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2012 Stable Ischemic Heart Disease (SIHD) Guideline Update
Core Slide: Stable Ischemic Heart Disease (SIHD) Guideline Update Jointly sponsored for CME credit by the University of Nebraska Medical Center and Practice Point Communications, Inc. Supported by an independent educational grant from Gilead Sciences Medical Affairs
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Content Development Faculty
Julius M. Gardin, MD, MBA, FACC, FACP, FAHA Professor and Chair Department of Medicine Hackensack University Medical Center Professor of Medicine University of Medicine and Dentistry of New Jersey New Jersey Medical School Hackensack, NJ Core Slide: Content Development Faculty
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Disclosure Information: Content Development Faculty
Julius M. Gardin, MD, MBA, FACC, FACP, FAHA Honorarium Gilead Sciences Core Slide: Disclosure Information: Content Development Faculty
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Copyright & Permissions
2012 SIHD Guidelines Update is Copyrighted 2013 by Practice Point Communications, unless otherwise noted. All rights reserved. Participants may use these slides for their educational presentations but may not publish or post online without permission from Practice Point Communications, Inc. Core Slide: Disclosure Information: Content Development Faculty
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Learning Objectives (CME/CNE/CPE)
At the completion of this educational activity, participants should be able to: Apply diagnostic modalities in symptomatic patients with suspected stable ischemic heart disease (SIHD) based on the ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease Risk stratify my patients with SIHD for the probability of developing complications based on the ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease Appropriately select optimal medical therapy and revascularization for my patients with SIHD based on the ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease Core Slide: Learning Objectives (CME/CNE/CPE) At the completion of this educational activity, participants should be able to: Apply diagnostic modalities in symptomatic patients with suspected stable ischemic heart disease (SIHD) based on the ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease. Risk stratify my patients with SIHD for the probability of developing coronary artery disease based on the ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease. Appropriately select optimal medical therapy and revascularization for my patients with SIHD based on the ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease.
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Spectrum of Ischemic Heart Disease: Relevant Guidelines
Asymptomatic (SIHD) Asymptomatic, Without Known IHD (CV Risk) New-Onset Chest Pain (SIHD, UA/NSTEMI, STEMI) Stable Angina or Low-Risk UA* (SIHD, PCI/CABG) Known IHD Core Slide: Spectrum of Ischemic Heart Disease: Relevant Guidelines The 2012 guideline for the diagnosis and management of SIHD is intended to apply to adult patients with stable known or suspected IHD, including new-onset chest pain (ie, low-risk unstable angina [UA]), or to adult patients with stable pain syndromes.1 Patients who have “ischemic equivalents,” such as dyspnea or arm pain with exertion, are included in the latter group. Many patients with IHD can become asymptomatic with appropriate therapy.1 Reference Fihn SD, Gardin JM, Abrams J, et al ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol. 2012;60:e44-e164. Non-Cardiac Chest Pain Acute Coronary Syndromes (UA/NSTEMI, STEMI, PCI/CABG) Sudden Cardiac Death (VA-SCD) Known IHD Relevant guidelines are in parentheses. *UA: features of low-risk unstable angina include age <70 years, exertional pain lasting <20 minutes, pain not rapidly accelerating, normal or unchanged ECG, no elevation of cardiac markers. Fihn SD, et al. J Am Coll Cardiol. 2012;60:e44-e164.
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2012 ACCF/AHA Guideline for the Diagnosis and Management of SIHD
Choices regarding diagnostic and therapeutic options should be made through a process of shared decision making Patient and provider Explain Risks Benefits Costs Core Slide: ACCF/AHA Guideline for the Diagnosis and Management of SIHD A key premise of the 2012 guideline is that diagnostic and therapeutic options should be selected through a process of shared decision making between the patient and provider where all the risks, benefits, and costs are explained.1 Reference Fihn SD, Gardin JM, Abrams J, et al ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol. 2012;60:e44-e164. Fihn SD, et al. J Am Coll Cardiol. 2012;60:e44-e164.
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ACCF/AHA Classification of Recommendations and Levels of Evidence
Size of Treatment Effect Class I Benefit >>> Risk (SHOULD be performed/administered) Class IIa Benefit >> Risk (IT IS REASONABLE to be performed/administered Tx) Class IIb Benefit > Risk (Procedure/treatment MAY BE CONSIDERED) Class III No Benefit or Harm Estimate of Certainty (Precision) of Treatment Effect Level A Multiple populations evaluated Multiple randomized clinical trials or meta- analyses Level B Limited populations evaluated Single randomized or non-randomized studies Level C Very limited populations evaluated Expert consensus opinion, case studies, or standard of care Is useful/effective Sufficient evidence Favors being useful/effective Some conflicting evidence Usefulness and efficacy less well established Greater conflicting evidence Not useful or effective Some conflicting evidence Not useful or effective or may be harmful Evidence from single randomized trial or non- randomized studies Is useful/effective Evidence from single randomized trial or non- randomized studies Favors being useful/effective Some conflicting evidence Usefulness or efficacy less well established Greater conflicting evidence Core Slide: ACCF/AHA Classification of Recommendations and Levels of Evidence This slide outlines the grading system used to categorize the overall size of treatment effect and estimate the certainty (precision) of treatment effect from key studies that formed the basis of each recommendation.1 Reference Fihn SD, Gardin JM, Abrams J, et al ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol. 2012;60:e44-e164. Is useful or effective Only expert opinion, case studies, or standard of care Favors being useful or effective Only diverging expert opinion, case studies, or standard of care Usefulness or efficacy less well established Only diverging expert opinion, case studies, or standard of care Not useful or effective or may be harmful Only expert opinion, case studies, or standard of care Fihn SD, et al. J Am Coll Cardiol. 2012;60:e44-e164.
