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© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (1): ITC1-1.
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© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (1): ITC1-1.
in the clinic
Stable Ischemic
Heart Disease
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (1): ITC1-1.
Why is it important to differentiate
SIHD from unstable angina?
 Stable angina
 Typically brought on by exertion or emotion
 Unstable angina
 More random and unpredictable, occurring without trigger
 Rest angina: Occurring at rest and lasting >20 minutes
 New-onset severe angina: Severe onset ≤2 months of initial
presentation
 Increasing angina: Previously diagnosed, crescendo pattern
 Manage low-risk unstable angina the same as SIHD
 Manage intermediate- or high-risk unstable angina more
aggressively
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (1): ITC1-1.
What other diseases might be confused
with stable ischemic heart disease?
 Nonischemic CV: aortic dissection, pericarditis
 Pulmonary: embolus, pneumothorax, pneumonia, pleuritis
 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/ affective/ somatoform/ thought disorders
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (1): ITC1-1.
Why is it important to estimate the probability
of disease separately from the mortality risk?
 If <5% probability of CAD: look for other causes of pain
 Predictors of CAD
 Patient age, sex, and type of angina
 Smoking history, hyperlipidemia, diabetes
Clinical Classification of Chest Pain
 Typical angina (definite)
 Substernal chest discomfort: characteristic quality, duration
 Provoked by stress; relieved by rest or nitroglycerin
 Atypical angina (probable)
 Meets 2 of the above characteristics
 Noncardiac chest pain
 Meets ≤1 of typical angina characteristics
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (1): ITC1-1.
How should information from the physical
exam be used to evaluate people with SIHD?
 May reveal related conditions (HF, valvular heart disease)
 Signs suggesting CAD (only present during chest pain)
 S3 or S4 gallop, mitral regurgitant murmur, bibasilar rales,
paradoxically split S2, or chest wall heave
 Signs of CHD
 Jugular venous pulsation, S3 gallop, mitral regurgitation
murmur, displaced apical impulse, pulmonary crackles,
diminished breath sounds, dullness to percussion, abdominojugular reflux, hepatomegaly, lower extremity edema
 Signs of noncoronary atherosclerotic vascular disease
 Carotid bruit, diminished / absent pedal pulses, abdominal
aneurysms
 Xanthelasma and xanthomas: hyperlipidemias
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (1): ITC1-1.
What other preliminary tests should be
used to evaluate people with suspected
SIHD?
 Electrocardiogram
 All patients: resting ECG
 Chest X-ray
 If no obvious noncardiac cause of angina
 Echocardiography (rest)
 If patient has signs or symptoms suggesting HF or cardiac
valvular lesions
 If ECG findings show a pathologic Q-wave
 If ECG findings show complex ventricular arrhythmias
 Not recommended for most patients with SIHD
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (1): ITC1-1.
Which diagnostic test should follow the
preliminary assessment?
 Standard exercise ECG
 If exercise ECG can’t be interpreted / performed:
 If due to left bundle branch block: Pharmacologic stress test
with imaging (radionuclide perfusion of myocardium / ECHO)
 If due to other abnormalities: Exercise stress test with
imaging (radionuclide perfusion of myocardium / ECHO)
 If patient can’t exercise: Pharmacologic stress test with
imaging (radionuclide perfusion of myocardium / ECHO)
 Coronary artery calcium for assessment: uncertain
 Low coronary artery calcium score identifies people w/o CAD
 High score is less reliable in ruling in CAD
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (1): ITC1-1.
Duke Treadmill Score
 Predicts mortality risk based on ECG once the diagnosis is
established
 If ≥ +5: estimated cardiac mortality rate ≤ 1%/y, usually no
further risk assessment required
 If < +5 and ≥ -10: use stress imaging or coronary angiography
to stratify into low-risk and high-risk groups
 If < -10: annual mortality ≥ 3%, consider for revascularization
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (1): ITC1-1.
When should clinicians refer patients with
suspected ischemic heart disease to
specialists?
 Consult a cardiologist when…
 Diagnosis uncertain after noninvasive testing
 Noninvasive testing is contraindicated
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (1): ITC1-1.
When should coronary angiography be
used as the initial test to evaluate people
with suspected ischemic heart disease?
 Patients have survived sudden cardiac death or a lifethreatening ventricular arrhythmia
 Patients have a high likelihood of severe CAD
 Coronary artery spasm strongly suspected
 Some patients with HF
 Some employers require before allowing return to work
 Regardless of the results from noninvasive testing
 Pilots, firefighters, police force
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (1): ITC1-1.
CLINICAL BOTTOM LINE: Diagnosis…
 Predictors of CAD
 Age, sex, type of chest pain
 Smoking history, hyperlipidemia, diabetes mellitus
Physical exam
 Identify cardiac disease other than CAD
 Identify comorbid diseases exacerbating angina
 Diagnostic tests
 Resting ECG and chest x-ray
 Exercise ECG: CAD probability, mortality risk
 Coronary angiography: specific, limited subset of patients
Consult cardiologist if:
 Diagnosis uncertain after noninvasive testing
 Noninvasive testing contraindicated
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (1): ITC1-1.
