Stable Ischemic Heart Disease

Stable
Ischemic Heart
Disease
Science Writer
Jennifer Fisher Wilson
Section Editors
Deborah Cotton, MD, MP
Darren Taichman, MD, PhD
Sankey Williams, MD
Diagnosis
page ITC1-2
Treatment
page ITC1-5
Practice Improvement
page ITC1-13
Tool Kit
page ITC1-14
Patient Information
page ITC1-15
CME Questions
page ITC1-16
The content of In the Clinic is drawn from the clinical information and education
resources of the American College of Physicians (ACP), including ACP Smart
Medicine and MKSAP (Medical Knowledge and Self-Assessment Program). Annals
of Internal Medicine editors develop In the Clinic from these primary sources in
collaboration with the ACPs Medical Education and Publishing divisions and with
the assistance of science writers and physician writers. Editorial consultants from
ACP Smart Medicine and MKSAP provide expert review of the content. Readers
who are interested in these primary resources for more detail can consult
http://smartmedicine.acponline.org, http://www.acponline.org/products_services/
mksap/15/?pr31, and other resources referenced in each issue of In the Clinic.
CME Objective: To review current evidence for diagnosis, treatment, and practice
improvement of stable ischemic heart disease.
The information contained herein should never be used as a substitute for clinical
judgment.
2014 American College of Physicians
Downloaded From: http://annals.org/ by Kathleen Ward on 04/10/2015
In theClinic
In the Clinic
table ischemic heart disease (SIHD) affects many millions of Americans, with associated annual costs measured in tens of billions of dollars. It is a leading cause of death in the United States. SIHD occurs
when coronary artery disease (CAD) reduces the blood supply to the heart
and typically causes recurrent chest pain or pressure known as angina. The
angina is exacerbated by activity or stress, lasts for minutes not seconds or
hours, and goes away with rest or medication. Timely diagnosis and optimal
treatment can reduce complications and mortality from SIHD.
Recent clinical guidelines are designed to improve clinical care for SIHD.
For example, in 2011, the U.K. National Institute of Clinical Excellence
released new guidance on the management of stable angina (www.nice.org
.uk/guidance/CG126) Also, in 2012, a collaboration of professional organizations in the United States released new guidelines for diagnosis and
management (1-3).
Diagnosis
Principal Presentations of
Unstable Angina*
Rest angina: Occurring at rest and
usually lasting >20 minutes
New-onset severe angina: Severe
onset within 2 months of initial
presentation
Increasing angina: Previously
diagnosed angina with a
crescendo pattern of occurrence
(increasing in intensity, duration,
and/or frequency)
*From reference 5.
1. Fihn SD, Gardin JM,

Abrams J, et al.
ACCF/AHA/ACP/AATS
/PCNA/SCAI/STS
Guideline for the Diagnosis and Management of Patients With
Stable Ischemic Heart
Disease: A Report of
the American College
of Cardiology Foundation/American
Heart Association
Task Force on Practice Guidelines, and
of Physicians, American Association for
Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for
Cardiovascular Angiography and Interventions, and Society
of Thoracic Surgeons.
Circulation.
2012;126:e354-e471.
diagnosis (see the Box: Alternative

Diagnoses to Angina for Patients
With Chest Pain).
Why is it important to differentiate patients with SIHD from

patients with unstable angina?
Stable angina is typically brought
on by exertion or emotion. In contrast, unstable angina symptoms
are more random and unpredictable
and often occur without an apparent trigger (see the Box: Principal
Presentations of Unstable Angina). Patients with low-risk unstable angina can be managed the
same way as patients with SIHD.
However, patients with high-risk
or intermediate-risk unstable
angina should be managed more
aggressively than described in
these materials (4).
Why is it important to estimate

the probability of disease
separately from the mortality risk
when evaluating people with
suspected SIHD?
It is important to identify patients with a probability of CAD
low enough (< 5%) that they can
benefit from studies looking for
causes of chest pain other than
CAD. The clinician should start
this process using the patients
age, sex, and type of angina
(Table 1 and the Box: Clinical
Classification of Chest Pain).
Smoking history, hyperlipidemia,
and diabetes mellitus increase the
likelihood of CAD for each type
of patient, with diabetes having
the greatest influence.
What other diseases might be

confused with SIHD?
Some patients with symptoms suggesting SIHD have an overall clinical picture that suggests another
Table 1. Pretest Likelihood of Coronary Artery Disease in Symptomatic Patients

According to Age and Sex*
Age, y
Nonangina Chest Pain, %
Atypical Angina, %
Typical Angina, %
Men
Women
Men
Women
Men
Women
4
13
20
27
2
3
7
14
34
51
65
72
12
22
31
51
76
87
93
94
26
55
73
86
3039
4049
5059
6069
* From reference 42.

See the Box: Clinical Classification of Chest Pain.
ITC1-2
In the Clinic
Annals of Internal Medicine
7 January 2014
How should information from the

physical examination be used to
evaluate people with suspected
SIHD?
The physical examination is often
normal or nonspecific in patients with
stable angina. It may, however, reveal
related conditions, such as heart failure, valvular heart disease, or hypertrophic cardiomyopathy. Signs that
suggest CAD when they are present
during chest pain and disappear with
resolution of angina include an S3 or
S4 gallop, mitral regurgitant murmur,
bibasilar rales, paradoxically split S2,
or chest wall heave.
Signs of congestive heart failure include jugular venous pulsation, S3
gallop, mitral regurgitation murmur,
displaced apical impulse, pulmonary
crackles, diminished breath sounds,
or dullness to percussion, abdominojugular reflux, hepatomegaly, and
lower extremity edema. Signs of
noncoronary atherosclerotic vascular
disease that increase the probability
of CAD include carotid bruit, diminished or absent pedal pulses, or
an abdominal aneurysm (6). Xanthelasma and xanthomas (yellow
patches or plaques on the skin
caused by lipid deposits) are signs of
hyperlipidemias.
What other preliminary tests
should be used to evaluate people
with suspected SIHD?
Electrocardiogram
All patients with suspected SIHD

should have a resting electrocardiogram (ECG). Most patients with
SIHD have a normal resting ECG,
but pathologic Q waves indicate a
prior myocardial infarction (MI).
Also, left bundle branch block and
some other ECG abnormalities help
determine which stress test to select
for patients who need stress testing.
Chest x-ray
All patients without an obvious noncardiac cause of angina should have a

chest x-ray. Chest x-rays are frequently normal in patients with stable angina, but they may find evidence of
7 January 2014
CHF, which worsens the prognosis,

and they may suggest causes of chest
pain other than angina.
Alternative Diagnoses to Angina

for Patients With Chest Pain*
Nonischemic cardiovascular
Echocardiography
Rest echocardiography is not recommended for most patients with suspected angina. The clinician should
consider rest echocardiography when
patients have signs or symptoms
suggesting heart failure or cardiac
valvular lesions, a pathologic Q-wave
on the ECG, or ECG findings of
complex ventricular arrhythmias.
Which diagnostic test should
follow the preliminary
assessment?
The next diagnostic test should establish or rule out the diagnosis of
CAD and at the same time estimate
the patients mortality risk, because
information on mortality risk is
necessary to choose among possible
therapies. For most patients the next
diagnostic test should be a standard
exercise ECG using as the diagnostic
endpoint for ischemia 1 mm horizontal or down-sloping ST-segment
depression at 80 ms after the J point
during peak exercise. Once the diagnosis is established, the Duke Treadmill Score, which is based on the
standard exercise ECG, accurately
predicts the mortality risk (see the
Box: Duke Treadmill Score). Patients with low-risk exercise treadmill scores ( + 5) have an estimated
cardiac mortality rate of 1% per
year and usually do not require further risk assessment. Patients with
intermediate exercise treadmill scores
(< + 5 and 10) may be stratified
into low-risk (appropriate for medical management) and high-risk
(consider for revascularization)
groups using follow-up stress imaging or coronary angiography (7).
Patients with high-risk exercise
treadmill scores (< 10) have an annual mortality of 3% and should
be considered for revascularization.
Aortic dissection
Pericarditis
Pulmonary
Embolus
Pneumothorax
Pneumonia
Pleuritis
Gastrointestinal
Esophageal
Esophagitis
Spasm
Reflux
Biliary
Colic
Cholecystitis
Choledocholithiasis
Cholangitis
Peptic ulcer
Pancreatitis
Chest wall
Costochondrosis
Fibrositis
Rib fracture
Sternoclavicular arthritis
Herpes zoster (before the rash)
Psychiatric
Anxiety disorders
Hyperventilation
Panic disorder
Primary anxiety
Affective disorders (e.g., depression)
Somatoform disorders
Thought disorders (e.g., fixed
delusions)
*From reference 40.
Clinical Classification of Chest

