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...
...ble 1. Clinical Classification of Chest PainHaving...
...ctrum of Ischemic Heart Disease (IH...
...le 2. Three Principal Presentations of U...
...ble 3. Alternative Diagnoses to An...
...t Likelihood of Coronary Artery Disease (CAD)...
...paring Pretest Likelihood of CAD in Lo...
...al Conditions Provoking or Exacerbat...
...agnosis of Patients with Suspected Ischemic H...
...Risk Assessment of Patients with S...
...Guideline-Directed Medical Therapy...
...igure 5. Revascularization to Improve...
...ation in the Initial Diagnosis of SIHD in Patien...
...th chest pain should receive a thor...
...who present with acute angina should be cat...
...trocardiogram (ECG) is recommended in patient...
...evascularization to Improve Symptoms of...
...and Advanced Imaging for Initial Diagnosis in...
...to Exercise
...d exercise ECG testing is recommended for...
...s with nuclear myocardial perfusion im...
...ents with a low pretest probability of ob...
...e stress with nuclear MPI or echocardiograph...
...stress with cardiac magnetic resonance (CMR...
...diac computed tomography angiography (CCT...
...h a low pretest probability of obstructive IH...
...logical stress with nuclear MPI, echocardio...
Exercise stress with nuclear MPI i...
Unable to Exercise
...ogical stress with nuclear MPI or echocard...
...acological stress echocardiography...
...nable for patients with a low to intermediate pre...
...l stress CMR is reasonable for patients wi...
...andard exercise ECG testing is NOT recommended fo...
...asonable for patients with an intermediate pretes...
...s with a low to intermediate pretest probab...
...Testing and Advance Imaging for Initial Diagnosi...
...ging to Assess Cardiac Structure and Function...
...ssment of resting left ventricular...
...sessment of cardiac structure and function...
...t of LV function with radionuclide imaging...
...cardiography, radionuclide imaging...
...ine reassessment (...
...ing and Advanced Imaging in Patients With Known...
...Assessment in Patients Able to E...
...d exercise ECG testing is recommended for r...
...of either nuclear MPI or echocard...
...ion of either nuclear MPI or echocardiograp...
...ological stress is reasonable for risk assess...
CCTA may be reasonable for risk assessment in pat...
...stress imaging (nuclear MPI, echocardiography, or...
...Assessment In Patients Unable To Exercise...
...stress with either nuclear MPI or e...
...ical stress CMR is reasonable for...
...be useful as a first-line test for risk assessme...
...isk Assessment Regardless Of Patientsâ€...
...logical stress with either nuclear M...
...or pharmacological stress with imaging (nuclea...
...e useful for risk assessment in patients with SIHD...
...nsidered for risk assessment in patients wi...
...uest to perform either a) more than 1 stress ima...
...le 8. Using Stress Testing and Advanc...
...graphy as an Initial Testing Strategy t...
...ts with SIHD who have survived sudde...
...ts with SIHD who develop symptoms and si...
...ary Angiography to Assess Risk After Ini...
...oronary arteriography is recommended f...
...ronary angiography is reasonable t...
...y angiography is reasonable to further assess risk...
...nary angiography for risk assessment is r...
...angiography for risk assessment is NOT recommende...
...oronary angiography is NOT recommende...
...iography is NOT recommended to assess r...
...onary angiography is NOT recommended t...
...Testing for Diagnosis of Coronary Ar...
...iography is useful in patients with...
...iography is reasonable to define the extent...
...ngiography is reasonable in patients with...
...angiography might be considered in...
...CAD Prognostic IndexHaving trouble viewing tab...
...Noninvasive Risk Stratification High risk...
Treatment
Treatmen...
...nt Education...
...ts with SIHD should have an individualized edu...
...the importance of medication adherenc...
...of medication management and cardiova...
...comprehensive review of all therapeutic options...
...scription of appropriate levels of exer...
...on to self-monitoring skills ( C , I )701...
Information on how to recognize worsening ca...
...with SIHDÂ should be educated about the...
...ontrol – maintenance of a body mass index (...
...is reasonable to educate patients with SIHD about...
...ce to a diet that is low in satura...
...ms of stress and depression to minimize st...
...rehensive behavioral approaches for the manageme...
...luation and treatment of major depressi...
...ctor Modification...
Lipid Manage...
...fications, including daily physical act...
