significant (≥50% diameter stenosis) unprotected left main CAD who have unfavorable anatomy for PCI and who are good candidates for CABG. ( B , III (harm) )
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Non–Left Main CAD Revascularization

CABG to improve survival is beneficial in patients with significant (≥70% diameter) stenoses in 3 major coronary arteries (with or without involvement of the proximal left anterior descending [LAD] artery) or in the proximal LAD artery plus 1 other major coronary artery.
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(Updated in 2014) CABG is generally recommended in preference to PCI to improve survival in patients with diabetes mellitus and multivessel CAD for which revascularization is likely to improve survival (3-vessel CAD or complex 2-vessel CAD involving the proximal LAD), particularly if a LIMA graft can be anastomosed to the LAD artery, provided the patient is a good candidate for surgery. ( B , I )
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CABG ( B , I )
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PCI to improve survival is beneficial in survivors of sudden cardiac death with presumed ischemia-mediated ventricular tachycardia caused by significant (≥70% diameter) stenosis in a major coronary artery. ( C , I )
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(New in 2014) A Heart Team approach to revascularization is recommended in patients with diabetes mellitus and complex multivessel CAD. ( C , I )
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CABG to improve survival is reasonable in patients with significant (≥70% diameter) stenoses in 2 major coronary arteries with severe or extensive myocardial ischemia (eg, high-risk criteria on stress testing, abnormal intracoronary hemodynamic evaluation, or >20% perfusion defect by myocardial perfusion stress imaging) or target vessels supplying a large area of viable myocardium. ( B , IIa )
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CABG to improve survival is reasonable in patients with mild– moderate LV systolic dysfunction (EF 35%-50%) and significant (≥70% diameter stenosis) multivessel CAD or proximal LAD coronary artery stenosis, when viable myocardium is present in the region of intended revascularization. ( B , IIa )
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CABG with a left internal mammary artery (LIMA) graft to improve survival is reasonable in patients with significant (≥70% diameter) stenosis in the proximal LAD artery and evidence of extensive ischemia. ( B , IIa )
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It is reasonable to choose CABG over PCI to improve survival in patients with complex 3-vessel CAD (eg, SYNTAX score >22), with or without involvement of the proximal LAD artery who are good candidates for CABG. ( B , IIa )
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The usefulness of CABG to improve survival is uncertain in patients with significant (70%) diameter stenoses in 2 major coronary arteries not involving the proximal LAD artery and without extensive ischemia. ( C , IIb )
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The usefulness of PCI to improve survival is uncertain in patients with 2- or 3-vessel CAD (with or without involvement of the proximal LAD artery) or 1-vessel proximal LAD disease. ( B , IIb )
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CABG might be considered with the primary or sole intent of improving survival in patients with SIHD with severe LV systolic dysfunction (EF<35%) whether or not viable myocardium is present. ( B , IIb )
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The usefulness of CABG or PCI to improve survival is uncertain in patients with previous CABG and extensive anterior wall ischemia on noninvasive testing. ( B , IIb )
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CABG or PCI should NOT be performed with the primary or sole intent to improve survival in patients with SIHD with one or more coronary stenoses that are not anatomically or functionally significant (eg, <70% diameter non-left main coronary artery stenosis, fractional flow reserve (FFR) >0.80, no or only mild ischemia on noninvasive testing), involve only the left circumflex or right coronary artery, or subtend only a small area of viable myocardium. ( B , III (harm) )
701

