Societies advise tailored approach to stable ischemic heart disease

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 - Vitals Bedside

Proper treatment of stable ischemic heart disease (SIHD) requires an individualized approach developed in consultation with the patient, but is often best managed through appropriate lifestyle changes and drug therapy, according to Guidelines for the Diagnosis and Management of Patients with Stable Ischemic Heart Disease, released Nov. 19 by the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and endorsed by several other societies.

According to the executive summary, ischemic heart disease (IHD) is the leading cause of death in adults in the U.S., killing 380,000 people in 2010. Considering the contribution that IHD makes to the morbidity and mortality of all cardiac diseases, the guidelines estimate the cost of caring for patients with IHD exceeds $150 billion.

Even so, many patients with SIHD have few or no symptoms and are able to participate in normal activities. They remain at higher risk of heart attack and other cardiac problems, however, so the guidelines recommend that physicians closely monitor and manage these patients.

The guidelines emphasize thorough examination and testing to identify the cause of a patient’s chest pain, but are careful to distinguish between tests to ascertain the cause of a patient’s symptoms and tests to assess risk of MI or other serious cardiac event. When a patient presents with no known IHD, the guidelines urge practitioners to take a careful history and analyze the characteristics of a patient’s pain to determine whether the patient is at high risk of IHD before doing further testing.

The guidelines recommended ECG and stress testing for patients with an interpretable resting ECG and myocardial perfusion imaging or echocardiogram with exercise stress test for those patients with ambiguous results on resting ECGs. The guidelines advise pharmacological stress testing for patients unable to exercise. Cardiac CT angiography and pharmacological cardiac MR are recommendeded only for patients known to be at high risk or for whom stress testing is contraindicated. The guidelines encouraged a stepped system of testing based on the patient’s history and risk factors, clinical presentation and likelihood of IHD, with the more sophisticated and/or invasive tests appropriate for those who are considered likely to have coronary lesions.

For most patients with SIHD, the guidelines promote Guidelines-Directed Medical Therapy (GDMT), an assortment of therapies directed at reducing or eliminating the patient’s symptoms and managing the patient’s risk of serious cardiac events. They recommended that physicians choose therapeutic strategies in conjunction with the patient, selecting those therapies that are most likely to be beneficial given patient’s circumstances and health status, including the patient’s ability and willingness to make necessary lifestyle changes. 

The guidelines recommended statins and antiplatelet medications such as aspirin for patients with SIHD, unless contraindicated. Beta blockers and drugs to control hypertension and diabetes also fall within GDMT.

Revascularization is recommendeded to improve survival in cases where the patient has anatomically or functionally significant stenosis, or certain other high-risk conditions. The guidelines also support revascularization to improve symptoms in patients with significant stenosis of at least one artery as well as unacceptable angina whose symptoms have not been relieved through GDMT.

The guidelines recommended close monitoring of the stable patient, with at least annual follow-up and testing if changes in functioning or symptoms occur.

Throughout the guidelines, the emphasis is on addressing the particular needs and preferences of the patient. The range of acceptable therapies under the guidelines depends upon the patient’s anatomical and functional condition, lifestyle factors, severity of symptoms and their impact on the patient’s activities.

The American College of Physicians, the American Association for Thoracic Surgery, the Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons also participated in developing the guidelines. The guidelines are available online at the Annals of Internal Medicine; the executive summary is available online at the Journal of the American College of Cardiology, where the guidelines will be published Dec. 18. The American College of Cardiology and the Society of Cardiovascular Angiography and Interventions also are posting guideline information.