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
Diagnosis
...e 1. Clinical Classification of Ch...
...igure 1. Spectrum of Ischemic Heart Disease...
...ee Principal Presentations of Unsta...
...ative Diagnoses to Angina for Patients with C...
...Likelihood of Coronary Artery Disease (C...
...omparing Pretest Likelihood of CAD in...
...le 6. Medical Conditions Provoking or...
...nosis of Patients with Suspected Ische...
...3. Risk Assessment of Patients with Stable Isch...
...e 4. Guideline-Directed Medical Therapy...
...ascularization to Improve Survival of Pat...
...inical Evaluation in the Initial Diagnosis of SIHD...
...ith chest pain should receive a th...
...ho present with acute angina should...
...esting electrocardiogram (ECG) is recom...
...e 6. Revascularization to Improve Symptoms of...
...Testing and Advanced Imaging for Initial Diagnos...
...e to Exercise
...ard exercise ECG testing is recommended for...
...with nuclear myocardial perfusion imaging (MPI...
...with a low pretest probability of obs...
...with nuclear MPI or echocardiography is reason...
...al stress with cardiac magnetic resonance (...
...iac computed tomography angiography (CCTA)...
...patients with a low pretest probability of...
...ogical stress with nuclear MPI, echocar...
...ercise stress with nuclear MPI is NOT r...
...ble to Exercise...
...rmacological stress with nuclear MPI or e...
...ological stress echocardiography is reasona...
...is reasonable for patients with a low t...
Pharmacological stress CMR is reasona...
...exercise ECG testing is NOT recommended...
...onable for patients with an intermediate pretes...
...ients with a low to intermediate prete...
...ress Testing and Advance Imaging fo...
...ting Imaging to Assess Cardiac Structure an...
Assessment of resting left ventricular (LV) sys...
...sment of cardiac structure and function w...
...ent of LV function with radionuclide imaging may b...
...ardiography, radionuclide imaging, CMR,...
...reassessment (...
...tress Testing and Advanced Imaging in Patients Wit...
...k Assessment in Patients Able to Exercise
...dard exercise ECG testing is recommen...
...ion of either nuclear MPI or echocardiography to...
...tion of either nuclear MPI or echocardiog...
...pharmacological stress is reasona...
...onable for risk assessment in patients...
...ological stress imaging (nuclear M...
...sk Assessment In Patients Unable To Exercis...
...cological stress with either nuclea...
...cal stress CMR is reasonable for risk assessm...
...an be useful as a first-line test for risk as...
...sk Assessment Regardless Of Patients’...
...stress with either nuclear MPI or e...
...r exercise or pharmacological stress with...
CCTA can be useful for risk assessment...
...be considered for risk assessment in patients wit...
...quest to perform either a) more than 1 stress imag...
...able 8. Using Stress Testing and Advanced Ima...
...Angiography as an Initial Testing Strat...
...nts with SIHD who have survived sudden cardiac...
...atients with SIHD who develop sympt...
Coronary Angiography to Assess Risk After Ini...
...iography is recommended for patients w...
...oronary angiography is reasonable to further asses...
Coronary angiography is reasonable to further a...
Coronary angiography for risk assessment is reaso...
...raphy for risk assessment is NOT recomm...
...ography is NOT recommended to further assess r...
...angiography is NOT recommended to a...
Coronary angiography is NOT recommended to ass...
...ve Testing for Diagnosis of Coronary...
...oronary angiography is useful in patients wi...
...graphy is reasonable to define the exte...
...onary angiography is reasonable in...
...raphy might be considered in patients with stress...
...CAD Prognostic IndexHaving trouble vie...
...Noninvasive Risk Stratification High risk (...
Treatment
...atment...
...tient Education
...ith SIHD should have an individualized education...
...e importance of medication adherence...
...lanation of medication management and cardiovas...
...review of all therapeutic options (...
...iption of appropriate levels of exercise, wit...
...self-monitoring skills ( C , I )701...
...n on how to recognize worsening cardi...
...ith SIHDÂ should be educated about the fo...
...€“ maintenance of a body mass index (BMI2...
...t is reasonable to educate patients with S...
...to a diet that is low in saturated fat, chol...
...oms of stress and depression to minimize stress-re...
...mprehensive behavioral approaches for the m...
...nd treatment of major depressive disorder when...
...ctor Modification...
...d Management
...ications, including daily physical activ...