Revascularization to Improve Symptoms

CABG or PCI to improve symptoms is beneficial in patients with one or more significant (≥70% diameter) coronary artery stenoses amenable to revascularization and unacceptable angina despite guideline-directed medical therapy (GDMT). ( A , I )
701
CABG or PCI to improve symptoms is reasonable in patients with one or more significant (≥70% diameter) coronary artery stenoses and unacceptable angina for whom GDMT cannot be implemented because of medication contraindications, adverse effects, or patient preferences. ( C , IIa )
701
PCI to improve symptoms is reasonable in patients with previous CABG, one or more significant (≥70% diameter) coronary artery stenoses associated with ischemia, and unacceptable angina despite GDMT. ( C , IIa )
701
It is reasonable to choose CABG over PCI to improve symptoms in patients with complex 3-vessel CAD (eg, SYNTAX score >22), with or without involvement of the proximal LAD artery, who are good candidates for CABG. ( B , IIa )
701
CABG to improve symptoms might be reasonable for patients with previous CABG, one or more significant (≥70% diameter) coronary artery stenoses not amenable to PCI, and unacceptable angina despite GDMT. ( C , IIb )
701
TMR performed as an adjunct to CABG to improve symptoms may be reasonable in patients with viable ischemic myocardium that is perfused by arteries that are not amenable to grafting. ( B , IIb )
701
CABG or PCI to improve symptoms should NOT be performed in patients who do not meet anatomic (≥50% diameter left main or ≥70% non-left main stenosis diameter) or physiological (eg, abnormal FFR) criteria for revascularization. ( C , III (harm) )
701

Dual Antiplatelet Therapy (DAPT) Compliance and Stent Thrombosis

PCI with coronary stenting (bare-metal stent [BMS] or drug-eluting stent [DES]) should NOT be performed if the patient is not likely to be able to tolerate and comply with DAPT for the appropriate duration of treatment based on the type of stent implanted. ( B , III (harm) )
701

Hybrid Coronary Revascularization

Hybrid coronary revascularization (defined as the planned combination of LIMA-to-LAD artery grafting and PCI of ≥1 non-LAD coronary arteries) is reasonable in patients with one or more of the following. ( B , IIa )
  • Limitations to traditional CABG, such as heavily calcified proximal aorta or poor target vessels for CABG (but amenable to PCI)
  • Lack of suitable graft conduits
  • Unfavorable LAD artery for PCI (ie, excessive vessel tortuosity or chronic total occlusion).
701
Hybrid coronary revascularization may be reasonable as an alternative to multivessel PCI or CABG in an attempt to improve the overall risk-benefit ratio of the procedures. ( C , IIb )
701

Follow-up

Clinical Evaluation, Echocardiography During Routine, Periodic Follow-Up

Patients with SIHD should receive periodic follow-up, at least annually, that includes all of the following: ( C , I )
  • Assessment of symptoms and clinical function
  • Surveillance for complications of SIHD, including heart failure and arrhythmias
  • Monitoring of cardiac risk factors
  • Assessment of the adequacy of and adherence to recommended lifestyle changes and medical therapy
701
Assessment of LVEF and segmental wall motion by echocardiography or radionuclide imaging is recommended in patients with new or worsening heart failure or evidence of intervening MI by history or ECG. ( C , I )
701
Periodic screening for important comorbidities that are prevalent in patients with SIHD, including diabetes mellitus, depression, and CKD, might be reasonable. ( C , IIb )
701
A resting 12-lead ECG at 1-year or longer intervals between studies in patients with stable symptoms might be reasonable. ( C , IIb )
701
Measurement of LV function with a technology such as echocardiography or radionuclide imaging is NOT recommended for routine periodic reassessment of patients who have not had a change in clinical status or who are at low risk of adverse cardiovascular events. ( C , III (no benefit) )
701

