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Clinical Guidelines |

Management 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 FREE

Amir Qaseem, MD, PhD, MHA; Stephan D. Fihn, MD, MPH; Paul Dallas, MD; Sankey Williams, MD; Douglas K. Owens, MD, MS; Paul Shekelle, MD, PhD, for the Clinical Guidelines Committee of the American College of Physicians*
[+] Article and Author Information

* This paper, written by Amir Qaseem, MD, PhD, MHA; Stephan D. Fihn, MD, MPH; Paul Dallas, MD; Sankey Williams, MD; Douglas K. Owens, MD, MS; and Paul Shekelle, MD, PhD, was developed for the Clinical Guidelines Committee of the American College of Physicians: Paul Shekelle, MD, PhD (Chair); Roger Chou, MD; Molly Cooke, MD; Paul Dallas, MD; Thomas D. Denberg, MD, PhD; Nick Fitterman, MD; Mary Ann Forciea, MD; Robert H. Hopkins Jr., MD; Linda L. Humphrey, MD, MPH; Tanveer P. Mir, MD; Holger J. Schünemann, MD, PhD; Donna E. Sweet, MD; and Timothy Wilt, MD, MPH. Approved by the ACP Board of Regents on 16 April 2012.


From the American College of Physicians and University of Pennsylvania, Philadelphia, Pennsylvania; Department of Veterans Affairs, Seattle, Washington; Veterans Affairs Palo Alto Health Care System and Stanford University, Stanford, California; Virginia Tech Carilion School of Medicine, Roanoke, Virginia; and West Los Angeles Veterans Affairs Medical Center, Los Angeles, California.

Note: Clinical practice guidelines are “guides” only and may not apply to all patients and all clinical situations. Thus, they are not intended to override clinicians' judgment. All ACP clinical practice guidelines are considered automatically withdrawn or invalid 5 years after publication or once an update has been issued.

Disclaimer: The authors of this article are responsible for its contents, including any clinical or treatment recommendations.

Financial Support: Financial support for the development of this guideline comes exclusively from the ACP operating budget.

Potential Conflicts of Interest: Any financial and nonfinancial conflicts of interest of the group members were declared, discussed, and resolved according to ACP's conflicts of interest policy. A record of conflicts of interest is kept for each Clinical Guidelines Committee meeting and conference call and can be viewed at www.acponline.org/clinical_information/guidelines/guidelines/conflicts_cgc.htm. Author and peer reviewer disclosure information for the multisocietal stable IHD guideline, on which these guidelines are based, may be found in the published multisocietal document (2). Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-1770.

Requests for Single Reprints: Amir Qaseem, MD, PhD, MHA, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, aqaseem@acponline.org.

Current Author Addresses: Dr. Qaseem: American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.

Dr. Fihn: 1100 Olive Way, Seattle, WA 98101.

Dr. Dallas: 1906 Bellview Avenue, Roanoke, VA 24014.

Dr. Williams: 423 Guardian Drive, Philadelphia, PA 19104.

Dr. Owens: 117 Encina Commons, Stanford, CA 94305.

Dr. Shekelle: 11301 Wiltshire Boulevard, Los Angeles, CA 90073.

Author Contributions: Conception and design: A. Qaseem, S.D. Fihn, D.K. Owens, P. Shekelle.

Analysis and interpretation of the data: A. Qaseem, S.D. Fihn, P. Dallas, S. Williams, D.K. Owens.

Drafting of the article: A. Qaseem, P. Dallas, S. Williams, D.K. Owens.

Critical revision of the article for important intellectual content: A. Qaseem, S.D. Fihn, P. Dallas, S. Williams, D.K. Owens, P. Shekelle.

Final approval of the article: A. Qaseem, S.D. Fihn, S. Williams, D.K. Owens, P. Shekelle.

Statistical expertise: A. Qaseem.

Administrative, technical, or logistic support: A. Qaseem.

Collection and assembly of data: A. Qaseem, S.D. Fihn.


Ann Intern Med. 2012;157(10):735-743. doi:10.7326/0003-4819-157-10-201211200-00011
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Description: The American College of Physicians (ACP) developed this guideline with the American College of Cardiology Foundation (ACCF), American Heart Association (AHA), American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, and Society of Thoracic Surgeons to present the available evidence on the management of stable known or suspected ischemic heart disease.

Methods: Literature on this topic published before November 2011 was identified by using MEDLINE, Embase, Cochrane CENTRAL, PsychINFO, AMED, and SCOPUS. Searches were limited to human studies published in English. This guideline grades the evidence and recommendations according to a translation of the ACCF/AHA grading system into ACP's clinical practice guidelines grading system.

Recommendations: The guideline includes 48 specific recommendations that address the following issues: patient education, management of proven risk factors (dyslipidemia, hypertension, diabetes, physical activity body weight, and smoking), risk factor reduction strategies of unproven benefit, medical therapy to prevent myocardial infarction and death and to relieve symptoms, alternative therapy, revascularization to improve survival and symptoms, and patient follow-up.

This guideline presents the available evidence on the management of stable known or suspected ischemic heart disease (IHD). This is the second of 2 guidelines addressing stable IHD; the first guideline addresses the diagnosis of patients with stable IHD (1). Internists and other primary care physicians are the target audiences for this guideline. The target population is all adult patients with stable known or suspected IHD. These recommendations are based on the joint American College of Cardiology Foundation (ACCF), American Heart Association (AHA), American College of Physicians (ACP), American Association for Thoracic Surgery (AATS), Preventive Cardiovascular Nurses Association (PCNA), Society for Cardiovascular Angiography and Interventions (SCAI), and Society of Thoracic Surgeons (STS) guideline for the diagnosis and management of patients with stable IHD published in 2012, which ACP recognized as a scientifically valid, high-quality review of the evidence (2). Full details about methods and evidence are available in the Appendix.