Pain*
Typical angina
1. Substernal chest discomfort
with a characteristic quality
and duration that is
2. Provoked by exertion or emotional stress and
3. Relieved by rest or nitroglycerin
Atypical angina
Meets 2 of the above characteristics
Nonanginal chest pain
Some patients have an ECG that

cannot be interpreted during exercise
because of left bundle branch block,
In the Clinic
ITC1-3
Meets 1 or none of typical angina

characteristics
*From reference 41.
Duke Treadmill Score*

Duke Treadmill Score = Minutes of
exercise (5 maximal mm of
ST deviation) (0 for no chest
pain, 4 for angina with exertion,
or 8 if angina is the reason for
stopping the test).
*From reference 8.
2. Qaseem A, Fihn SD,

Williams S, Dallas P,
Owens DK, Shekelle P,
for the Clinical Guidelines Committee of
of Physicians. 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.
Ann Intern Med.
2012;157:729-34.
3. Qaseem A, Fihn SD,
Williams S, Dallas P,
Owens DK, Shekelle P,
for the Clinical Guidelines Committee of
of Physicians. 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.
Ann Intern Med.
2012;157:735-43.
4. Anderson JL, Adams
CD, Antman EM, et al.
American College of
Association Task Force
on Practice Guidelines. 2012 ACCF/AHA
focused update incorporated into the
ACCF/AHA 2007
guidelines for the
management of patients with unstable
angina/non-ST-elevation myocardial infarction: a report of the
American College of
Association Task Force
on Practice Guidelines. Circulation.
2013;127:e663-828.
ventricular pacing, or some other

ECG abnormality. A patient whose
ECG is not interpretable during exercise because of left bundle branch
block should have a pharmacologic
stress test using imaging during the
test to replace ECG monitoring,
with imaging based either on radionuclide perfusion of the myocardium or echocardiography. A
patient whose ECG is not interpretable during exercise because of
abnormalities other than left bundle
branch block should have an exercise
stress test with imaging, using either
radionuclide perfusion of the myocardium or echocardiography.
Some patients cannot exercise or
cannot exercise strenuously enough
to generate a valid test result. These
patients should have a pharmacologic stress test with imaging, using either radionuclide perfusion of the
myocardium or echocardiography.
Although a low coronary artery calcium score reliably identifies people
without CAD, a high score is less
reliable in ruling in CAD, which is
why the role of this technology in
evaluating patients with suspected
SIHD remains uncertain. Some experts recommend it for patients with
atypical symptoms who are at low
risk for CAD because a low score
might help rule out CAD. Other experts recommend it for patients with
an intermediate risk after initial
stress testing because it might help
decide next steps for assessing risk.
Other noninvasive tests are being

used at some institutions, including
cardiac computed tomography angiography and stress with cardiac
magnetic resonance imaging. These
tests are not generally available, and
most observers believe we need to
know more about them before recommending widespread use.
When should clinicians refer
patients with suspected SIHD to
specialists?
Clinicians should consider consulting
a cardiologist for patients with an uncertain diagnosis after noninvasive
testing and for patients in whom
noninvasive testing is contraindicated.
When should coronary
angiography be used as the initial
test to evaluate people with
suspected SIHD?
Some patients should have coronary
angiography instead of noninvasive
tests to establish the diagnosis of
CAD and to assess its mortality
risk. Included are patients who have
survived sudden cardiac death or a
life-threatening ventricular arrhythmia, patients who have a high likelihood of severe CAD, patients in
whom coronary artery spasm is
strongly suspected, and some patients with heart failure. For other
patients, such as airplane pilots,
firefighters, and police officers, the
employer may require coronary angiography before allowing a return
to work, regardless of the results
from noninvasive testing.
DIAGNOSIS... The most useful preliminary predictors of clinically significant CAD are
the patients age, sex, and type of chest pain, but smoking history, hyperlipidemia, and
diabetes mellitus are also useful. Information from the physical examination can identify cardiac disease other than CAD and comorbid diseases that exacerbate angina. All
patients should have a resting ECG, and nearly all patients should have a chest x-ray.
Most patients should have a standard exercise ECG test as the initial noninvasive test
for measuring the probability of CAD and estimating the mortality risk. The clinician
should consider coronary angiography instead of noninvasive testing for a specific and
limited subset of patients. The clinician should consider consulting a cardiologist for
patients with an uncertain diagnosis after noninvasive testing and for patients in
whom noninvasive testing is contraindicated.
CLINICAL BOTTOM LINE
ITC1-4
In the Clinic
7 January 2014
Treatment
What are the goals of treatment?
The main goals are minimizing the
likelihood of death while maximizing health and function. More
specifically, these goals include reducing premature cardiovascular
death while preventing complications of SIHD that impair patients
functional well-being, including
acute MI and heart failure; eliminating ischemic symptoms to the
extent possible; and maintaining or
restoring a level of activity and
quality of life that is satisfactory to
the patient. This approach acknowledges that some treatments
are intended more to improve survival while others are intended
more to reduce symptoms, although many treatments help
achieve both goals at the same time
(see the Box: Strategies for Achieving Treatment Goals).
What is guideline-directed
medical therapy for patients with
SIHD?
A specific combination of treatments that is appropriate for most
patients is called guideline-directed
medical therapy (Figure 1) (3) and
should be instituted regardless of
whether revascularization occurs.
What is the role of patient
education?
Patient education plays a crucial role
in reducing risk factors and improving medication adherence in patients with SIHD. It should include
information about the underlying
disease process and therapeutic options, including the anticipated
risks, costs, and outcomes.
Individualized patient education
tends to improve adherence to
medical therapy and patient satisfaction. It should focus on reviewing individual prognosis, important
risk factors and lifestyle modifications, behavioral approaches, and
medications that reduce these risk
factors. It should include a review
7 January 2014
of the benefits and potential side

effects of medications and the
proper method of administering
medications. Any limitations on
physical activity, including sexual
activity, should be addressed.
Patients should be instructed on
when to seek medical help. In particular, they should know the warning signs and symptoms of MI and
when to use aspirin and nitroglycerin. They should know how to contact emergency medical personnel
and where to find the nearest hospital with 24-hour emergency cardiovascular services. Consider advising
CPR training for family members.
Patients may also benefit from
group education, which is often behaviorally oriented. It may involve
motivational reminders for lifestyle
change received on their mobile
telephone and recommendations to
access health information Web
sites. Home blood pressure (BP),
blood glucose monitoring, and other self-monitoring techniques can
support lifestyle change.
Strategies for Achieving

Treatment Goals
Patient education
Lifestyle modification
Medical therapy
Revascularization (coronary artery
bypass grafting or percutaneous
coronary intervention)
Which risk factors should be

modified?
About half of the decline in cardiovascular mortality observed during
the past 40 years has been due to
interventions directed at risk factors. According to 1 analysis, lowering total cholesterol accounted
for approximately 24% of the observed mortality reduction, lowering systolic BP for 20%, reducing
smoking for 12%, and increasing
physical activity for 5% (9).
5. Kumar A, Cannon CP.

