Treatment Guidelines for Stable Ischemic Heart Disease Also Offer Recommendations for Patients with Angina

Recently released guidelines for the diagnosis and management of stable ischemic heart disease focus on evaluation and testing, risk factor modification, medical therapy and other therapeutic options, and follow-up.

The American College of Physicians (ACP), the American Association for Thoracic Surgery (AATS), the American College of Cardiology Foundation (ACCF), the American Heart Association (AHA), the Preventive Cardiovascular Nurses Association (PCNA), and the Society of Thoracic Surgeons (STS) recently collaborated to publish updated clinical practice guidelines for the diagnosis and management of stable ischemic heart disease (IHD).

According to the executive summary, the guidelines are “intended to apply to adult patients with stable known or suspected IHD, including new-onset chest pain (i.e., low-risk unstable angina [UA]), or to adult patients with stable pain syndromes,” which includes “who have ‘ischemic equivalents,’ such as dyspnea or arm pain with exertion.”

The guideline also addresses “the initial diagnostic approach to patients who present with symptoms that suggest IHD, such as anginal-type chest pain, but who are not known to have IHD.” When managing these patients, clinicians should “ascertain whether such symptoms represent the initial clinical recognition of chronic stable angina, reflecting gradual progression of obstructive CAD or an increase in supply/demand mismatch precipitated by a change in activity or concurrent illness (such as anemia or infection), or whether they represent an acute coronary syndrome (ACS), most likely due to an unstable plaque causing acute thrombosis.”

In addition to being appropriate for use with patients with newly diagnosed stable angina, the guideline also addresses the management of patients with unstable angina “who can be categorized as low risk.”

Some of the recommendations in the guideline that pertain to the diagnosis and management of patients with chest pain/angina include:

• Patients with chest pain should receive a thorough history and physical examination to assess the probability of IHD before additional testing.
• Patients who present with acute angina should be categorized as stable or unstable; patients with UA should be further categorized as being at high, moderate, or low risk
• Coronary angiography for risk assessment is reasonable for patients with SIHD who have unsatisfactory quality of life due to angina, have preserved LV function (ejection fraction >50%), and have intermediate risk criteria on noninvasive testing
• Patients with SIHD should be educated about common symptoms of stress and depression to minimize stress-related angina symptoms
• Sublingual nitroglycerin or nitroglycerin spray is recommended for immediate relief of angina in patients with SIHD
• Enhanced external counterpulsation, spinal cord stimulation, and transmyocardial revascularization may be considered for relief of refractory angina in patients with SIHD
• PCI to improve survival is reasonable in patients with unstable angina/non—ST-elevation MI when an unprotected left main coronary artery is the culprit lesion and the patient is not a candidate for CABG
• CABG or PCI to improve symptoms is beneficial in patients with 1 or more significant (≥70% diameter) coronary artery stenoses amenable to revascularization and unacceptable angina despite GDMT
• CABG or PCI to improve symptoms is reasonable in patients with 1 or more significant (≥70% diameter) coronary artery stenoses and unacceptable angina for whom GDMT cannot be implemented because of medication contraindications, adverse effects, or patient preferences
• PCI to improve symptoms is reasonable in patients with previous CABG, 1 or more significant (≥70% diameter) coronary artery stenoses associated with ischemia, and unacceptable angina despite GDMT