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ACP Interpretation of ACCF/AHA SIHD Guideline: Key Diagnostic Questions
Diagnosis Management How should a clinician evaluate a patient with chest pain that is consistent with IHD? What is the role of non-invasive and angiographic testing in the diagnosis of SIHD? What should be the approach to modifying cardiovascular risk factors to reduce the mortality and morbidity associated with SIHD? What is the role of coronary revascularization in reducing mortality and morbidity associated with SIHD? How should chronic anginal symptoms be managed with medications? Core Slide: ACP Interpretation of ACCF/AHA SIHD Guideline: Key Diagnostic Questions The American College of Physicians synthesized the 2012 guideline for its members with the goal of answering key questions on diagnosis and management.1,2 The key questions for diagnosis were:2 How should a clinician evaluate a patient with chest pain that is consistent with IHD? What is the role of non-invasive and angiographic testing in the diagnosis of SIHD? References Qasseem A, Fihn SD, Williams S, et al. Diagnosis of stable ischemic heart disease: summary of a clinical practice guideline from the American College of Physicians/American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med. 2012;157: Qasseem A, Fihn SD, Dallas P, et al. Management of stable ischemic heart disease: summary of a clinical practice guideline from the American College of Physicians/American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med. 2012;157: Qaseem A, et al. Ann Intern Med. 2012;157: Qaseem A, et al. Ann Intern Med. 2012;157:
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Diagnosis: Suspected IHD (or Change in Clinical Status in Known IHD Patient)
Intermediate or High-Risk Unstable Angina No Yes Comprehensive Clinical Assessment of Risk Personal Characteristics Coexisting Cardiac and Medical Conditions Health Status See ACCF/AHA UA/NSTEMI Guidelines Symptoms or findings suggest high-risk lesion(s)? OR Prior sudden death or serious ventricular arrhythmia? Prior stent in unprotected left main coronary artery? Initiate Guideline-Directed Medical Therapy (consider coronary revascularization to improve survival) Core Slide: Diagnosis: Suspected IHD (or Change in Clinical Status in Known IHD Patient) This flow diagram provides an overview of evaluating suspected IHD patients, with a key decision point of determining if the patient is at intermediate or high-risk of unstable angina.1,2 References Fihn SD, Gardin JM, Abrams J, et al ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol. 2012;60:e44-e164. Qasseem A, Fihn SD, Williams S, et al. Diagnosis of stable ischemic heart disease: summary of a clinical practice guideline from the American College of Physicians/American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med. 2012;157: Yes No Continue Assessment Initiate or continue Guideline-Directed Medical Therapy Fihn SD, et al. J Am Coll Cardiol. 2012;60:e44-e164. Qaseem A, et al. Ann Intern Med. 2012;157:
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Clinical Classification of Chest Pain
Typical angina (definite) Substernal chest discomfort with a characteristic quality and duration that is Provoked by exertion or emotion and Relieved by rest or nitroglycerin Atypical angina (probable) Meets 2 of the characteristics of typical angina Non-cardiac chest pain Meets <1 of the typical anginal characteristics Slide: Clinical Classification of Chest Pain The 2012 guideline uses the following clinical classification of chest pain:1-3 Typical angina (definite): substernal chest discomfort with a characteristic quality and duration that is provoked by exertion or emotion and relieved by rest or nitroglycerin. Atypical angina (probable): meets 2 of the characteristics of typical angina. Non-cardiac chest pain: meets <1 of the typical anginal characteristics. References Cannon CP, Braunwald E. In: Bonow RO, Mann DL, Zipes DP, et al. eds. Braunwald’s Heart Disease. A Textbook of Cardiovascular Medicine. 9th Edition. Saunders Elsevier; Philadelphia, PA. 2012:1178. Fihn SD, Gardin JM, Abrams J, et al ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol. 2012;60:e44-e164. Qasseem A, Fihn SD, Williams S, et al. Diagnosis of stable ischemic heart disease: summary of a clinical practice guideline from the American College of Physicians/American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med. 2012;157: Cannon CP, et al. In: Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 9th Edition Fihn SD, et al. J Am Coll Cardiol. 2012;60:e44-e164. Qaseem A, et al. Ann Intern Med. 2012;157:
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Pretest Likelihood of CAD by Cardiac Catheterization in Symptomatic Patients (Diamond/Forrester and CASS) Non-Anginal Chest Pain Atypical Angina Typical Angina Female Male Female Male Female Male 93% 94% 87% 86% 76% 72% 73% 65% 55% Likelihood of CAD (%) Likelihood of CAD (%) 51% Likelihood of CAD (%) 51% Core Slide: Pretest Likelihood of CAD by Cardiac Catheterization in Symptomatic Patients (Diamond/Forrester and CASS) The Diamond and Forrester probabilities were compared with those published in the Coronary Artery Surgery Study (CASS), a large 15-center study that compared clinical and angiographic findings in more than 20,000 patients. In both studies, probability tables were presented in which patients were categorized by age, gender, and pain type. Tables with 24 patient groupings were published.1-3 With the exception of adults younger than 50 years of age with atypical angina, for whom the CASS data estimated a probability of disease is 17% higher than the Diamond-Forrester data, the agreement between studies was very close: the difference averaged 5%. Because the results were so similar, the committee combined the probabilities from both studies in one evidence table, which is illustrated here in graphic form.1-3 Notice that a woman aged 60 to 69 years with non-anginal chest pain had a 14% likelihood of CAD where a similarly aged male had a 27% likelihood. For a woman and man aged 60 to 69 years with atypical angina, the likelihood of CAD was 51% and 72%, respectively.1-3 Note that the Diamond/Forrester model overestimates likelihood of CAD in women compared with the WISE study and also does not include data in those >70 years of age.1-3 References Diamond GA, Forrester JS. Analysis of probability as an aid in the clinical diagnosis of coronary-artery disease. N Engl J Med. 1979;300: Chaitman BR, Bourassa MG, Davis K, et al. Angiographic prevalence of high-risk coronary artery disease in patient subsets (CASS). Circulation. 1981;64: Fihn SD, Gardin JM, Abrams J, et al ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol. 2012;60:e44-e164. 34% 31% 27% 26% 22% 20% 13% 14% 12% 7% 4% 2% 3% 30-39 40-49 50-59 60-69 30-39 40-49 50-59 60-69 30-39 40-49 50-59 60-69 Age (years) Age (years) Age (years) CASS: Coronary Artery Surgery Study. Diamond GA, et al. N Engl J Med. 1979;300: Chaitman BR, et al. Circulation. 1981;64: Fihn SD, et al. J Am Coll Cardiol. 2012;60:e44-e164.
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2012 ACCF/AHA Guideline Criteria for Non-Invasive Risk Stratification
Low risk (<1% annual death or MI) Low-risk treadmill score (score >5) or no new ST-segment changes or exercise-induced chest pain symptoms, when achieving maximal levels of exercise Normal or small myocardial perfusion defect at rest or with stress encumbering <5% of myocardium* Normal stress echocardiographic wall motion or no change of limited resting wall motion abnormalities during stress* CAC <100 Agatston units No coronary stenosis >50% on CCTA Core Slide: ACCF/AHA Guideline Criteria for Non-Invasive Risk Stratification Non-Invasive test findings that identify patients at low risk (<1% annual mortality rate) include:1 Low-risk Duke treadmill score (score >5) or no new ST-segment changes or exercise-induced chest pain symptoms, when achieving maximal levels of exercise Normal or small myocardial perfusion defect at rest or with stress encumbering <5% of myocardium* Normal stress echocardiographic wall motion or no change of limited resting wall motion abnormalities during stress* CAC <100 Agatston units No coronary stenosis >50% on CCTA Reference Fihn SD, Gardin JM, Abrams J, et al ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol. 2012;60:e44-e164. *Although published data are limited, patients with these findings will probably not be at low risk in the presence of either a high-risk treadmill score or severe resting LV dysfunction (LV ejection fraction <35%). CAC: coronary artery calcium; CCTA: coronary CT angiography. Fihn SD, et al. J Am Coll Cardiol. 2012;60:e44-e164.
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2012 ACCF/AHA Guideline Criteria for Non-Invasive Risk Stratification
Intermediate risk (1% to 3% annual mortality rate) Mild/moderate resting LV dysfunction (LVEF 35% to 49%) not readily explained by non-coronary causes Resting perfusion abnormalities in 5% to 9.9% of the myocardium in patients without a history or prior evidence of MI >1 mm of ST-segment depression occurring with exertional symptoms Stress-induced perfusion abnormalities encumbering 5% to 9.9% of the myocardium or stress segmental scores (in multiple segments) indicating 1 vascular territory with abnormalities but without LV dilation Small wall motion abnormality involving 1 to 2 segments and only 1 coronary bed CAC score 100 to 399 Agatston units 1-vessel CAD with >70% stenosis or moderate CAD stenosis (50% to 69% stenosis) in >2 arteries on CCTA Core Slide: ACCF/AHA Guideline Criteria for Non-Invasive Risk Stratification Non-invasive test findings that identify patients at intermediate risk (1% to 3% annual mortality rate) include:1 Mild/moderate resting LV dysfunction (LVEF 35% to 49%) not readily explained by noncoronary causes Resting perfusion abnormalities in 5% to 9.9% of the myocardium in patients without a history or prior evidence of MI >1 mm of ST-segment depression occurring with exertional symptoms Stress-induced perfusion abnormalities encumbering 5% to 9.9% of the myocardium or stress segmental scores (in multiple segments) indicating 1 vascular territory with abnormalities but without LV dilation Small wall motion abnormality involving 1 to 2 segments and only 1 coronary bed CAC score 100 to 399 Agatston units 1-vessel CAD with >70% stenosis or moderate CAD stenosis (50% to 69% stenosis) in >2 arteries on CCTA . Reference Fihn SD, Gardin JM, Abrams J, et al ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol. 2012;60:e44-e164. CAC: coronary artery calcium; CCTA: coronary CT angiography. Fihn SD, et al. J Am Coll Cardiol. 2012;60:e44-e164.