Acute Coronary Syndromes: Diagnosis
and Management,
Part I. Mayo Clin Proc.
2009;84:917-38.
6. Pryor DB, Shaw L, Harrell FE Jr, et al. Estimating the likelihood
of severe coronary artery disease. Am J
Med. 1991;90:553-62.
7. Hachamovitch R,
Berman DS, Kiat H, et
al. Incremental prognostic value of
adenosine stress myocardial perfusion
single-photon emission computed tomography and impact on subsequent
management in patients with or suspected of having myocardial ischemia. Am
J Cardiol.
1997;80:426-33.
8. Mark DB, Hlatky MA,
Harrell FE Jr, et al. Exercise treadmill score
for predicting prognosis in coronary artery disease. Ann Intern Med.
1987;106:793-800.
9. Ford ES, Ajani UA,
Croft JB, et al. Explaining the decrease in
U.S. deaths from coronary disease, 19802000. N Engl J Med.
2007;356:2388-98.
ITC1-5
Factors that may complicate patient

education include low literacy, emotional disorders, social isolation, cultural beliefs, environmental factors,
poverty, advanced age, and complex
comorbid conditions. These factors
may impair a patients ability to adhere to recommended medical therapies and lifestyle changes.
In the Clinic
Therefore, reducing risk factors

should be pursued as intensively as
is reasonable, and initial patient
management should focus on
eliminating unhealthy behaviors
and on promoting weight loss,
physical activity, and a hearthealthy diet (2).
Smoking cessation
Smoking increases cardiovascular disease mortality by 50% (10). Among

nondrug therapies, smoking cessation
confers the greatest possibility of risk
reduction. Physicians should systematically identify all tobacco users and
recommend smoking cessation at each
Stable Ischemic Heart

Heart Disease
Clopidogrel,
Clopidogrel,
75 mg daily,
daily,
or ASA
desensitization
desensitization
ASA,
75162 mg
daily
SSerious
errious adverse
adverse eect
e ect
e
contraindication
or contraindication
Lifestyle
Lif
estyle
modication,
modication,
including diet, weight
weight
loss, ph
ysical
loss,
physical
activity
activity
SSee
ee AHA/A
CCF
AHA/ACCF
car
diovascular rrisk
isk
cardiovascular
reduction
reduction guideline
Guideline-directed
Guideline-directed
medical therapy
therapy
with ongoing
patient
education
patient educa
tion
Angina
Angina
No
Yess
Ye
Smok
ing
Smoking
ccessation
essation
pr
ogram
program
Cigarette
Cigar
ette
smok
ing?
smoking?
Yess
Ye
See
ATP
See NHLBI A
TP III
prevention
pr
evention guideline
-blocker
-blocker
if no contraindication
contraindication
(especially if pr
prior
ior MI,
heart failure,
failure, or other
heart
indication)
indication)
Consider
C
onsider
adding
bile sequestrant
sequestrant
or niacin
Drug ther
therapy
apy
to achieve
achieve BP
to
<140/90 mm Hg
Consider ACEI/ARB
ACEI/ARB
Consider
V dysfunction,
dysfunction,
if LLV
diabetes,
diabetes, CKD
See
See JNC VII
guideline
Sublingual
N
TG
NTG
ModerateM
oderatetto
o highdose
high-dose
statin
statin
Contraindicated
C
ontraindicated
adverse e
ect
or adverse
eect
Yes
Yes
BP 140/90
after diet,
mm Hg after
physical activity
activity
physical
program?
program?
Appr
opriate
Appropriate
glycemic
glycemic
control
control
Yes
Yes
Successful
Suc
cessful
treatment?
tr
eatment?
Yess
Ye
No
SSerious
erious contraindication
con
o traiindication
Add/substitute
A
dd/substitute
C
CB and/or long-ac
ting
CCB
long-acting
nitrate if no
nitrate
ccontraindication
ontraindication
Yes
Yes
Yes
Yes H
Hypertension?
ypertension?
Successful
Suc
cessful
treatment?
tr
eatment?
Yes
Yes
No
SSerious
erious contraindication
con
o traiindication
Yes
Yes
Diabetes?
Diabet
es?
Add/substitute
A
dd/substitute
ranolazine
ranolazine
Yes
Yes
Suc
cessful
Successful
tr
eatment?
treatment?
Yes
Yes
No
Persistent sympt
Persistent
symptoms
oms
despit
e adequa
te tr
ial
despite
adequate
trial
of guideline
-directed
guideline-directed
medical ther
apy
therapy
Yess
Ye
Consider
C
onsider
revascularization
revascularization
improve
tto
o impr
ove
symptoms
sympt
oms
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. From reference 3. Reprinted with permission from the American
College of Physicians.
* 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.
ITC1-6
In the Clinic
7 January 2014
clinic visit, because consistent, direct

physician reminders to stop smoking
increase smoking cessation (11). Patients with symptomatic CAD are
particularly receptive to treatment directed at smoking cessation (12). Patients who are receptive should be
helped to develop a cessation plan that
includes both drug (nicotine replacemen, bupropion) and nondrug (smoking cessation programs) approaches.
to 5% (13-16) If alcohol is part of

the diet, consumption should be
moderate.
Lipid management
Regular exercise reduces coronary

heart disease mortality and may reduce angina and improve functional
capacity. Physicians should encourage persons with chronic stable
angina to incorporate moderate
aerobic physical activity, such as
30 minutes of brisk walking, at
least 5 days a week. Resistance
therapy is also well-tolerated and
associated with improvements in
quality of life, strength, and endurance when added to a program
of regular aerobic exercise, although
it has not been extensively evaluated in patients with SIHD. Patients
at high risk for cardiac complications should participate in a medically supervised program for 8 to
12 weeks to establish the safety of
the prescribed exercise regimen.
A combination of therapeutic
lifestyle interventions, such as dietary modification with increased
exercise activity, along with
HMG-COA reductase inhibitors
(statins) should be used for lipid
management, unless contraindicated or adverse events occur. Although previous guidelines recommended titrating statin doses to
target levels for LDL cholesterol,
current guidelines recommend
standard doses of statins for patients in specific risk categories.
For example, in patients with stable angina, the guidelines recommend high-intensity statin therapy
(atorvastatin 80 mg or rosuvastatin
20 mg) for patients 75 y and
moderate-intensity statin therapy
(atorvastatin 10 mg, rosuvastatin
10 mg, and other doses for other
statins) for patients > 75 y (17).
For patients who do not tolerate
statins, ezetimibe, plant stanol/
sterols, and omega-3 fatty acids
may be considered, although they
have not been shown to improve
clinical outcomes.
Dietary modification
BP control
An unhealthy diet contributes to

dyslipidemia, hypertension, obesity,
and diabetes mellitus. In contrast,
consuming a diet that is low in saturated fat, cholesterol, trans-fatty
acids, and sodium and rich in fresh
fruits, vegetables, and whole grains
can reduce serum cholesterol and
cardiovascular risk. Consumption
of omega-3 fatty acids in the form
of fish (3 servings per week) or in
capsule form (1 g/day [2 to 4 g/day
for treatment of elevated triglycerides]) can also reduce risk in
patients with SIHD. Plant stanols/
sterols (2 g/day) can lower lowdensity lipoprotein (LDL) cholesterol by 5% to 15%, and the
addition of viscous fiber (> 10 g/day)
can reduce LDL cholesterol by 3%
Hypertension is an important independent risk factor for coronary