Noninvasive Testing in Known SIHD

Follow-Up Noninvasive Testing in Patients With Known SIHD: New, Recurrent, or Worsening Symptoms Not Consistent With Unstable Angina
Patients Able to Exercise
Standard exercise ECG testing is recommended in patients with known SIHD who have new or worsening symptoms not consistent with UA and who have: ( B , I )
  • at least moderate physical functioning and no disabling comorbidity and
  • an interpretable ECG
701
Exercise with nuclear MPI or echocardiography is recommended in patients with known SIHD who have new or worsening symptoms not consistent with UA and who have: ( B , I )
    • at least moderate physical functioning or no disabling comorbidity but
    • an uninterpretable ECG
701
Exercise with nuclear MPI or echocardiography is reasonable in patients with known SIHD who have new or worsening symptoms not consistent with UA and who have:
  • at least moderate physical functioning and no disabling comorbidity,
  • previously required imaging with exercise stress, or
  • known multivessel disease or high risk for multivessel disease
( B , IIa )
701
Pharmacological stress imaging with nuclear MPI, echocardiography, or CMR is NOT recommended in patients with known SIHD who have new or worsening symptoms not consistent with UA and who are capable of at least moderate physical functioning or have no disabling comorbidity. ( C , III (no benefit) )
701
Patients Unable To Exercise
Pharmacological stress imaging with nuclear MPI or echocardiography is recommended in patients with known SIHD who have new or worsening symptoms not consistent with UA and who are incapable of at least moderate physical functioning or have disabling comorbidity. ( B , I )
701
Pharmacological stress imaging with CMR is reasonable in patients with known SIHD who have new or worsening symptoms not consistent with UA and who are incapable of at least moderate physical functioning or have disabling comorbidity. ( B , IIa )
701
Standard exercise ECG testing should NOT be performed in patients with known SIHD who have new or worsening symptoms not consistent with UA and who:
  • are incapable of at least moderate physical functioning or
  • have disabling comorbidity or
  • have an uninterpretable ECG
( C , III (no benefit) )
701
Irrespective Of Ability To Exercise
CCTA for assessment of patency of CABG or of coronary stents ≥3 mm in diameter might be reasonable in patients with known SIHD who have new or worsening symptoms not consistent with UA, irrespective of ability to exercise. ( B , IIb )
701
CCTA might be reasonable in patients with known SIHD who have new or worsening symptoms not consistent with UA, irrespective of ability to exercise, in the absence of known moderate or severe calcification or if the CCTA is intended to assess coronary stents <3 mm in diameter. ( B , IIb )
701
CCTA should NOT be performed for assessment of native coronary arteries with known moderate or severe calcification or with coronary stents <3 mm in diameter in patients with known SIHD who have new or worsening symptoms not consistent with UA, irrespective of ability to exercise. ( B , III (no benefit) )
701

Table 14. Follow-Up Noninvasive Testing in Patients with Known SIHD: New, Recurrent, or Worsening Symptoms Not Consistent With UA

Patients Able to Exercise
Standard exercise ECG testing is recommended in patients with known SIHD who have new or worsening symptoms not consistent with UA and who have a) at least moderate physical functioning and no disabling comorbidity and b) an interpretable ECG. ( B , I )
701
Exercise with nuclear MPI or echocardiography is recommended in patients with known SIHD who have new or worsening symptoms not consistent with UA and who have a) at least moderate physical functioning or no disabling comorbidity but b) an uninterpretable ECG. ( B , I )
701
Exercise with nuclear MPI or echocardiography is reasonable in patients with known SIHD who have new or worsening symptoms not consistent with UA and who have a) at least moderate physical functioning and no disabling comorbidity, b) previously required imaging with exercise stress, or c) known multivessel disease or high risk for multivessel disease. ( B , IIa )
701
Pharmacological stress imaging with nuclear MPI, echocardiography, or CMR is not recommended in patients with known SIHD who have new or worsening symptoms not consistent with UA and who are capable of at least moderate physical functioning or have no disabling comorbidity. ( C , III (no benefit) )
701
Patients Unable to Exercise
Pharmacological stress imaging with nuclear MPI or echocardiography is recommended in patients with known SIHD who have new or worsening symptoms not consistent with UA and who are incapable of at least moderate physical functioning or have disabling comorbidity. ( B , I )
701
Pharmacological stress imaging with CMR is reasonable in patients with known SIHD who have new or worsening symptoms not consistent with UA and who are incapable of at least moderate physical functioning or have disabling comorbidity. ( B , IIa )
701
Standard exercise ECG testing should NOT be performed in patients with known SIHD who have new or worsening symptoms not consistent with UA and who a) are incapable of at least moderate physical functioning or have disabling comorbidity or b) have an uninterpretable ECG. ( C , III (no benefit) )
701
Irrespective of Ability to Exercise
CCTA for assessment of patency of CABG or of coronary stents 3 mm or larger in diameter might be reasonable in patients with known SIHD who have new or worsening symptoms not consistent with UA, irrespective of ability to exercise. ( B , IIb )
701
CCTA might be reasonable in patients with known SIHD who have new or worsening symptoms not consistent with UA, irrespective of ability to exercise, in the absence of known moderate or severe calcification or if the CCTA is intended to assess coronary stents less than 3 mm in diameter. ( B , IIb )
701
CCTA should NOT be performed for assessment of native coronary arteries with known moderate or severe calcification or with coronary stents less than 3 mm in diameter in patients with known SIHD who have new or worsening symptoms not consistent with UA, irrespective of ability to exercise. ( B , III (no benefit) )
701

