Stable Ischemic Heart Disease
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.
Diagnosis
...gnosis
...linical Classification of Chest Pai...
...ctrum of Ischemic Heart Disease (IH...
...2. Three Principal Presentations of Unstable An...
...ble 3. Alternative Diagnoses to Angina for Patien...
...able 4. Pretest Likelihood of Coronary Artery Dise...
...aring Pretest Likelihood of CAD in Lo...
Table 6. Medical Conditions Provokin...
...gure 2. Diagnosis of Patients with S...
...Assessment of Patients with Stable Ischemic Hea...
...e 4. Guideline-Directed Medical Therapy for Patien...
...gure 5. Revascularization to Improve...
...tion in the Initial Diagnosis of SIHD in Patien...
...h chest pain should receive a thorough history...
...ients who present with acute angina sh...
...resting electrocardiogram (ECG) is recommended in...
...6. Revascularization to Improve Symptoms of Patie...
...ss Testing and Advanced Imaging for...
...to Exercise...
...ndard exercise ECG testing is recommended for pati...
...xercise stress with nuclear myocardial perf...
...patients with a low pretest probability...
...ess with nuclear MPI or echocardiography...
...ogical stress with cardiac magnetic r...
...ardiac computed tomography angiogr...
...s with a low pretest probability of...
...ical stress with nuclear MPI, echocardiography,...
...ss with nuclear MPI is NOT recommended as an in...
...e to Exercise...
...stress with nuclear MPI or echocardiograp...
...logical stress echocardiography is reasonable for...
...CTA is reasonable for patients with a low to int...
...cological stress CMR is reasonable for pat...
...cise ECG testing is NOT recommende...
...reasonable for patients with an intermediate pr...
...th a low to intermediate pretest prob...
...able 7. Stress Testing and Advance Imaging fo...
...to Assess Cardiac Structure and Functio...
...essment of resting left ventricular (L...
...ardiac structure and function with resting...
...ment of LV function with radionuclide imaging may...
...y, radionuclide imaging, CMR, and cardia...
...reassessment (...
...ress Testing and Advanced Imaging in Patient...
...Assessment in Patients Able to E...
...e ECG testing is recommended for ri...
...addition of either nuclear MPI or ech...
...of either nuclear MPI or echocardiography to sta...
...acological stress is reasonable for ris...
...be reasonable for risk assessment in patients...
...l stress imaging (nuclear MPI, echocardiography, o...
Risk Assessment In Patients Unable To Exercis...
...stress with either nuclear MPI or echocardiograph...
...ogical stress CMR is reasonable for risk assessm...
...ful as a first-line test for risk assessment in p...
...t Regardless Of Patients’ Ability To Exerc...
...ical stress with either nuclear MPI...
...r exercise or pharmacological stress w...
...an be useful for risk assessment in patien...
...might be considered for risk assessment in pati...
...to perform either a) more than 1 stress imaging...
...ble 8. Using Stress Testing and Advanced Imaging...
...Angiography as an Initial Testing Strat...
...ith SIHD who have survived sudden cardiac death...
...s with SIHD who develop symptoms and signs of...
...graphy to Assess Risk After Initial Work...
...onary arteriography is recommended for...
...angiography is reasonable to further assess r...
...raphy is reasonable to further assess risk in pat...
...iography for risk assessment is reaso...
...ry angiography for risk assessment is NOT rec...
Coronary angiography is NOT recommended to fur...
...aphy is NOT recommended to assess risk in pat...
...aphy is NOT recommended to assess ris...
...g for Diagnosis of Coronary Artery Dis...
...raphy is useful in patients with presu...
...y angiography is reasonable to def...
...ngiography is reasonable in patients wit...
...ngiography might be considered in patients with s...
...CAD Prognostic IndexHaving trouble viewing table?...
...oninvasive Risk Stratification High risk...
Treatment
Treatment
...nt Education...
...ts with SIHD should have an individualized educ...
...cation on the importance of medication adherence f...
...n explanation of medication management a...
...rehensive review of all therapeutic optio...
...appropriate levels of exercise, with encourage...
...to self-monitoring skills ( C , I )701...
...ion on how to recognize worsening cardiova...
...ts with SIHDÂ should be educated about the fo...
...– maintenance of a body mass index (BMI2 ) o...
It is reasonable to educate patients with...
...diet that is low in saturated fat,...
...oms of stress and depression to minimize stress...
