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

Diagnos...

...Clinical Classification of Chest Pain...


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


...2. Three Principal Presentations o...


...ative Diagnoses to Angina for Patients...


...Likelihood of Coronary Artery Disease...


.... Comparing Pretest Likelihood of CAD...


...6. Medical Conditions Provoking or Exacerbating...


...igure 2. Diagnosis of Patients with Suspected Isc...


...ssessment of Patients with Stable Ischemic He...


.... Guideline-Directed Medical Therapy...


...scularization to Improve Survival of Patients wit...


...aluation in the Initial Diagnosis of SIHD in...

...s with chest pain should receive a thorough histor...

...who present with acute angina should be categori...

...lectrocardiogram (ECG) is recommended in patient...


...ure 6. Revascularization to Improve Symptoms of Pa...


...s Testing and Advanced Imaging for Initial Diagn...

...e to Exercise...

...rd exercise ECG testing is recommended for patien...

...ss with nuclear myocardial perfusion imag...

...tients with a low pretest probability o...

...with nuclear MPI or echocardiography is reasonabl...

...harmacological stress with cardiac magneti...

...ry/cardiac computed tomography angiography...

For patients with a low pretest probabilit...

...logical stress with nuclear MPI, echocardi...

...ise stress with nuclear MPI is NOT recommended as...

...able to Exerc...

...ical stress with nuclear MPI or echocardiograph...

...ological stress echocardiography is reasonable...

...asonable for patients with a low to intermediate p...

...ogical stress CMR is reasonable for patients with...

...cise ECG testing is NOT recommende...

...A is reasonable for patients with an intermedi...

For patients with a low to intermediate...

...ble 7. Stress Testing and Advance Ima...


...ng to Assess Cardiac Structure and Func...

...resting left ventricular (LV) systolic and dias...

...of cardiac structure and function with resting...

...asurement of LV function with radionuclide imag...

..., radionuclide imaging, CMR, and cardiac CT a...

...tine reassessmen...


...ss Testing and Advanced Imaging in Pa...

...sk Assessment in Patients Able to Exercise

...exercise ECG testing is recommended f...

...n of either nuclear MPI or echocardiograp...

...of either nuclear MPI or echocardiography to sta...

...acological stress is reasonable for risk asses...

CCTA may be reasonable for risk assessment in...

...acological stress imaging (nuclear...

...k Assessment In Patients Unable To Exer...

...armacological stress with either nuclear...

...stress CMR is reasonable for risk assessment in...

...e useful as a first-line test for risk...

...sment Regardless Of Patients’ Ability To...

...macological stress with either nuclea...

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

...seful for risk assessment in patient...

...CTA might be considered for risk assessment in p...

...request to perform either a) more than 1 st...

...able 8. Using Stress Testing and Advance...


...ary Angiography as an Initial Testing...

Patients with SIHD who have survive...

...IHD who develop symptoms and signs of he...


...nary Angiography to Assess Risk Aft...

...ography is recommended for patients with SIHD...

...angiography is reasonable to further assess...

...graphy is reasonable to further assess ris...

...aphy for risk assessment is reasonable for pa...

...nary angiography for risk assessment is NOT r...

...aphy is NOT recommended to further assess risk in...

...aphy is NOT recommended to assess risk in patie...

Coronary angiography is NOT recommend...


...ing for Diagnosis of Coronary Artery Disease i...

...angiography is useful in patients with pr...

...nary angiography is reasonable to define...

...y angiography is reasonable in patients with s...

...y angiography might be considered in patients...


...gnostic IndexHaving trouble viewing table? Expand...


...ninvasive Risk Stratification...


Treatment

...atment...

...atient Education

...IHD should have an individualized educ...

...ucation on the importance of medication...

...on of medication management and cardiovascular r...

...nsive review of all therapeutic options ( B ,...

...escription of appropriate levels of exercise, with...

...uction to self-monitoring skills ( C , I )70...

...mation on how to recognize worseni...

...SIHD should be educated about th...

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

...is reasonable to educate patients w...

...nce to a diet that is low in saturate...

...symptoms of stress and depression to minim...