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2012 ACCF/AHA Guideline Criteria for Non-Invasive Risk Stratification
High risk (>3% annual mortality rate) Severe resting LV dysfunction (LVEF <35%) not readily explained by non-coronary causes Resting perfusion abnormalities >10% of the myocardium in patients without prior history or evidence of MI Stress-induced Stress ECG findings including >2 mm of ST-segment depression at low workload or persisting into recovery, exercise-induced ST-segment elevation, or exercise-induced VT/VF Severe stress-induced LV dysfunction (peak exercise LVEF <45% or drop in LVEF with stress >10%) Stress-induced perfusion abnormalities encumbering >10% of myocardium or stress segmental scores indicating multiple vascular territories with abnormalities Stress-induced LV dilation Inducible wall motion abnormality (involving >2 segments or 2 coronary beds) Wall motion abnormality developing at a low dose of dobutamine (<10 mg/kg/min) or at a low heart rate (<120 beats/min) CAC score >400 Agatston units Multivessel obstructive CAD (>70% stenosis) or left main stenosis (>50% stenosis) on CCTA Core Slide: ACCF/AHA Guideline Criteria for Non-Invasive Risk Stratification Non-Invasive test findings that identify patients at high risk (>3% annual mortality rate) include:1 Severe resting LV dysfunction (LVEF <35%) not readily explained by non-coronary causes Resting perfusion abnormalities >10% of the myocardium in patients without prior history or evidence of MI Stress ECG findings including >2 mm of ST-segment depression at low workload or persisting into recovery, exercise-induced ST-segment elevation, or exercise-induced VT/VF Severe stress-induced LV dysfunction (peak exercise LVEF <45% or drop in LVEF with stress >10%) Stress-induced perfusion abnormalities encumbering >10% of myocardium or stress segmental scores indicating multiple vascular territories with abnormalities Stress-induced LV dilation Inducible wall motion abnormality (involving >2 segments or 2 coronary beds) Wall motion abnormality developing at a low dose of dobutamine (<10 mg/kg/min) or at a low heart rate (<120 beats/min) CAC score >400 Agatston units Multivessel obstructive CAD (>70% stenosis) or left main stenosis (>50% stenosis) on CCTA. Reference Fihn SD, Gardin JM, Abrams J, et al ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol. 2012;60:e44-e164. CAC: coronary artery calcium; CCTA: coronary CT angiography. Fihn SD, et al. J Am Coll Cardiol. 2012;60:e44-e164.
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Initial Cardiac Test for Diagnosis: Able to Exercise*
No Contraindications to Stress Testing No Previous Revascularization Interpretable Resting ECG Previous Revascularization or Resting ECG Not Interpretable MPI or Echocardiogram With Exercise Likelihood of IHD I IIa IIb III B Core Slide: Initial Cardiac Test for Diagnosis: Able to Exercise* This slide illustrates the initial cardiac tests for diagnosis in patients who are able to exercise (*suspected IHD or change in clinical status in known IHD).1,2 References Fihn SD, Gardin JM, Abrams J, et al ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol. 2012;60:e44-e164. Qasseem A, Fihn SD, Williams S, et al. Diagnosis of stable ischemic heart disease: summary of a clinical practice guideline from the American College of Physicians/American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med. 2012;157: Intermediate to High MPI or Echocardiogram With Exercise Low Standard Exercise ECG Intermediate Standard Exercise ECG IIa I IIb III C I IIa IIb III A IIa I IIb III B *Suspected IHD or change in clinical status in known IHD patients. MPI: myocardial perfusion imaging. Fihn SD, et al. J Am Coll Cardiol. 2012;60:e44-e164. Qaseem A, et al. Ann Intern Med. 2012;157:
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Initial Cardiac Test for Diagnosis: Not Able to Exercise*
No Contraindications to Stress Testing Low Likelihood of IHD Pharmacologic Stress Echocardiogram Intermediate-to-High Likelihood of IHD OR IIa I IIb III C Pharmacologic Stress MPI or Echocardiogram Pharmacologic Stress CMR or CCTA† Core Slide: Initial Cardiac Test for Diagnosis: Not Able to Exercise* This slide illustrates the initial cardiac tests for diagnosis in patients who are not able to exercise (*suspected IHD or change in clinical status in known IHD).1,2 References Fihn SD, Gardin JM, Abrams J, et al ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol. 2012;60:e44-e164. Qasseem A, Fihn SD, Williams S, et al. Diagnosis of stable ischemic heart disease: summary of a clinical practice guideline from the American College of Physicians/American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med. 2012;157: I IIa IIb III B IIa I IIb III B IIa I IIb III C *Suspected IHD or change in clinical status in known IHD patients. †CMR (recommendation: intermediate-to-high probability); CCTA (recommendation: intermediate probability). MPI: myocardial perfusion imaging; CMR: cardiac magnetic resonance; CCTA: coronary CT angiography. Fihn SD, et al. J Am Coll Cardiol. 2012;60:e44-e164. Qaseem A, et al. Ann Intern Med. 2012;157:
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Initiate Guideline-Directed Medical Therapy
Initial Cardiac Test for Diagnosis: Contraindications to Stress Testing* Contraindications to Stress Testing OR CCTA Initiate Guideline-Directed Medical Therapy (If treatment is unsuccessful, consider coronary angiography and revascularization to improve symptoms) IIa I IIb III B Core Slide: Initial Cardiac Test for Diagnosis: Contraindications to Stress Testing* This slide illustrates the initial cardiac tests for diagnosis in patients who have contraindications to stress testing (*suspected IHD or change in clinical status in known IHD).1,2 References Fihn SD, Gardin JM, Abrams J, et al ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol. 2012;60:e44-e164. Qasseem A, Fihn SD, Williams S, et al. Diagnosis of stable ischemic heart disease: summary of a clinical practice guideline from the American College of Physicians/American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med. 2012;157: *Suspected IHD or change in clinical status in known IHD patients. CCTA: coronary CT angiography. Fihn SD, et al. J Am Coll Cardiol. 2012;60:e44-e164. Qaseem A, et al. Ann Intern Med. 2012;157:
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Risk Assessment in Patients With Known SIHD
Able to Exercise Resting ECG Not Interpretable Resting ECG Interpretable OR OR MPI or Echocardiogram With Exercise Core Slide: Risk Assessment in Patients With Known SIHD This slide provides an overview of risk assessment in patients with known SIHD who are able to exercise. The key differentiating issue is the interpretability of the resting ECG.1,2 References Fihn SD, Gardin JM, Abrams J, et al ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol. 2012;60:e44-e164. Qasseem A, Fihn SD, Williams S, et al. Diagnosis of stable ischemic heart disease: summary of a clinical practice guideline from the American College of Physicians/American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med. 2012;157: Pharmacologic Stress CMR or CCTA Standard Exercise Test MPI or Echocardiogram With Exercise I IIa IIb III B IIa I IIb III B IIb I IIa III B I IIa IIb III B IIa I IIb III B MPI: myocardial perfusion imaging; CMR: cardiac magnetic resonance; CCTA: coronary CT angiography. Fihn SD, et al. J Am Coll Cardiol. 2012;60:e44-e164. Qaseem A, et al. Ann Intern Med. 2012;157:
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Risk Assessment in Patients With Known SIHD
Unable to Exercise OR Pharmacologic Stress MPI or Echocardiogram Pharmacologic Stress CMR or CCTA I IIa IIb III B IIa I IIb III B IIa I IIb III C Core Slide: Risk Assessment in Patients With Known SIHD This slide provides an overview of risk assessment in patients with known SIHD who are not able to exercise.1,2 References Fihn SD, Gardin JM, Abrams J, et al ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol. 2012;60:e44-e164. Qasseem A, Fihn SD, Williams S, et al. Diagnosis of stable ischemic heart disease: summary of a clinical practice guideline from the American College of Physicians/American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med. 2012;157: MPI: myocardial perfusion imaging; CMR: cardiac magnetic resonance; CCTA: coronary CT angiography. Fihn SD, et al. J Am Coll Cardiol. 2012;60:e44-e164. Qaseem A, et al. Ann Intern Med. 2012;157:
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Risk Assessment in Patients With Known SIHD and Special Circumstances or High-Risk Lesions
Risk Assessment Tests Special Circumstances (irrespective of exercise ability) Risk Assessment Tests Standard Exercise ECG MPI or Echocardiogram With Exercise Pharmacologic CMR or CCTA Pharmacologic Stress MPI or Echocardiogram Pharmacologic MPI or Echo With Exercise (I-B) LBBB on ECG No Pharmacologic MPI, Echo, CCTA, or CMR (I-B) Non-Invasive Tests Suggest High-Risk Coronary Lesion Known stenosis of unclear significance being considered for revascularization Core Slide: Risk Assessment in Patients With Known SIHD and Special Circumstances or High-Risk Lesions This slide provides an overview of risk assessment in patients with special circumstances (left side of slide) and in those whom non-invasive tests suggest a high-risk coronary lesion (right side of slide).1,2 References Fihn SD, Gardin JM, Abrams J, et al ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol. 2012;60:e44-e164. Qasseem A, Fihn SD, Williams S, et al. Diagnosis of stable ischemic heart disease: summary of a clinical practice guideline from the American College of Physicians/American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med. 2012;157: Yes No No Indeterminant results from functional testing CCTA (IIa-C) Consider Coronary Revascularization to Improve Survival (based on patient preferences, anatomy, other clinical factors, and local resources and expertise) Observe Response to Guideline-Directed Medical Therapy MPI: myocardial perfusion imaging; CMR: cardiac magnetic resonance; CCTA: coronary CT angiography. Fihn SD, et al. J Am Coll Cardiol. 2012;60:e44-e164. Qaseem A, et al. Ann Intern Med. 2012;157:
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ACP Interpretation of ACCF/AHA SIHD Guideline: Key Management Questions
Diagnosis Management How should a clinician evaluate a patient with chest pain that is consistent with IHD? What is the role of non-invasive testing in the diagnosis of SIHD? What should be the approach to modifying cardiovascular risk factors to reduce the mortality and morbidity associated with SIHD? What is the role of coronary revascularization in reducing mortality and morbidity associated with SIHD? How should chronic anginal symptoms be managed with medications? Core Slide: ACP Interpretation of ACCF/AHA SIHD Guideline: Key Management Questions The American College of Physicians synthesized the 2012 guideline for its members with the goal of answering key questions on diagnosis and management.1,2 The key questions for management were:2 What should be the approach to modifying cardiovascular risk factors to reduce the mortality and morbidity associated with SIHD? What is the role of coronary revascularization in reducing mortality and morbidity associated with SIHD? How should chronic anginal symptoms be managed with medications? References Qasseem A, Fihn SD, Williams S, et al. Diagnosis of stable ischemic heart disease: summary of a clinical practice guideline from the American College of Physicians/American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med. 2012;157: Qasseem A, Fihn SD, Dallas P, et al. Management of stable ischemic heart disease: summary of a clinical practice guideline from the American College of Physicians/American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med. 2012;157: Qaseem A, et al. Ann Intern Med. 2012;157: Qaseem A, et al. Ann Intern Med. 2012;157:
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Goals of Therapy Minimize the likelihood of death while maximizing health and function Reduce premature cardiovascular death Prevent complications of SIHD that directly or indirectly impair patients’ functional well-being Including non-fatal AMI and heart failure Maintain or restore a level of activity, functional capacity, and quality of life that is satisfactory to the patient Completely, or nearly completely, eliminate ischemic symptoms Minimize costs of health care Eliminate avoidable adverse effects of tests and treatments by preventing hospital admissions, and by eliminating unnecessary tests and treatments Core Slide: Goals of Therapy The overall goals of therapy for patients with SIHD are to minimize the likelihood of death while maximizing health and function. This includes:1,2 Reducing premature cardiovascular death. Preventing complications of SIHD that directly or indirectly impair patients’ functional well-being (including non-fatal AMI and heart failure). Maintaining or restoring a level of activity, functional capacity, and quality of life that is satisfactory to the patient. Completely, or nearly completely, eliminating ischemic symptoms. Minimizing costs of health care, including eliminating avoidable adverse effects of tests and treatments by preventing hospital admissions, and by eliminating unnecessary tests and treatments. References Fihn SD, Gardin JM, Abrams J, et al ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol. 2012;60:e44-e164. Qasseem A, Fihn SD, Dallas P, et al. Management of stable ischemic heart disease: summary of a clinical practice guideline from the American College of Physicians/American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med. 2012;157: Fihn SD, et al. J Am Coll Cardiol. 2012;60:e44-e164. Qaseem A, et al. Ann Intern Med. 2012;157:
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Strategies to Achieve Goals
Educate and engage patients in treatment decisions Etiology, clinical manifestations, treatment options, and IHD prognosis Identify and treat conditions that contribute to, worsen, or complicate IHD Effectively modify risk factors for IHD Pharmacologic and non-pharmacologic methods Use evidence-based pharmacological treatments to improve patients’ health status and survival Avoid drug interactions and side effects Use revascularization (PCI or CABG) when there is clear evidence of the potential to improve patients’ health status and survival Slide: Strategies to Achieve Goals The key strategies to achieve the goals of therapy include the following:1,2 Educate and engage patients in treatment decisions to include a discussion of etiology, clinical manifestations, treatment options, and IHD prognosis. Identify and treat conditions that contribute to, worsen, or complicate IHD. Effectively modify risk factors for IHD (both pharmacologic and non-pharmacologic methods). Use evidence-based pharmacological treatments to improve patients’ health status and survival while avoiding drug interactions and side effects. Use revascularization (PCI or CABG) when there is clear evidence of the potential to improve patients’ health status and survival. References Fihn SD, Gardin JM, Abrams J, et al ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol. 2012;60:e44-e164. Qasseem A, Fihn SD, Dallas P, et al. Management of stable ischemic heart disease: summary of a clinical practice guideline from the American College of Physicians/American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med. 2012;157: Fihn SD, et al. J Am Coll Cardiol. 2012;60:e44-e164. Qaseem A, et al. Ann Intern Med. 2012;157:
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PCI Versus Medical Therapy: Findings From Studies and Systematic Reviews
PCI reduces the incidence of angina No study has demonstrated that PCI improves survival rates in SIHD PCI may increase the short-term risk of MI PCI does not lower the long-term risk of MI Core Slide: PCI Versus Medical Therapy: Findings From Studies and Systematic Reviews A number of studies have evaluated the role of PCI and medical therapy in the management of SIHD. Overall, these studies have shown that PCI reduces the incidence of angina, but no study has demonstrated that PCI improves survival rates in SIHD. In addition, PCI may increase the short-term risk of MI, but it does not lower the long-term risk of MI.1 Reference Fihn SD, Gardin JM, Abrams J, et al ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol. 2012;60:e44-e164. Fihn SD, et al. J Am Coll Cardiol. 2012;60:e44-e164.
