MANAGEMENT OF STABLE ISCHEMIC HEART DISEASE: OVERVIEW OF RECENT GUIDELINES


Julius M. Gardin, M.D., Hackensack University Medical Center, NJ, USA

Management guidelines regarding diagnosis and treatment of stable ischemic heart disease (SIHD) have evolved with time. In 2012, the ACCF/AHA/ACP SIHD Guidelines (Fihn, Gardin, et al. J Am Coll Cardiol. 2012;60:e44-e164.) emphasized important concepts, e.g., the following: (1) Most SIHD patients should have a trial of guideline-directed medical therapy (GDMT), including risk factor modification, before considering revascularization to improve symptoms. Deferring revascularization is generally not associated with worse outcomes: In the COURAGE Trial (Boden, et al. N Engl J Med. 2007;356:1503-16.), percutaneous coronary intervention (PCI) added to GDMT did not reduce the risk of death, MI, or other major CV events compared with GDMT alone. (2) Prior to revascularization to improve symptoms, coronary anatomy should be correlated with functional studies to ensure that lesions responsible for symptoms are targeted. In the FAME Study (Pijls, et al. J Am Coll Cardiol. 2010;56:177-84.), routine measurement of fractional flow reserve in patients with multi-vessel CAD undergoing PCI reduced mortality and MI compared with standard angiography-guided PCI (12.9% vs 8.4%, p=0.02). (3) Exercise and imaging studies should generally be repeated only for a change in clinical status—not annually. (4) A beta blocker is a first-line agent for treatment of angina; however, most patients require multiple medications with different mechanisms of action for symptom control. Angina may persist for many patients despite medical therapy and/or revascularization. The 2013 European Society of Cardiology guidelines on management of SIHD (Montalescot, et al. Eur Heart J. 2013;34:2949-3003.) also emphasize that in light of the results of the FREEDOM Trial (Farkouh, et al. N Engl J Med. 2012;367:2375-84.), coronary artery bypass graft surgery may be the preferred revascularization strategy in diabetic patients with multi-vessel disease. Guidelines have emphasized the importance of shared decision-making between patient and provider in making important diagnostic and therapeutic choices.