Dietary therapy for all patients should...
...addition to therapeutic lifestyle c...
...r patients who do not tolerate statins, low-den...
...bile acid sequestrant is relatively cont...
...ood Pressure Management...
...should be counseled about the need for...
In patients with SIHD with BP ≥140/90 mm...
The specific medications used for trea...
...Indications for Individual Drug Classes...
...betes Managemen...
For selected individual patients, such as those wi...
...bA1c between 7% and 9% is reasonable...
...tiation of pharmacotherapy interventions to achiev...
...rosiglitazone should NOT be initiated in patients...
...hysical Activ...
...atients, the clinician should encoura...
...tients, risk assessment with a physical activity...
...ically supervised programs (cardiac rehabilitatio...
...nable for the clinician to recommen...
Weight Manageme...
...waist circumference should be assessed at every...
...of weight loss therapy should be to reduc...
...Cessation Counseling
...ng cessation and avoidance of exposure to...
...ment Of Psychological Factor...
...onable to consider screening SIHD patients for de...
...depression has not been shown to improve c...
...lcohol Consumpt...
...ients with SIHD who use alcohol, it might be r...
...posure To Air Pollution...
...le for patients with SIHD to avoid exposur...
...tiplatelet Therapy
...ment with aspirin 75-162 mg daily should be cont...
...h clopidogrel is reasonable when aspirin is...
...tment with aspirin 75-162 mg daily and clopido...
...ipyridamole is NOT recommended as antipla...
Beta-Blocker Ther...
...-blocker therapy should be started...
...blocker therapy should be used in all pati...
...kers may be considered as chronic therapy f...
...ensin-Aldosterone Blocker Ther...
...should be prescribed in all patients...
...tensin-receptor blockers (ARBs) are recommende...
...reatment with an ACE inhibitor is reasonabl...
...onable to use ARBs in other patients who ar...
...ion Therapy (Updated in 2014)...
...fulness of chelation therapy is uncertain for re...
Influenza Vacc...
...influenza vaccine is recommended for...
...erapy for Relief of Symptoms...
...e Of Antiischemic Medication...
...ould be prescribed as initial therapy for relief o...
...annel blockers or long-acting nitrates s...
...cium channel blockers or long-acting nitrates, i...
...nitroglycerin or nitroglycerin spray is recommend...
Treatment with a long-acting nondihydr...
...can be useful when prescribed as a subst...
...mbination with beta blockers can be useful w...
...ernative Therapies for Relief of Sym...
...d external counterpulsation (EECP) m...
...l cord stimulation may be considered fo...
...rdial revascularization (TMR) may be...
...ncture should NOT be used for the purpose of imp...
...ditional Therapy to Reduce Risk of MI And Deat...
... recommended with the intent of reducin...
...ogen therapy ( A , III (no benef...
...C, vitamin E, and beta-carotene supp...
...of elevated homocysteine with folate or vitamins...
...py. ( C , III (no benefit) )701...
...rlic, coenzyme Q10, selenium, and chromium. ( C ,...
...evascularizat...
...roach to revascularization is recommen...
...on of the STS (http://riskcalc.sts.org/STSWebRisk...
.... Revascularization to Improve Survival Com...
...atomic Settin...
...ft Main (UPLM) or complex CAD...
... and PCI...
...am approach recommended ( C , I )701...
...TS and SYNTAX scores ( B , IIa )701...
UPL...
CAB...
...B , I )7...
...CI
For SIHD when both of the followin...
...UA/NSTEMI if not a CABG candidate ( B , IIa )7...
...I when distal coronary flow is TIMI...
...HD when both of the following are present: An...
...r SIHD in patients (versus performing CABG...
...e with or without proximal LAD art...
CAB...
70...
...t is reasonable to choose CABG over PCI in patient...
PCI
...ain benefit ( B , IIb )701...
...se with proximal LAD artery disease*...
CABG
70...
PCI
...uncertain benefit ( B , IIb )701...
...sel disease without proximal LAD artery dis...
...ABG
...ve ischemia ( B , IIa )701...
...in benefit without extensive ischemia ( C , I...
PCI
...ain benefit ( B , IIb )...
...roximal LAD artery disease...
CABG
...MA for long-term benefit ( B ,...
PC...
...uncertain benefit ( B , IIb...
...e without proximal LAD artery involvement...
CABG
...01...
