Nearly 10 million Americans have stable ischemic heart disease (SIHD), which ranks among the leading causes of death among adults in the United States. According to study data, SIHD was the cause of nearly 380,000 deaths in the U.S. in 2010. The total costs associated with caring for heart disease has been estimated at $316.4 billion, while the total cost for coronary heart disease accounts for about $177.1 billion (Figure 1). More than 5 years have passed since guidelines were released on the management of patients with SIHD. In an effort to revisit those recommendations, the American College of Cardiology Foundation/ American Heart Association Task Force on Practice Guidelines and five other medical societies collaborated to release a 2012 guideline update for these patients that was published in Circulation.
Influential Studies Shaping Revascularization
The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial helped shape the revascularization section of the guidelines update, according to James C. Blankenship, MD, FSCAI, who was on the task force that revised the recommendations. “For the COURAGE trial, stable patients in whom catheterization demonstrated a need for revascularization were randomized to medical therapy or coronary intervention. The researchers concluded that neither showed a benefit with regard to death or heart attack. Stenting showed a benefit in angina control for 3 years. This finding, along with data from other studies, indicates that every lesion doesn’t necessarily need to be fixed and that the strongest indication for coronary stenting in stable patients is relief of symptoms.”
Revisions in the revascularization section were also shaped by results of the Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) trial. In this analysis, patients with left main and multi-vessel coronary disease were randomized to receive either PCI or CABG. “The SYNTAX trial showed that for the most complex disease, CABG had a survival benefit over PCI,” explains Dr. Blankenship. “However, outcomes for death and heart attack were similar with less complex disease.” He adds that there was more need for repeat procedures with PCI, based on findings from the trial.
Key Themes For Ischemic Heart Disease
According to the guidelines, patients diagnosed with SIHD should be assessed for risks of death or complications associated with ischemic heart disease (IHD). Risk-stratification of IHD—particularly if the likelihood is intermediate—should be based on a standard exercise test in patients with an interpretable ECG and who are able to exercise. In patients with an uninterpretable ECG who are able to exercise, the guidelines recommend that risk stratification be based on an exercise stress test with nuclear myocardial perfusion imaging (MPI) or echocardiography. Nuclear MPI or echocardiography with pharmacologic stress is recommended for those who cannot exercise.
An important emphasis of the guidelines is to ensure that patients are informed on the risks, benefits, and costs associated with their diagnostic and therapeutic options (Figure 2). “Patient education should focus on medication adherence, risk reduction strategies, therapeutic options, appropriate exercise, self-monitoring, how to recognize worsening cardiac symptoms, and when to seek help,” says Dr. Blankenship. Lifestyle interventions and medications should also be provided to patients as part of a package. These include smoking cessation, a daily aspirin (75 mg to 162 mg), a moderate-dose statin, and antihypertensive medication, as necessary.
Dr. Blankenship suggests that clinicians encourage patients to be active participants in their own care and not just give them explanations of what clinicians feel are the best courses of action. “Patients should be informed well enough to have educated preferences on the therapeutic approach,” says Dr. Blankenship. “Patient-centered decision making has really come to the forefront since the last version of the guidelines.”
Using a heart team approach is recommended for patients with complex coronary disease, and Dr. Blankenship says this shift represents a new paradigm in care. “Clinicians have been using this approach for decades—consulting with cardiologists or cardiac surgeons and making decisions collaboratively about what to recommend to patients. The current guidelines provide a Class I recommendation for doing so in cases of complex disease.”
Advancements for Ischemic Heart Disease Management
There are even more opportunities to improve upon the diagnosis and management of SIHD, according to Dr. Blankenship. “There are several ongoing registries, and more technological developments are occurring in imaging. We also need more studies on lipid management and better definitions of the benefits of CABG versus PCI. Until these data emerge, clinicians can refer to the current guidelines to assist them in optimizing care for patients with SIHD.”
Readings & Resources (click to view)
Fihn S, Gardin J, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2012, Nov 19 [Epub ahead of print]. Available at http://circ.ahajournals.org/content/early/2012/11/19/CIR.0b013e318277d6a0.full.pdf+html.
Antman E, Hand M, Armstrong P, et al. 2007 focused update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2008;117:296-329.
Kushner F, Hand M, Smith S Jr, et al. 2009 focused updates: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction (updating the 2004 guideline and 2007 focused update) and ACC/AHA/SCAI guidelines on percutaneous coronary intervention (updating the 2005 guideline and 2007 focused update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2009;120:2271-2306.
Jneid H, Anderson J, Wright R, et al. 2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/non–ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2012;126:875-910.
Greenland P, Alpert J, Beller G, et al. 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2010;122:e584-e636.
Smith S Jr, Benjamin E, Bonow R, et al. AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation. Circulation. 2011;124:2458 -2473.