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
...agnosis...
...Clinical Classification of Chest Pai...
...1. Spectrum of Ischemic Heart Disease (IHD)...
...e Principal Presentations of Unstable An...
...lternative Diagnoses to Angina for Pat...
...est Likelihood of Coronary Artery Disease (CAD)...
...paring Pretest Likelihood of CAD in Low-Risk Sympt...
...cal Conditions Provoking or Exacerbating Ischemi...
...ure 2. Diagnosis of Patients with...
...isk Assessment of Patients with Stable Isch...
...ine-Directed Medical Therapy for Patients...
...Revascularization to Improve Survival o...
...ion in the Initial Diagnosis of SIHD in Patients...
...atients with chest pain should receive a thorough...
...s who present with acute angina should be cate...
...electrocardiogram (ECG) is recommended in patients...
...scularization to Improve Symptoms of Patients...
...ng and Advanced Imaging for Initial Dia...
...ble to Exercise...
...ard exercise ECG testing is recommend...
...rcise stress with nuclear myocardial perfusion ima...
...th a low pretest probability of obstruc...
...stress with nuclear MPI or echocardiograph...
...gical stress with cardiac magnetic...
...diac computed tomography angiography (CCTA) mig...
...or patients with a low pretest probability of o...
...gical stress with nuclear MPI, echocardiography,...
...cise stress with nuclear MPI is NOT recommended as...
...le to Exercise...
Pharmacological stress with nuclea...
...ical stress echocardiography is reasonable fo...
...CTA is reasonable for patients with a low to int...
...rmacological stress CMR is reasonable for...
...rd exercise ECG testing is NOT recommended for pat...
CCTA is reasonable for patients with an...
For patients with a low to intermed...
...le 7. Stress Testing and Advance Imaging for...
...esting Imaging to Assess Cardiac Structur...
Assessment of resting left ventricular (LV) syst...
...ardiac structure and function with...
...nt of LV function with radionuclide imaging...
...graphy, radionuclide imaging, CMR, an...
...tine reassessment (
...nd Advanced Imaging in Patients With Known SIH...
...Assessment in Patients Able to Exerc...
...xercise ECG testing is recommended for...
...ition of either nuclear MPI or echocardiography t...
The addition of either nuclear MPI or echocardio...
...armacological stress is reasonable for ris...
...CTA may be reasonable for risk assessment in p...
...l stress imaging (nuclear MPI, echoca...
...sessment In Patients Unable To Exerci...
...cal stress with either nuclear MPI or...
Pharmacological stress CMR is reasonable for...
...be useful as a first-line test for risk asse...
...Regardless Of Patients’ Ability To Exercise...
...armacological stress with either nu...
...exercise or pharmacological stress with i...
...seful for risk assessment in patients with SIHD...
...CTA might be considered for risk assessment in...
...request to perform either a) more than 1 str...
...Using Stress Testing and Advanced Imaging for P...
...ngiography as an Initial Testing St...
...with SIHD who have survived sudden ca...
Patients with SIHD who develop symptoms and signs...
...iography to Assess Risk After Initial Wor...
...arteriography is recommended for patients...
...ngiography is reasonable to further asses...
...nary angiography is reasonable to fu...
...ry angiography for risk assessment is...
...y angiography for risk assessment is NOT rec...
...aphy is NOT recommended to further assess...
...ronary angiography is NOT recommended to...
...ography is NOT recommended to assess r...
...Testing for Diagnosis of Coronary Arter...
...y angiography is useful in patients with presum...
...iography is reasonable to define the extent...
Coronary angiography is reasonable in patients...
...aphy might be considered in patients w...
...rognostic IndexHaving trouble viewing t...
...oninvasive Risk Stratification H...
Treatment
Treatmen...
...ient Education...
...with SIHD should have an individualized educ...
Education on the importance of medication adher...
...nation of medication management and cardiovasc...
...nsive review of all therapeutic options (...
...of appropriate levels of exercise, with encou...
...duction to self-monitoring skills ( C , I )...
...how to recognize worsening cardiovascu...
...with SIHDÂ should be educated about the fol...
...ol – maintenance of a body mass index (B...
...asonable to educate patients with SIHD a...
...dherence to a diet that is low in saturated f...
...n symptoms of stress and depression to minimize st...
...prehensive behavioral approaches for...
...valuation and treatment of major depressive dis...
...tor Modification...
...ipid Manage...