heart disease events. Various studies
have demonstrated a continuous and
graded relationship between BP and
cardiovascular risk.
Physical activity
7 January 2014
An overview of 17 placebo-controlled trials

showed that a reduction of 5 to 6 mm Hg in
diastolic BP (or an estimated 10 to 20 mm
Hg in systolic BP) was associated with a significant reduction in vascular mortality,
10. Reducing the health

consequences of
smoking: 25 years of
progress: a report of
the Surgeon General.
Rockville, MD: U.S.
Department of
Health and Human
Services, Public
Health Service, CDC,
Center for Chronic
Disease Prevention
and Health Promotion, Office on Smoking and Health; 1989.
DHHS publication
no. (CDC) 89-8411.
11. Kottke TE, Battista
RN, DeFriese GH,
Brekke ML. Attributes of successful
smoking cessation
interventions in
medical practice. A
meta-analysis of 39
controlled trials.
JAMA.
1988;259:2883-9.
12. Taylor CB, HoustonMiller N, Killen JD,
DeBusk RF. Smoking
cessation after acute
myocardial infarction: effects of a
nurse-managed intervention. Ann Intern Med.
1990;113:118-23.
13. Goldberg AC,
Ostlund RE, Jr., Bateman JH, et al. Effect
of plant stanol
tablets on low-density lipoprotein cholesterol lowering in
patients on statin
drugs. Am J Cardiol.
2006;97:376-9.
14. Hallikainen MA,
Sarkkinen ES, Uusitupa MI. Plant stanol
esters affect serum
cholesterol concentrations of hypercholesterolemic men
and women in a
dose-dependent
manner. J Nutr.
2000;130:767-76.
15. Nguyen TT, Dale LC,
von BK, et al. Cholesterol-lowering effect
of stanol ester in a
US population of
mildly hypercholesterolemic men and
women: a randomized controlled trial.
Mayo Clin Proc.
1999;74:1198-206.
16. Chen JT, Wesley R,
Shamburek RD, et al.
Meta-analysis of natural therapies for hyperlipidemia: plant
sterols and stanols
versus policosanol.
Pharmacotherapy.
2005;25:171-83.
ITC1-7
A meta-analysis of prospective studies of

nearly 1 million adults without preexisting
vascular disease found that risk for vascular death increased linearly over the BP
range of 115/75 mm Hg to 185/115 mm
Hg, without a threshold effect. Each increment of 20 mm Hg in systolic BP or 10 mm
Hg in diastolic BP was associated with a
doubling of risk (18).
In the Clinic
17. Stone NJ, Robinson

J, Lichtenstein AH, et
al. 2013 ACC/AHA
Guideline on the
Treatment of Blood
Cholesterol to Reduce Atherosclerotic
Cardiovascular Risk
in Adults: A Report
of the American College of
Cardiology/American Heart Association Task Force on
Practice
Guidelines.Circulation. 2013 Nov 12.
[Epub ahead of
print]
18. Lewington S, Clarke
R, Qizilbash N, et al.
Age-specific relevance of usual blood
pressure to vascular
mortality: a metaanalysis of individual
data for one million
adults in 61 prospective studies. Lancet.
2002;360:1903-13.
19. Collins R, Peto R. Antihypertensive drug
therapy: effects on
stroke and coronary
heart disease. In:
Swales JD, editor.
Textbook of Hypertension. Blackwell
Scientific Publications, 1994.
20. Rees K, Bennett P,
West R, et al. Psychological interventions
for coronary heart
disease. Cochrane
Database Syst Rev.
2004;CD002902.
21. Collaborative metaanalysis of randomised trials of antiplatelet therapy for
prevention of death,
myocardial infarction, and stroke in
high risk patients.
BMJ. 2002;324:71-86.
22. Collaborative
overview of randomised trials of antiplatelet therapyI:
Prevention of death,
myocardial infarction, and stroke by
prolonged antiplatelet therapy in
various categories of
patients. Antiplatelet
Trialists Collaboration. BMJ.
1994;308:81-106.
23. Wolff T, Miller T, Ko S.
Aspirin for the primary prevention of
cardiovascular
events: an update of
the evidence for the
U.S. Preventive Services Task Force. Ann
Intern Med.
2009;150:405-10.
24. de Diego C, Vila-Corcoles A, Ochoa O, et
al. Effects of annual
influenza vaccination on winter mortality in elderly people with chronic
heart disease. Eur
Heart J. 2008;30:20916.
with an approximately 40% reduction in

stroke and 20% reduction in coronary
events (19).
In many patients, therapy with

antihypertensive medications is
required to lower BP. There is no
established optimal threshold of
benefit with regard to reduction in
BP levels (3). There are, however,
reasons for caution in intensive BP
lowering in patients with SIHD
because excessive reduction in diastolic BP may compromise coronary
perfusion.
Psychological well-being
Interventions to reduce psychological stress may improve clinical outcomes in patients with SIHD (19).
Clinicians may recommend that
patients seek counseling or stress
management interventions, like
meditation, to reduce risks and
improve well-being.
Which medical therapies can
prevent MI or death?
Antiplatelet therapy
Because platelet aggregation is a

key element of the thrombotic response to plaque disruption, platelet inhibition is recommended in
patients with SIHD.
Among 2920 patients with SIHD, a metaanalysis associated aspirin use with a 33% reduction in the risk for serious vascular events,
including a 46% decrease in the risk for
unstable angina and a 53% decrease in the
risk for requiring coronary angioplasty (20)
A meta-analysis of 145 randomized trials
found an association between mediumdose aspirin (75 to 325 mg/d) and a 27%
reduction in the odds ratio for major cardiovascular events over 5 years in patients with
known coronary or vascular disease (21).
A meta-analysis from the U.S. Preventive
Services Task Forces concluded that aspirin
reduces cardiovascular disease in patients,
with men having fewer MIs and women
having fewer ischemic strokes (22).
dose of 75 to 162 mg daily is as

effective as higher doses and is
associated with a lower risk for
bleeding. When aspirin is contraindicated, patients can be treated
with clopidogrel 75 mg daily.
Influenza vaccine
Patients with SIHD should receive

an annual influenza vaccine (23).
ACE inhibitors
Angiotensin-converting enzyme
(ACE) inhibitors should be prescribed for patients with SIHD
who also have hypertension, diabetes, left ventricular (LV) systolic
dysfunction (ejection fraction
< 40%) or chronic kidney disease.
For example, ACE inhibitors reduce mortality, composite cardiovascular events, MI, and stroke in
patients with LV ejection fraction
< 35% or diabetes and 1 additional cardiovascular risk factor.
In the CONSENSUS trial, enalapril titrated
to 40 mg/d in patients with class IV CHF reduced mortality by 18% at 6 months (NNT
= 5.5) (24).
In the SOLVD treatment trial, enalapril
titrated to 20 mg/d in patients with class II
and III CHF reduced mortality by 4.5% at
3 years (NNT = 22) (25).
In the SOLVD prevention trial, enalapril
titrated to 20 mg/d in patients with
asymptomatic LV dysfunction reduced
death from CHF, hospitalization for CHF,
and the composite outcome of death or
development of CHF (26).
In the HOPE trial, patients with vascular
disease or diabetes and 1 additional cardiovascular risk factor who were treated
with ramipril, 10 mg/d for an average of
4.5 years, had significantly reduced risk for
cardiovascular events (27).
Angiotensin-receptor blockers
Therefore, in the absence of contraindications, all patients with