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COURAGE Trial: Optimal Medical Therapy + PCI for Stable Coronary Disease
Randomization 1:1 Follow-Up: 2.5 to 7 Years Patients (n=2287) AHA/ACC Class I/II indications for PCI Suitable coronary artery anatomy >70% stenosis in >1 proximal epicardial vessel Objective evidence of ischemia (or >80% stenosis + CCS class III angina without provocation testing) Optimal Medical Therapy + PCI (n=1149) Optimal Medical Therapy (n=1138) Core Slide: COURAGE Trial: Optimal Medical Therapy + PCI for Stable Coronary Disease Data from previous studies show that aggressive medical management provides advantages over less aggressive management as demonstrated by less disease progression and fewer clinical events.1,2 The COURAGE trial was undertaken to determine whether PCI plus optimal medical therapy (consisting of lifestyle modification and antiplatelet, antianginal, BP- and glucose-lowering, and lipid-modifying therapies) decreased the risk of death or nonfatal MI in patients with stable coronary disease compared with optimal medical therapy alone.1,2 References Boden WE, O‘Rourke RA, Teo KK, et al. Design and rationale of the Clinical Outcomes Utilizing Revascularization and Aggressive DruG Evaluation (COURAGE) trial Veterans Affairs Cooperative Studies Program no Am Heart J. 2006;151: Boden WE, O’Rourke RA, Teo KK, et al, for the COURAGE Trial Research Group. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 2007;356: Primary Outcome: All-cause mortality, non-fatal MI Secondary Outcomes: Death, MI, stroke, ACS hospitalization Median follow-up: 4.6 years CCS: Canadian Cardiovascular Society; ACS: acute coronary syndrome. Boden WE, et al. Am Heart J. 2006;151: Boden WE, et al. N Engl J Med. 2007;356:
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COURAGE Study: All-Cause Mortality/Non-Fatal MI
Death From Any Cause and Non-Fatal MI OMT + PCI OMT Survival Free of Primary Outcome Core Slide: COURAGE Study: All-Cause Mortality/Non-Fatal MI As an initial management strategy in patients with stable coronary artery disease, PCI added to optimal medical therapy did not reduce the primary composite endpoint of death and nonfatal MI, or reduce major cardiovascular events, as compared with optimal therapy alone during follow-up.1 The primary outcome (a composite of death from any cause and nonfatal MI) occurred in 211 patients in the PCI group and 202 patients in the medical therapy group.1 The estimated 4.6-year cumulative primary event rates were 19.0% in the PCI group and 18.5% in the medical therapy group (unadjusted HR for the PCI group 1.05, 95% CI ; P=0.62). Reference Boden WE, O'Rourke RA, Teo KK, et al. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 2007;356: Unadjusted Hazard Ratio 1.05 (95% CI ) P=0.62 Follow-Up (years) OMT: optimal medical therapy. Boden WE, et al. N Engl J Med. 2007;356:
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COURAGE Study: Impact of Treatment on Angina
Angina Free OMT + PCI (n=1149) OMT (n=1138) 72%† 74% 72% 66%* 67% 58% Patients (%) Core Slide: COURAGE Study: Impact of Treatment on Angina Both treatment groups had a substantial reduction in the prevalence of angina during follow-up.1 The only significant difference between the 2 treatment strategies was a reduced prevalence of angina in the PCI group at 1 and 3 years; however, by 5 years there was no significant difference between groups in freedom from angina.1 Most of the increase in freedom from angina in the medical-therapy group took place at 1 year, with a further improvement at 5 years.1 Reference Boden WE, O'Rourke RA, Teo KK, et al. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 2007;356: 12% 13% Baseline 1 3 5 Follow-Up (years) *P<0.001 and †P=0.02 versus OMT (optimal medical therapy). Boden WE, et al. N Engl J Med. 2007;356:
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BARI 2D Study: Medical Therapy Versus Revascularization
Primary Outcome (All-Cause Death) PCI CABG 89.9% 86.4% 89.2% 83.6% P=0.48 P=0.33 Survival (%) Survival (%) Slide: BARI 2D Study: Medical Therapy Versus Revascularization in Patients with Type 2 Diabetes and Angiographic CAD Over 5 years of follow-up, the rate of death did not differ significantly between the revascularization group and the medical therapy group in either the CABG or the PCI stratum.1 Reference BARI 2D Study Group, Frye RL, August P, et al. A randomized trial of therapies for type 2 diabetes and coronary artery disease. N Engl J Med. 2009;360: Medical therapy Revascularization Medical therapy Revascularization Follow-Up (Years) Follow-Up (Years) BARI 2D Study Group. N Engl J Med. 2009;360:
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CABG Versus Medical Therapy: Findings From Studies and Systematic Reviews
Surgical techniques and medical therapy have improved substantially over the years Uncertain if the relative benefits for survival and angina relief observed several decades ago with CABG might no longer be observed Concurrent administration of GDMT with CABG may substantially improve long-term outcomes compared with GDMT alone ISCHEMIA trial (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) Goal: elimination or reduction of at least moderate myocardial ischemia Usual care (optimal medical therapy and prompt revascularization when feasible) versus optimal medical therapy alone with deferred revascularization when clinically indicated (excluding left main disease detected by cardiac CT angiography) Outcome: hard cardiac events Follow-up: average 4 years (results expected in 2019) Patients (n=8000) Core Slide: CABG Versus Medical Therapy: Findings From Studies and Systematic Reviews Surgical techniques and medical therapy have improved substantially over the years. However, it is uncertain if the relative benefits for survival and angina relief observed several decades ago with CABG might no longer be observed. Concurrent administration of GDMT with CABG may substantially improve long-term outcomes compared with GDMT alone.1 The ISCHEMIA trial (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) was undertaken with the goal of determining if elimination or reduction of at least moderate myocardial ischemia can be accomplished with usual care (optimal medical therapy and prompt revascularization when feasible) versus optimal medical therapy alone with deferred revascularization when clinically indicated (excluding left main disease detected by cardiac CT angiography).2 Outcome: hard cardiac events. Follow-up: average 4 years. Patients (n=8000). Results expected in 2019. References Fihn SD, Gardin JM, Abrams J, et al ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol. 2012;60:e44-e164. Available at: Fihn SD, et al. J Am Coll Cardiol. 2012;60:e44-e164. Available at:
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Coronary Revascularization to Improve Survival
Clinical Setting Method Grade No anatomic or physiologic criteria for revascularization CABG or PCI III-B HARM 1-vessel disease without proximal LAD artery involvement Significant (>50%) unprotected left main CAD who have unfavorable anatomy for PCI and are good candidates for CABG PCI (versus CABG) Significant (>50%) left main coronary artery stenosis CABG PCI I-B IIa-IIb* Significant (>70%) stenosis in 3-vessel disease with or without proximal LAD artery disease IIb-B Survivors of sudden cardiac death with presumed ischemic-mediated ventricular tachycardia caused by significant (>70%) stenosis in a major coronary artery I-C 2-vessel disease with proximal LAD artery disease II-B 1-vessel proximal LAD artery disease CABG (with LIMA) IIa-B Left ventricular dysfunction Ejection fraction 35% to 50% Ejection fraction <35% without significant left main CAD Core Slide: Coronary Revascularization to Improve Survival This slide summaries the recommendations for CABG or PCI to improve survival following the results of a coronary angiography.1,2 References Fihn SD, Gardin JM, Abrams J, et al ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol. 2012;60:e44-e164. Qasseem A, Fihn SD, Williams S, et al. Diagnosis of stable ischemic heart disease: summary of a clinical practice guideline from the American College of Physicians/American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med. 2012;157: *For certain circumstances, there are IIa and IIb (LOE B or C) indications for PCI for left main CAD. Fihn SD, et al. J Am Coll Cardiol. 2012;60:e44-e164. Qaseem A, et al. Ann Intern Med. 2012;157:
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Revascularization to Improve Persistent Symptoms in Patients With SIHD
Persistent Symptoms Despite Adequate Trial of Guideline-Directed Medical Therapy Is potential revascularization warranted based on assessment of coexisting cardiac and non-cardiac factors and patient preferences? Yes No Perform Coronary Angiography Do results indicate that revascularization may improve symptoms? No Guideline-Directed Medical Therapy Core Slide: Revascularization to Improve Persistent Symptoms in Patients With SIHD In patients who have persistent symptoms despite adequate guideline-directed medical therapy, the first step is to determine whether the patient is a candidate for and amenable to revascularization. If not, then continuation of guideline-directed medical therapy is recommended. If revascularization is an option, then results from a coronary angiography are used to guide the next steps of management.1,2 References Fihn SD, Gardin JM, Abrams J, et al ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol. 2012;60:e44-e164. Qasseem A, Fihn SD, Williams S, et al. Diagnosis of stable ischemic heart disease: summary of a clinical practice guideline from the American College of Physicians/American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med. 2012;157: No Yes Do lesions correlate with evidence of ischemia? Yes Determine PCI or CABG Guideline-Directed Medical Therapy Continued in All Patients Fihn SD, et al. J Am Coll Cardiol. 2012;60:e44-e164. Qaseem A, et al. Ann Intern Med. 2012;157:
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Coronary Revascularization to Improve Symptoms
Significant Anatomic (>50% Left Main or >70% Non-Left Main CAD) or Physiologic (FFR <0.80) Coronary Artery Stenosis Clinical Setting Method Grade No anatomic or physiologic criteria for revascularization CABG or PCI III-C HARM >1 significant stenosis (>70%) amenable to revascularization and unacceptable angina despite GDMT I-A >1 significant stenosis (>70%) and unacceptable angina in whom GDMT cannot be implemented (medical contraindication, adverse events, preference) IIa-C Previous CABG with >1 significant stenosis (>70%) associated with ischemia and unacceptable angina despite GDMT PCI CABG IIa-B Complex 3-vessel CAD (eg, SYNTAX score >22) with or without involvement of proximal LAD artery and a good candidate for CABG CABG preferred over PCI Viable ischemic myocardium that is perfused by coronary arteries that are not amenable to grafting TMR as an adjunct to CABG IIb-B Core Slide: Coronary Revascularization to Improve Symptoms This slide lists the 2012 guideline recommendations for PCI or CABG in patients with significant anatomic (>50% left main or >70% non-left main CAD) or physiologic (FFR <0.80) coronary artery stenosis and who have persistent symptoms despite adequate trials of guideline-directed medical therapy.1 Reference Fihn SD, Gardin JM, Abrams J, et al ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol. 2012;60:e44-e164. TMR: transmyocardial revascularization. Fihn SD, et al. J Am Coll Cardiol. 2012;60:e44-e164.
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Guideline-Directed Medical Therapy for Patients With SIHD
Risk factor modification Additional medical therapy to prevent MI and death Medical therapy for relief of symptoms Alternative therapies for relief of symptoms in patients with refractory angina Core Slide: Guideline-Directed Medical Therapy for Patients With SIHD The key components of guideline-directed medical therapy include:1,2 Risk factor modification. Additional medical therapy to prevent MI and death. Medical therapy for relief of symptoms. Alternative therapies for relief of symptoms in patients with refractory angina. References Fihn SD, Gardin JM, Abrams J, et al ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol. 2012;60:e44-e164. Qasseem A, Fihn SD, Williams S, et al. Diagnosis of stable ischemic heart disease: summary of a clinical practice guideline from the American College of Physicians/American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med. 2012;157: Fihn SD, et al. J Am Coll Cardiol. 2012;60:e44-e164. Qaseem A, et al. Ann Intern Med. 2012;157:
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Risk Factor Modification
Modifiable Not Modifiable Smoking Hypertension Hyperlipidemia Diabetes, glycemic control Obesity, sedentary lifestyle Hyperuricemia Psychosocial factors Stress, type A behavior Medications Progestins, corticosteroids Environmental influences Climate, air pollution, trace metals in drinking water Gender Age Family history Core Slide: Risk Factor Modification As chronic stable angina is almost always related to underlying coronary atherosclerosis, particular attention should be paid to the presence of risk factors and/or lifestyle habits that facilitated the emergence of coronary artery disease. Patients should be assessed for smoking status, the presence of hypertension, hyperlipidemia, diabetes, and overall dietary and activity status, as well as for hyperuricemia, psychosocial factors, and certain medications such as progestins and corticosteroids.1 When identified, lifestyle and/or pharmacologic interventions should be implemented to modify/reduce these modifiable risk factors and thereby reduce the progression of coronary artery disease, as well as prevent morbidity and mortality. However, some risk factors are not modifiable, but nonetheless factor into anti-anginal management plan.1 Reference Kones R. Recent advances in the management of chronic stable angina II. Anti-ischemic therapy, options for refractory angina, risk factor reduction, and revascularization Vasc Health Risk Manag. 2010;6: Kones R. Vasc Health Risk Manag. 2010;6:
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Exposure to air pollution
Lifestyle Modification for Patients With SIHD: Additional Risk Factor Modification Grade Risk Factor Goal Physical activity Moderate-intensity aerobic activity minutes, 7 days/week (minimum 5 days/week) Weight management Body mass index: 18.5 to 24.9 kg/m2 Waist circumference: men (<40 inches), women (<35 inches) Smoking Complete cessation No exposure to environmental tobacco smoke Psychologic factors Consider screening for depression Alcohol consumption Non-pregnant women: 1 drink/day (4 oz wine, 12 oz beer, 1 oz spirits) Men: 1 to 2 drinks/day Exposure to air pollution Avoid I IIa IIb III B I IIa IIb III B I IIa IIb III B Core Slide: Lifestyle Modification for Patients With SIHD: Additional Risk Factor Modification Risk factor management is the foundation of guideline-directed medical therapy. This slide outlines the key recommendations for physical activity, weight management, smoking, psychologic factors, alcohol consumption, and exposure to air pollution.1 Reference Fihn SD, Gardin JM, Abrams J, et al ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol. 2012;60:e44-e164. IIa I IIb III B IIb I IIa III C IIa I IIb III C Fihn SD, et al. J Am Coll Cardiol. 2012;60:e44-e164.
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Guideline-Directed Medical Therapy for SIHD: Risk Factor Modification
Lipid Management Blood Pressure >140/90 mm Hg Diabetes Management Lifestyle modification Lifestyle modification Antihypertensive drug therapy HbA1c goal: <7%† Dietary therapy Saturated fats: <7% Trans fatty acids: <1%* Cholesterol: <200 mg/dL I IIa IIb III A I IIa IIb III A I IIa IIb III B Initiate pharmacotherapy to achieve goal HbA1c Choice of BP medication based on specific patient characteristics IIa I IIb III A Moderate-to-High Dose Statin Core Slide: Guideline-Directed Medical Therapy for SIHD: Risk Factor Modification Risk factor management is the foundation of guideline-directed medical therapy. This slide outlines the key recommendations for lipid management, blood pressure control, and diabetes in patients with SIHD.1 Reference Fihn SD, Gardin JM, Abrams J, et al ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol. 2012;60:e44-e164. I IIa IIb III B I IIa IIb III A Rosiglitazone should not be initiated For Patients Intolerant to Statins, Bile Acid Sequestrant and/or Niacin III I IIa IIb C IIa I IIb III B HARM *Percent of total calories. †HbA1c goal of 7% to 9% is reasonable for certain patients according to age, history of hypoglycemia, presence of microvascular or macrovascular complications, or presence of coexisting medical conditions Fihn SD, et al. J Am Coll Cardiol. 2012;60:e44-e164.
