Stable Ischemic Heart Disease

Publication Date: July 28, 2014

Key Points

Key Points

  • It is estimated that 1 in 3 adults in the United States (about 81 million) has some form of cardiovascular disease, including >17 million with ischemic heart disease and nearly 10 million with angina pectoris.
  • Among persons 60-79 years of age, approximately 25% of men and 16% of women have ischemic heart disease, and these figures rise to 37% and 23% among men and women >80 years of age, respectively.
  • Ischemic Heart Disease (IHD) is the number one cause of death in both men and women. It was responsible for nearly 380,000 deaths in the United States during 2010, with an age-adjusted mortality rate of 113 per 100,000 population.
  • The total estimated cost for heart disease in the US in 2010 was $316 billion.
  • Angina pectoris is the initial manifestation of IHD in approximately 50% of patients.

Choices about diagnostic and therapeutic options should be made through a process of shared decision making involving the patient and provider, with the provider explaining information about risks, benefits, and costs to the patient. ( C , I )
701

Diagnosis

...agnosis...

...le 1. Clinical Classification of Chest Pai...


...ectrum of Ischemic Heart Disease (IHD)...


...2. Three Principal Presentations of Unstable...


.... Alternative Diagnoses to Angina for Patients wit...


...Pretest Likelihood of Coronary Artery...


...e 5. Comparing Pretest Likelihood of CAD in Low-...


...Medical Conditions Provoking or Exacerbating Is...


...igure 2. Diagnosis of Patients with Suspe...


...sk Assessment of Patients with Stable Isch...


...gure 4. Guideline-Directed Medical Therapy fo...


...ascularization to Improve Survival of Patients w...


...ion in the Initial Diagnosis of SIHD in Patie...

Patients with chest pain should re...

...esent with acute angina should be categoriz...

A resting electrocardiogram (ECG) is recommended...


...Revascularization to Improve Symptoms of Patie...


...sting and Advanced Imaging for Initi...

...e to Exercise...

...cise ECG testing is recommended for pati...

...ise stress with nuclear myocardial perfusion i...

...or patients with a low pretest pro...

...rcise stress with nuclear MPI or ec...

...armacological stress with cardiac magnetic resona...

...oronary/cardiac computed tomography a...

...or patients with a low pretest probabi...

...ical stress with nuclear MPI, echocardiograp...

...xercise stress with nuclear MPI is NO...

...le to Exercise...

...ogical stress with nuclear MPI or echocardiograph...

...al stress echocardiography is reasonable for p...

...onable for patients with a low to intermediate...

...ogical stress CMR is reasonable for patient...

...ndard exercise ECG testing is NOT recommen...

...ble for patients with an intermediate pretest pr...

...atients with a low to intermediate p...

...s Testing and Advance Imaging for Initial Dia...


...to Assess Cardiac Structure and Function...

...f resting left ventricular (LV) sys...

...ssessment of cardiac structure and fun...

...f LV function with radionuclide ima...

...hocardiography, radionuclide imaging, CMR, a...

...ine reassessmen...


...ting and Advanced Imaging in Patients Wi...

...sk Assessment in Patients Able t...

...rcise ECG testing is recommended for risk assess...

...of either nuclear MPI or echocardiography...

...n of either nuclear MPI or echocardiography t...

...with pharmacological stress is reasonable for r...

...A may be reasonable for risk assessment in...

...l stress imaging (nuclear MPI, ech...

...isk Assessment In Patients Unable To Exercise

...stress with either nuclear MPI or ech...

...l stress CMR is reasonable for risk assess...

...A can be useful as a first-line te...

...essment Regardless Of Patients’ Ability To...

...al stress with either nuclear MPI or echocardiog...

...xercise or pharmacological stress with i...

...an be useful for risk assessment in...

...A might be considered for risk assessment...

...to perform either a) more than 1 stress ima...

...g Stress Testing and Advanced Imaging...


...ography as an Initial Testing Strategy to A...

...ith SIHD who have survived sudden...

...tients with SIHD who develop symptoms and s...


...oronary Angiography to Assess Risk After Initia...

...y arteriography is recommended for patients wi...

...ronary angiography is reasonable to furthe...

...ronary angiography is reasonable to further...

...aphy for risk assessment is reasonable for patien...

...ronary angiography for risk assessment is NOT re...

...oronary angiography is NOT recommen...

Coronary angiography is NOT recommended to...

...giography is NOT recommended to assess risk in...


...ting for Diagnosis of Coronary Artery D...

...raphy is useful in patients with pres...

...ary angiography is reasonable to defi...

...nary angiography is reasonable in patients...

...ngiography might be considered in pa...


...Prognostic IndexHaving trouble viewing table?...


...Noninvasive Risk Stratification High risk...


