ACP, other groups issue joint recommendations on stable ischemic heart disease

Two new clinical practice guidelines for diagnosing and treating stable ischemic heart disease (IHD) were released today by a collaboration of medical organizations.

The guidelines were issued by 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 and were published Nov. 20 by Annals of Internal Medicine and Journal of the American College of Cardiology.

The recommendations in “Diagnosis 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.

Because angina is often a symptom of stable IHD, the guidelines noted 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.

The guideline “Management of Patients with Stable Ischemic Heart Disease” addresses 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.

The organizations recommended against several potential risk reduction strategies because of their unproven benefit for patients with stable IHD:

• Estrogen therapy should not be initiated in postmenopausal women.
• Vitamin C, vitamin E, and beta-carotene supplementation should not be used.
• Elevated homocysteine should not be treated with folate and/or vitamins B6 and B12.

The above therapies may be indicated in people with other conditions, the guidelines noted. Aspirin therapy, in a 75- to 162-mg daily dose, should be continued indefinitely in the absence of contraindications in patients with stable IHD.

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; and
• assessment of the adequacy of and adherence to recommended lifestyle changes and medical therapy.

An accompanying editorial in Annals noted several surprising aspects to the guidelines, including recommendations for treadmill electrocardiography stress testing without imaging in women with intermediate-probability symptoms, which the editorialist said “may not match common clinical practice, but … probably should,” and initial testing with stress imaging for all patients with prior revascularization, which the editorialist said “may not match current practice but 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.”