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

Amir Qaseem; Stephan D. Fihn; Sankey Williams; Paul Dallas; Douglas K. Owens; Paul Shekelle

doi:10.7326/0003-4819-157-10-201211200-00010

Clinical Guidelines |20 November 2012

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 Free

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

Article, Author, and Disclosure Information

* This paper, written by Amir Qaseem, MD, PhD, MHA; Stephan D. Fihn, MD, MPH; Sankey Williams, MD; Paul Dallas, 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 All ACP clinical practice guidelines are considered automatically withdrawn or invalid 5 years after publication or once an update has been issued.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=M12-1769.
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. Williams: 423 Guardian Drive, Philadelphia, PA 19104.
Dr. Dallas: 1906 Bellview Avenue, Roanoke, VA 24014.
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, S. Williams, P. Dallas, D.K. Owens.
Drafting of the article: A. Qaseem, S.D. Fihn, S. Williams, P. Dallas, D.K. Owens.
Critical revision of the article for important intellectual content: A. Qaseem, S.D. Fihn, S. Williams, P. Dallas, 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.

Abstract

Description:

The American College of Physicians (ACP) developed this guideline in collaboration 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 help clinicians diagnose known or suspected stable 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:

This guideline includes 28 recommendations that address the following issues: the initial diagnosis of the patient who might have stable ischemic heart disease, cardiac stress testing to assess the risk for death or myocardial infarction in patients diagnosed with stable ischemic heart disease, and coronary angiography for risk assessment.

Executive Summary

This guideline presents the available evidence on the diagnosis of stable known or suspected ischemic heart disease (IHD). This is the first of 2 guidelines addressing stable IHD; the second guideline addresses the management 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, 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 (3) (Tables 1 and 2). We included only class I and class III statements from the joint guideline because the evidence for these statements very clearly demonstrates the tradeoff between benefits and harms (Table 2). For details on other recommendations, refer to the ACCF, AHA, ACP, AATS, PCNA, SCAI, and STS guideline for the diagnosis and management of patients with stable IHD (2).

Table 1.

The American College of Physicians' Guideline Grading System

Table 1.

Table 2.

Comparison of Grading Systems From the ACP and ACCF/AHA

Table 2.

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

1: How should a clinician evaluate a patient with chest pain that is consistent with IHD?

2: What is the role of noninvasive testing in the diagnosis of stable IHD?

Recommendations

In interpreting these recommendations, it is important to distinguish between the probability of having IHD and the probability (risk) of death or myocardial infarction once the diagnosis of IHD is established.

Initial Cardiac Testing to Establish Diagnosis of IHD

Recommendation 1: The organizations recommend that patients with chest pain should receive a thorough history and physical examination to assess the probability of IHD prior to additional testing (Grade: strong recommendation; low-quality evidence).

Recommendation 2: The organizations recommend that choices regarding diagnostic and therapeutic options should be made through a process of shared decision making involving the patient and provider, explaining information about risks, benefits, and costs to the patient (Grade: strong recommendation; low-quality evidence).

Recommendation 3: The organizations recommend that patients who present with acute angina must be categorized as stable or unstable; patients with unstable angina should be further categorized as high, moderate, or low risk (Grade: strong recommendation; low-quality evidence).

Recommendation 4: The organizations recommend a resting electrocardiography (ECG) in patients without an obvious noncardiac cause of chest pain for risk assessment (Grade: strong recommendation; moderate-quality evidence).

Recommendation 5: The organizations recommend standard exercise ECG for initial diagnosis in patients with an intermediate pretest probability of IHD who have an interpretable ECG and at least moderate physical functioning or no disabling comorbidity (Grade: strong recommendation; high-quality evidence).

Recommendation 6: The organizations recommend that exercise stress with radionuclide myocardial perfusion imaging or echocardiography should be used for patients with an intermediate to high pretest probability of IHD that have an uninterpretable ECG and at least moderate physical functioning or no disabling comorbidity (Grade: strong recommendation; moderate-quality evidence).

Recommendation 7: The organizations recommend that pharmacologic stress with radionuclide myocardial perfusion imaging, echocardiography, or cardiac magnetic resonance imaging should not be used for patients who have an interpretable ECG and at least moderate physical functioning or no disabling comorbidity (Grade: strong recommendation; low-quality evidence).

Recommendation 8: The organizations recommend that exercise stress with nuclear myocardial perfusion imaging should not be used as an initial test in low-risk patients who have an interpretable ECG and at least moderate physical functioning or no disabling comorbidity (Grade: strong recommendation; low-quality evidence).