...CI...
...01
... dysfunctio...
CAB...
...0% ( B , IIa )701...
...F...
PCI
Insufficient data...
...vors of sudden cardiac death with presumed...
...ABG
701
PCI
701
...mic or physiological criteria for revascul...
...ABG
701
PCI
701
...articularly with LIMA graft to LAD) is g...
...cularization to Improve Symptoms With Signific...
...”CABG (A)701...
...€”PCI ( A ,...
IIa—CABG7...
IIa—PCI (...
...€”PCI (C)701...
...€”CABG (, )7...
...mplex 3-vessel CAD (eg, SYNTAX score...
...preferred over PCI (B)701...
...ble ischemic myocardium that is perfu...
...MR as an adjunct to CABG (B)70...
No anatomic or physiological criteria for revascu...
...arm—CABG (C)701...
...I: Harm—PCI701...
...ascularization to Improve Sur...
...n CAD Revascularization...
Coronary artery bypass graft (CABG) to imp...
...neous coronary intervention (PCI) to improve s...
...ove survival is reasonable in patients with...
...ove survival is reasonable in patients with acute...
...ve survival may be reasonable as an a...
...prove survival should NOT be performed in stab...
...Left Main CAD Revasculari...
...G to improve survival is beneficial...
...014) CABG is generally recommended...
...( B , I )701...
...prove survival is beneficial in surviv...
...2014) A Heart Team approach to revascula...
...o improve survival is reasonable in patie...
...G to improve survival is reasonable i...
...G with a left internal mammary artery (...
...reasonable to choose CABG over PCI to improve sur...
...f CABG to improve survival is uncertai...
...fulness of PCI to improve survival is u...
...considered with the primary or sole...
...ess of CABG or PCI to improve survival is unce...
CABG or PCI should NOT be performed with the...
...larization to Improve Sympto...
...improve symptoms is beneficial in patient...
...improve symptoms is reasonable in patients with...
...ove symptoms is reasonable in patients with p...
...able to choose CABG over PCI to improve sym...
...ove symptoms might be reasonable for pat...
...ormed as an adjunct to CABG to improv...
...to improve symptoms should NOT be perfor...
...Antiplatelet Therapy (DAPT) Compliance and...
...coronary stenting (bare-metal stent [BMS] or...
...ronary Revascularization...
...ary revascularization (defined as t...
...ybrid coronary revascularization may be...
Follow-up
...low-up...
...ation, Echocardiography During Routin...
...ients with SIHD should receive periodic...
...LVEF and segmental wall motion by echocard...
...dic screening for important comorbidi...
...d ECG at 1-year or longer intervals between stu...
...nt of LV function with a technology...
...oninvasive Testing in Known...
...ollow-Up Noninvasive Testing in Patients W...
...tients Able to Ex...
...d exercise ECG testing is recommended in pa...
...th nuclear MPI or echocardiography i...
...ith nuclear MPI or echocardiography is reas...
...gical stress imaging with nuclear...
...Unable To Exercise...
...ogical stress imaging with nuclear M...
...ogical stress imaging with CMR is r...
...ercise ECG testing should NOT be performed...
...tive Of Ability To Exercise...
...or assessment of patency of CABG or of coron...
...ght be reasonable in patients with kno...
...NOT be performed for assessment of native cor...
...e 14. Follow-Up Noninvasive Testing in Pa...
...atients Able to Exerc...
...rcise ECG testing is recommended in patient...
Exercise with nuclear MPI or echocardiograp...
...ith nuclear MPI or echocardiography is reasonable...
...logical stress imaging with nuclear MPI...
...Unable to Exercise...
...logical stress imaging with nuclear MPI...
...armacological stress imaging with...
...se ECG testing should NOT be performed...
Irrespective of Ability to Exer...
...sment of patency of CABG or of coro...
...e reasonable in patients with known SIHD who h...
...A should NOT be performed for assessment of na...
...5. Noninvasive Testing in Known SIHD: As...
...be performed for assessment of nat...
...ercise ECG testing performed at 1-year or lon...
...atients who have no new or worsening sym...
...n patients who have no new or worseni...
...esting in Known SIHD— Asymptomatic (or Stable...
...hocardiography, or CMR with either...
...se ECG testing performed at ≥1-year...
...n patients who have no new or worsening sympt...
...echocardiography, or CMR, with either...