Comprehensive behavioral approaches fo...
...and treatment of major depressive disord...
...Factor Modificat...
Lipid Managemen...
Lifestyle modifications, including dail...
...for all patients should include reduced int...
...on to therapeutic lifestyle changes, a moderate...
...who do not tolerate statins, low-density lipop...
...e of bile acid sequestrant is relat...
...Pressure Manageme...
...l patients should be counseled about the nee...
...ients with SIHD with BP ≥140/90 mm Hg...
...ific medications used for treatment of h...
...cations for Individual Drug Classes in the...
...abetes Managemen...
...individual patients, such as those with a s...
...between 7% and 9% is reasonable for certain patien...
...ion of pharmacotherapy intervention...
...rosiglitazone should NOT be initiate...
...ical Activit...
...ll patients, the clinician should encourag...
...r all patients, risk assessment with a...
...lly supervised programs (cardiac rehabilitat...
It is reasonable for the clinician to recommend...
...ght Management...
...I and/or waist circumference should b...
...goal of weight loss therapy should be to red...
...essation Counseling
...n and avoidance of exposure to environme...
...agement Of Psychological...
...reasonable to consider screening SI...
...t of depression has not been shown to impr...
...ohol Consumption...
...s with SIHD who use alcohol, it might be reas...
...posure To Air Pollution...
...t is reasonable for patients with SI...
...tiplatelet Therap...
...t with aspirin 75-162 mg daily should b...
...h clopidogrel is reasonable when aspir...
...spirin 75-162 mg daily and clopidogrel 75 m...
...idamole is NOT recommended as antip...
...Blocker Therapy
...er therapy should be started and continued fo...
Beta-blocker therapy should be used in all p...
...ers may be considered as chronic therapy for all...
...Angiotensin-Aldosterone Blocker Therapy...
...s should be prescribed in all patients with SIHD w...
...eceptor blockers (ARBs) are recomm...
...with an ACE inhibitor is reasonable in...
...ble to use ARBs in other patients who are ACE inhi...
...herapy (Updated in 2014)...
...he usefulness of chelation therapy is uncert...
...za Vaccination...
...nfluenza vaccine is recommended for patie...
...Therapy for Relief of Symptoms...
...Antiischemic Medications...
...eta blockers should be prescribed as initi...
...alcium channel blockers or long-acting nitrates s...
...annel blockers or long-acting nitrates,...
...ngual nitroglycerin or nitroglycerin spray is re...
...ent with a long-acting nondihydropyrid...
...an be useful when prescribed as a subst...
...combination with beta blockers can be...
...erapies for Relief of Symptoms in Patients with...
...d external counterpulsation (EECP) may b...
...cord stimulation may be considered for relie...
...myocardial revascularization (TMR) m...
...uncture should NOT be used for the pur...
Additional Therapy to Reduce Risk of MI A...
... recommended with the intent of reducing cardi...
...py ( A , III (no benefit) )701...
...in E, and beta-carotene supplementatio...
...nt of elevated homocysteine with folate or...
...ation therapy. ( C , III (no benefit) )70...
...enzyme Q10, selenium, and chromium. ( C , III (n...
...ascularizatio...
...Heart Team approach to revascularization is recom...
...culation of the STS (http://riskcalc.sts.org...
...e 12. Revascularization to Improve Survival...
...omic Setting
...ected Left Main (UPLM) or complex CAD...
...ABG and P...
Heart Team approach recommended ( C , I )7...
Calculation of STS and SYNTAX scores ( B , IIa...
UPLM
CABG
...B , I )701...
PCI
...or SIHD when both of the following a...
...A/NSTEMI if not a CABG candidate (...
...STEMI when distal coronary flow is TIMI flow gra...
...D when both of the following are pr...
...patients (versus performing CABG) wi...
...disease with or without proximal LA...
...ABG...
70...
...sonable to choose CABG over PCI in patients wi...
PCI
...tain benefit ( B , IIb )...
...l disease with proximal LAD artery disease*
CABG
70...
...CI...
...ain benefit ( B , IIb )701
...sel disease without proximal LAD arter...
CABG
...tensive ischemia ( B , IIa...
...n benefit without extensive ischemia...
...CI
...in benefit ( B , IIb )701...
...ximal LAD artery disease
CAB...
...long-term benefit ( B , IIa )701...
...CI
...f uncertain benefit ( B , IIb...
