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New Guidelines Address Diagnosis, Treatment of Stable Ischemic Heart Disease
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Six organizations, including the American Heart Association, American College of Cardiology Foundation and American College of Physicians, have issued two new clinical practice guidelines for diagnosing and treating patients with stable ischemic heart disease.
The joint guidelines, which also include the American Association for Thoracic Surgery, The Society of Thoracic Surgeons and the Preventive Cardiovascular Nurses Association, were published in the Annals of Internal Medicine. A longer version was published simultaneously in the Journal of the American College of Cardiology.
Patient Evaluation
In the “Evaluation of Patients with Stable Ischemic Heart Disease” guidelines, the organizations make recommendations on diagnosing patients with this condition. These include initial cardiac testing to diagnose stable ischemic heart disease (IHD); cardiac stress testing to assess the risk in patients with known stable IHD who are able to exercise, unable to exercise and regardless of exercise ability; and coronary angiography as an initial testing strategy to determine risk in patients with stable IHD and to assess risk after initial workup with noninvasive testing.
Amir Qaseem
Regarding angiography, Amir Qaseem, MD, PhD, MHA, one of the authors of the guidelines, told Cardiology Today’s Intervention that “it is recommended to assess cardiac risk in patients whose clinical characteristics and results of non-invasive testing indicate a high likelihood of severe IHD and the benefits outweigh the risks,” he said. “It should not be utilized in patients who elect not to undergo revascularization or who are not good candidates for revascularization, such as patients with comorbid conditions.”
The organizations also recommend patients with angina receive a thorough history and physical examination to determine the likelihood of stable IHD before additional testing, and that patients who present with acute angina be categorized as stable or unstable. Additionally, they advise that choices regarding diagnostic and therapeutic options be made through a process of shared decision making that involves the patient and provider, and explains information about risks, benefits and costs.
Patient Management
The second set of guidelines, “Management of Patients with Stable Ischemic Heart Disease,” involves specific recommendations relevant to the primary care setting. The guidelines address the role of patient education, risk factor management, medical therapy to prevent MI and death and to relieve symptoms, alternative therapy, revascularization to improve survival and symptoms, and patient follow-up.
The authors suggest that to optimize care, patients with stable IHD should have an individualized education plan that addresses medication adherence and management, and includes a comprehensive review of all therapeutic options. Patients should also be educated on following lifestyle elements that may influence prognosis, such as weight and BP control, lipid management and smoking cessation.
“Most physicians know that patient education and individualized education plans are extremely important, but it is really critical that they keep stressing it to their patients,” Qaseem said. “The problem is physicians are short of time; however, it is important to talk to your patients so that they understand the importance of lifestyle changes and medication adherence.”
In addition, the organizations recommend not using several strategies of unproven benefit with the intent to reduce CV risk or improve clinical outcomes in patients with stable IHD. These include estrogen in postmenopausal women; supplementation with beta-carotene and vitamins C and E; elevation of homocysteine with folate and/or vitamins B6 and B12; chelation therapy; and treatment with garlic, coenzyme Q10, selenium or chromium.
According to the guidelines, the choice of revascularization strategy in cases of unprotected left main or complex CAD should involve a shared decision-making approach that includes a cardiac surgeon, interventional cardiologist and the patient.
Periodic follow-up at least once a year should also be part of the equation, the authors said.
Disclosure: Qaseem reports no relevant financial disclosures.