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 PainHavin...
...e 1. Spectrum of Ischemic Heart Disea...
...Principal Presentations of Unstable An...
...lternative Diagnoses to Angina for Pa...
...Pretest Likelihood of Coronary Artery Disease (...
...mparing Pretest Likelihood of CAD in Low-Risk Symp...
Table 6. Medical Conditions Provoking o...
...agnosis of Patients with Suspected Isch...
...re 3. Risk Assessment of Patients...
.... Guideline-Directed Medical Therapy for Pa...
...cularization to Improve Survival of Patients w...
...ion in the Initial Diagnosis of SIHD in Patient...
...ients with chest pain should receive a tho...
...o present with acute angina should be...
...rocardiogram (ECG) is recommended in patients w...
Figure 6. Revascularization to Impro...
...ing and Advanced Imaging for Initial Diagn...
...le to Exercis...
...e ECG testing is recommended for patients...
...cise stress with nuclear myocardial perfusi...
...nts with a low pretest probability o...
...tress with nuclear MPI or echocardiography...
...acological stress with cardiac magnetic...
...oronary/cardiac computed tomography a...
For patients with a low pretest probability...
...armacological stress with nuclear MPI,...
...tress with nuclear MPI is NOT recommend...
...ble to Exercise...
...harmacological stress with nuclear MPI...
...harmacological stress echocardiography...
...onable for patients with a low to intermediate pr...
...rmacological stress CMR is reasonab...
...rd exercise ECG testing is NOT recommended...
...reasonable for patients with an intermediate p...
...with a low to intermediate pretest...
...7. Stress Testing and Advance Imaging for Initia...
Resting Imaging to Assess Cardiac Str...
...ent of resting left ventricular (LV) syst...
...ent of cardiac structure and function wi...
...f LV function with radionuclide imaging m...
...ography, radionuclide imaging, CMR,...
...tine reassessment (...
...g and Advanced Imaging in Patients Wi...
...Assessment in Patients Able to Exercise...
...e ECG testing is recommended for r...
...tion of either nuclear MPI or echocardiography to...
...addition of either nuclear MPI or echocardiogra...
...macological stress is reasonable for risk...
...TA may be reasonable for risk assessment in pa...
...rmacological stress imaging (nuclear...
...ssment In Patients Unable To Exercise...
Pharmacological stress with either nuclear MPI or...
...stress CMR is reasonable for risk assessment i...
...eful as a first-line test for risk...
...Regardless Of Patients’ Ability T...
...armacological stress with either nuclear M...
...cise or pharmacological stress with imaging (n...
CCTA can be useful for risk assessment i...
...CTA might be considered for risk assessment i...
A request to perform either a) more...
...Using Stress Testing and Advanced Imag...
...aphy as an Initial Testing Strategy to Assess...
...SIHD who have survived sudden cardiac deat...
...tients with SIHD who develop sympt...
...aphy to Assess Risk After Initial Wor...
...graphy is recommended for patients wi...
...oronary angiography is reasonable to further...
...angiography is reasonable to furth...
Coronary angiography for risk assessment is...
...ronary angiography for risk assessment is NOT r...
...ry angiography is NOT recommended to fur...
...ography is NOT recommended to assess ris...
...graphy is NOT recommended to assess risk in...
Invasive Testing for Diagnosis of Coronary Arte...
...nary angiography is useful in patients...
...nary angiography is reasonable to def...
...ronary angiography is reasonable in patients wit...
...oronary angiography might be considered i...
...9. CAD Prognostic IndexHaving trouble view...
...e 10. Noninvasive Risk Stratification High...
Treatment
...eatment...
...atient Educatio...
...IHD should have an individualized educat...
...ducation on the importance of medi...
...explanation of medication management and cardi...
...ve review of all therapeutic options ( B , I )...
...on of appropriate levels of exercise, w...
...troduction to self-monitoring skills (...
...on how to recognize worsening cardio...
...ients with SIHDÂ should be educated about t...
...t control – maintenance of a body mass index...
...e to educate patients with SIHD abo...
...to a diet that is low in saturated...
...ommon symptoms of stress and depression to min...
...rehensive behavioral approaches for th...
...nd treatment of major depressive di...
...ctor Modification...
Lipid Manageme...
...fications, including daily physical activity...
...apy for all patients should include reduced...
...ition to therapeutic lifestyle changes, a...
For patients who do not tolerate statins,...
