New clinical recommendations for diagnosing and treating stable ischemic heart disease

Six organizations representing physicians, other health care professionals, and patients today issued two new clinical practice guidelines for diagnosing and treating stable ischemic heart disease (IHD), which affects an estimated one in three adults in the United States. The guidelines and patient summaries appear in the November 20 issue of Annals of Internal Medicine, published by the American College of Physicians (ACP).

ACP, the American Association for Thoracic Surgery, the American College of Cardiology Foundation, the American Heart Association, the Preventive Cardiovascular Nurses Association, and the Society of Thoracic Surgeons collaborated to create the guidelines.

"Stable ischemic heart disease is a major public health issue," said David L. Bronson, MD, FACP, president, ACP. "Although survival of patients with the disease has been steadily improving, it was still responsible for nearly 380,000 deaths in the United States in 2010."

Evaluation of Patients with Stable Ischemic Heart Disease Guideline

The recommendations in "Evaluation of Patients with Stable Ischemic Heart Disease" address initial cardiac testing to diagnose stable IHD; cardiac stress testing to assess risk in patients with known stable IHD who are able to exercise, who are unable to exercise, and regardless of ability to exercise; coronary angiography as an initial testing strategy to assess risk in patients with stable IHD; and coronary angiography to assess risk after initial workup with noninvasive testing.

Angina—chest pain or discomfort occurring in an area of the heart that does not get enough blood—is often a symptom of stable IHD.

The organizations recommend that patients with chest pain should receive a thorough history and physical examination to assess the probability of stable IHD prior to additional testing. Choices regarding diagnostic and therapeutic options should be made through a process of shared decision making between the patient and physician to discuss the risks, benefits, and costs to the patient.

Management of Patients with Stable Ischemic Heart Disease Guideline

The recommendations in "Management of Patients with Stable Ischemic Heart Disease" address patient education, risk factor modification, medical therapy to prevent myocardial infarction and death, medical therapy and alternative therapy for relief of symptoms, revascularization, and patient follow-up.

Patients with stable IHD should have an individualized education plan to optimize care including education on the importance of medication adherence, an explanation of cardiovascular risk reduction strategies, a description of appropriate levels of daily physical activity, and information on how to recognize worsening cardiovascular symptoms and take appropriate action.

"Educating patients with stable IHD in the areas of weight control, proper nutrition, lipid management, blood pressure control, and smoking cessation may influence prognosis," said Dr. Bronson.

The organizations make the following recommendations for risk reduction strategies for patients with stable IHD because of their unproven benefit:

• estrogen therapy should not be initiated in postmenopausal women
• vitamin C, vitamin E, and beta-carotene supplementation should not be used
• treatment of elevated homocysteine with folate and/or vitamins B6 and B12 should not be used

The above therapies may be indicated in people with other conditions.

Regarding aspirin, the organizations recommend that 75-162 daily mg should be continued indefinitely in the absence of contraindications in patients with stable IHD.

Shared decision making should be utilized for revascularization surgery in patients with unprotected left main or complex coronary artery disease and should include a cardiac surgeon, interventional cardiologist, and the patient. The organizations recommend coronary artery bypass graft to improve survival for patients with significant narrowing of the left main coronary artery.

Patients with stable IHD should receive periodic follow-up at least annually that includes:

• assessment of symptoms and clinical function
• surveillance for complications of stable IHD including heart failure and arrhythmias
• monitoring of cardiac risk factors
• assessment of the adequacy of and adherence to recommended lifestyle changes and medical therapy

The guidelines are being published in Annals of Internal Medicine. The Journal of the American College of Cardiology is simultaneously publishing a longer version of the guidelines as one document.