...nsive behavioral approaches for the manage...

...ation and treatment of major depres...


...actor Modificatio...

...id Managemen...

...festyle modifications, including daily ph...

...ary therapy for all patients should...

In addition to therapeutic lifestyle change...

...s who do not tolerate statins, low...

...The use of bile acid sequestrant is relatively...

...lood Pressure Managemen...

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

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

...pecific medications used for treatment of...

...1. Indications for Individual Drug Class...

...abetes Management

...ted individual patients, such as those with a...

...1c between 7% and 9% is reasonable for...

...pharmacotherapy interventions to achiev...

...rosiglitazone should NOT be initiate...

...cal Activity

...ents, the clinician should encourage 30-60 minutes...

...or all patients, risk assessment with a phy...

...supervised programs (cardiac rehabilitation) and...

...e for the clinician to recommend compleme...

...ght Management...

...MI and/or waist circumference shou...

...ial goal of weight loss therapy shoul...

...g Cessation Counselin...

...king cessation and avoidance of exposure...

...agement Of Psychological Factors

...asonable to consider screening SIHD p...

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

Alcohol Consump...

...ith SIHD who use alcohol, it might be reasonable...

...posure To Air Pollution...

...sonable for patients with SIHD to avo...

...iplatelet Thera...

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

...ith clopidogrel is reasonable when aspirin is...

...atment with aspirin 75-162 mg daily and...

...is NOT recommended as antiplatelet ther...

Beta-Blocker T...

...locker therapy should be started and...

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

...blockers may be considered as chronic thera...

...ngiotensin-Aldosterone Blocker...

...s should be prescribed in all patients wi...

...-receptor blockers (ARBs) are recom...

...t with an ACE inhibitor is reasonable...

...reasonable to use ARBs in other pa...

...helation Therapy (Update...

...sefulness of chelation therapy is...

Influenza Vacc...

...l influenza vaccine is recommended for patients...


...apy for Relief of Symptoms...

...ntiischemic Medications...

...ckers should be prescribed as initial therapy for...

...el blockers or long-acting nitrates should be...

...blockers or long-acting nitrates, i...

...itroglycerin or nitroglycerin spray is r...

...eatment with a long-acting nondihyd...

Ranolazine can be useful when prescribed as...

...anolazine in combination with beta blockers can...

...lternative Therapies for Relief of Symptoms in Pat...

...xternal counterpulsation (EECP) may be...

...cord stimulation may be considered...

...ransmyocardial revascularization (TMR)...

...e should NOT be used for the purpose o...

...ditional Therapy to Reduce Risk of MI And...

...recommended with the intent of reducing car...

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

Vitamin C, vitamin E, and beta-carotene supplem...

...reatment of elevated homocysteine with folate or...

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

...Q10, selenium, and chromium. ( C , II...


...ascularization...

...eart Team approach to revascularization is recom...

...ation of the STS (http://riskcalc.sts.org/...

...evascularization to Improve Survival...

...omic Setting...

...d Left Main (UPLM) or complex C...

CABG and PCI

...art Team approach recommended (...

Calculation of STS and SYNTAX scores...

UPL...

CABG

...( B , I )701

...CI

...oth of the following are present:...

...not a CABG candidate ( B , IIa )701...

...when distal coronary flow is TIMI flow grad...

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

...n patients (versus performing CABG) with unfavo...

...sel disease with or without proximal...

...ABG

...01...

...le to choose CABG over PCI in patients with...

...CI...

...ncertain benefit ( B , I...

2-vessel disease with proximal LAD art...

CABG

...01...

...CI...

...certain benefit ( B , IIb...

...se without proximal LAD artery disea...

CABG

...th extensive ischemia ( B...

...ncertain benefit without extensive...

PC...

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

...el proximal LAD artery disease...

CAB...

With LIMA for long-term benefit ( B , IIa )701

...CI

...ncertain benefit ( B , IIb )7...

1-vessel disease without proximal LAD artery in...

CAB...

...01...

PCI

...01...

...ysfunction...

CAB...

...50% ( B , IIa )701...

...F...

PCI

...ficient data701...

...vivors of sudden cardiac death with pres...