...e use of bile acid sequestrant is rel...
...ood Pressure Mana...
...ould be counseled about the need for lifestyl...
...n patients with SIHD with BP ≥140/90 mm Hg,...
...dications used for treatment of high BP...
...ble 11. Indications for Individual Drug Clas...
...abetes Managemen...
...individual patients, such as those w...
...bA1c between 7% and 9% is reasonable for certain...
...pharmacotherapy interventions to achie...
...y with rosiglitazone should NOT be initiated in...
Physical Activi...
...s, the clinician should encourage 30...
...ients, risk assessment with a physical acti...
...ically supervised programs (cardiac reha...
It is reasonable for the clinician to recommend...
...ht Management
BMI and/or waist circumference should be asses...
...ial goal of weight loss therapy should be t...
...essation Counseling...
...cessation and avoidance of exposure to environme...
...Of Psychological Factors...
It is reasonable to consider screeni...
...f depression has not been shown to improve card...
...ol Consumption...
...ents with SIHD who use alcohol, it might be reaso...
...oiding Exposure To Air Pollution
...is reasonable for patients with SIHD...
Antiplatelet The...
...ment with aspirin 75-162 mg daily should be contin...
...nt with clopidogrel is reasonable when aspirin i...
...spirin 75-162 mg daily and clopidogre...
...pyridamole is NOT recommended as antiplatelet...
...locker Therapy...
...cker therapy should be started and continued for 3...
...ta-blocker therapy should be used in all pat...
...kers may be considered as chronic therapy for all...
...n-Angiotensin-Aldosterone Blocker Therap...
...should be prescribed in all patients with...
...eptor blockers (ARBs) are recommend...
...with an ACE inhibitor is reasonable in patients...
...t is reasonable to use ARBs in other patients who...
...lation Therapy (Updated...
...usefulness of chelation therapy is uncertain...
Influenza Vaccin...
...nual influenza vaccine is recommended for pat...
...ical Therapy for Relief of Sympt...
...Of Antiischemic Medica...
...ers should be prescribed as initial t...
...hannel blockers or long-acting nitrates...
...m channel blockers or long-acting nitrates...
...blingual nitroglycerin or nitroglyce...
...a long-acting nondihydropyridine cal...
...anolazine can be useful when prescribe...
...nolazine in combination with beta blockers can b...
...apies for Relief of Symptoms in Pa...
...xternal counterpulsation (EECP) may be consid...
...mulation may be considered for relie...
...yocardial revascularization (TMR)...
...e should NOT be used for the purpose of im...
...onal Therapy to Reduce Risk of MI And D...
...recommended with the intent of reducing cardiovas...
...rogen therapy ( A , III (no benefit)...
...in C, vitamin E, and beta-carotene s...
...of elevated homocysteine with folate or...
...helation therapy. ( C , III (no benefit) )701...
...lic, coenzyme Q10, selenium, and chromium. ( C...
...cularization...
...t Team approach to revascularization is recomme...
...of the STS (http://riskcalc.sts.o...
...Revascularization to Improve Survival...
...tomic Setting
...ft Main (UPLM) or complex CAD...
... and PCI...
...proach recommended ( C , I )701...
...ation of STS and SYNTAX scores ( B , IIa )701...
...PLM...
...ABG
...B , I )701...
...CI...
...both of the following are present: Anatom...
...STEMI if not a CABG candidate ( B ,...
...STEMI when distal coronary flow is TIM...
...r SIHD when both of the following a...
...tients (versus performing CABG) with un...
...ase with or without proximal LAD artery...
CABG
70...
...sonable to choose CABG over PCI in patien...
PC...
...f uncertain benefit ( B , IIb )7...
...el disease with proximal LAD artery d...
...ABG
...01...
...CI...
...uncertain benefit ( B , IIb )701
...disease without proximal LAD arter...
CAB...
...sive ischemia ( B , IIa )701...
Of uncertain benefit without extensive ischemi...
PCI
...tain benefit ( B , IIb )70...
...ssel proximal LAD artery d...
CAB...
...MA for long-term benefit ( B , II...
...CI
...rtain benefit ( B , IIb...
...ease without proximal LAD artery inv...
...ABG
...01
PCI
70...
LVÂ dysfunction
CABG
EF 35%-50% ( B , II...
EF...
...CI...
...ufficient data70...
...of sudden cardiac death with presumed isc...
