New Guidelines for Controlling Stable Ischemic Heart Disease

The new guidelines, a collaboration of the American College of Physicians (ACP; Philadelphia, PA, USA), the American College of Cardiology Foundation, the American Heart Association, the American Association for Thoracic Surgery, the Preventive Cardiovascular Nurses Association (PCNA; Madison, WI, USAt), and the Society of Thoracic Surgeons, stress that the primary focus of interventions in these patients should be reducing the risk of nonfatal myocardial infarct (MI) and premature cardiovascular death, while maintaining activity levels and a quality of life.

The guidelines, which focus on the initial approach to patient management, call for the elimination of all unhealthy behaviors, such as smoking, and promoting weight loss, physical activity, and a heart-healthy diet. The new guidelines also provide an algorithm that emphasizes an evidence-based set of pharmacologic interventions intended to reduce the risk of future events, including the use of antiplatelet agents, lipid-lowering drugs (particularly statins), and beta blockers. ACE inhibitors are recommended for many patients with stable IHD, such as those with diabetes or left ventricular dysfunction.

For revascularization to improve symptoms, coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI) is recommended in patients with one or more significant lesions. CABG surgery or PCI is not recommended in patients who do not meet the anatomic or physiologic criteria for revascularization. In addition, PCI should not be performed if the patient is unable or unlikely to comply with dual antiplatelet therapy.

In addition, the guidelines recommend CABG or PCI to improve survival in several clinical scenarios, such as in patients with stenosis of the left main coronary artery, patients with lesions in three major coronary arteries, or patients with presumed ischemia-mediated ventricular tachycardia caused by a stenosis in a major coronary artery. PCI or CABG surgery is not recommended to improve survival in patients with stable IHD with one or more coronary lesions that are not anatomically or functionally significant.

The guidelines also include 48 specific recommendations relevant for primary-care physicians and emphasize patient education, managing cardiovascular risk factors, a discussion of unproven risk-reduction strategies, use of medical therapy to prevent MI and death and to relieve angina symptoms, the use of revascularization to improve survival and symptoms, and patient follow-up. The new guidelines were published online on November 19, 2012, in Annals of Internal Medicine.

“Because of the variation in symptoms and clinical characteristics among patients, as well as their unique perceptions, expectations, and preferences, there is clearly no single correct approach to any given set of clinical circumstances,” concluded lead author Amir Qaseem, MD, of the ACP, and colleagues. “Patient education regarding various therapeutic options, appropriate levels of exercise, diet and weight control, and the importance of various clinical manifestations play a key role in achieving the treatment goal.”

Related Links:
American College of Physicians
Preventive Cardiovascular Nurses Association