New Guideline Addresses Diagnosis and Treatment of Patients With Stable Ischemic Heart Disease

November 20, 2012—The Society for Cardiovascular Angiography and Interventions (SCAI) announced the publication of the multisociety 2012 guideline for the diagnosis and management of patients with stable ischemic heart disease (SIHD). The guideline will appear in the December 18 issue of the Journal of the American College of Cardiology and will be accessible on the websites of the American College of Cardiology (www.cardiosource.org) and SCAI (www.scai.org).

The ACC/American Heart Association Task Force on Practice Guidelines along with SCAI, the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, and the Society of Thoracic Surgeons jointly released the comprehensive guidelines to provide clinicians with a framework to optimally care for patients with SIHD.

According to SCAI, the 170-page report presents an extensive assessment of the evidence and key issues involved in the diagnosis, risk assessment, treatment, and follow-up of patients with known or suspected SIHD. Among the topics covered are 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.

SCAI noted in its announcement that a 2002 ACC/AHA guideline on chronic stable angina focused on specific drugs and interventions to reduce individual cardiovascular risk factors. However, SCAI stated that the present document represents a more holistic view to managing SIHD. It also highlights key clinical considerations for certain subgroups of patients—in particular, women, older adults, and people with diabetes and kidney disease—who may present with different symptoms and have worse outcomes in terms of cardiac events.

Stephan D. Fihn, MD, MPH, served as Chair of the 2012 writing committee. Dr. Fihn, who is affiliated with the Division of General Internal Medicine at the University of Washington, is also the Director of the Office of Analytics and Business Intelligence at the Veterans Health Administration.

“We have a phenomenal body of evidence about effective therapies both in terms of improving survival and quality of life,” commented Dr. Fihn in the SCAI press release. “These guidelines help identify those therapies that have been shown to possess benefit and those that have not, which can guide medical decision making.”

Dr. Fihn added, “Our thinking about this disease has evolved. We now better understand the interplay of risk factors involved in both the progression of the disease and the occurrence of adverse events such as heart attack and cardiac death. With this new guideline, we have transitioned from arbitrarily picking and choosing individual therapies to recognizing there is a package of lifestyle modifications and medications—what we call guideline-directed medical therapy—that benefits most patients.” SCAI stated that this “package” should ideally include an antiplatelet drug like daily aspirin (75–162 mg daily), an appropriate-dose statin, and heart-healthy lifestyle changes. Therapy should also be tailored to individual patients to ensure that additional risk factors, such as smoking, high blood pressure, and diabetes, are concurrently addressed.

Cardiologist Julius M. Gardin, MD, who served as Vice Chair of the writing committee commented in the SCAI's announcement, “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.” Dr. Gardin, who is Professor and Chair of the Department of Medicine at Hackensack University Medical Center, added that even if clinicians identify a narrowing, they need to demonstrate the functional significance of that narrowing. He continued, “The percent narrowing in and of itself isn't as important as what it [the blockage] is doing downstream in terms of the heart getting—or not getting—enough nutrients. For this reason, we emphasize testing to show this, whether it's through some of the noninvasive imaging tests or in the cath lab.” 

When such testing shows evidence of a severe blockage in patients on optimal medical therapy, and the patients are limited by their chest pain, coronary stenting or bypass surgery provides relief faster and at least as effectively as medication. Patients with stable symptoms should have the final say in how their chest pain is treated, stated SCAI. 

As in the previous guideline for patients with chronic stable angina, the standard treadmill stress test is still recommended as the first-line test for diagnosing SIHD or assessing the risk of death or complications in someone who can tolerate exercise and has a normal or interpretable electrocardiogram. However, because patients are now often older, more overweight/obese, and perhaps unable to exercise, other imaging techniques such as nuclear myocardial perfusion imaging or echocardiography with pharmacologic stress are often needed. Routine annual stress and imaging studies are generally not recommended in stable patients unless there are changes in clinical circumstances. 


The guideline also highlights and identifies the limited niches in which newer imaging technologies, such as cardiac magnetic resonance imaging and computed tomography, might provide benefit.

Throughout the report, the writing committee stresses the need to inform patients and engage them in their own care, pointing to the value of shared decision making, which also considers personal preferences.

Dr. Gardin stated, “Patient preference is very important in terms of directing care, so the answer may not be the same for every patient. 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.”