...ABG
...01...
PC...
701
...c or physiological criteria for revascula...
...ABG
70...
...CI...
...01
...G (particularly with LIMA graft to LAD) is...
...le 13. Revascularization to Improve Sympto...
1—CABG (A)7...
...PCI ( A , )7...
...—CABG701...
...a—PCI (C)...
...a—PCI (C)701...
...”CABG (, )701
...ssel CAD (eg, SYNTAX score >22) with or w...
...”CABG preferred over PCI (B)701...
...ic myocardium that is perfused by coronary ar...
...—TMR as an adjunct to CABG (B)70...
...anatomic or physiological criteria for r...
...I: Harm—CABG (C)701
...Harm—PCI701...
...ization to Improve Survival...
...t Main CAD Revasculariz...
...nary artery bypass graft (CABG) to imp...
...oronary intervention (PCI) to improve surv...
...survival is reasonable in patients with unstable...
...improve survival is reasonable in patien...
...prove survival may be reasonable as an...
...survival should NOT be performed in stabl...
...t Main CAD Revascularization...
...e survival is beneficial in patients with sign...
...14) CABG is generally recommended i...
...( B , I )701
...e survival is beneficial in survivors of sudden...
...New in 2014) A Heart Team approach to reva...
...improve survival is reasonable in patients wi...
...mprove survival is reasonable in patient...
...internal mammary artery (LIMA) graft to imp...
...nable to choose CABG over PCI to improve surv...
...s of CABG to improve survival is uncert...
...fulness of PCI to improve survival is uncertai...
...t be considered with the primary or sole int...
...ess of CABG or PCI to improve survival...
...should NOT be performed with the primary or sole i...
...rization to Improve Sympto...
...to improve symptoms is beneficial in patients wi...
CABG or PCI to improve symptoms is reasonabl...
...rove symptoms is reasonable in patients with prev...
...able to choose CABG over PCI to improve sympt...
...BG to improve symptoms might be rea...
...an adjunct to CABG to improve symptoms...
...BG or PCI to improve symptoms should NOT be perfor...
...elet Therapy (DAPT) Compliance and Stent Thrombosi...
...y stenting (bare-metal stent [BMS] or drug-elu...
...ybrid Coronary Revascularizatio...
...d coronary revascularization (defined as...
...rid coronary revascularization may be reaso...
Follow-up
Follow...
...cal Evaluation, Echocardiography During Routine,...
...tients with SIHD should receive pe...
...EF and segmental wall motion by echocardio...
...reening for important comorbidities that ar...
...2-lead ECG at 1-year or longer intervals...
...of LV function with a technology such...
...sive Testing in Known S...
...nvasive Testing in Patients With Known SIHD:...
...nts Able to Exercise...
...tandard exercise ECG testing is recommend...
...nuclear MPI or echocardiography is recommende...
...nuclear MPI or echocardiography is re...
...stress imaging with nuclear MPI, ec...
...ts Unable To Exercise...
...stress imaging with nuclear MPI or echocardiogra...
...rmacological stress imaging with CMR is re...
...d exercise ECG testing should NOT...
...espective Of Ability To Exercise
...or assessment of patency of CABG or o...
...t be reasonable in patients with known SIHD who ha...
...A should NOT be performed for assessment of...
...llow-Up Noninvasive Testing in Patients with Kno...
...Able to Exercise...
...xercise ECG testing is recommended in...
Exercise with nuclear MPI or echocardiography is...
...nuclear MPI or echocardiography is reasona...
...stress imaging with nuclear MPI, echocardiography...
...s Unable to Exercise...
...acological stress imaging with nuclear MPI or ec...
...gical stress imaging with CMR is reasonable in pat...
...ard exercise ECG testing should NOT be p...
...respective of Ability to Exercise...
...or assessment of patency of CABG or of coronary...
...e reasonable in patients with known S...
...T be performed for assessment of native c...
...5. Noninvasive Testing in Known SIHD: Asymp...
...CTA should NOT be performed for assessme...
...ise ECG testing performed at 1-year or longer in...
...nts who have no new or worsening symptoms...
...who have no new or worsening symptoms or no pri...
...ive Testing in Known SIHD— Asymptomat...
...I, echocardiography, or CMR with either exercis...
...xercise ECG testing performed at ≥1-year interv...
...ients who have no new or worsening...
...r MPI, echocardiography, or CMR, with eithe...