2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease

Perspective:

The following are 10 points to remember from recent guidelines for the diagnosis and management of patients with stable ischemic heart disease (SIHD):

1. 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.

2. Coronary computed tomography angiography (CTA) is reasonable for patients with an intermediate pretest probability of IHD who: a) have continued symptoms with prior normal test findings, or b) have inconclusive results from exercise or pharmacological stress testing, or c) are unable to undergo stress testing with nuclear myocardial perfusion imaging (MPI) or echocardiography.

3. A normal exercise nuclear MPI study or a normal exercise stress echocardiogram during which the age-predicted target heart rate is achieved is associated with a very low annual risk of cardiac death and acute myocardial infarction (MI) (generally <1%) in both men and women.

4. Lifestyle modifications, including daily physical activity and weight management, are strongly recommended for all patients with SIHD. For all patients, the clinician should encourage 30-60 minutes of moderate-intensity aerobic activity, such as brisk walking, at least 5 days and preferably 7 days per week.

5. Treatment with aspirin 75-162 mg daily should be continued indefinitely in the absence of contraindications in patients with SIHD.

6. Beta-blocker therapy should be started and continued for 3 years in all patients with normal left ventricular function after MI or acute coronary syndrome. Angiotensin-converting enzyme inhibitors should be prescribed in all patients with SIHD who also have hypertension, diabetes mellitus, left ventricular ejection fraction of 40% or less, or chronic kidney disease, unless contraindicated.

7. Ranolazine can be useful when prescribed as a substitute for beta-blockers for relief of symptoms in patients with SIHD if initial treatment with beta-blockers leads to unacceptable side effects or is ineffective, or if initial treatment with beta-blockers is contraindicated.

8. Coronary artery bypass grafting (CABG) surgery is probably recommended in preference to percutaneous coronary intervention (PCI) to improve survival in patients with multivessel coronary artery disease and diabetes mellitus, particularly if a left internal mammary artery graft can be anastomosed to the left anterior descending artery.

9. Coronary CTA should not be performed for assessment of native coronary arteries with known moderate or severe calcification, or with coronary stents <3 mm in diameter in patients with known SIHD who have new or worsening symptoms not consistent with unstable angina, irrespective of ability to exercise.

10. Compared to patients receiving CABG, complete revascularization is accomplished less often in subjects receiving PCI (e.g., in <70% of patients), and the extent to which the absence of complete initial revascularization influences outcomes is less clear.

Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Atherosclerotic Disease (CAD/PAD), ACS and Cardiac Biomarkers, Aortic Surgery, Cardiac Surgery and Heart Failure, Heart Failure and Cardiac Biomarkers, Interventions and ACS, Interventions and Coronary Artery Disease, Interventions and Imaging, Echocardiography/Ultrasound, Exercise, Hypertension

Keywords: Life Style, Coronary Artery Disease, Angioplasty, Balloon, Coronary, Tomography, Hypertension, Echocardiography, Exercise Test, Myocardial Infarction, Myocardial Ischemia, Acute Coronary Syndrome, Ventricular Function, Left, Calcinosis, Piperazines, Proliferating Cell Nuclear Antigen, Heart Rate, Stents, Percutaneous Coronary Intervention, Walking, Death, Mammary Arteries, Coronary Artery Bypass, Diabetes Mellitus, Renal Insufficiency, Chronic


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