Recommendation 9: The organizations recommend pharmacologic stress with radionuclide myocardial perfusion imaging or echocardiography for patients with an intermediate to high pretest probability of IHD who are incapable of at least moderate physical functioning or with disabling comorbidity (Grade: strong recommendation; moderate-quality evidence).

Recommendation 10: The organizations recommend that standard exercise ECG testing should not be used for patients that have an uninterpretable ECG or are incapable of at least moderate physical functioning or with disabling comorbidity (Grade: strong recommendation; low-quality evidence).

Recommendation 11: The organizations recommend assessing resting left ventricular systolic and diastolic ventricular function and evaluating for abnormalities of myocardium, heart valves, or pericardium using Doppler echocardiography in patients with known or suspected IHD and a prior myocardial infarction, pathologic Q waves, symptoms or signs suggestive of heart failure, complex ventricular arrhythmias, or an undiagnosed heart murmur (Grade: strong recommendation; moderate-quality evidence).

Recommendation 12: The organizations recommend that echocardiography, radionuclide imaging, cardiac magnetic resonance imaging, or cardiac computed tomography should not be used for routine assessment of left ventricular function in patients with a normal ECG, no history of myocardial infarction, no symptoms or signs suggestive of heart failure, and no complex ventricular arrhythmias (Grade: strong recommendation; low-quality evidence).

Recommendation 13: The organizations recommend that routine reassessment (<1 year) of left ventricular function using technologies such as echocardiography radionuclide imaging, cardiac magnetic resonance imaging, or cardiac computed tomography should not be used in patients with no change in clinical status and for whom no change in therapy is contemplated (Grade: strong recommendation; low-quality evidence).

Cardiac Stress Testing to Assess Risk in Patients With Known Stable IHD Who Are Able to Exercise

Recommendation 14: The organizations recommend standard exercise ECG testing for risk assessment in patients who are able to exercise to an adequate workload and have an ECG that can be interpreted during exercise (Grade: strong recommendation; moderate-quality evidence).

Recommendation 15: The organizations recommend the addition of either radionuclide myocardial perfusion imaging or echocardiography to standard exercise ECG testing for risk assessment, in patients with stable IHD who are able to exercise to an adequate workload but have an uninterpretable ECG not due to left bundle branch block or ventricular pacing (Grade: strong recommendation; moderate-quality evidence).

Recommendation 16: The organizations recommend that pharmacologic stress imaging (radionuclide myocardial perfusion imaging, echocardiography, cardiac magnetic resonance imaging) or cardiac computed tomography angiography should not be used for risk assessment in patients with stable IHD who are able to exercise to an adequate workload and have an interpretable ECG (Grade: strong recommendation; low-quality evidence).

Cardiac Stress Testing to Assess Risk in Patients With Known Stable IHD Who Are Unable to Exercise

Recommendation 17: The organizations recommend pharmacologic stress with either radionuclide myocardial perfusion imaging or echocardiography for risk assessment in patients who are unable to exercise to an adequate workload regardless of interpretability of ECG (Grade: strong recommendation; moderate-quality evidence).

Cardiac Stress Testing to Assess Risk in Patients With Stable IHD Regardless of Ability to Exercise

Recommendation 18: The organizations recommend pharmacologic stress with either radionuclide myocardial perfusion imaging or echocardiography for risk assessment in patients with stable IHD who have left bundle branch block on ECG, regardless of ability to exercise to an adequate workload (Grade: strong recommendation; moderate-quality evidence).

Recommendation 19: The organizations recommend either exercise or pharmacological stress with imaging (radionuclide myocardial perfusion imaging, echocardiography, or cardiac magnetic resonance) for risk assessment in patients being considered for revascularization of known coronary stenosis of unclear physiologic significance (Grade: strong recommendation; moderate-quality evidence).

Recommendation 20: The organizations recommend that a) more than 1 stress imaging study or b) a stress imaging study and cardiac computed tomography angiography at the same time should not be used for risk assessment in patients with stable IHD (Grade: strong recommendation; low-quality evidence).

Coronary Angiography as an Initial Testing Strategy to Assess Risk in Patients With Stable IHD

Recommendation 21: The organizations recommend that patients with stable IHD who have survived sudden cardiac death or potentially life-threatening ventricular arrhythmia undergo coronary angiography to assess cardiac risk (Grade: strong recommendation; moderate quality-evidence).

Recommendation 22: The organizations recommend that patients with stable IHD who develop symptoms and signs of heart failure should be evaluated to determine whether coronary angiography should be performed for risk assessment (Grade: strong recommendation; moderate quality-evidence).

