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

...Diagnosis...

...e 1. Clinical Classification of Chest Pain...


...e 1. Spectrum of Ischemic Heart Disease (IHD)...


...ee Principal Presentations of Unstabl...


...3. Alternative Diagnoses to Angina for Patients...


...ble 4. Pretest Likelihood of Coronary A...


...5. Comparing Pretest Likelihood of CAD i...


...6. Medical Conditions Provoking or Exace...


...2. Diagnosis of Patients with Suspected Isch...


...sk Assessment of Patients with Stable Ischemic He...


...deline-Directed Medical Therapy for Patients wit...


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


...Clinical Eva...

...with chest pain should receive a thorough hi...

...ts who present with acute angina shou...

...resting electrocardiogram (ECG) is r...


.... Revascularization to Improve Symptoms o...


...Stress Testing an...

...Able to Exercise...

...ercise ECG testing is recommended for patient...

...ess with nuclear myocardial perfusion imaging (M...

...ents with a low pretest probability of obstructive...

...cise stress with nuclear MPI or echocardiog...

...armacological stress with cardiac magnetic resonan...

...cardiac computed tomography angiography...

...with a low pretest probability of obstruc...

...macological stress with nuclear MPI, echocardiogr...

...ss with nuclear MPI is NOT recommend...

...Unable to Exercise...

...rmacological stress with nuclear MPI or echoc...

...ological stress echocardiography is reasonable...

...s reasonable for patients with a low to inter...

...harmacological stress CMR is reasonable for patien...

...rd exercise ECG testing is NOT recommended...

...able for patients with an intermediate pretest...

...atients with a low to intermediate pret...

.... Stress Testing and Advance Imaging for...


...Resting Imaging to...

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

...ssessment of cardiac structure and function...

...urement of LV function with radionuclide im...

...ography, radionuclide imaging, CMR, a...

...outine reassessment (


...Stress Testing and Adva...

...Risk Assessment in Patien...

...e ECG testing is recommended for risk...

...on of either nuclear MPI or echocardiog...

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

...ith pharmacological stress is reason...

CCTA may be reasonable for risk assessment in pati...

...rmacological stress imaging (nuclear MPI, ec...

...Risk Assessm...

...ological stress with either nuclear M...

...macological stress CMR is reasonable f...

...eful as a first-line test for risk assessmen...

...Risk Assessment Rega...

...l stress with either nuclear MPI or echocard...

...cise or pharmacological stress with imaging...

...A can be useful for risk assessmen...

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

...perform either a) more than 1 stress imaging stud...

...8. Using Stress Testing and Advanced Imagi...


...Coronary Angiogra...

...h SIHD who have survived sudden cardiac death o...

...tients with SIHD who develop symptoms and signs o...


...Coronary A...

...ronary arteriography is recommended for pat...

...oronary angiography is reasonable to furthe...

...ary angiography is reasonable to further...

...ography for risk assessment is rea...

Coronary angiography for risk assessme...

...iography is NOT recommended to furth...

...nary angiography is NOT recommende...

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


...Invasive Te...

...ary angiography is useful in patients with presum...

...ngiography is reasonable to define the extent...

...ry angiography is reasonable in patients with...

...iography might be considered in patients...


...ognostic Index Extent of CAD...


...ble 10. Noninvasive Risk Stratification H...


Treatment

...Treatment...

...P...

...n on the importance of medication adherence f...

...n explanation of medication managem...

...ensive review of all therapeutic options ( B , I...

...ription of appropriate levels of ex...

...troduction to self-monitoring skills ( C , I )7...

...rmation on how to recognize worsening...

...Patients...

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

...It is reasonab...

...erence to a diet that is low in sa...

Common symptoms of stress and depression t...

...omprehensive behavioral approaches for th...

...luation and treatment of major depre...


...Risk Factor Mod...

...Lipid Mana...

...style modifications, including daily physical a...

...tary therapy for all patients should include red...

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

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

...of bile acid sequestrant is relatively co...

...Blood Pressu...

...ts should be counseled about the need fo...

...s with SIHD with BP ≥140/90 mm H...

...specific medications used for treatmen...

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

...Diabetes...

...dividual patients, such as those wit...

...oal HbA1c between 7% and 9% is reasonable f...

...pharmacotherapy interventions to achi...

...iglitazone should NOT be initiated in patie...

...Physical Activity...

..., the clinician should encourage 30-60 minut...

...atients, risk assessment with a ph...

...ically supervised programs (cardiac...

...e for the clinician to recommend complementar...

...Wei...

...and/or waist circumference should b...

...al of weight loss therapy should be to r...

...Smoking Cessation...

...sation and avoidance of exposure to envi...

...Management Of Psy...

...easonable to consider screening SIHD patients f...

...nt of depression has not been shown to improve car...

...Alcohol Consumpti...

...s with SIHD who use alcohol, it might be r...

...Avoiding...

...able for patients with SIHD to avoid exposure...

...Anti...

...with aspirin 75-162 mg daily should be conti...

...lopidogrel is reasonable when aspirin...

...reatment with aspirin 75-162 mg daily and cl...

...idamole is NOT recommended as anti...

...Beta-Bl...

...therapy should be started and continued for 3 yea...

...ker therapy should be used in all patients with...

...rs may be considered as chronic therapy for...

...Re...

...rs should be prescribed in all patients with...

...nsin-receptor blockers (ARBs) are re...