SIHD should receive aspirin therapy and continue it indefinitely. A
When ACE inhibitors are contraindicated, angiotensin-receptor blockers should be prescribed for patients
with SIHD who also have hypertension, diabetes, LV systolic dysfunction
(ejection fraction < 40%), or chronic
kidney disease (28).
ITC1-8
In the Clinic
7 January 2014
-blocker therapy
Metoprolol succinate, carvedilol, or

bisoprolol should be prescribed for
patients with LV systolic dysfunction (ejection fraction < 40%) and
heart failure or prior MI (29-31).
Alternative therapies
Vitamins and mineral supplements

are not recommended for preventing CAD events (32, 33).
Which medical therapies relieve
symptoms?
A range of drugs are available that
are effective at reducing symptoms,
including -blockers, calciumchannel blockers, and nitrates. All of
the classes of agents seem to be relatively similar in antianginal efficacy
and have acceptable safety and tolerability profiles. Comparative trials
among these medications are relatively few and for the most part
small. Because -blockers have been
shown to improve survival in patients after acute MI and have a
long history of clinical use, they are
considered first-line drugs for treating angina. In patients who do not
tolerate or adequately respond to
-blockers, calcium-channel blockers or long-acting nitrates may be
substituted or added (34).
Short-acting nitrates
Sublingual nitroglycerin or nitroglycerin spray should be used for

immediate relief of angina.
-blocker therapy
-blockers should be prescribed

as initial therapy for relief of
symptoms. Expert panels recommend titrating -blockers to a
resting heart rate of 55 to 60
beats/min.
Calcium-channel blockers and longacting nitrates
Calcium-channel blockers or
long-acting nitrates can be prescribed when -blockers are contraindicated or produce unacceptable side effects. When -blockers
are ineffective, calcium-channel
blockers or long-acting nitrates
7 January 2014
can be prescribed in addition to or

instead of -blockers (35).
When patients are candidates for

revascularization to improve
survival, which patients should
have CABG, and which patients
should have PCI?
Patients with SIHD at high risk for
mortality are candidates for revascularization to improve survival and
should have coronary angiography.
Revascularization should not be
done to improve survival if coronary
angiography reveals stenoses that are
not anatomically or functionally significant, involve only the left circumflex artery or right coronary artery, or
affect only a small area of viable myocardium. If coronary angiography
finds left main CAD or complex
CAD, the decision between either
25. Effects of enalapril

on mortality in severe congestive
heart failure. Results
of the Cooperative
North Scandinavian
Enalapril Survival
Study (CONSENSUS).
The CONSENSUS Trial Study Group. N
Engl J Med.
1987;316:1429-35.
26. Effect of enalapril on
survival in patients
with reduced left
ventricular ejection
fractions and congestive heart failure.
The SOLVD Investigators. N Engl J Med.
1991;325:293-302.
27. Yusuf S, Pepine CJ,
Garces C, et al. Effect
of enalapril on myocardial infarction
and unstable angina
in patients with low
ejection fractions.
Lancet.
1992;340:1173-8.
28. Yusuf S, Sleight P,
Pogue J, et al. Effects
of an angiotensinconverting-enzyme
inhibitor, ramipril, on
cardiovascular
events in high-risk
patients. The Heart
Outcomes Prevention Evaluation
Study Investigators.
N Engl J Med.
2000;342:145-53.
29. Turnbull F, Neal B, Pfeffer M, et al. Blood
pressure-dependent
and independent effects of agents that
inhibit the renin-angiotensin system. J
Hypertens.
2007;25:951-8.
30. Tepper D. Frontiers
in congestive heart
failure: Effect of
Metoprolol CR/XL in
chronic heart failure:
Metoprolol CR/XL
Randomised Intervention Trial in Congestive Heart Failure
(MERIT-HF). Congest
Heart Fail.
1999;5:184-5.
31. Packer M, Bristow
MR, Cohn JN, et al.
The effect of
carvedilol on morbidity and mortality
in patients with
chronic heart failure.
U.S. Carvedilol Heart
Failure Study Group.
N Engl J Med.
1996;334: 1349-55.
761.
32. Leizorovicz A, Lechat
P, Cucherat M, et al.
Bisoprolol for the
treatment of chronic
heart failure: a metaanalysis on individual data of two
placebo-controlled
studiesCIBIS and
CIBIS II. Cardiac Insufficiency Bisoprolol Study. Am Heart
J. 2002;143:301-7.
ITC1-9
Ranolazine
Ranolazine is a recently approved

drug that shares characteristics with
calcium-channel blockers but seems
to act via different mechanisms.
Consider using ranolazine when
-blockers are contraindicated or
produce unacceptable side effects.
Consider using ranolazine combined or instead of -blockers if blockers are ineffective (36, 37).
Alternative therapies
Alternative therapies, including

spinal cord stimulation, enhanced
external counterpulsation, and
transmyocardial revascularization,
may be considered for relief of refractory angina in patients with
SIHD (1).
Which patients are candidates for
revascularization with either
coronary artery bypass graft
surgery (CABG) or percutaneous
coronary intervention (PCI)?
Consider revascularization to improve survival in patients with
SIHD who are at high risk for
mortality, and consider revascularization to relieve persistent symptoms despite an adequate trial of
guideline-directed medical therapy
(Figures 1 and 2).
In the Clinic
33. Brown BG, Zhao XQ,

Chait A, et al. Simvastatin and niacin,
antioxidant vitamins,
or the combination
for the prevention of
coronary disease. N
Engl J Med.
2001;345:1583-92.
34. Fortmann SP, Burda
BU, Senger CA, et al.
Vitamin and mineral
supplements in the
primary prevention
of cardiovascular disease and cancer: an
updated systematic
evidence review for
the U.S. Preventive
Services Task Force.
Ann Intern Med.
2013;159:824-34.
35. Shaw LJ, Berman DS,
Maron DJ, et al. Optimal medical therapy
with or without percutaneous coronary
intervention to reduce ischemic burden: results from the
Clinical Outcomes
Utilizing Revascularization and Aggressive Drug Evaluation
(COURAGE) trial nuclear substudy. Circulation.
2008;117:1283-91.
type of revascularization should involve the patient, a cardiac surgeon,

and an interventional cardiologist.
CABG is recommended when the
patient has stenosis of the left main
coronary artery that is 50% of the
lumen diameter or stenosis of 70%
in 3 major coronary arteries or
stenosis of 70% in the proximal left
anterior descending artery and 1
other major coronary artery. Either
method can be used for survivors of
sudden cardiac death with presumed
ischemia-mediated ventricular tachycardia caused by 70% stenosis in a
major artery.
and sudden death in men. Atypical

chest pain and angina-equivalent
symptoms, such as dyspnea, are
more common in women, although
the patterns, duration, and frequency of symptoms in women are similar to those in men.
When patients are candidates

for revascularization to relieve
symptoms, which patients should
have CABG and which patients
should have PCI?
Patients who have persistent symptoms despite an adequate trial of
guideline-directed medical therapy
(Figure 2) are candidates for revascularization to relieve symptoms and
should have coronary angiography.
When the patient has the types of
stenosis described previously that are
likely to affect survival, the same recommendations apply. Either CABG
or PCI is recommended for other
patients who have 70% stenosis in
1 or more coronary arteries.
Older adults
Are there special considerations

for women, older adults, or
patients with diabetes mellitus,
chronic kidney disease, or other
conditions?
Special considerations for diagnosis
and therapy may be warranted in patients with certain clinical features.
Such differences in presentation

