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Diagnosis of Stable Ischemic Heart Disease: Recommendations From the American College of Physicians, American College of Cardiology Foundation, American Heart Association, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, and Society of Thoracic Surgeons FREE

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The full report is titled “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.” It is in the 20 November 2012 issue of Annals of Internal Medicine (volume 157, pages 729-734). The authors are A. Qaseem, S.D. Fihn, S. Williams, P. Dallas, D.K. Owens, and P. Shekelle, for the Clinical Guidelines Committee of the American College of Physicians.

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Ann Intern Med. 2012;157(10):I-42. doi:10.7326/0003-4819-157-10-201211200-00002
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Who developed these guidelines?

Members of the American College of Physicians (ACP) are internists—specialists in the care of adults. The ACP developed the recommendations with the American College of Cardiology Foundation, American Heart Association, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, and Society of Thoracic Surgeons.

What is the problem and what is known about it so far?

Similar to other body organs in a body, the heart requires oxygen that is carried by blood. In ischemic heart disease, blockages in blood vessels lead to low blood flow to the heart, which can cause chest pain (angina) or other symptoms, such as shortness of breath. If low blood flow is severe and lasts long enough, a section of heart muscle dies, a condition called myocardial infarction or “heart attack.”

Ischemic heart disease can be “unstable” or “stable.” People with unstable ischemic heart disease have symptoms that are rapidly worsening and occur at lower levels of exertion or at rest. Patients with stable ischemic heart disease (SIHD) have chest pain or other symptoms that occur at predictable levels of exertion and can be controlled with rest. The goal of SIHD treatment is to keep disease from becoming unstable.

Many conditions besides SIHD can cause chest pain and shortness of breath. Patients with known SIHD require monitoring to prevent the disease from becoming unstable and to start additional treatment if the disease worsens.

How did the ACP develop these recommendations?

The ACP and the other associations reviewed studies published through November 2011 on the benefits and harms of testing to diagnose and monitor SIHD and then rated the quality of information and made recommendations about diagnosing patients with SIHD.

What did the authors find?

Published studies show that various tests, including electrocardiography, echocardio-graphy, and stress tests can help diagnose SIHD and identify patients who need treatment. However, the approach to testing an individual patient should be guided by patient preferences.

What does the ACP recommend that patients and doctors do?

The ACP offers 28 specific recommendations about when to use specific strategies and tests for evaluating SIHD. The recommended evaluation strategy starts with history and physical examination. This is followed by electrocardiography to test the electrical activity of the heart to rule out heart attack and blood tests to measure various chemicals in blood. If needed, stress tests can check if the heart is getting enough blood during exercise and identify patients who might benefit from invasive treatment, such as stents or surgery. Finally, coronary angiography, where a small tube is inserted in the heart through the leg and a dye is injected, can determine if a blood vessel is clogged. Tests are done on the basis of the results of the electrocardiography, patient risk factors, and preferences.

What are the cautions related to these recommendations?

These recommendations are based on evidence published through November 2011 and might not reflect studies published since that time.





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