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

...onable to use ARBs in other patients who are...

Chelatio...

The usefulness of chelation therapy is uncer...

...Influe...

...nual influenza vaccine is recommended for patie...


...Medical Therap...

...Use...

Beta blockers should be prescribed as ini...

...channel blockers or long-acting nitrates sho...

...alcium channel blockers or long-acting n...

...itroglycerin or nitroglycerin spray is recomm...

...nt with a long-acting nondihydropyridine calcium...

...azine can be useful when prescribed as...

...ombination with beta blockers can be usefu...

...Altern...

...d external counterpulsation (EECP) may be...

Spinal cord stimulation may be consid...

...revascularization (TMR) may be considered fo...

Acupuncture should NOT be used for the purp...

...Add...

...recommended with the intent of redu...

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

...tamin C, vitamin E, and beta-carote...

Treatment of elevated homocysteine with folate...

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

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


...Revascularization...

...t Team approach to revascularization is re...

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

...Table 12. Revascularizat...

...Anato...

...Unprotected Left Ma...

...CABG and PCI...

...approach recommended ( C , I )701...

...STS and SYNTAX scores ( B , IIa )701...

...CAB...

..., I )701

...PCI...

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

For UA/NSTEMI if not a CABG candidate (...

...when distal coronary flow is TIMI f...

...when both of the following are presen...

...SIHD in patients (versus performing CABG)...

3-v...

70...

...le to choose CABG over PCI in patien...

...PCI...

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

...2-ve...

70...

...PCI...

...tain benefit ( B , IIb )...

...2-vessel diseas...

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

...ertain benefit without extensive is...

...P...

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

...1-vessel prox...

...CABG...

...for long-term benefit ( B , IIa )7...

...uncertain benefit ( B ,...

...1-vessel disease withou...

...CAB...

701

...P...

70...

...LV dysfunction...

...CABG...

...5%-50% ( B , IIa )701...

...F...

...PCI

...sufficient data7...

...Survivors of s...

70...

...PCI...

...01...

...No anatomic...

70...

...PCI...

701

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

...Table 13. Rev...

...CABG (A)701...

...PCI ( A ,...

...CABG701...

...—PCI (C)70...

...—PCI (C)701...

...CABG (, )701...

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

...referred over PCI (B)701...

...ble ischemic myocardium that is perfused by coro...

...—TMR as an adjunct to CABG (B)70...

...anatomic or physiological criteria for reva...

...I: Harm—CABG (C)701...

...II: Harm—PCI...


...Reva...

...artery bypass graft (CABG) to improve surv...

...utaneous coronary intervention (PCI) to improve s...

...ove survival is reasonable in patients...

...survival is reasonable in patients with a...

...o improve survival may be reasonable...

...o improve survival should NOT be performe...

...Non–Left Mai...

...BG to improve survival is beneficial in p...

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

...B , I )701...

...ove survival is beneficial in survivors...

...014) A Heart Team approach to revascularization i...

...G to improve survival is reasonable in patients...

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

CABG with a left internal mammary...

...to choose CABG over PCI to improve surv...

...usefulness of CABG to improve sur...

...fulness of PCI to improve survival is uncert...

CABG might be considered with the primary o...

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

...PCI should NOT be performed with the pri...


Revasc...

...PCI to improve symptoms is beneficial in patien...

...improve symptoms is reasonable in patients...

...mprove symptoms is reasonable in patients wit...

...t is reasonable to choose CABG over PCI...

...ABG to improve symptoms might be reasonable for pa...

...erformed as an adjunct to CABG to i...

...BG or PCI to improve symptoms should NOT...


...Dual Antiplatelet Thera...

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


...Hybrid Coronary Revas...

...y revascularization (defined as the plann...

Hybrid coronary revascularization may be reasonab...


Follow-up

...Follow-up

...Clinical Evaluatio...

...with SIHD should receive periodic follow-up,...

...VEF and segmental wall motion by e...

...iodic screening for important comorbidities t...

...resting 12-lead ECG at 1-year or longer i...

...urement of LV function with a technology such as...

...Noninvasive T...

...Follow-Up Noninvasive...

...Patients Able to Exer...

Standard exercise ECG testing is recommende...

...th nuclear MPI or echocardiography is recommended...

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

...ological stress imaging with nuclear MPI, echoca...

...Patients Unable To...

...al stress imaging with nuclear MPI or echocar...

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

...e ECG testing should NOT be performed in patients...

Irres...

...ssessment of patency of CABG or of coronary...

...might be reasonable in patients with known...

CCTA should NOT be performed for assessment...

...Table 14. Follo...

...Patients Able to Exercis...

...e ECG testing is recommended in patients wit...

...rcise with nuclear MPI or echocardiog...

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

...gical stress imaging with nuclear MPI, echocardio...

...Patients...

...acological stress imaging with nuclear MP...

...stress imaging with CMR is reasonable in patient...

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

...Irre...

...CTA for assessment of patency of CABG or...

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

...be performed for assessment of native co...

...Table 15....

...T be performed for assessment of nati...

...xercise ECG testing performed at 1-y...

...n patients who have no new or worsening sympto...

...have no new or worsening symptoms or no prior e...

...Noninvasive...

Nuclear MPI, echocardiography, or CMR w...

...ard exercise ECG testing performed at ≥...

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

...r MPI, echocardiography, or CMR, with...