...ry therapy for all patients should include redu...
...ition to therapeutic lifestyle changes, a moderate...
...or patients who do not tolerate statins, l...
...The use of bile acid sequestrant is...
...Pressure Management
...s should be counseled about the nee...
...nts with SIHD with BP ≥140/90 mm...
...medications used for treatment of...
...cations for Individual Drug Classes in the Tre...
...iabetes Manageme...
...or selected individual patients, such a...
...ween 7% and 9% is reasonable for cert...
...on of pharmacotherapy interventions...
...rapy with rosiglitazone should NOT be initiat...
...cal Activity
...patients, the clinician should encourage 30-6...
...patients, risk assessment with a physical act...
...supervised programs (cardiac rehabilit...
...le for the clinician to recommend complement...
Weight Managem...
...aist circumference should be assessed at every vi...
The initial goal of weight loss therapy...
...king Cessation Coun...
...sation and avoidance of exposure to...
...ent Of Psychological Factors...
...nable to consider screening SIHD patients for depr...
...of depression has not been shown to impr...
...ohol Consumptio...
...ients with SIHD who use alcohol, it might be...
...ng Exposure To Air Pollution...
...is reasonable for patients with SIHD to avoi...
Antiplatelet Therap...
...reatment with aspirin 75-162 mg daily...
...h clopidogrel is reasonable when aspirin is co...
...ent with aspirin 75-162 mg daily and clopidogrel...
...pyridamole is NOT recommended as antiplatelet th...
...ta-Blocker Ther...
...rapy should be started and continu...
...eta-blocker therapy should be used in all patient...
...blockers may be considered as chroni...
...tensin-Aldosterone Blocker Ther...
...E inhibitors should be prescribed in all...
...ptor blockers (ARBs) are recommended for...
...ment with an ACE inhibitor is reasonable in pati...
...t is reasonable to use ARBs in other patients wh...
...ion Therapy (Updated in 2014)...
...ess of chelation therapy is uncertain for reducing...
...za Vaccination...
...luenza vaccine is recommended for patients...
...herapy for Relief of Symptoms...
...Of Antiischemic Medicati...
...ers should be prescribed as initia...
...lcium channel blockers or long-acting ni...
...hannel blockers or long-acting nit...
...ingual nitroglycerin or nitroglycerin spray is rec...
...h a long-acting nondihydropyridine calcium channe...
...e useful when prescribed as a subs...
...combination with beta blockers can be us...
...apies for Relief of Symptoms in Patients w...
...ernal counterpulsation (EECP) may b...
...rd stimulation may be considered for re...
Transmyocardial revascularization (TMR)...
...should NOT be used for the purpose of improving...
...tional Therapy to Reduce Risk of MI And Death...
...mended with the intent of reducing...
...y ( A , III (no benefit) )701...
...itamin E, and beta-carotene supplementation...
Treatment of elevated homocysteine with fol...
...n therapy. ( C , III (no benefit)...
...oenzyme Q10, selenium, and chromium. ( C , II...
...cularization...
A Heart Team approach to revascularization is re...
...he STS (http://riskcalc.sts.org/STSWebRisk...
...12. Revascularization to Improve Surviva...
...omic Setting
...tected Left Main (UPLM) or complex C...
CABGÂ andÂ...
...Team approach recommended ( C , I )...
Calculation of STS and SYNTAX scores ( B , IIa )7...
...PLM
CABG
...B , I )701...
...CI
...HD when both of the following are present:...
...TEMI if not a CABG candidate ( B , IIa...
...distal coronary flow is TIMI flow grade...
...oth of the following are present: Anatomic...
...ents (versus performing CABG) with...
...vessel disease with or without proximal LAD art...
CAB...
70...
It is reasonable to choose CABG over...
PCI
...uncertain benefit ( B , IIb...
...se with proximal LAD artery disease*...
CAB...
...01
...CI...
...in benefit ( B , IIb )701...
2-vessel disease without proximal LAD artery...
...ABG...
...extensive ischemia ( B , IIa...
...benefit without extensive ischemia ( C...
...CI
...in benefit ( B , IIb )701...
...ximal LAD artery disease...
...ABG...
...IMA for long-term benefit ( B ,...
...CI...
...ain benefit ( B , IIb )701...
...e without proximal LAD artery involvement...
...ABG
701
...CI...
...01...
... dysfunction...
CAB...