...difications, including daily physical a...
...y therapy for all patients should include reduced...
...ion to therapeutic lifestyle changes, a...
...patients who do not tolerate statins, low-densit...
...e acid sequestrant is relatively cont...
...Pressure Management...
...atients should be counseled about the need for li...
In patients with SIHD with BP ≥140/90 m...
...specific medications used for treatment of...
...Indications for Individual Drug Cl...
Diabetes Manage...
...selected individual patients, such as those wit...
...l HbA1c between 7% and 9% is reasonable for cert...
Initiation of pharmacotherapy interventio...
...iglitazone should NOT be initiated in pati...
...ical Activity...
...l patients, the clinician should enco...
...nts, risk assessment with a physical activ...
...ly supervised programs (cardiac rehabilitatio...
...t is reasonable for the clinician to recommend...
...ht Management...
...waist circumference should be ass...
...l goal of weight loss therapy should be to...
...Cessation Counseling...
...ing cessation and avoidance of exposu...
...Of Psychological Factors...
...to consider screening SIHD patients for depr...
...eatment of depression has not been shown to impr...
...l Consumption...
...ents with SIHD who use alcohol, it might b...
...ding Exposure To Air Pollution...
...reasonable for patients with SIHD to avoid...
...ntiplatelet Th...
...t with aspirin 75-162 mg daily should...
...nt with clopidogrel is reasonable when aspiri...
...aspirin 75-162 mg daily and clopidogrel 75 m...
...e is NOT recommended as antiplatelet...
Beta-Blocker Therap...
...eta-blocker therapy should be started and continue...
...ta-blocker therapy should be used in all pa...
...lockers may be considered as chronic therapy for...
Renin-Angiotensin-Aldosterone Blocke...
...CE inhibitors should be prescribed in all patients...
...eceptor blockers (ARBs) are recomm...
...ment with an ACE inhibitor is reasonab...
...to use ARBs in other patients who ar...
...n Therapy (Updated in 2014...
...usefulness of chelation therapy is uncertai...
...uenza Vaccination...
...al influenza vaccine is recommende...
...al Therapy for Relief of S...
Use Of Antiischemic Medicat...
...blockers should be prescribed as initial therapy...
...channel blockers or long-acting nitrates shoul...
...m channel blockers or long-acting nitrat...
...lingual nitroglycerin or nitroglycerin spray...
...atment with a long-acting nondihyd...
Ranolazine can be useful when prescribed a...
...e in combination with beta blockers can be useful...
...herapies for Relief of Symptoms in Patients with...
...external counterpulsation (EECP) may be c...
...stimulation may be considered for relief of r...
...l revascularization (TMR) may be considered...
...e should NOT be used for the purpos...
...al Therapy to Reduce Risk of MI And Death...
...ecommended with the intent of reducing cardi...
...trogen therapy ( A , III (no benefit) )701...
...vitamin E, and beta-carotene supplementation....
...of elevated homocysteine with fol...
...erapy. ( C , III (no benefit) )701...
...coenzyme Q10, selenium, and chromium. (...
...scularization...
...pproach to revascularization is rec...
...he STS (http://riskcalc.sts.org/STSW...
Table 12. Revascularization to Improve Survival Co...
...natomic Set...
...ft Main (UPLM) or complex CAD...
... and PCI...
Heart Team approach recommended (...
...lculation of STS and SYNTAX scores ( B , I...
...PLM
...ABG...
- ( B , I )701
...CI...
...th of the following are present: Anatomi...
...not a CABG candidate ( B , IIa )701...
...en distal coronary flow is TIMI flow...
...oth of the following are present:...
...SIHD in patients (versus performing...
...ase with or without proximal LAD artery diseas...
CABG
70...
...reasonable to choose CABG over PCI in patients w...
PC...
...in benefit ( B , IIb )701...
...ase with proximal LAD artery disease*...
CAB...
...01
PCI
...n benefit ( B , IIb )701...
...without proximal LAD artery dis...
CAB...
...ensive ischemia ( B , IIa )701...
...ertain benefit without extensive ischemia ( C...
...CI...
...uncertain benefit ( B , IIb )701
1-vessel proximal LAD artery...
...ABG...
...LIMA for long-term benefit ( B ,...
...CI
...benefit ( B , IIb )701...
1-vessel disease without proximal LAD...
...ABG
70...
...CI
...01...
...ysfunction...
