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New
Guidelines Outline the ABCs (and the Ds and the Es)
of Treating Stable Angina
(Jun. 1, 1999) Comprehensive recommendations on treating
patients with a common heart problem, called chronic
stable angina, have been compiled for the first time,
filling an important gap in evidence-based resources
for physicians. Three major national medical organizations
have joined forces to publish this information on stable
angina, a significant source of cardiovascular morbidity
and mortality that affects more than 10 million Americans—with
associated costs that are measured in tens of billions
of dollars.
Ischemic heart disease is the leading cause of death
in the United States. The most common manifestation
of this disease is chronic stable angina. Angina is
characterized by discomfort in the chest, jaw, shoulder,
back, or arm and is typically aggravated by exertion
or emotional stress. It occurs when the heart muscle
doesn't receive enough oxygen, either from narrowed
arteries caused by cholesterol deposits or from hypertension
or valvular disease. Stable angina has a predictable
pattern for a prolonged time. Unstable angina
is characterized by symptoms that are new or increasing.
The guidelines do not address unstable angina.
The complete "ACC/AHA/ACP-ASIM Guidelines for the Management
of Chronic Stable Angina" appear in the June issue of
the Journal of the American College of Cardiology.
An executive summary appears in the June 7 issue of
Circulation: Journal of the American Heart Association.
The American College of Cardiology (ACC) and the American
Heart Association (AHA) have an ongoing partnership
to produce practice guidelines. The ACC and the AHA
have been joined by the American College of Physicians-American
Society of Internal Medicine (ACP-ASIM) to produce this
guideline, reflecting the frequency that internists
encounter patients suffering from angina.
"The
cooperation of these three groups indicates the importance
of the problem of chronic stable angina," said Dr. Raymond
Gibbons, a cardiologist at the Mayo Clinic in Rochester,
Minn., and chair of the committee that wrote the guidelines.
"The role of the ACP-ASIM in these guidelines is a reflection
of the large number of stable angina patients who are
being treated by general internists."
The guidelines are divided into four sections: diagnosis,
risk stratification, treatment, and patient follow up.
In addition, a simple treatment mnemonic—ABCDE—is
provided for ten items that are of fundamental importance
to the care of people with chronic stable angina:
- Aspirin,
Anti-anginal drugs
- Blood
pressure control, Beta blocker drugs
- Cholesterol,
Cigarettes
- Diet,
Diabetes
- Exercise,
Education of the patient
The
new guidelines encourage physicians and patients to take
advantage of proven therapies that now are often underutilized.
"Given the ongoing explosion of knowledge about cardiovascular
disease, physicians may not always be aware of all of
the latest advances. These guidelines will help physicians
improve care," said Dr. Gibbons. For example, lipid-lowering
therapy has now been shown to reduce deaths and heart
attacks in patients with coronary artery disease. "Physicians
need to recognize that lipid-lowering therapy is now clearly
proven to improve patient outcome."
The guidelines also point out that many commonly used
therapies have not yet been shown to be beneficial or
effective. "Although there's been a wave of enthusiasm
for vitamin E and vitamin C, the committee felt that
current evidence doesn't support their use as routine
therapy," said Dr. Gibbons. He also cited the use of
electron beam computed tomography, which despite an
increase in popularity in recent years has not been
demonstrated to be clinically beneficial.
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