2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons


The following are 10 points to remember from the 2014 Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease (SIHD):

1. The 2014 SIHD update includes a section on the role of coronary angiography for the diagnosis of coronary artery disease (CAD). A Class IIb (Level of Evidence: C) recommendation is given for the consideration of coronary angiography in patients with stress test results that do not suggest the presence of CAD when a high clinical suspicion of CAD persists and there is a high likelihood that the findings will result in changes in medical management.

2. For patients with suspected SIHD who have indeterminate or nondiagnostic stress tests or who cannot undergo such noninvasive evaluation, coronary angiography is reasonable if there is a high likelihood that the findings will result in important changes to therapy (Class IIa Level of Evidence: C).

3. The ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) trial may provide guidance on when to perform diagnostic angiography. In this trial, patients with at least moderate ischemia on stress testing are randomized to a strategy of optimal medical therapy alone or routine cardiac catheterization followed by revascularization (if and when appropriate) plus optimal medical therapy.

4. Several studies have suggested that a percutaneous coronary intervention (PCI) strategy guided by fractional flow reserve may be superior to a strategy guided by angiography and visual assessment alone.

5. The update includes a modified class of recommendation and level of evidence for the use of chelation therapy (with intravenous infusions of disodium ethylene diamine tetracetic acid [EDTA]). The 2012 recommendations assigned a Class III recommendation for such therapy. The update offers a Class IIb recommendation (Level of Evidence: B), indicating that ‘the usefulness of chelation therapy is uncertain for reducing cardiovascular events in patients with stable ischemic heart disease.’ Disodium EDTA is currently not approved for use in preventing or treating cardiovascular disease.

6. Enhanced external counterpulsation (EECP) may be considered for relief of refractory angina in patients with SIHD (Class IIb, Level of Evidence: B). Contraindications for EECP include decompensated heart failure, peripheral artery disease, and severe aortic regurgitation.

7. The update offers a new recommendation for ‘a Heart Team approach to revascularization in patients with diabetes mellitus and complex multivessel CAD’ (Class I, Level of Evidence: C). The authors write, ‘The Heart Team involves a multidisciplinary approach composed of an interventional cardiologist and a cardiac surgeon who jointly 1) review the patient’s medical condition and coronary anatomy, 2) determine that PCI and/or coronary artery bypass grafting (CABG) are technically feasible and reasonable, and 3) discuss revascularization options with the patient before a treatment strategy is selected.’

8. Major clinical outcomes in selected patients with left main CAD are similar with CABG and PCI at 1- and 2-year follow-up. However, repeat revascularization rates are higher after PCI, compared to CABG.

9. The update offers a modified recommendation (previously Class II, now Class I) for CABG in preference to PCI to improve survival in patients with diabetes mellitus and multivessel CAD.

10. In most patients with diabetes mellitus and complex multivessel disease, CABG appears to be associated with lower risk of mortality than PCI. In the FREEDOM (Future Revascularization Evaluation in Patients With Diabetes Mellitus: Optimal Management of Multivessel Disease) trial, the primary outcome (a composite of death, nonfatal myocardial infarction, or nonfatal stroke) occurred more frequently in the PCI group (p = 0.005) with 5-year rates of 26.6% and 18.7%, respectively.

Keywords: Coronary Artery Disease, Myocardial Infarction, Stroke, Follow-Up Studies, Cardiac Catheterization, Peripheral Arterial Disease, Ethylenes, Counterpulsation, Angioplasty, Balloon, Coronary, Chelation Therapy, Edetic Acid, Coronary Angiography, Heart Failure, Infusions, Intravenous, Coronary Artery Bypass, Diabetes Mellitus, Exercise Test

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