Table 15. Noninvasive Testing in Known SIHD: Asymptomatic (or Stable Symptoms)

CCTA should NOT be performed for assessment of native coronary arteries with known moderate or severe calcification or with coronary stents less than 3 mm in diameter in patients with known SIHD who have new or worsening symptoms not consistent with UA, irrespective of ability to exercise. ( C , IIa )
701
Standard exercise ECG testing performed at 1-year or longer intervals might be considered for follow-up assessment in patients with SIHD who have had prior evidence of silent ischemia or are at high risk for a recurrent cardiac event and are able to exercise to an adequate workload and have an interpretable ECG. ( C , IIb )
701
In patients who have no new or worsening symptoms or no prior evidence of silent ischemia and are not at high risk for a recurrent cardiac event, the usefulness of annual surveillance exercise ECG testing is not well established. ( C , IIb )
701
In patients who have no new or worsening symptoms or no prior evidence of silent ischemia and are not at high risk for a recurrent cardiac event, the usefulness of annual surveillance exercise ECG testing is not well established. ( C , III (no benefit) )
701

Noninvasive Testing in Known SIHD— Asymptomatic (or Stable Symptoms)

Nuclear MPI, echocardiography, or CMR with either exercise or pharmacological stress can be useful for follow-up assessment at ≥2-year intervals in patients with SIHD with prior evidence of silent ischemia or who are at high risk for a recurrent cardiac event and:
  • are unable to exercise to an adequate workload,
  • have an uninterpretable ECG, or
  • have a history of incomplete coronary revascularization
( A , IIa )
701
Standard exercise ECG testing performed at ≥1-year intervals might be considered for follow-up assessment in patients with SIHD who have had prior evidence of silent ischemia or are at high risk for a recurrent cardiac event and are able to exercise to an adequate workload and have an interpretable ECG. ( C , IIb )
701
In patients who have no new or worsening symptoms or no prior evidence of silent ischemia and are not at high risk for a recurrent cardiac event, the usefulness of annual surveillance exercise ECG testing is not well established. ( C , IIb )
701
Nuclear MPI, echocardiography, or CMR, with either exercise or pharmacological stress or CCTA, is NOT recommended for follow-up assessment in patients with SIHD, if performed more frequently than at:
  • 5-year intervals after CABG or
  • 2-year intervals after PCI
( C , III (no benefit) )
701

Recommendation Grading

Disclaimer

Overview

Title

Diagnosis and Management of Patients With Stable Ischemic Heart Disease

Authoring Organizations

Publication Month/Year

July 28, 2014

Last Updated Month/Year

November 17, 2022

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Operating and recovery room

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Diagnosis, Management, Treatment

Diseases/Conditions (MeSH)

D006331 - Heart Diseases, D017202 - Myocardial Ischemia

Keywords

revascularization, stable coronary artery disease, coronary artery disease, stable ischemic heart disease, SIHD, Ischemic Heart Disease, myocardial ischemia, CAD