...vessel disease without proximal LAD arter...
CABG
70...
PCI
70...
...ysfunction...
CABG
...35%-50% ( B , II...
EF...
...CI...
...icient data701...
...of sudden cardiac death with presu...
CAB...
701
PCI
...01...
...physiological criteria for revascularization...
CAB...
...01
PCI
...01...
...G (particularly with LIMA graft to LAD) is g...
...ascularization to Improve Symptoms With...
...”CABG (A)701...
...€”PCI ( A , )701...
...€”CABG701...
...”PCI (C)701...
IIa—PCI (C)...
...b—CABG (, )70...
...3-vessel CAD (eg, SYNTAX score >22) with or wi...
...CABG preferred over PCI (B)701...
...ble ischemic myocardium that is perfused...
...”TMR as an adjunct to CABG (B)70...
...r physiological criteria for revasc...
III: Harm—CABG (C)7...
...Harm—PCI701...
...vascularization to Improve...
Left Main CAD Revascu...
...rtery bypass graft (CABG) to improve survi...
Percutaneous coronary intervention (PCI...
...survival is reasonable in patients...
...survival is reasonable in patients with...
...ve survival may be reasonable as an alternative to...
...improve survival should NOT be perfor...
...“Left Main CAD Revasculariza...
...G to improve survival is beneficial in patients w...
...014) CABG is generally recommended in pref...
...BG ( B , I )...
...o improve survival is beneficial in s...
...Heart Team approach to revascularizati...
...rove survival is reasonable in patients with sign...
...survival is reasonable in patients with mil...
...ABG with a left internal mammary art...
...is reasonable to choose CABG over PCI to impr...
...usefulness of CABG to improve survival is un...
...of PCI to improve survival is uncertain in pati...
...e considered with the primary or sole...
...e usefulness of CABG or PCI to improve sur...
...r PCI should NOT be performed with...
...ularization to Improve Symptom...
...o improve symptoms is beneficial in pati...
...ABG or PCI to improve symptoms is reasonab...
...o improve symptoms is reasonable in p...
...able to choose CABG over PCI to improve sym...
...improve symptoms might be reasonable...
...formed as an adjunct to CABG to improv...
CABG or PCI to improve symptoms sh...
...telet Therapy (DAPT) Compliance and...
...CI with coronary stenting (bare-metal...
...oronary Revascularizati...
...y revascularization (defined as the planned com...
...coronary revascularization may be...
Follow-up
...llow-up...
...ion, Echocardiography During Routine,...
...SIHD should receive periodic follow-up, at l...
...VEF and segmental wall motion by echocardi...
...dic screening for important comorb...
...resting 12-lead ECG at 1-year or longer i...
...surement of LV function with a technolo...
...ive Testing in Known SIHD...
...invasive Testing in Patients With Known SIHD: New...
...tients Able to Exercise...
...ise ECG testing is recommended in patients...
...xercise with nuclear MPI or echocardiog...
...rcise with nuclear MPI or echocardiography is re...
...stress imaging with nuclear MPI, ech...
...ents Unable To Exercise...
...macological stress imaging with nuclear M...
...l stress imaging with CMR is reasonab...
...exercise ECG testing should NOT be per...
Irrespective Of Ability To Exe...
...ment of patency of CABG or of coronar...
...CTA might be reasonable in patients with k...
...uld NOT be performed for assessment of native co...
...e 14. Follow-Up Noninvasive Testing in Pa...
...ients Able to Exercise
...se ECG testing is recommended in pat...
...h nuclear MPI or echocardiography is recommended i...
...ercise with nuclear MPI or echocardiography is r...
...stress imaging with nuclear MPI, echocard...
...Unable to Exercise...
Pharmacological stress imaging wit...
...acological stress imaging with CMR is...
...exercise ECG testing should NOT be performed in p...
...ctive of Ability to Exercis...
...for assessment of patency of CABG or of co...
...might be reasonable in patients w...
...hould NOT be performed for assessment o...
...e 15. Noninvasive Testing in Known SIHD:...
...T be performed for assessment of native coron...
...e ECG testing performed at 1-year or l...
...patients who have no new or worsen...
...atients who have no new or worsening sympto...
...sting in Known SIHD— Asymptomatic...
...echocardiography, or CMR with either exerci...
...ise ECG testing performed at ≥1-year inte...
...who have no new or worsening symptoms...
Nuclear MPI, echocardiography, or C...