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

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.

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.

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.

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.

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.

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