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Additional Medical Therapy: Prevention of MI in Patients With SIHD
Renin-Angiotensin- Aldosterone Blocker Aspirin Beta-Blocker No Contraindications Normal LV Function After MI or ACS Hypertension, Diabetes Mellitus, LVEF <40%, or Chronic Kidney Disease Aspirin mg/day (continue indefinitely) Start, continue for 3 years I IIa IIb III A I IIa IIb III B ACE inhibitor I IIa IIb III A Aspirin mg/day + clopidogrel 75 mg/day (certain high-risk patients) LV Systolic Dysfunction (EF <40%) With Heart Failure or Prior MI ARB inhibitor (if intolerant to ACE inhibitor) Core Slide: Additional Medical Therapy: Prevention of MI in Patients With SIHD Prevention of MI is a key management goal in patients with SIHD undergoing guideline-directed medical therapy. This slide lists the recommended use of aspirin, beta-blockers and renin-angiotensin-aldosterone blocker.1,2 References Fihn SD, Gardin JM, Abrams J, et al ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol. 2012;60:e44-e164. Qasseem A, Fihn SD, Dallas P, et al. Management of stable ischemic heart disease: summary of a clinical practice guideline from the American College of Physicians/American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med. 2012;157: IIb I IIa III B Carvedilol, metoprolol succinate, bisoprolol (shown to reduce risk of death) I IIa IIb III A I IIa IIb III A Contraindications Clopidogrel 75 mg/day SIHD or Other Vascular Disease I IIa IIb III B Other Patients With Coronary or Vascular Disease ACE inhibitors IIa I IIb III B IIb I IIa III C Fihn SD, et al. J Am Coll Cardiol. 2012;60:e44-e164. Qaseem A, et al. Ann Intern Med. 2012;157:
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Additional Medical Therapy: Prevention of MI in Patients With SIHD
Grade Medical Therapy Comments (Patients With SIHD) Influenza vaccination Annually Estrogen therapy Postmenopausal women: not recommended for reducing cardiovascular risk or improving clinical outcomes Vitamin C Vitamin E Beta-carotene All patients: not recommended for reducing cardiovascular risk or improving clinical outcomes Folate Vitamin B6 or B12 Elevated homocysteine: not recommended for reducing cardiovascular risk or improving clinical outcomes Chelation therapy All patients: not recommended for improving symptoms or reducing cardiovascular risk Garlic Coenzyme Q10 Selenium Chromium I IIa IIb III B III I IIa IIb B NO BENEFIT III I IIa IIb A NO BENEFIT Core Slide: Additional Medical Therapy: Prevention of MI in Patients With SIHD Prevention of MI is a key management goal in patients with SIHD undergoing guideline-directed medical therapy. This slide lists the recommended use of influenza vaccination and the non-recommended use of estrogen therapy, vitamin supplementation, chelation therapy and other supplements (garlic, coenzyme Q10, selenium, chromium).1 Reference Fihn SD, Gardin JM, Abrams J, et al ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol. 2012;60:e44-e164. III I IIa IIb A NO BENEFIT III I IIa IIb C NO BENEFIT III I IIa IIb C NO BENEFIT Fihn SD, et al. J Am Coll Cardiol. 2012;60:e44-e164.
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Guideline-Directed Medical Therapy: Relief of Symptoms
Angina Initial Therapy Sublingual Nitroglycerin or Nitroglycerin Spray (for immediate relief) Add/Substitute CCB and/or Long-Acting Nitrate Add/Substitute Ranolazine Beta Blocker (especially if prior MI, heart failure, or other indication) Contraindication Unacceptable side effects Contraindication Unacceptable side effects IIa I IIb III B Core Slide: Guideline-Directed Medical Therapy: Relief of Symptoms This slide lists the preferred therapies for initial control of anginal symptoms and uncontrolled symptoms in patients with SIHD. It is recommended to provide adequate trials of medical therapy to control symptoms before considering revascularization to improve persistent symptoms.1,2 References Fihn SD, Gardin JM, Abrams J, et al ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol. 2012;60:e44-e164. Qasseem A, Fihn SD, Dallas P, et al. Management of stable ischemic heart disease: summary of a clinical practice guideline from the American College of Physicians/American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med. 2012;157: I IIa IIb III B I IIa IIb III B Persistent Symptoms Despite Adequate Trial of Guideline-Directed Medical Therapy Consider Revascularization to Improve Symptoms Fihn SD, et al. J Am Coll Cardiol. 2012;60:e44-e164. Qaseem A, et al. Ann Intern Med. 2012;157:
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Therapeutic Targets of FDA-Approved Agents for Myocardial Ischemia
Development of Ischemia Consequences of Ischemia Increased oxygen demand Tachycardia Hypertension Preload Contractility Decreased oxygen supply Ca2+ overload Electrical instability Myocardial dysfunction (decreased systolic function/ increased diastolic stiffness) Myocardial Ischemia Core Slide: Therapeutic Targets of FDA-Approved Agents for Myocardial Ischemia FDA-approved anti-anginal agents have different mechanisms of action that impact the development of ischemia (eg, beta blockers, nitrates, and calcium channel blockers) and the consequences of ischemia (eg, ranolazine). Ranolazine (reduces late Na+ current) β-blockers Nitrates Calcium Channel Blockers
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Calcium Channel Blockers
Chronic Stable Angina: Ideal Candidates for β-Blockers and Calcium Channel Blockers β-Blockers Calcium Channel Blockers Physical activity figures prominently in anginal attacks Coexistent hypertension (combined α-/β-blockers) History of Supraventricular arrhythmias Ventricular tachycardia Congestive heart failure Post-MI angina or LV dysfunction Anxiety associated with angina Coexistent hypertension Contraindications/intolerance to β-blockers Coexisting conduction system disease Except verapamil, diltiazem Prinzmetal angina Peripheral vascular disease Core Slide: Chronic Stable Angina: Ideal Candidates for β-Blockers and Calcium Channel Blockers β-Blockers are effective at reducing anginal symptoms and ischemia (including silent ischemia) and primarily reduce myocardial oxygen demand by lowering heart rate, myocardial contractility, and intramyocardial wall tension. Ideal candidates for therapy with β-blockers include:1 Physical activity figures prominently in anginal attacks. Coexistent hypertension (combined α-/β-blockers). History of supraventricular arrhythmias, ventricular tachycardia, or congestive heart failure. Post-MI angina or LV dysfunction. Anxiety associated with angina Both dihydropyridine (DHP) and nondihydropyridine (non-DHP) calcium channel blockers are also effective at reducing anginal episodes in patients with chronic stable angina. Both classes of agents would be expected to reduce myocardial oxygen demand by lowering intramyocardial wall tension (by lowering systemic blood pressure) and increase myocardial oxygen supply through vasodilation of the coronary arteries. However, non-DHP calcium channel blockers would be expected to lower myocardial oxygen demand to a greater degree because of additional reductions in heart rate and contractility. Consequently, patients with compromised left ventricular function or reduced heart rate should receive a DHP calcium channel blocker if therapy is indicated. Ideal candidates for calcium channel blocker therapy include:1 Coexistent hypertension. Contraindications/intolerance to β-blockers. Coexisting conduction system disease (except verapamil, diltiazem). Prinzmetal angina. Peripheral vascular disease. Reference Fihn SD, Gardin JM, Abrams J, et al ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol. 2012;60:e44-e164. Fihn SD, et al. J Am Coll Cardiol. 2012;60:e44-e164.
