MISHMERES GUF
American College of Cardiology Press Release
Guidelines Recommend a Patient-Centered Approach to the
Diagnosis and Management of SIHD
November 19, 2012
New, comprehensive guidelines released by the ACC Foundation (ACCF)/American
Heart Association (AHA) Task Force on Practice Guidelines, in partnership with
several other medical specialty societies, aim to provide physicians with a
framework to optimally diagnose and manage patients with stable ischemic heart
disease (SIHD).
SIHD affects nearly 10 million Americans, and remains the leading cause of death
among U.S. adults. As such, the new guidelines present an extensive assessment
of the evidence and key issues involved in the diagnosis, risk assessment,
treatment and follow up of known or suspected SIHD. Among the topics covered:
guideline-directed medical therapy as the cornerstone of treatment for most
patients; how to optimally care for women and other subgroups of patients who
may be more prone to complications; the use of newer imaging and diagnostic
technologies; the role of catheter-based and surgical procedures in treatment;
the value of patient preferences in decision making; and the need for careful
follow up to monitor for progression of disease and adherence to therapy.
Specifically, the guidelines recommend that patients diagnosed with SIHD should
undergo assessment of risk for death or complications of IHD. For patients with
an interpretable ECG and who are able to exercise, a standard exercise test
should be the first choice test for diagnosis of IHD, especially if the
likelihood is intermediate. Those who have an un-interpretable ECG and are able
to exercise, should undergo an exercise stress with nuclear MPI or
echocardiography, particularly if the likelihood of IHD is intermediate to high.
For patients unable to exercise, nuclear MPI or echocardiography with
pharmacologic stress is recommended. However, it's important to note that
routine annual stress and imaging studies are generally not recommended in
stable patients unless there are changes in clinical circumstances. While an
earlier ACC/AHA guideline on chronic stable angina issued in 2002 focused on
specific drugs and interventions to reduce individual cardiovascular risk
factors, the new document also represents a more patient-centered approach to
managing SIHD.
The new guidelines recommend that patients with SIHD generally receive a
"package" of Guideline-Directed Medical Therapy (GDMT) that includes lifestyle
interventions and medications shown to improve outcomes which includes (as
appropriate):
• Diet, weight loss and regular physical activity;
• If a smoker, smoking cessation;
• Aspirin 75 – 162 mg daily;
• A statin medication in moderate dosage;
• If hypersensitive, antihypertensive medication to achieve a BP <140/90;
• If diabetic, appropriate glycemic control.
That being said, the writing committee notes throughout the document that
patients need to be informed and engaged in their own care. "Patient preference
is very important in terms of directing care, so the answer may not be the same
for every patient," said Julius M. Gardin, MD, FACC, of Hackensack University
Medical Center and vice chair of the writing committee. "Additionally, to
provide quality care, we need to consistently devote time to each patient to
educate them about the things that they can do in terms of self-care – stopping
smoking, watching their diet, losing weight, getting regular exercise and taking
their medications as prescribed."
The writing committee also took a stance on when to use more invasive
strategies. For the vast majority of patients with stable disease – even those
with considerable ischemia – medical management is warranted before considering
revascularization by placing a stent in the blocked artery or through surgical
bypass grafting. "Overall, there is a misperception that somehow opening up and
stenting an artery saves lives for patients with stable disease; however, in the
majority of these cases there is no evidence from any study that this procedure
prolongs life," said Gardin.
The new guideline was developed by experts at ACC and AHA in partnership with
the American College of Physicians, American Association for Thoracic Surgery,
Preventive Cardiovascular Nurses Association, Society for Cardiovascular
Angiography and Interventions, and The Society of Thoracic Surgeons without
commercial support. The recommendations were also informed by discussions with
other ACC writing committees to ensure consistency.