Treatment

Treatment

...nt Education...

...nts with SIHD should have an individuali...

...on the importance of medication adherence...

An explanation of medication management and card...

...ehensive review of all therapeutic...

...tion of appropriate levels of exerc...

...self-monitoring skills ( C , I )701...

...how to recognize worsening cardiovasc...

...tients with SIHD should be educated about th...

...trol – maintenance of a body mass index (BMI2 )...

...e to educate patients with SIHD abo...

...ence to a diet that is low in saturated fat, chol...

...ymptoms of stress and depression to minimize stre...

...ve behavioral approaches for the management of...

...aluation and treatment of major depre...


...Factor Modification...

Lipid Manageme...

...style modifications, including daily...

...ietary therapy for all patients should include re...

...n to therapeutic lifestyle changes, a modera...

...do not tolerate statins, low-density lipopr...

...e acid sequestrant is relatively contr...

...Pressure Management...

...should be counseled about the nee...

...with SIHD with BP ≥140/90 mm Hg, antihyperte...

The specific medications used for tre...

...1. Indications for Individual Drug Classes in t...

...betes Management...

...ndividual patients, such as those with a sho...

A goal HbA1c between 7% and 9% is reasonable...

...on of pharmacotherapy interventions to achieve tar...

...rosiglitazone should NOT be initiated in patie...

...ysical Activi...

...all patients, the clinician should encourage...

...ts, risk assessment with a physical...

...edically supervised programs (cardi...

...easonable for the clinician to recommend compl...

...ght Management...

...and/or waist circumference should be a...

The initial goal of weight loss therapy...

...ng Cessation Counseling

...moking cessation and avoidance of exposure to envi...

...t Of Psychological Factors...

...easonable to consider screening SIHD patie...

Treatment of depression has not been shown to i...

...cohol Consumpti...

...patients with SIHD who use alcohol...

Avoiding Exposure To Air Pollu...

...is reasonable for patients with SIHD to avoi...

...atelet Therapy...

...h aspirin 75-162 mg daily should b...

...with clopidogrel is reasonable when...

...tment with aspirin 75-162 mg daily and clopid...

...le is NOT recommended as antiplatel...

...ta-Blocker Therapy...

...ker therapy should be started and contin...

...therapy should be used in all patients w...

...y be considered as chronic therapy...

...nsin-Aldosterone Blocker Therapy...

...tors should be prescribed in all p...

...tensin-receptor blockers (ARBs) ar...

...an ACE inhibitor is reasonable in patien...

...t is reasonable to use ARBs in other pati...

...lation Therapy (Updated in 2014...

...ss of chelation therapy is uncertain for reducin...

...nfluenza Vaccinati...

An annual influenza vaccine is recommended for p...


...cal Therapy for Relief of Sympto...

...se Of Antiischemic Medication...

...eta blockers should be prescribed as initial...

...blockers or long-acting nitrates sh...

...ium channel blockers or long-acting nitrates,...

...gual nitroglycerin or nitroglycerin spr...

...a long-acting nondihydropyridine calcium ch...

...zine can be useful when prescribed as a su...

Ranolazine in combination with beta blockers can...

...e Therapies for Relief of Symptoms in Patients...

...hanced external counterpulsation (EEC...

...rd stimulation may be considered for relief o...

...revascularization (TMR) may be considere...

Acupuncture should NOT be used for the purpose of...

...erapy to Reduce Risk of MI And Death...

...ended with the intent of reducing cardiovascula...

Estrogen therapy ( A , III (no benefit) )7...

...amin C, vitamin E, and beta-carotene suppl...

...ment of elevated homocysteine with folat...

...rapy. ( C , III (no benefit) )701

Garlic, coenzyme Q10, selenium, and chromium. (...


...ascularization...

...roach to revascularization is recommended in patie...

...lculation of the STS (http://riskcalc...

...12. Revascularization to Improve Survival...

...mic Setting...

...Left Main (UPLM) or complex C...

... and PCI...

...rt Team approach recommended ( C , I...

Calculation of STS and SYNTAX scores (...

...PLM

CAB...

...B , I )70...

...CI...

...SIHD when both of the following are present:...

...or UA/NSTEMI if not a CABG candidat...

...when distal coronary flow is TIMI flo...

...D when both of the following are present: An...

...patients (versus performing CABG) with unfavorable...

...e with or without proximal LAD arte...

...ABG

70...

...is reasonable to choose CABG over PCI in patients...

PCI

...uncertain benefit ( B , IIb )701...

...ease with proximal LAD artery disease*...

...ABG

...01

PCI

...ncertain benefit ( B , IIb )701...

...-vessel disease without proximal LAD arte...

CAB...

...sive ischemia ( B , IIa )701...

...efit without extensive ischemia ( C ,...