Methods

The databases used for the literature search included MEDLINE, Embase, Cochrane CENTRAL, PsychINFO, AMED, and SCOPUS for studies published up until November 2011. The criteria for search included human participants and English-language articles. For more details on the methods, please refer to the Appendix and the ACCF, AHA, ACP, AATS, PCNA, SCAI, and STS guideline for the diagnosis and management of patients with stable IHD (2).

Because this document is based on the joint guideline, ACP translated the ACCF/AHA evidence and recommendation grades into ACP's guideline grading system (Tables 1 and 2) (3). We included only class I and class III statements from the joint guideline because the evidence very clearly demonstrates the tradeoff between benefits and harms (Table 2). For details on other recommendations, please refer to the ACCF, AHA, ACP, AATS, PCNA, SCAI, and STS guideline for the diagnosis and management of patients with stable IHD (2).

Table Jump PlaceholderTable 1. 

The American College of Physicians Guideline Grading System

Table Jump PlaceholderTable 2. 

Comparison of Grading Systems From the ACP and ACCF/AHA

The objective of this guideline is to synthesize the evidence for the following key questions:

1: What should be the approach to modifying cardiovascular risk factors to reduce the mortality and morbidity associated with stable IHD?

2: What is the role of coronary revascularization in reducing mortality and morbidity associated with stable IHD?

3: How should chronic anginal symptoms be managed with medications?

General Approach to Treatment

The goals of treating patients with stable IHD are to 1) prevent premature cardiovascular death and complications of stable IHD, including nonfatal acute myocardial infarction (MI) and heart failure, and 2) maintain or restore a quality of life that is satisfactory to the patient while eliminating avoidable adverse effects of tests and treatments, preventing hospital admissions, and eliminating unnecessary tests and treatments. This approach acknowledges that certain interventions are primarily aimed at improving survival, whereas others are undertaken largely to reduce symptoms, although under some circumstances, a treatment may be provided to achieve both aims simultaneously. The evolving approach to management of patients with stable IHD entails a “package” of therapies that are appropriate for most patients who do not have specific contraindications. These include lifestyle changes and specific medications, which together are called guideline-directed medical therapy and are prescribed regardless of decisions regarding revascularization (Figure 1).

Grahic Jump Location
Figure 1.

Guideline-directed medical therapy for patients with stable ischemic heart disease.

ACCF = American College of Cardiology Foundation; ACEI = angiotensin-converting enzyme inhibitor; AHA = American Heart Association; ARB = angiotensin-receptor blocker; ASA = aspirin; ATP III = Adult Treatment Panel III; BP = blood pressure; CCB = calcium-channel blocker; CKD = chronic kidney disease; JNC VII = Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; LV = left ventricular; MI = myocardial infarction; NHLBI = National Heart, Lung, and Blood Institute; NTG = nitroglycerin.

* The use of bile acid sequestrant is relatively contraindicated when triglyceride levels are 200 mg/dL or greater and is contraindicated when triglyceride levels are 500 mg/dL or greater.

† Dietary supplement niacin must not be used as a substitute for prescription niacin.

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The initial approach to all patients should be focused on eliminating unhealthy behaviors, such as smoking, and effectively promoting lifestyle changes that reduce cardiovascular risk, such as increasing weight loss, physical activity, and adopting a healthy diet. In addition, for most patients, an evidence-based set of pharmacologic interventions is indicated to reduce the risk for future events. The presumed mechanism by which these interventions are effective is by stabilizing the coronary plaque to prevent rupture and thrombosis (4). These include antiplatelet agents (5); lipid-lowering agents, in particular hydroxymethylglutaryl coenzyme A reductase inhibitors (statins) (613); and β-blockers (1415). Angiotensin-converting enzyme (ACE) inhibitors are indicated in many patients with stable IHD, especially those with diabetes or left ventricular (LV) dysfunction (1618). Similarly, although tight glycemic control has not been shown to reduce the risk for macrovascular complications in patients with type 2 diabetes, weight loss, aerobic exercise, an AHA Step II diet, and ACE inhibitors in those with proteinuria can all improve patients' risks for microvascular complications and, potentially, cardiac events. Revascularization improves survival in specific subgroups of patients, whereas it should be undertaken to relieve symptoms in others.

Recommendations
Patient Education

Recommendation 1: 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).

Recommendation 2: 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.

Risk Factor Modification
Lipid Management.

Recommendation 3: 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).

Recommendation 4: 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).

Recommendation 5: 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).

Hypertension.

Recommendation 6: 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).

Recommendation 7: 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).

Diabetes.

Recommendation 8: The organizations recommend that therapy with rosiglitazone should not be initiated in diabetic patients with stable IHD (Grade: strong recommendation; low-quality evidence).

Physical Activity.

Recommendation 9: 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).

Weight Management.

Recommendation 10: 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).

Smoking Cessation.

Recommendation 11: 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).

Risk Factor Reduction Strategies of Unproven Benefits.

Recommendation 12: 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).

Recommendation 13: 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).

Recommendation 14: 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).

Recommendation 15: 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).