Recommendation 23: The organizations recommend that patients with stable IHD and clinical characteristics that indicate a high likelihood of severe IHD should undergo coronary angiography to assess cardiac risk (Grade: strong recommendation; low-quality evidence).

Coronary Angiography to Assess Risk After Initial Workup With Noninvasive Testing

Recommendation 24: The organizations recommend that coronary arteriography should be used for risk assessment in patients with stable IHD whose clinical characteristics and results of noninvasive testing indicate a high likelihood of severe IHD and when the benefits are deemed to exceed risk (Grade: strong recommendation; low-quality evidence).

Recommendation 25: The organizations recommend that coronary angiography for risk assessment should not be utilized for stable IHD patients who elect not to undergo revascularization or who are not candidates for revascularization based on comorbidities or individual preferences (Grade: strong recommendation; moderate-quality evidence).

Recommendation 26: The organizations recommend that coronary angiography should not be used to further assess risk in patients with stable IHD who have preserved left ventricular function (ejection fraction >50%) and low-risk criteria on noninvasive testing (Grade: strong recommendation; moderate-quality evidence).

Recommendation 27: The organizations recommend that coronary angiography should not be used to assess risk in patients who are at low risk based upon clinical criteria and who have not undergone noninvasive risk testing (Grade: strong recommendation; low-quality evidence).

Recommendation 28: The organizations recommend that coronary angiography should not be used to assess risk in asymptomatic patients with no evidence of ischemia on noninvasive testing (Grade: strong recommendation; low-quality evidence).

Summary

Physicians should integrate the information from their clinical evaluation with patient preferences when making decisions about further testing. Two patients with the same pretest probability of IHD may prefer different approaches because of variations in personal beliefs, economic considerations, or stage of life. A resting ECG helps in establishing a diagnosis and assessing the risk for stable IHD. Rest echocardiography and radionuclide imaging are helpful in assessing patients with clinically evident ventricular dysfunction. Cardiac stress testing is indicated in most symptomatic patients suspected of having IHD to establish the diagnosis, and it is indicated in most patients with both suspected and established IHD to identify patients at very high risk for death or myocardial infarction who might have lesions where anatomical intervention could be beneficial. See Figure 1 for an algorithm on the diagnosis of patients suspected of having IHD and Figure 2 for an algorithm on risk assessment in patients with established stable IHD.

Figure 1.

Diagnosis of patients suspected of having ischemic heart disease.

CCTA = computed coronary tomography angiography; CMR = cardiac magnetic resonance; ECG = electrocardiogram; echo = echocardiography; IHD = ischemic heart disease; MPI = myocardial perfusion imaging; UA = unstable angina; UA/NSTEMI = unstable angina/non–ST-segment elevation myocardial infarction.

* See Table 2 of reference 2 for short-term risk of death or nonfatal myocardial infarction in patients with UA/NSTEMI.

† CCTA is reasonable only for patients with intermediate probability of IHD.

Figure 2.

Risk assessment of patients with stable ischemic heart disease.

CCTA = coronary computed tomography angiography; CMR = cardiac magnetic resonance; ECG = electrocardiogram; echo = electrocardiography; LBBB = left bundle branch block; MPI = myocardial perfusion imaging.

Appendix: Diagnosis of Stable Ischemic Heart Disease: A Clinical Practice Guideline Summary 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

Ischemic heart disease (IHD) is a major public health issue that affects an estimated 1 in 3 adults in the United States (4). Approximately 71 million Americans have some form of cardiovascular disease, including more than 13 million with coronary artery disease and more than 9 million with angina pectoris (4). The prevalence of IHD increases with age; approximately 23% of men and 15% of women aged 60 to 79 years in the United States have IHD. Although survival of patients with IHD has been steadily improving, it was still responsible for nearly 380 000 deaths in the United States in 2010, with an age-adjusted mortality rate of 113 per 100 000 population (5). The costs of caring for patients with IHD are enormous: $156 billion in the U.S. for both direct and indirect costs in 2008 (6). These costs include hospitalizations, invasive procedures, emergency department visits, and long-term care.

The purpose of this guideline is to present the available evidence on the diagnosis of stable known or suspected IHD. This is the first of 2 guidelines addressing stable IHD; the second guideline addresses the management of patients with stable IHD (7). The target audience for this guideline is all internists and other primary care physicians. The target population is all adult patients with stable known or suspected IHD. These recommendations are based on the joint guideline on the diagnosis and management of patients with stable IHD from the 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), published in 2012, which ACP recognized as a scientifically valid, high-quality review of the evidence (8).