...CI

...f uncertain benefit ( B ,...

...proximal LAD artery disease...

CABG

...for long-term benefit ( B , IIa )701...

...CI

...f uncertain benefit ( B , IIb )7...

...el disease without proximal LAD artery involveme...

CAB...

...01...

...CI

...01

LV dysfuncti...

...ABG

...5%-50% ( B , IIa )...

...F...

...CI...

...ufficient data7...

...f sudden cardiac death with presumed ischem...

CAB...

...01...

...CI

70...

...omic or physiological criteria for revasculariz...

...ABG

...01

...CI...

701

...BG (particularly with LIMA graft to LAD...

...Revascularization to Improve Symptoms Wit...

...CABG (A)701...

...PCI ( A , )701...

...Ia—CABG70...

...a—PCI (C)701...

...Ia—PCI (C)...

...Ib—CABG (, )701...

...3-vessel CAD (eg, SYNTAX score >22...

...preferred over PCI (B)7...

...ischemic myocardium that is perfuse...

...Ib—TMR as an adjunct to C...

...physiological criteria for revascularization...

...I: Harm—CABG (C)701...

...I: Harm—PC...


...cularization to Improve Survival...

...Main CAD Revascularizati...

...nary artery bypass graft (CABG) to...

Percutaneous coronary intervention (PCI) t...

...prove survival is reasonable in patie...

...rove survival is reasonable in patients with acute...

...mprove survival may be reasonable as an alterna...

...o improve survival should NOT be perf...

...eft Main CAD Revascularization...

...prove survival is beneficial in pati...

...2014) CABG is generally recommended i...

...( B , I )701...

...urvival is beneficial in survivors of...

...Heart Team approach to revascularizat...

...mprove survival is reasonable in patients w...

...to improve survival is reasonable in pa...

...ith a left internal mammary artery (LIMA...

It is reasonable to choose CABG over...

...ness of CABG to improve survival is unc...

...of PCI to improve survival is uncerta...

...considered with the primary or so...

...ulness of CABG or PCI to improve survival...

...or PCI should NOT be performed with th...


...ularization to Improve Sym...

CABG or PCI to improve symptoms is benefi...

...I to improve symptoms is reasonable in patients...

...ymptoms is reasonable in patients...

...easonable to choose CABG over PCI to improve...

...improve symptoms might be reasonable f...

...an adjunct to CABG to improve symptoms ma...

...G or PCI to improve symptoms should NOT be perform...


...latelet Therapy (DAPT) Compliance and Stent Thromb...

...ry stenting (bare-metal stent [BMS] or drug...


...onary Revascularization...

...oronary revascularization (defined as...

...rid coronary revascularization may be re...


Follow-up

...llow-up...

...tion, Echocardiography During Routine, Periodic...

...ients with SIHD should receive periodi...

...f LVEF and segmental wall motion by echocar...

...creening for important comorbidities tha...

...ead ECG at 1-year or longer intervals between s...

...ement of LV function with a technology such as e...

...oninvasive Testing in Known SIHD...

...low-Up Noninvasive Testing in Patients With Kn...

...atients Able to Exercis...

Standard exercise ECG testing is reco...

...nuclear MPI or echocardiography is recomm...

...with nuclear MPI or echocardiography is reason...

Pharmacological stress imaging with nucl...

...s Unable To Exerci...

...gical stress imaging with nuclear MPI or e...

...ogical stress imaging with CMR is reaso...

...tandard exercise ECG testing should NOT b...

...rrespective Of Ability To Exercise...

...r assessment of patency of CABG or of co...

...be reasonable in patients with known SIHD...

...be performed for assessment of native coronary...

...ow-Up Noninvasive Testing in Patients with Known...

...tients Able to Ex...

...dard exercise ECG testing is recommended in patie...

...h nuclear MPI or echocardiography is recommen...

...th nuclear MPI or echocardiography is reasonable...

...ological stress imaging with nuclear M...

...ients Unable to Exercise...

...harmacological stress imaging with nu...

...ical stress imaging with CMR is reasonable i...

...ndard exercise ECG testing should NOT be perfo...

...espective of Ability to Exercise...

CCTA for assessment of patency of CABG...

...e reasonable in patients with known SIHD who...

...NOT be performed for assessment of nati...

...e 15. Noninvasive Testing in Known SIHD: Asympto...

...hould NOT be performed for assessment of native co...

...exercise ECG testing performed at 1-year o...

...ts who have no new or worsening symptom...

...tients who have no new or worsening...

...esting in Known SIHD— Asymptomatic (or Stable Sy...

..., echocardiography, or CMR with either exercise...

...ndard exercise ECG testing performed at...

...ients who have no new or worsening sympto...

...chocardiography, or CMR, with either...