Guidelines Update Approaches to Stable Ischemic Heart Disease

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Algorithms Enhance Clinical Value

The revised guidelines provide some surprises, noted Dr. William G. Kussmaul III. Although the recommendation for treadmill ECG stress testing without imaging in women who have intermediate-probability symptoms "may not match common clinical practice," Dr. Kussmaul noted, "it probably should."

In addition, the recommendation for initial testing with stress imaging for all patients who’ve had prior revascularization "makes good clinical sense, because it tells us not only if the chest pain is ‘real,’ but also how large a region of myocardium is at risk," he explained.

Dr. Kussmaul found the absence of CT coronary calcium scoring from the diagnostic algorithm surprising, given that it involves less radiation than coronary computed tomography angiography and requires no contrast. In addition, "a coronary calcium score of zero drastically reduces the probability of having significant coronary disease," he noted.

While the evaluation and management guidelines provide sound guidance, Dr. Kussmaul said, "digesting the 28 recommendations for diagnosis and 48 for management is daunting. Fortunately, the guidelines also contain algorithm figures that are clear, usable, and comprehensive.

"My advice: Go straight to the algorithms," he said.

Dr. Kussmaul is at Hahnemann University Hospital, Philadelphia. These remarks were taken from his editorial accompanying the publication of the two clinical practice guidelines (Ann. Intern. Med. 2012;157:749-51).



Updated clinical guidelines on stable ischemic heart disease should help primary care physicians navigate the complex and growing array of options to diagnose and treat the condition formerly known as chronic stable angina.

Revised by six medical organizations and published online Nov. 19 in Annals of Internal Medicine, the evaluation and management guidelines incorporate the best available evidence concerning known and suspected stable ischemic heart disease (SIHD) in adults.

The target audience for the guidelines is primary care clinicians who treat these patients, said Dr. Amir Qaseem and his associates on the clinical guidelines committee of the American College of Physicians, Philadelphia.

In the clinical practice guideline for evaluating patients with known or suspected SIHD, there are 28 recommendations that address initial cardiac testing to establish the diagnosis; cardiac stress testing in diagnosed patients to assess their risk of myocardial infarction or death; and coronary angiography for risk assessment.

Cardiac stress testing "is indicated in most symptomatic patients suspected of having SIHD to establish the diagnosis, and it is indicated in most patients with both suspected and established SIHD to identify [those] at very high risk for death or MI who might have lesions where anatomic intervention could be beneficial," stated the evaluation guideline’s executive summary.

Also helpful in establishing the diagnosis is resting ECG. And in patients with clinically evident ventricular dysfunction, rest echocardiography and radionuclide imaging are helpful.

Overall, "Physicians should integrate the information from their clinical evaluation with patient preferences when making decisions about further testing. Two patients with the same pretest probability of SIHD may prefer different approaches because of variations in personal beliefs, economic considerations, or stage of life," said Dr. Qaseem, who is also at Jefferson Medical College, Philadelphia, and his associates.

This clinical practice guideline includes detailed algorithms for diagnosing patients who are suspected of having SIHD, and for assessing risk in those who are known to have SIHD, which may be particularly helpful for clinicians in primary care practice.

The second guideline, for management of SIHD, includes 48 specific recommendations that address patient education, management of known risk factors (dyslipidemia, hypertension, diabetes, low levels of physical activity, overweight/obesity, and smoking), medical therapy to prevent MI and death, medical therapy to relieve symptoms, revascularization to improve symptoms, revascularization to improve survival, and patient follow-up.

"The goals of managing patients with SIHD include reducing premature cardiovascular death and nonfatal MI while maintaining a level of activity, functional capacity, and quality of life that is satisfactory to the patient," according to the management guideline’s executive summary.

Of particular interest is the finding that there is not sufficient high-quality evidence to support using estrogen therapy in postmenopausal women as a means to limit their cardiovascular risk. Similarly, supplementation with vitamin C, vitamin E, or beta-carotene is of unproven benefit for SIHD and is not recommended. And elevated homocysteine levels should not be treated with folate and/or vitamins B6 and B12.

Patients who have SIHD should receive 75-162 mg per day of aspirin indefinitely, as long as there are no contradindications. They also should be followed at least annually so that symptoms and clinical function can be assessed, complications of SIHD such as heart failure and arrhythmias can be tracked, cardiac risk factors can be monitored, and adherence to lifestyle changes and medical therapy can be assessed.

This guideline also includes detailed algorithms for tailoring medical therapy to patients’ individual needs, for choosing revascularization to improve survival, and for choosing revascularization to improve symptoms.

Besides the ACP, the other organizations that jointly developed the guidelines are the American College of Cardiology Foundation, the American Heart Association, the American Association for Thoracic Surgery, the Preventive Cardiovascular Nurses Association, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons.

The full clinical practice guidelines are available at and are being published simultaneously in the Journal of the American College of Cardiology.

The American College of Physicians financed the development of these clinical practice guidelines. Potential conflicts of interest can be accessed at

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