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Traditional Anti-Anginal Therapy: Conditions That May Limit Their Uses
Calcium Channel Blockers† β-Blockers Nitrates Asthma Severe bradycardia AV block Severe depression Raynaud’s syndrome Sick sinus syndrome Severe aortic stenosis Hypertrophic obstructive cardiomyopathy Erectile dysfunction* AV block Bradycardia Heart failure LV dysfunction Sinus node dysfunction Core Slide: Traditional Anti-Anginal Therapy: Conditions That May Limit Their Uses Although these agents have been used to treat myocardial ischemia for decades, they can have major limiting factors across all patient populations.1 Reference Fihn SD, Gardin JM, Abrams J, et al ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol. 2012;60:e44-e164. *Treated with PDE5 inhibitors. †Non-dihydropyridine. Fihn SD, et al. J Am Coll Cardiol. 2012;60:e44-e164.
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Ranolazine in Chronic Stable Angina
MARISA (n=191) Exercise-Limiting Angina Ranolazine Monotherapy CARISA (n=823) Exercise-Induced Angina Ranolazine Add-On to BB or CCB ‡ ‡ Placebo Ranolazine (bid) 500 mg 1000 mg 1500 mg Placebo Ranolazine (bid) 750 mg 1000 mg † † * † Time (seconds) Time (seconds) † ‡ ‡ Core Slide: Ranolazine in Chronic Stable Angina Ranolazine has been studied in large-scale clinical trials involving patients with chronic stable angina.1,2 The MARISA study (left panel) evaluated the anti-anginal effects and tolerability of ranolazine monotherapy at doses of 500, 1000, and 1500 mg bid versus placebo. This was a double-blind, cross-over study design with each cross-over period being 1 week in duration.1 Patients had coronary artery disease and effort angina for >3 months. All patients were withdrawn from other antianginal medications before undergoing the baseline qualifying exercise test (reproducible angina-limited exercise duration and >1 mm ST depression). Ranolazine at doses of 500, 1000, and 1500 mg bid produced significantly greater improvement in total exercise duration, time to angina onset, and time to 1 mm ST depression.1 The CARISA study (right panel) evaluated the anti-anginal effects and tolerability of ranolazine 750 and mg bid versus beta blocker or calcium channel blocker. In this randomized, double-blind, placebo-controlled study, patients had chronic angina while still on a once-daily regimen of 50 mg atenolol, 180 mg diltiazem, or 5 mg amlodipine.2 Ranolazine ER 750 and 1000 mg bid added to standard therapy significantly improved total exercise duration, time to angina onset, time to 1 mm ST downward displacement, and anginal frequency and nitroglycerin consumption. References Chaitman BR, Skettino SL, Parker JO, et al. Anti-ischemic effects and long-term survival during ranolazine monotherapy in patients with chronic severe angina. J Am Coll Cardiol. 2004;43: Chaitman BR, Pepine CJ, Parker JO, et al. Effects of ranolazine with atenolol, amlodipine, or diltiazem on exercise tolerance and angina frequency in patients with severe chronic angina: a randomized controlled trial. JAMA. 2004;291: † † † * Exercise Duration Onset of Angina Onset of ST-Segment Depression Exercise Duration Onset of Angina Onset of ECG Ischemia *P<0.005; †P<0.001, ‡P<0.05 versus placebo. Chaitman BR, et al. J Am Coll Cardiol. 2004;43: Chaitman BR, et al. JAMA. 2004;291:
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ERICA Study: Angina Frequency and Nitrate Consumption
Nitrate Use Ranolazine (n=277) Placebo (n=281) Ranolazine (n=277) Placebo (n=281) 5.59 5.68 5.02 4.43 Number per Week Number per Week 3.31 2.88* Core Slide: ERICA Study: Angina Frequency and Nitrate Consumption ERICA study evaluated the anti-anginal effects of ranolazine in combination with amlodipine in patients who were experiencing angina >3 times weekly despite receiving amlodipine 10 mg daily.1 During the first week of this randomized, double-blind study, patients in the ranolazine arm received 500 mg bid before receiving 1000 mg bid for weeks 2 through 6 of the study.1 Patients in the ranolazine + amlodipine arm had a significant reduction in angina frequency and nitrate use at week 7 compared with placebo (amlodipine alone).1 Reference Stone PH, Gratsiansky NA, Blokhin A, et al. Antianginal efficacy of ranolazine when added to treatment with amlodipine: the ERICA (Efficacy of Ranolazine in Chronic Angina) trial. J Am Coll Cardiol. 2006;48: 2.68 2.03† Baseline Week 7 Baseline Week 7 Both groups received amlodipine 10 mg/day bid. *P=0.028 and †P=0.014 versus placebo. Stone PH, et al. J Am Coll Cardiol. 2006;48:
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Ranolazine Drug Interactions
Avoid using ranolazine with strong CYP3A4 inhibitors (ketoconazole, itraconazole, clarithromycin, ritonavir, indinavir, saquinavir, nefazodone) Limit the dose of ranolazine to 500 mg bid with moderate CYP3A4 inhibitors (diltiazem, verapamil, erythromycin, fluconazole) P-gp inhibitors (cyclosporine) may require a dose reduction of ranolazine Drugs transported by P-gp or metabolized by CYP2D6 (digoxin) may need a reduced dose when used in combination with ranolazine Core Slide: Ranolazine Drug Interactions Avoid using ranolazine with strong CYP3A4 inhibitors (ketoconazole, itraconazole, clarithromycin, ritonavir, indinavir, saquinavir, nefazodone). Limit the dose of ranolazine to 500 mg bid with moderate CYP3A4 inhibitors (diltiazem, verapamil, erythromycin, fluconazole). P-gp inhibitors (cyclosporine) may require a dose reduction of ranolazine. Drugs transported by P-gp or metabolized by CYP2D6 (digoxin) may need a reduced dose when used in combination with ranolazine. Reference Ranolazine full prescribing information. Ranolazine full prescribing information.
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Alternative Therapies: Relief of Symptoms in Patients With Refractory Angina
Grade Medical Therapy Comments (Patients With Refractory Angina) Enhanced external counterpulsation May be considered an option Transmyocardial revascularization Spinal cord stimulation Acupuncture Not recommended IIb I IIa III B IIb I IIa III B IIb I IIa III C Core Slide: Alternative Therapies: Relief of Symptoms in Patients With Refractory Angina This slide lists the recommendations from the 2012 guideline on the use of enhanced external counterpulsation, transmyocardial revascularization, spinal cord stimulation, and acupuncture in patients with anginal symptoms refractory to preferred medications.1 Reference Fihn SD, Gardin JM, Abrams J, et al ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol. 2012;60:e44-e164. III I IIa IIb C NO BENEFIT Fihn SD, et al. J Am Coll Cardiol. 2012;60:e44-e164.
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Summary Diagnostic and therapeutic choices in SIHD should be made through a process of shared decision making with patient and provider Explain the risks, benefits, and costs All patients with angina Aggressive risk factor modification and optimized medical management must be instituted β-blocker is a likely first-line agent, however most patients require multiple medications with different mechanisms of action for symptom control Revascularization for high-risk patients or patients with persistent symptoms Angina persists for many patients despite medical therapy and/or revascularization Core Slide: Summary Diagnostic and therapeutic choices in SIHD should be made through a process of shared decision making with patient and provider. Informed decisions require an understanding of the risks, benefits, and costs of diagnostic and management approaches. All patients with angina should undergo aggressive risk factor modification and receive optimized medical management. β-blocker is a likely first-line agent, however most patients require multiple medications with different mechanisms of action for symptom control. Coronary revascularization is recommended for high-risk patients or patients with persistent symptoms. It is important to recognize that angina may persist for many patients despite medical therapy and/or revascularization.
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