What are the goals of treatment?
 Minimize likelihood of death & maximize health and function
 Reduce premature CV death
 Prevent complications that impair functional well-being
 Strategies for achieving treatment goals
 Patient education
 Lifestyle modification
 Medical therapy
 Revascularization (coronary artery bypass grafting or PCI)
 Use guideline-directed medical therapy — whether or not
revascularization occurs
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (1): ITC1-1.
What is the role of patient education?
 Reduce risk factors
 Improve medication adherence
 Improve patient satisfaction
 Should include:
 Review of individual prognosis and important risk factors
 Ways to reduce these risk factors
 Benefits + side effects of medications and how to administer
 Address limitations on physical activity
 When to seek medical help
 MI signs, symptoms; when to use aspirin, nitroglycerin
 What to do in an emergency
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (1): ITC1-1.
Which risk factors should be modified?
 Smoking
 Recommend smoking cessation and develop cessation plan
 Physical activity
 If angina chronic + stable: moderate aerobic activity ≥5 d/wk
 If high risk of cardiac complications: medically supervised
program helps establish safe exercise regimen
 Dietary modification
 Diet low in saturated fat, cholesterol, trans-fatty acids, and
sodium and rich in fresh fruits, vegetables, whole grains
 Omega-3 fatty acids, plant stanols/sterols, fiber: reduce risk
 If alcohol is part of the diet, consumption should be moderate
 Lipid management
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (1): ITC1-1.
Which medical therapies can prevent
myocardial infarction or death?
 Antiplatelet therapy
 Annual influenza vaccine
 ACE inhibitors
 Angiotensin-receptor antagonists
 Beta-blocker therapy
 Vitamins and mineral supplements aren’t recommended
for preventing CAD events
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (1): ITC1-1.
Which medical therapies relieve symptoms?
 Short-acting nitrates
 β-blocker Therapy
 Calcium-channel blockers and long-acting nitrates
 Ranolazine
 Alternative therapies for refractory angina in SIHD
 Spinal cord stimulation
 Enhanced external counterpulsation
 Transmyocardial revascularization
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (1): ITC1-1.
Which patients with SIHD are candidates for
revascularization with either CABG or a
PCI?
 To improve survival if mortality risk is high
 Left main or complex CAD
 >50% stenosis in left main coronary artery
 >70% in 3 major coronary arteries
 >70% in proximal left anterior descending artery + 1 other
major coronary artery
 Survivors of sudden cardiac death
(presumed ischemia-mediated ventricular tachycardia from
>70% stenosis in major coronary artery)
 To relieve symptoms if they persist despite therapy
 For stenosis likely to affect survival: same recommendations
 Other patients with >70% stenosis in ≥1 coronary arteries
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (1): ITC1-1.
Are there special considerations for women,
older adults, or patients with diabetes
mellitus, CKD, or other conditions?
 Women
 More atypical chest pain + angina-equivalent symptoms
 Tend to be treated less aggressively (bc different presentation
and testing compared to men?)
 Older adults
 Diagnosis and stress testing harder due to physiologic
changes of aging, coexisting conditions
 Receive less evidence-based care (bc pharmacotherapy
more difficult? bc of increased CABG morbidity, mortality?)
 Diabetes mellitus
 Greater risk of SIHD + magnified effects of other risk factors
 Chronic kidney disease
 Greater risk of SIHD + poor outcomes after AMI interventions
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (1): ITC1-1.
How should patients with treated ischemic
heart disease be followed?
 Each visit: obtain detailed information on angina
 Decreased level of physical activity since the last visit?
 Has angina increased in frequency or become more severe?
 Are risk factors modified and IHD knowledge improved?
 Any new comorbid illnesses?
 Has severity or treatment of comorbid illnesses worsened
angina?
 Assess adherence to therapy and AEs
 Encourage smoking cessation, exercise, balanced diet
 Use lab evaluation to monitor modifiable risk factors
 ECHO / radionuclide imaging / stress test: new symptoms
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (1): ITC1-1.
What do professional organizations
recommend with regard to prevention,
screening, diagnosis and treatment of
SIHD?
 Use 2012 clinical guideline for diagnosis and
management of SIHD

From the ACP, ACC Foundation, AHA, American
Association for Thoracic Surgery, Preventive
Cardiovascular Nurses Association, Society for
Cardiovascular Angiography and Interventions, and
Society of Thoracic Surgeons
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (1): ITC1-1.
CLINICAL BOTTOM LINE: Treatment…
 Minimize likelihood of death & maximize health and function
 Use guideline-directed medical therapy
 Reduce risk factors with lifestyle modifications and medical Rx
 Patient education ensures
 Understanding of underlying disease process
 Understanding of warning signs and symptoms of MI
 Informed decisions about treatment options
Consider revascularization if mortality risk is high or
symptoms persist despite guideline-directed medical
therapy
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (1): ITC1-1.