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Clinical Guildelines

  1. Management of Patients With Stable Ischemic Heart Disease: Executive 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
  2. Patient Education
  3. The organizations recommend that patients with stable IHD should have an individualized education plan to optimize care and promote wellness, including:

    A. Education on the importance of medication adherence for managing symptoms and reducing disease progression (Grade: strong recommendation; low-quality evidence).
    B. An explanation of medication management and cardiovascular risk reduction strategies in a manner that respects the patient's level of understanding, reading comprehension, and ethnicity (Grade: strong recommendation; moderate-quality evidence).
    C. A comprehensive review of all therapeutic options (Grade: strong recommendation; moderate-quality evidence).
    D. A description of appropriate levels of exercise with encouragement to maintain recommended levels of daily physical activity (Grade: strong recommendation; low-quality evidence).
    E. Introduction to self-monitoring skills (Grade: strong recommendation; low-quality evidence).
    F. Information on how to recognize worsening cardiovascular symptoms and take appropriate action (Grade: strong recommendation, low-quality evidence).

  4. The organizations recommend that patients with stable IHD should be educated regarding the following lifestyle elements that may influence prognosis (Grade: strong recommendation; low-quality evidence):

    A. Weight control and maintenance of a body mass index of 18.5 to 24.9 kg/m2 and waist circumference less than 40 inches for men and less than 35 inches for women (less for certain racial groups).
    B. Lipid management.
    C. Blood pressure control.
    D. Smoking cessation and avoidance of exposure to second-hand smoke.
    E. Individualized medical, nutrition, and lifestyle education for patients with diabetes mellitus to supplement diabetes treatment goals and education.