...ABG

...01

...CI...

70...

...c or physiological criteria for revasc...

...ABG

...01

PCI

701

...arly with LIMA graft to LAD) is gener...

...ble 13. Revascularization to Improv...

...CABG (A)701...

...CI ( A , )701...

...a—CABG701...

...a—PCI (C)701...

...PCI (C)701

...Ib—CABG (, )70...

...CAD (eg, SYNTAX score >22) with or with...

...Ia—CABG preferred over PCI (B)70...

...myocardium that is perfused by coronary arte...

...TMR as an adjunct to CABG (B...

...atomic or physiological criteria for...

...II: Harm—CABG...

...I: Harm—PCI701...


...arization to Improve Survival...

...eft Main CAD Revascul...

...ry bypass graft (CABG) to improve survival is r...

...taneous coronary intervention (PCI) to i...

...o improve survival is reasonable in patients with...

...o improve survival is reasonable in patients...

...o improve survival may be reasonable as an alt...

PCI to improve survival should NOT be perf...

...Left Main CAD Revascularization...

...survival is beneficial in patients w...

...ed in 2014) CABG is generally recommended in...

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

...ve survival is beneficial in survivo...

...in 2014) A Heart Team approach to revascularizati...

...e survival is reasonable in patients with signific...

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

...eft internal mammary artery (LIMA)...

...onable to choose CABG over PCI to improv...

...sefulness of CABG to improve survival is unce...

...usefulness of PCI to improve surviva...

...be considered with the primary or sole intent o...

...ss of CABG or PCI to improve survival is unc...

CABG or PCI should NOT be performed with...


...scularization to Improve Symptoms...

...G or PCI to improve symptoms is beneficial in pati...

...r PCI to improve symptoms is reasonable in pa...

...ove symptoms is reasonable in patients...

...ble to choose CABG over PCI to impr...

CABG to improve symptoms might be reas...

...s an adjunct to CABG to improve symptoms may...

...improve symptoms should NOT be performe...


...et Therapy (DAPT) Compliance and Stent...

...with coronary stenting (bare-metal stent [BMS]...


...oronary Revascularizatio...

...d coronary revascularization (defined as th...

...nary revascularization may be reasonable as an...


Follow-up

...llow-u...

Clinical Evaluation, Echocardiography During R...

Patients with SIHD should receive periodic foll...

...EF and segmental wall motion by echocardiograph...

...screening for important comorbidities that a...

A resting 12-lead ECG at 1-year or longer in...

...easurement of LV function with a technology such...

...ninvasive Testing in Kno...

...vasive Testing in Patients With Known...

...ients Able to Exercise...

...ercise ECG testing is recommended in pat...

...cise with nuclear MPI or echocardiography...

...uclear MPI or echocardiography is reasonable in...

...armacological stress imaging with nuclear MPI...

...atients Unable To Exercise...

Pharmacological stress imaging with nuclear...

...logical stress imaging with CMR is reasona...

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

...ctive Of Ability To Exercise...

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

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

...be performed for assessment of na...

...14. Follow-Up Noninvasive Testing in...

...tients Able to Exercis...

...andard exercise ECG testing is recommended in pat...

...xercise with nuclear MPI or echocardiography is re...

...with nuclear MPI or echocardiograp...

...l stress imaging with nuclear MPI,...

...nts Unable to Exercise...

...gical stress imaging with nuclear...

...acological stress imaging with CMR is reasonable...

...se ECG testing should NOT be performed in p...

...ctive of Ability to Exerc...

...essment of patency of CABG or of corona...

...easonable in patients with known SIHD who have new...

...be performed for assessment of native coron...

...ble 15. Noninvasive Testing in Known SIHD:...

...ld NOT be performed for assessment of native cor...

...rcise ECG testing performed at 1-year or...

...who have no new or worsening sympt...

...nts who have no new or worsening symptoms o...

...sive Testing in Known SIHD— Asymp...

...uclear MPI, echocardiography, or CMR with ei...

...rd exercise ECG testing performed at...

...have no new or worsening symptoms o...

...MPI, echocardiography, or CMR, wit...