1. 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

2. 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

3. Disclosure Information: Content Development Faculty
Julius M. Gardin, MD, MBA, FACC, FACP, FAHA
Honorarium
Gilead Sciences
Core Slide: Disclosure Information: Content Development Faculty

4. 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

5. 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.

6. 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.

7. 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.

8. 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.

9. 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:

10. 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:

11. 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:

12. 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.

13. 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.

14. 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.

15. 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.

16. 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:

17. 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:

18. 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:

19. 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:

20. 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:

21. 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:

22. 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:

23. 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:

24. 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:

25. 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.

26. 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:

27. 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:

28. 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:

29. 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:

30. 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:

31. 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:

32. 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:

33. 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.

34. 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:

35. 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:

36. 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.

37. 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.

38. 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:

39. 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.

40. 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:

41. 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

42. 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.

43. 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.

44. 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:

45. 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:

46. 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.

47. 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.

48. 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.