and testing may account, in part,
for discrepancies in care between
men and women with coronary disease. Women receive aspirin and
other antithrombotics less frequently than men and are less likely
to have revascularization.
In adults older than 75 years, coronary stenoses tend to be more diffuse and severe, with a higher
prevalence of 3-vessel and left main
disease. Common coexisting conditions of the pulmonary, gastrointestinal, and musculoskeletal
systems can cause chest pain, making diagnosis more difficult, even in
patients with documented SIHD.
Stress testing is more difficult due
to physiologic changes associated
with aging, including alterations in
cardiac output, muscle loss, neuropathies, lung disease, and degenerative joint disease. Baseline ECG
changes, arrhythmias, and LV hypertrophy, which are more common
in older adults who have accumulated cardiac comorbid conditions,
limit the value of stress testing. The
higher prevalence of SIHD in older
adults causes more false-negative
results, although stress testing still
provides useful information for
management.
Women generally have a lower incidence of SIHD than men until

older age but outcomes after MI
are worse. Microvascular disease
and coronary spasm are more common in women, and obstructing
epicardial CAD is less prevalent.
Stable angina is the most common
initial manifestation of SIHD in
women, as opposed to acute MI
Several studies have shown less frequent use of evidence-based therapies in older adults. This may be
because pharmacotherapy is more
difficult in older adults. A more
conservative approach to coronary
angiography is often appropriate
given the higher risk for contrastinduced side effects. Morbidity and
mortality from CABG are increased
in older adults.
ITC1-10
Women
In the Clinic
7 January 2014
Persistent sympt
oms despit
e
Persistent
symptoms
despite
adequate tr
ial of guidelineguidelineadequate
trial
directed medical therapy
therapy
directed
Consider
Consider
rrevascularization
evascularization
to
to improve
improve
symptoms
symptoms
Potential
P
otential rrevascularization
evascularization pr
procedure
ocedure
w
arranted on the basis of assessmen
warranted
assessmentt
of ccoexisting
oexisting car
diac and noncar
diac
cardiac
noncardiac
factors
preferences?
fac
tors and patient
patient pr
eferences?
No
Continue
C
ontinue
guideline-directed
guideline-directed
medical therapy
therapy with
careful
monitoring
careful monit
oring
Ye
Yess
Perform
Per form
coronary
coronary
angiography
angiography
Heartt team
Hear
team concludes
concludes that
that
ana
tomy and clinical fac
tors
anatomy
factors
indicate
mayy
indica
te rrevascularization
evascularization ma
improve
improve symptoms
symptoms
No
Ye
Yess
Lesions
Lesions ccorrelated
orrelated with
evidence
evidence of ischemia
No
Yes
Yes
Determine
Determine optimal method of
revascularization
revascularization on the basis
of patient
preferences,
anatomy,
patient pr
eferences, ana
tomy,
other clinical factors,
factors, and local
resources
resources and expertise
expertise
CABG preferred
preferred
CABG
SSee
ee text
text for
for indications
indications
preferred
PCI preferred
SSee
ee ttext
ext ffor
or indica
indications
tions
Guideline-Directed
Guideline-Directed Medical
Medical Therapy
Therapy
continued
continued in all patients
patients
Figure 2. Revascularization to improve symptoms of patients with stable ischemic heart

disease. CABG = coronary artery bypass grafting; PCI = percutaneous coronary intervention.
7 January 2014
In the Clinic
ITC1-11
36. Heidenreich PA, McDonald KM, Hastie T,

et al. Meta-analydsis
of trials comparing
beta-blockers, calcium antagonists, and
nitrates for stable
angina. JAMA.
1999;281:1927-36.
Rousseau MF,
Pouleur H, Cocco G,
et al. Comparative
efficacy of ranolazine versus
atenolol for chronic
angina pectoris. Am
J Cardiol.
2005;95:311- 6.
37. Chaitman BR, Pepine
CJ, Parker JO, et al.
Effects of ranolazine
with atenolol, amlodipine, or diltiazem
on exercise tolerance and angina frequency in patients
with severe chronic
angina: a randomized controlled trial.
JAMA. 2004;291:30916.
Diabetes mellitus
Type 1 and type 2 diabetes mellitus

increase risk for SIHD and magnify the effects of other risk factors,
such as hypercholesterolemia. Mortality risk for SIHD among diabetics is equivalent to that of persons
with previous MI. Intensive and
early diagnosis and management
are important, as is a focus on
achievement and maintenance of
optimal blood sugar control, lipid
management, and attention to other risk factors.
Among patients with CAD, concomitant diabetes increases the risk
for adverse events with both medical
therapy and revascularization. CABG
may be preferable to PCI in these
patients, but the data are evolving.
Chronic kidney disease
38. Farkouh ME, Domanski M, Sleeper

LA, et al; FREEDOM
Trial Investigators.
Strategies for multivessel revascularization in patients with
diabetes. N Engl J
Med. 2012;367:237584. N Engl J Med.
2012; 367:2375-84.
39. De Bruyne B, Pijls
NH, Kalesan B, Barbato E, Tonino PA,
Piroth Z, et al; FAME
2 Trial Investigators.
Fractional flow reserve-guided PCI
versus medical therapy in stable coronary disease. N Engl
J Med. 2012;367:9911001.
40. Gibbons RJ, Abrams
J, Chatterjee K, et al;
American College of
Cardiology.
ACC/AHA 2002
guideline update for
the management of
patients with chronic stable angina
summary article: a
report of the American College of Cardiology/American
Heart Association
Task Force on practice guidelines
(Committee on the
Management of Patients With Chronic
Stable Angina). J Am
Coll Cardiol.
2003;41:159-68.
Chronic kidney disease confers

greater risk for SIHD, for progression of SIHD, and for poor outcomes after interventions for AMI.
To avoid these complications,
physicians should consider creatinine clearance when choosing and
dosing drugs, risk scores for predicting contrast-induced nephropathy, and renal protective strategies
during angiography.
Survival may be longer in patients
with chronic kidney disease after
CABG than PCI; however, the data
are inconclusive.
How should patients with treated
SIHD be followed?
Follow-up visits should be scheduled
periodically according to the stability
of clinical status and the establishment of consistent communication
with patients and other physicians
involved in the care of the patient.
Appointments should be scheduled
every 4 to 6 months during the first
year of treatment and every 4 to 12
months thereafter, as long as angina
remains stable and treatment is otherwise successful. Visits may be more
frequent after changes in medical
management.
ITC1-12
In the Clinic
During each visit, obtain detailed

information on angina (see the
Box: Questions for Follow-up
Visits). If symptoms increase in
frequency or severity, inquire about
the exacerbating and alleviating
conditions. If the symptoms have
worsened or the patient has decreased his or her physical activity
to avoid angina, evaluate and treat
according to either the unstable
angina or chronic stable angina
guideline. Changes in angina severity or frequency may indicate worsening CAD, changes in comorbid
conditions, or changes in social factors (e.g., personal finance) that
may affect disease severity.
Assess the patient for adherence to
therapy, which may decline over
time, and adverse drug effects. Attention to modifiable risk factors,
such as smoking, at each visit increases the likelihood of successful
risk reduction. Physicians should
continue to encourage patients to
engage in regular physical activity
and recommend a balanced diet.
Laboratory evaluation should be
used to monitor modifiable risk factors. Perform a fasting lipid panel
6 to 8 weeks after initiating lipidlowering therapy, then less frequently
during the first year of therapy.
Measure creatine phosphokinase in
patients receiving statins who have
muscle weakness or pain, and monitor glycosylated hemoglobin at least
annually in patients with stable,
Questions for Follow-up Visits