  5. Risk Factor Modification
  6. Lipid Management.
  7. The organizations recommend lifestyle modifications for lipid management in all patients with stable IHD, including daily physical activity and weight management (Grade: strong recommendation; moderate-quality evidence).
  8. The organizations recommend dietary therapy for all patients, which should include reduced intake of saturated fats (to <7% of total calories), trans-fatty acids (to <1% of total calories), and cholesterol (to <200 mg per day) (Grade: strong recommendation; moderate-quality evidence).
  9. The organizations recommend that in addition to therapeutic lifestyle changes, a moderate or high dose of a statin therapy should be prescribed in the absence of contraindications or documented adverse effects. (Grade: strong recommendation; high-quality evidence).
  10. Hypertension.
  11. The organizations recommend that patients with stable IHD who have high blood pressure should be counseled regarding the need for lifestyle modifications, including maintenance of recommended weight; increased physical activity; moderation of alcohol consumption; limitation of dietary sodium; and emphasis on increased consumption of fresh fruits, vegetables, and low-fat dairy products (Grade: strong recommendation; moderate-quality evidence).
  12. The organizations recommend that patients with stable IHD with blood pressure of 140/90 mm Hg or higher should be treated with antihypertensive drug therapy in addition to following a trial of lifestyle modifications (Grade: strong recommendation; high-quality evidence). The specific medications used for treatment of high blood pressure should be based on specific patient characteristics, and may include ACE inhibitors and/or β-blockers, with addition of other drugs, such as thiazide diuretics or calcium-channel blockers, if needed to achieve a goal blood pressure of less than 140/90 mm Hg (Grade: strong recommendation; moderate-quality evidence).
  13. Diabetes.
  14. The organizations recommend that therapy with rosiglitazone should not be initiated in diabetic patients with stable IHD (Grade: strong recommendation; low-quality evidence).
  15. Physical Activity.
  16. The organizations recommend risk assessment with a physical activity history to guide prognosis and prescription for all patients. An exercise test should be obtained when clinically indicated (Grade: strong recommendation; moderate-quality evidence). As indicated, based on this assessment, patients with stable IHD should be encouraged to engage in 30 to 60 minutes of moderate-intensity aerobic activity, such as brisk walking, at least 5 days and preferably 7 days of the week, supplemented by an increase in daily activities (such as walking breaks at work, gardening, or household work) to improve cardiorespiratory fitness and motivate patients of the least fit, least active high-risk cohort (bottom 20%) (Grade: strong recommendation; moderate-quality evidence). Medically supervised programs (cardiac rehabilitation) and physician-directed, home-based programs are recommended for at-risk patients at first diagnosis (Grade: strong recommendation; high-quality evidence).
  17. Weight Management.
  18. The organizations recommend assessing body mass index and/or waist circumference at every visit and consistently encouraging weight maintenance/reduction through an appropriate balance of lifestyle physical activity, structured exercise, caloric intake, and formal behavioral programs when indicated to maintain/achieve a body mass index between 18.5 and 24.9 kg/m2, and waist circumference less than 40 inches in men and less than 35 inches in women (less for certain racial groups) (Grade: strong recommendation; moderate-quality evidence). The initial goal of weight loss therapy should be to reduce body weight by approximately 5% to 10% from baseline. With success, further weight loss can be attempted if indicated (Grade: strong recommendation; low-quality evidence).
  19. Smoking Cessation.
  20. The organizations recommend that smoking cessation and avoidance of exposure to environmental tobacco smoke at work and at home should be encouraged for all patients with stable IHD. A stepwise strategy for smoking cessation (Ask, Advise, Assess, Assist, Arrange), follow-up, referral to special programs, and/or pharmacotherapy are recommended (Grade: strong recommendation; moderate-quality evidence).
  21. Risk Factor Reduction Strategies of Unproven Benefits.
  22. The organizations recommend that estrogen therapy should not be initiated in postmenopausal women with stable IHD with the intent of reducing cardiovascular risk or improving clinical outcomes (Grade: strong recommendation; high-quality evidence).
  23. The organizations recommend that vitamin C, vitamin E, and β-carotene supplementation should not be used with the intent of reducing cardiovascular risk or improving clinical outcomes in patients with stable IHD (Grade: strong recommendation; high-quality evidence).
  24. The organizations recommend that treatment of elevated homocysteine with folate and/or vitamins B6 and B12 should not be used with the intent of reducing cardiovascular risk or improving clinical outcomes in patients with stable IHD (Grade: strong recommendation; high-quality evidence).
  25. The organizations recommend that chelation therapy should not be used with the intent of improving symptoms or reducing cardiovascular risk in patients with stable IHD (Grade: strong recommendation; low-quality evidence).
  26. The organizations recommend that treatment with garlic, coenzyme Q10, selenium, or chromium should not be used with the intent of reducing cardiovascular risk or improving clinical outcomes in patients with stable IHD (Grade: strong recommendation; low-quality evidence).
  27. Medical Therapy to Prevent MI and Death in Patients With Stable IHD
  28. The organizations recommend that aspirin, 75 to 162 mg daily, should be continued indefinitely in the absence of contraindications in patients with stable IHD (Grade: strong recommendation; high-quality evidence).
  29. The organizations recommend treatment with clopidogrel as a reasonable option when aspirin is contraindicated in patients with stable IHD (Grade: strong recommendation; moderate-quality evidence).
  30. The organizations recommend that dipyridamole should not be used as antiplatelet therapy for patients with stable IHD (Grade: strong recommendation; low-quality evidence).