...ABG
...50% ( B , IIa )701...
...F...
...CI
...icient data701...
...udden cardiac death with presumed ischemi...
...ABG
...01...
PC...
...01...
...mic or physiological criteria for re...
CAB...
701
...CI
...01
...(particularly with LIMA graft to LAD) is generally...
...13. Revascularization to Improve Symptoms Wi...
...ABG (A)701...
...—PCI ( A ,...
...Ia—CABG70...
...—PCI (C)70...
...”PCI (C)701...
...—CABG (, )7...
...omplex 3-vessel CAD (eg, SYNTAX score >22)...
...€”CABG preferred over PCI...
...le ischemic myocardium that is perfused by...
...b—TMR as an adjunct to CA...
...r physiological criteria for revascularization...
...Harm—CABG (C)701...
...I: Harm—PCI7...
...rization to Improve Survival...
Left Main CAD Revascularizat...
...ery bypass graft (CABG) to improve surv...
...aneous coronary intervention (PCI) to imp...
...e survival is reasonable in patients...
...ve survival is reasonable in patients with acut...
...to improve survival may be reasonable...
...to improve survival should NOT be performed in st...
...Main CAD Revascularization...
...ove survival is beneficial in patients...
...ated in 2014) CABG is generally recommended i...
...( B , I )701...
...e survival is beneficial in survivor...
...ew in 2014) A Heart Team approach to revasculariz...
...e survival is reasonable in patients with...
...to improve survival is reasonable in patients w...
...with a left internal mammary artery (LIMA)...
...onable to choose CABG over PCI to improve surviva...
...sefulness of CABG to improve survival...
...ss of PCI to improve survival is un...
...ABG might be considered with the primar...
...he usefulness of CABG or PCI to imp...
...uld NOT be performed with the primary or sole i...
...evascularization to Improve S...
...or PCI to improve symptoms is beneficial in...
...to improve symptoms is reasonable in patients with...
...rove symptoms is reasonable in pati...
...asonable to choose CABG over PCI to im...
...improve symptoms might be reasonable for pa...
...rformed as an adjunct to CABG to improve symptoms...
...mprove symptoms should NOT be perform...
...elet Therapy (DAPT) Compliance and Stent Thr...
...coronary stenting (bare-metal stent [BMS] or dr...
...id Coronary Revasculariza...
...brid coronary revascularization (defin...
...ry revascularization may be reasonable...
Follow-up
...low-up...
...inical Evaluation, Echocardiography Durin...
Patients with SIHD should receive periodic f...
...ssessment of LVEF and segmental wall m...
...iodic screening for important comorbidities that...
...ng 12-lead ECG at 1-year or longer i...
...f LV function with a technology such...
...asive Testing in Known SIHD...
...Up Noninvasive Testing in Patients With Known S...
...ients Able to Exercise...
...cise ECG testing is recommended in patients...
Exercise with nuclear MPI or echoc...
...nuclear MPI or echocardiography is reasonabl...
...armacological stress imaging with nucl...
...ients Unable To Exercise...
...ogical stress imaging with nuclear MPI or e...
...acological stress imaging with CMR is reasonable i...
...ise ECG testing should NOT be performed...
...espective Of Ability To Exerci...
...CTA for assessment of patency of CABG...
...ight be reasonable in patients with known SIH...
...d NOT be performed for assessment o...
...Follow-Up Noninvasive Testing in Patients with K...
...ts Able to Exerci...
Standard exercise ECG testing is rec...
...xercise with nuclear MPI or echocardiogra...
...with nuclear MPI or echocardiography i...
...acological stress imaging with nuclear MPI, echoc...
...tients Unable to Exe...
...stress imaging with nuclear MPI or echocardiog...
...armacological stress imaging with CMR i...
...ndard exercise ECG testing should NOT be per...
...ective of Ability to Exercise...
...TA for assessment of patency of CABG or of co...
...might be reasonable in patients wi...
...be performed for assessment of native co...
...15. Noninvasive Testing in Known SIHD...
CCTA should NOT be performed for assessment of na...
...exercise ECG testing performed at 1...
...n patients who have no new or worsening s...
...nts who have no new or worsening symptoms or no...
...vasive Testing in Known SIHD— Asympto...
..., echocardiography, or CMR with either exercis...
...ndard exercise ECG testing performed at...
...have no new or worsening symptoms or n...
...MPI, echocardiography, or CMR, with eith...