Has the patient decreased his or her
level of physical activity since the last
visit?
Has angina increased in frequency or
become more severe since the last
visit?
How successful has the patient been in
modifying risk factors and improving
knowledge about ischemic heart
disease?
Has the patient developed any new
comorbid illnesses or has the severity
or treatment of known comorbid
illnesses worsened angina?
7 January 2014
treated diabetes mellitus. Perform

echocardiography or radionuclide
imaging only in patients with new or
worsening heart failure or evidence
of an intervening MI. Perform a

stress test only in patients with new
or worsening symptoms that are not
consistent with unstable angina.
TREATMENT... The main goals of treating patients with SIHD are to minimize the
likelihood of death while maximizing health and function. Risk factors like smoking, hyperlipidemia, diabetes, and high BP should be reduced as intensively as is
reasonable with lifestyle modifications and medical therapy. Education is critical
to ensuring that the patient understands the underlying disease process, can make
informed decisions about treatment options, and knows the warning signs and
symptoms of MI. All patients should have guideline-directed medical therapy to
reduce the risk for mortality and relieve symptoms. Consider revascularization for
patients at high risk for mortality and for those with persistent symptoms despite
guideline-directed medical therapy. Follow-up should address angina, medication
use, and modifiable cardiac risk factors, and follow-up testing should be directed
by changes in symptoms.
CLINICAL BOTTOM LINE
Practice Improvement
What do professional organizations
recommend with regard to
prevention, screening, diagnosis
and treatment of stable SIHD?
The American College of Cardiology Foundation, American Heart
Association, American College of
Physicians, American Association
for Thoracic Surgery, Preventive
Cardiovascular Nurses Association,
Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons published
a joint clinical guideline for the diagnosis and management of patients with SIHD in 2012.
Based on this clinical guideline, the
American College of Pyysicians published 28 recommendations addressing the initial diagnosis of the patient
who might have SIHD, cardiac stress
testing to assess the risk for death or
MI in SIHD, and coronary angiography for risk assessment. ACP also
published 48 recommendations on
management of SIHD that addresses
patient education, management of
risk factors, medical therapy to prevent MI and death and to relieve
symptoms, revascularization to im-
7 January 2014
prove survival and symptoms, and

patient follow-up.
Guidelines on management of SIHD
were released in 2011 from the U.K.
National Institute of Clinical Excellence. The guideline includes an
emphasis on offering optimal drug
treatment for managing patients
with SIHD and revascularization
when symptoms are not controlled
with optimal drug treatment.
Some noteworthy trials on choosing
between CABG and PCI were published since these guidelines were
written. The Future Revascularization Evaluation in Patients with
Diabetes Mellitus: Optimal Management of Multivessel Disease
(FREEDOM) trial found that
CABG resulted in lower rates of
mortality, MI and stroke compared
with PCI (18.7% vs. 26.6% overall at
5 years follow up) (38). Meanwhile,
the FAME II trial showed that in
stable patients with a functionally
significant coronary lesion, PCI reduced the need for urgent revascularization more than medical therapy
alone (the trial was stopped early).
41. Braunwald E, Mark

D, Jones RH. Unstable angina: diagnosis
and management.
Clinical Practice
Guideline Number
10. Rockville, MD:
Agency for Health
Care Policy and Research and the National Heart, Lung,
and Blood Institute,
Public Health Service, U.S. Department
of Health and Human Services; 1994.
42. Diamond GA, Forrester JS. Analysis of
probability as an aid
in the clinical diagnosis of coronary-artery disease. N Engl
J Med. 1979;300:
1350-8.
ITC1-13
In the Clinic
Tool Kit
Stable Ischemic
Heart Disease
ACP Smart Medicine Module

http://smartmedicine.acponline.org/content.aspx?gbosId=33&resultClick=3
&ClientActionType=SOLR%20Direct%20to%20Content&ClientAction
Data=Module%20link%20Click
http://smartmedicine.acponline.org/content.aspx?gbosId=160&resultClick=3
&ClientActionType=SOLR%20Direct%20to%20Content&ClientAction
Data=Module%20link%20Click
Access the American College of Physicians Smart Medicine modules
on stable coronary heart disease and coronary artery disease in
women. ACP Smart Medicine modules provide evidence-based,
updated information on current diagnosis and treatment in an
electronic format designed for rapid access at the point of care.
Patient Information
www.nlm.nih.gov/medlineplus/coronaryarterydisease.html
www.nlm.nih.gov/medlineplus/angina.html
www.nlm.nih.gov/medlineplus/ency/patientinstructions/000088.htm
www.nlm.nih.gov/medlineplus/ency/article/000198.htm
Information on coronary artery disease and on angina from the
National Institutes of Health MedlinePlus.
www.nhlbi.nih.gov/health/health-topics/topics/angina/
www.nhlbi.nih.gov/health-spanish/health-topics/temas/angina/
Information for patients on angina, in English and in Spanish from
the National Heart, Lung, and Blood Institute.
Clinical Guidelines
http://eurheartj.oxfordjournals.org/content/34/38/2949.short
Evidence-based guidelines for the management of stable coronary
artery disease from the European Society of Cardiology in 2013.
http://content.onlinejacc.org/article.aspx?articleid=1391404
Evidence-based guidelines for the diagnosis and management of
patients with SIHD from the American College of Cardiology
Foundation/American Heart Association Task Force on Practice
Guidelines, and the American College of Physicians, American
Association for Thoracic Surgery, Preventive Cardiovascular Nurses
Association, Society for Cardiovascular Angiography and Interventions,
and Society of Thoracic Surgeons in 2012.
http://guidance.nice.org.uk/CG126
Clinical guidelines on the management of stable angina from the
United Kingdoms National Institute of Health and Care Excellence
in 2011.
Diagnostic Tests and Criteria

http://smartmedicine.acponline.org/content.aspx?gbosId=33&resultClick
=3&ClientActionType=SOLR%20Direct%20to%20Content&Client
ActionData=Module%20link%20Click&resultClick=3&ClientActionType
=SOLR%20Direct%20to%20Content&ClientActionData=Module%20link
%20Click
List of laboratory and other studies for diagnosis and risk stratification
of patients with angina from ACP Smart Medicine.
http://smartmedicine.acponline.org/content.aspx?gbosId=33&resultClick
=3&ClientActionType=SOLR%20Direct%20to%20Content&Client
ActionData=Module%20link%20Click&resultClick=3&ClientAction
Type=SOLR%20Direct%20to%20Content&ClientActionData=Module
%20link%20Click
Table showing the posttest probabilities of significant coronary artery
disease based on exercise electrocardiogram results from ACP Smart
Medicine.
Quality-of-Care Guidelines
http://guidance.nice.org.uk/QS21
Quality standards on stable angina from the United Kingdoms
National Institute of Health and Care Excellence in 2012.
www.cardiosource.org/Lifelong-Learning-and-MOC/Certified-Learning/
SA/2012/Chronic-CAD-Stable-Ischemic-Heart-Disease/Chronic-CAD
-Self-Assessment-Quiz.aspx?w_nav=Search&WT.oss=stable%20heart
%20disease&WT.oss_r=5520&
Self-assessment quiz to identify physician knowledge gaps in chronic
CAD and SIHD from the American College of Cardiology.
ITC1-14
In the Clinic
In the Clinic
In the Clinic
7 January 2014
WHAT YOU SHOULD