  31. The organizations recommend that β-blocker therapy should be initiated and continued for 3 years in all patients with normal LV function following MI or acute coronary syndromes (Grade: strong recommendation; moderate-quality evidence).
  32. The organizations recommend that metoprolol succinate, carvedilol, or bisoprolol should be used for all patients with systolic LV dysfunction (ejection fraction ≤40%) with heart failure or prior MI, unless contraindicated (Grade: strong recommendation; high-quality evidence).
  33. The organizations recommend that ACE inhibitors should be prescribed in all patients with stable IHD who also have hypertension, diabetes, LV systolic dysfunction (ejection fraction ≤40%), and/or chronic kidney disease, unless contraindicated (Grade: strong recommendation; high-quality evidence).
  34. The organizations recommend angiotensin-receptor blockers for patients with stable IHD who have hypertension, diabetes, LV systolic dysfunction, or chronic kidney disease and have indications for, but are intolerant of, ACE inhibitors (Grade: strong recommendation; high-quality evidence).
  35. The organizations recommend an annual influenza vaccine for patients with stable IHD (Grade: strong recommendation; moderate-quality evidence).
  36. Medical Therapy for Relief of Symptoms in Patients With Stable IHD
  37. The organizations recommend that β-blockers should be prescribed as initial therapy for relief of symptoms in patients with stable IHD (Grade: strong recommendation; moderate-quality evidence).
  38. The organizations recommend that calcium-channel blockers or long-acting nitrates should be prescribed for relief of symptoms when β-blockers are contraindicated or cause unacceptable side effects in patients with stable IHD (Grade: strong recommendation; moderate-quality evidence).
  39. The organizations recommend that calcium-channel blockers or long-acting nitrates, in combination with β-blockers, should be prescribed for relief of symptoms when initial treatment with β-blockers is unsuccessful in patients with stable IHD (Grade: strong recommendation; moderate-quality evidence).
  40. The organizations recommend that sublingual nitroglycerin or nitroglycerin spray should be used for immediate relief of angina in patients with stable IHD (Grade: strong recommendation; moderate-quality evidence).
  41. Alternative Therapy for Relief of Symptoms in Patients With Stable IHD
  42. The organizations recommend that acupuncture should not be used for the purpose of improving symptoms or reducing cardiovascular risk in stable IHD patients (Grade: strong recommendation; low-quality evidence).
  43. Revascularization
  44. The organizations recommend that a shared decision-making approach should be utilized when making decisions about revascularization in patients with unprotected left main or complex coronary artery disease and should include a cardiac surgeon, an interventional cardiologist, and the patient (Grade: strong recommendation; low-quality evidence).
  45. Revascularization to Improve Survival.
  46. The organizations recommend coronary artery bypass graft to improve survival for patients with significant (≥50% diameter stenosis) left main coronary artery stenosis (Grade: strong recommendation; moderate-quality evidence).
  47. The organizations recommend that percutaneous coronary intervention to improve survival should not be performed in stable patients with significant (≥50% diameter stenosis) unprotected left main coronary artery disease who have unfavorable anatomy for percutaneous coronary intervention and who are good candidates for coronary artery bypass graft (Grade: strong recommendation; moderate-quality evidence).
  48. The organizations recommend the use of coronary artery bypass graft to improve survival in patients with significant (≥70% diameter) stenoses in 3 major coronary arteries (with or without involvement of the proximal left anterior descending artery) or in the proximal left anterior descending artery plus 1 other major coronary artery (Grade: strong recommendation; moderate-quality evidence).
  49. The organizations recommend the use of coronary artery bypass graft or percutaneous coronary intervention to improve survival in survivors of sudden cardiac death with presumed ischemia-mediated ventricular tachycardia caused by significant (≥70% diameter) stenosis in a major coronary artery (Grade: strong recommendation; moderate-quality evidence for coronary artery bypass graft, low-quality evidence for percutaneous coronary intervention).
  50. The organizations recommend that coronary artery bypass graft or percutaneous coronary intervention should not be performed with the primary or sole intent to improve survival in patients with stable IHD with 1 or more coronary stenoses that are not anatomically or functionally significant (for example, <70% diameter non-left main coronary artery stenosis, fractional flow reserve >0.80, no or only mild ischemia on noninvasive testing), involve only the left circumflex or right coronary artery, or subtend only a small area of viable myocardium (Grade: strong recommendation; moderate-quality evidence).
  51. Revascularization to Improve Symptoms.
  52. The organizations recommend the use coronary artery bypass graft or percutaneous coronary intervention to improve symptoms in patients with 1 or more significant (≥70% diameter) coronary artery stenoses amenable to revascularization and unacceptable angina despite guideline-directed medical therapy (Grade: strong recommendation; high-quality evidence).
  53. The organizations recommend that the use coronary artery bypass graft or percutaneous coronary intervention to improve symptoms should not be performed in patients who do not meet anatomical (≥50% diameter left main or ≥70% non-left main stenosis diameter) or physiologic (for example, abnormal fractional flow reserve) criteria for revascularization (Grade: strong recommendation; low-quality evidence).
  54. The organizations recommend that percutaneous coronary intervention with coronary stenting (bare-metal stent or drug-eluting stent) should not be performed if the patient is not likely to be able to tolerate and comply with dual antiplatelet therapy for the appropriate duration rof treatment based on the type of stent implanted (Grade: strong recommendation; moderate-quality evidence).
  55. Patient Follow-up
  56. The organizations recommend that patients with stable IHD should receive periodic follow-up at least annually that includes all of the following (Grade: strong recommendation; low-quality evidence):