...-50% ( B , IIa )701...
EF...
...CI
...fficient data7...
...of sudden cardiac death with presumed is...
CAB...
701
PC...
70...
...or physiological criteria for revasculariz...
...ABG...
...01...
PCI
701
...particularly with LIMA graft to LAD) is generally...
Table 13. Revascularization to Improve Sy...
...”CABG (A)701...
1—PCI ( A , )7...
IIa—CABG70...
IIa—PCI (...
...a—PCI (C)70...
...Ib—CABG (, )...
...ssel CAD (eg, SYNTAX score >22) with or...
IIa—CABG preferred over PCI (B...
...ischemic myocardium that is perfused by coronar...
...€”TMR as an adjunct to CABG (B)701...
...mic or physiological criteria for reva...
...Harm—CABG (C)7...
...: Harm—PCI701...
...cularization to Improve Surviv...
...ft Main CAD Revascularization
Coronary artery bypass graft (CABG) to...
...coronary intervention (PCI) to impro...
...survival is reasonable in patients with unst...
...CI to improve survival is reasonable...
...improve survival may be reasonable as an...
...ve survival should NOT be performed in...
...Left Main CAD Revascularization
...mprove survival is beneficial in patients...
...2014) CABG is generally recommended in pref...
...( B , I )701
...rove survival is beneficial in survivors of sudde...
(New in 2014) A Heart Team approach to revas...
...to improve survival is reasonable...
...prove survival is reasonable in patients...
CABG with a left internal mammary artery (...
...le to choose CABG over PCI to improve survi...
...fulness of CABG to improve survival is...
...of PCI to improve survival is uncertain i...
CABG might be considered with the primary or sole...
...usefulness of CABG or PCI to improve survival...
...ABG or PCI should NOT be performed with the...
...vascularization to Improve Sympt...
...to improve symptoms is beneficial in patie...
...BG or PCI to improve symptoms is reasonable...
...rove symptoms is reasonable in pati...
...is reasonable to choose CABG over PCI to imp...
...rove symptoms might be reasonable...
...formed as an adjunct to CABG to improve...
...PCI to improve symptoms should NOT...
...telet Therapy (DAPT) Compliance and Stent T...
...with coronary stenting (bare-meta...
...id Coronary Revascularizati...
...brid coronary revascularization (defi...
...oronary revascularization may be reasonable as an...
Follow-up
Follow...
...aluation, Echocardiography During Routine,...
...ts with SIHD should receive periodic follow-u...
...of LVEF and segmental wall motion by echo...
...ning for important comorbidities that...
...resting 12-lead ECG at 1-year or longer int...
...asurement of LV function with a technology...
...e Testing in Known SIHD...
Follow-Up Noninvasive Testing in Patients With Kn...
...tients Able to Exerc...
...tandard exercise ECG testing is reco...
...th nuclear MPI or echocardiography is recommended...
...e with nuclear MPI or echocardiography is...
...harmacological stress imaging with nuclear MPI, e...
...nts Unable To Exercise...
...stress imaging with nuclear MPI or...
...cal stress imaging with CMR is reasona...
...cise ECG testing should NOT be performed in pati...
...respective Of Ability To Exercise...
CCTA for assessment of patency of CABG...
...reasonable in patients with known SIHD who hav...
...be performed for assessment of native...
...4. Follow-Up Noninvasive Testing in Patients...
...s Able to Exercis...
...ercise ECG testing is recommended in patients...
...e with nuclear MPI or echocardiography...
...nuclear MPI or echocardiography is reasonabl...
...logical stress imaging with nuclear MPI, echoca...
...Unable to Exercise...
...al stress imaging with nuclear MPI or ec...
...stress imaging with CMR is reasonable in p...
...ercise ECG testing should NOT be performed in...
...ective of Ability to Exe...
...ent of patency of CABG or of coronary stents...
...CTA might be reasonable in patients with kn...
...TA should NOT be performed for assessment of...
.... Noninvasive Testing in Known SIHD: Asymp...
...T be performed for assessment of native...
...ndard exercise ECG testing performed at 1-year or...
...patients who have no new or worsening symptoms or...
...s who have no new or worsening symptoms...
...nvasive Testing in Known SIHD— Asymptomatic (o...
...echocardiography, or CMR with either exercise...
...exercise ECG testing performed at...
...who have no new or worsening sympt...
...ocardiography, or CMR, with either exercise or...