KNOW ABOUT STABLE
ISCHEMIC HEART DISEASE
In the Clinic
What is a stable ischemic heart

disease?
How is it diagnosed?
Your doctor will perform a thorough history and
physical examination and order blood tests to learn
more about your condition.
You may undergo painless tests to show how your
heart is working, including an electrocardiogram,
which measures the electrical activity of the heart
muscle, and an echocardiogram, which creates
moving pictures of how your heart is functioning.
You may take a stress test, which provides information on how exercise affects angina symptoms and
overall heart functioning.
Other tests may be needed, such as cardiac catheterization or coronary angiography to study the
arteries and heart functioning.
How is it treated?
Your doctor may prescribe medications to help control
high blood pressure and blood cholesterol levels, to help
prevent heart attacks, and to help you live longer.
A medication called nitroglycerin can reduce angina
symptoms when they occur.
If your arteries are clogged, your doctor may perform
a nonsurgical procedure called percutaneous
coronary intervention to widen them.
Blockages that cannot be treated with percutaneous
coronary intervention may need heart bypass surgery.
Can complications be prevented?
Stop smoking.
Make heart-healthy changes to your diet.
Practice stress reduction.
Exercise moderately on a regular basis.
Take your medications.
For More Information

www.cardiosmart.org/Heart-Conditions/Coronary-Artery-Disease
www.cardiosmart.org/Heart-Conditions/Angina
www.cardiosmart.org/Heart-Conditions/Angina/Questions-to-Ask
-Your-Doctor
Patient information on coronary artery disease and angina from

the American College of Cardiology, including questions to ask
your doctor.
www.heart.org/HEARTORG/Conditions/HeartAttack/SymptomsDiagnosis
ofHeartAttack/Angina-Pectoris-Stable-Angina_UCM_437515_Article.jsp
www.heart.org/HEARTORG/Conditions/HeartAttack/WarningSignsofa
HeartAttack/Angina-in-Women-Can-Be-Different-Than-Men_UCM
_448902_Article.jsp
Information on stable angina and on angina in women from the

American Heart Association.
www.cdc.gov/heartdisease/
www.cdc.gov/heartdisease/materials_for_patients.htm
Information about heart disease from the U.S. Centers for Disease
Control and Prevention, including educational materials for
patients.
Patient Information
Stable ischemic heart disease occurs due to poor blood

flow through the blood vessels in the heart.
During times of activity or stress when the heart
muscle works harder and needs more oxygen, it can
cause pain or pressure in your chest.
You may also feel angina in your shoulders, arms,
neck, jaw, or back.
The pain or pressure lasts for minutes, not seconds
or hours, and goes away with rest or medication.
Early diagnosis and treatment are important to
reduce the risk for more serious complications.
The most common cause is coronary heart disease,
which results from the buildup of plaque in the
arteries to your heart.
CME Questions
1. A 70-year-old woman is seen for an

evaluation. Medical history is significant
for ischemic cardiomyopathy and
hypertension. She had an implantable
cardioverter-defibrillator placed 5 years
ago. She has good functional capacity
and is able to walk 3 blocks without
limitations. Medications are lisinopril,
carvedilol, aspirin, and pravastatin.
On physical examination, she is afebrile,
blood pressure is 137/70 mm Hg, pulse
rate is 82/min, and respiration rate is
18/min. BMI is 23. The remainder of the
examination is normal. Laboratory
studies reveal the following: Hemoglobin
A1c, 6.9%; total cholesterol, 115 mg/dL
(2.98 mmol/L); LDL cholesterol, 53 mg/dL
(1.37 mmol/L); HDL cholesterol, 40 mg/dL
(1.04 mmol/L); and triglycerides, 112 mg/dL
(1.27 mmol/L).
Which of the following clinical measures
is most important to target in this
patient to reduce her risk for a
cardiovascular event?
A. Blood pressure
B. Hemoglobin A1c
C. LDL cholesterol level
D. Triglyceride level
2. A 67-year-old woman is evaluated for a
3-week history of intermittent exertional
chest pain. She walks several days per
week. She has type 2 diabetes mellitus

and hypertension. Her father had a
myocardial infarction at age 54 years.
Medications are aspirin, metformin,
glyburide, and lisinopril.
On physical examination, she is afebrile,
blood pressure is 128/90 mm Hg, pulse
18/min. BMI is 35. Cardiac sounds are
distant but otherwise unremarkable,
without extra sounds or murmur.
Figure 1 is the patients electrocardiogram (ECG).
Which is the most appropriate diagnostic
test to perform next?
A. Cardiovascular magnetic resonance

imaging with gadolinium
enhancement
B. Exercise ECG stress test
C. Exercise stress echocardiography
D. Pharmacologic perfusion imaging
study
3. A 68-year-old woman is evaluated during
a routine examination. She went through
menopause 16 years ago. She is obese.
Family history is significant for a
paternal aunt with ovarian cancer at age
64 years. She takes no medications.
Blood pressure is 148/90 mm Hg, pulse
18/min. BMI is 35. Waist measurement is

100 cm (39.3 in).
Which disease poses the greatest risk for
death in this patient?
A. Breast cancer
B. Coronary artery disease
C. Diabetes mellitus
D. Ovarian cancer
4. A 35-year-old woman is evaluated during a
follow-up examination. She has had
recurrent episodes of presyncope and
syncope over the past few months. She
continues to have an episode every 3 to 4
weeks, with no discernible pattern or
trigger. She reports becoming light-headed
and feeling faint, without other associated
symptoms, followed by transient loss of
consciousness for several seconds followed
by spontaneous recovery without residual
symptoms. On previous evaluation, an
electrocardiogram (ECG) and
echocardiogram were normal. Results of
24-hour continuous ambulatory ECG
monitoring were unremarkable, and a
cardiac event recorder showed no
arrhythmia associated with presyncopal
symptoms. History is significant for anxiety
and intermittent insomnia; the patient
takes no medications for these conditions.
There is no history of prior head trauma.
She does not use drugs or alcohol.
On physical examination, temperature is
normal. Blood pressure is 122/68 mm Hg
and pulse rate is 72/min while supine.
After three minutes of standing, blood
pressure is 112/84 mm Hg and pulse rate
is 88/min, without reproduction of
syncope or symptoms. The remainder of
the examination is normal. Serum
electrolytes, kidney function, and thyroid
function studies are normal.
Which is the most appropriate next step
in the evaluation of this patient?
A. Electroencephalograph
B. Exercise cardiac stress test
C. Signal-averaged electrocardiogram
D. Tilt-table testing
Figure 1.
Questions are largely from the ACPs Medical Knowledge Self-Assessment Program (MKSAP, accessed at
http://www.acponline.org/products_services/mksap/15/?pr31). Go to www.annals.org/intheclinic/
to complete the quiz and earn up to 1.5 CME credits, or to purchase the complete MKSAP program.
ITC1-16
In the Clinic
7 January 2014

Stable Ischemic Heart Disease

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Stable Ischemic Heart Disease

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Stable

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1. Fihn SD, Gardin JM,

2014 American College of Physicians

diagnosis (see the Box: Alternative

Why is it important to differentiate patients with SIHD from

Why is it important to estimate

What other diseases might be

Table 1. Pretest Likelihood of Coronary Artery Disease in Symptomatic Patients

Nonangina Chest Pain, %

* From reference 42.

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Annals of Internal Medicine

How should information from the

All patients with suspected SIHD

All patients without an obvious noncardiac cause of angina should have a

CHF, which worsens the prognosis,

Alternative Diagnoses to Angina

Clinical Classification of Chest

Nonanginal chest pain

Some patients have an ECG that

Annals of Internal Medicine

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Meets 1 or none of typical angina

2014 American College of Physicians

Duke Treadmill Score*

2. Qaseem A, Fihn SD,

2014 American College of Physicians

ventricular pacing, or some other

Other noninvasive tests are being

CLINICAL BOTTOM LINE

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Annals of Internal Medicine

of the benefits and potential side

Strategies for Achieving

Which risk factors should be

5. Kumar A, Cannon CP.

2014 American College of Physicians

Factors that may complicate patient

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Therefore, reducing risk factors

Smoking increases cardiovascular disease mortality by 50% (10). Among