In the first substantial revision in a decade, an expert panel has produced comprehensive clinical guidelines featuring an integrated approach to evaluation and management of patients with stable ischemic heart disease.
The complete guidelines, along with an executive summary, were developed jointly by 7 professional societies including the American College of Cardiology Foundation and the American Heart Association. Both documents were published online November 19, 2012, ahead of print in the Journal of the American College of Cardiology.
Written by a committee that spanned cardiovascular interventionalists and surgeons, internists, and imagers, the recommendations are based on extensive review of the medical literature through 2008, with clinical trial updates as late as December 2011.
Algorithms Help Guide Clinicians
The guidelines are organized around key recommendations for diagnosis and risk assessment of patients with suspected ischemic heart disease as well as appropriate use of medical therapy and/or revascularization, and patient follow-up. These are summarized in practice-friendly algorithms.
“Our thinking about this disease has evolved,” said writing committee chair Stephan D. Fihn, MD, MPH, of the University of Washington (Seattle, WA), in a press statement. “With this new guideline, we have transitioned form arbitrarily picking and choosing individual therapies to recognizing there is a package of lifestyle modifications and medications—what we call guideline-directed medical therapy—that benefits most patients.”
According to the authors, a guiding principle throughout the document is the need to educate patients and engage them in their own care. For physicians, that entails conscientious presentation of treatment options, including benefits and risks, enabling patients to share in decision making.
“We’ve been waiting for these guidelines for several years, but it was worth the wait,” William E. Boden, MD, of the Albany Stratton VA Medical Center (Albany, NY), told TCTMD in a telephone interview. “The writing committee has done a masterful job of imparting balance, emphasizing the importance of risk-factor identification, lifestyle intervention, and of treating intensively with respect to secondary prevention.”
Start With Medical Therapy--Usually
The guidelines “highlight the importance of patient education, and lay out a beautiful algorithm [describing] what guideline-directed therapy is,” Dr. Boden continued, noting that this portion is essentially unchanged from the 2002 recommendations. One surprise, he said, is that the anti-anginal agent ranolazine was not accorded a more prominent role, given the evidence of its benefit in several trials since the earlier guidelines. It appears as a fourth-line agent at the bottom of the algorithm.
With regard to the overall stepwise approach to treatment, however, Dr. Boden called the document “spot on.”
The guidelines “are pretty emphatic that you should first undertake intensive medical therapy, although they don’t say for how long,” he said. “Then, if symptoms persist despite an adequate trial, consider revascularization to improve them. That is what the data support.”
In a press release, writing committee vice chair Julius M. Gardin, MD, of Hackensack University Medical Center (Hackensack, NJ), said this strategy reflects the fact that in most cases, there is no evidence that revascularization prolongs life. Moreover, the degree of artery narrowing is less important than whether or not a lesion is functionally significant, he said, adding, “For this reason, we emphasize testing to show this.”
Dr. Boden said the threshold for intervention is lower in the presence of high-grade stenosis, especially if stress testing shows moderate ischemia. “The extent and magnitude of ischemia is a major driver in decision making,” he commented, adding, “It’s important to know the anatomy and the functional capacity of the patient.” That being said, Dr. Boden reported using FFR selectively, in cases of borderline stenosis.
Benefits of Revascularization Go Beyond Symptom Relief
In a telephone interview with TCTMD, Ajay J. Kirtane, MD, SM, of Columbia University Medical Center (New York, NY), said that in general he agrees with the approach of trying medical therapy prior to revascularization for patients with stable ischemic heart disease.
“[But] I think what’s missing [in the guidelines] is the aspect of patient choice. In people with severe symptoms, revascularization is more effective than medical therapy and ought to be offered upfront,” he stressed. “We have abundant data demonstrating that patients feel better than they would with medical therapy, and many patients would choose [revascularization] because they don’t want to take anti-anginal medications.”
Dr. Kirtane also argued that the guidelines’ division of revascularization goals into ‘survival’ vs. ‘symptom relief’ obscures the fact that prognosis associated with a given treatment choice can affect quality of life as much as symptoms. For example, for patients with proven ischemia, an increased likelihood of needing urgent rehospitalization if they are put on medical therapy—as shown by FAME II—may sway their choice of treatment, he suggested.
Perhaps more troubling, Dr. Kirtane said, is the guidelines’ apparent movement away from an anatomic assessment strategy. “Traditionally, there has been an emphasis on anatomic delineation of disease, whether through CT angiography or diagnostic catheterization, in order to risk-stratify patients and rule out dangerous disease. Only then do we go to the symptom relief component of the algorithm. Here, however, consideration of angiography comes further downstream than is appropriate, or in fact justified, by the data.”
An emphasis on noninvasive stress testing in patients with suspected CAD may not spot underlying high-risk left main or multivessel disease, he said.
The guidelines imply that angiography should be performed only if medical therapy is “unsuccessful,” Dr. Kirtane said. But even in the COURAGE trial, all patients underwent diagnostic catheterization, he pointed out.
“I worry that [the new guidelines] will lead to underuse of coronary angiography,” he said. “That has been associated with a higher rate of ACS and death.”
Drs. Kirtane and Boden agreed that the new guidelines are handicapped by not taking into account data from recent key trials, such as FAME II. Going forward, the guidelines should be updated more frequently, perhaps even annually, to reflect the current evidence base, Dr. Boden suggested.
2. Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: Executive summary. J Am Coll Cardiol. 2012;Epub ahead of print.