    A. Assessment of symptoms and clinical function.
    B. Surveillance for complications of stable IHD, including heart failure and arrhythmias.
    C. Monitoring of cardiac risk factors.
    D. Assessment of the adequacy of and adherence to recommended lifestyle changes and medical therapy.

  57. The organizations recommend assessment of LV ejection fraction and segmental wall motion byechocardiography or radionuclide imaging in patients with new or worsening heart failure or evidence of intervening MI by history or electrocardiogram (Grade: strong recommendation; low-quality evidence).
  58. The organizations recommend that measurement of LV function with a technology such as echocardiography or radionuclide imaging should not be used for routine periodic reassessment of patients who have not had a change in clinical status or who are at low risk of adverse cardiovascular events (Grade: strong recommendation; low-quality evidence).
  59. The organizations recommend standard exercise electrocardiogram in patients with known stable IHD who have new or worsening symptoms not consistent with unstable angina and who have a) at least moderate physical functioning and no disabling comorbidity and b) an interpretable electrocardiogram (Grade: strong recommendation; moderate-quality evidence).
  60. The organizations recommend exercise with radionuclide myocardial perfusion imaging or echocardiography in patients with known stable IHD who have new or worsening symptoms not consistent with unstable angina, and who have a) at least moderate physical functioning or no disabling comorbidity but b) an uninterpretable electrocardiogram (Grade: strong recommendation; moderate-quality evidence).
  61. The organizations recommend that pharmacologic stress imaging with radionuclide myocardial perfusion imaging, echocardiography, or cardiac magnetic resonance should not be used in patients with known stable IHD who have new or worsening symptoms not consistent with unstable angina and who are capable of at least moderate physical functioning or have no disabling comorbidity (Grade: strong recommendation; low-quality evidence).
  62. The organizations recommend pharmacologic stress imaging using radionuclide myocardial perfusion or echocardiography in patients with known stable IHD who have new or worsening symptoms not consistent with unstable angina and who are incapable of at least moderate physical functioning or have disabling comorbidity (Grade: strong recommendation; moderate-quality evidence).
  63. The organizations recommend that standard exercise electrocardiogram testing should not be performed in patients with known stable IHD who have new or worsening symptoms not consistent with unstable angina and who a) are incapable of at least moderate physical functioning or have disabling comorbidity or b) have an uninterpretable electrocardiogram (Grade: strong recommendation; low-quality evidence).
  64. The organizations recommend that coronary/cardiac computed tomography angiography should not be performed for assessment of native coronary arteries with known moderate or severe calcification or of coronary stents less than 3 mm in diameter in patients with known stable IHD who have new or worsening symptoms not consistent with unstable angina, irrespective of ability to exercise (Grade: strong recommendation; moderate-quality evidence).
  65. The organizations recommend that radionuclide myocardial perfusion imaging, echocardiography, or cardiac magnetic resonance, with either exercise or pharmacologic stress or coronary/cardiac computed tomography angiography, should not be used for follow-up assessment in patients with stable IHD, if performed more frequently than at a) 5-year intervals after coronary artery bypass graft or b) 2-year intervals after percutaneous coronary intervention (Grade: strong recommendation; low-quality evidence).

American College of Physicians