Initial assessment of stable ischemic heart disease involves a thorough history, including chest discomfort and related symptoms as well as risk factors, in order to assess the likelihood of coronary artery disease. This is followed by appropriate noninvasive testing guided by the probability of disease.
Management should focus on lifestyle modification, with emphasis on smoking cessation, weight management, physical activity, lipid control, and blood pressure control.
Antiplatelet therapy should be prescribed for all patients, and dual antiplatelet therapy may be considered in selected patients.
Beta-blockers may improve survival in selected patients. Addition of short- and long-acting nitrates, beta-blockers, and calcium-channel blockers can reduce chronic anginal symptoms.
Patients with persistent angina despite lifestyle modification and guideline-directed medical therapy may warrant percutaneous or surgical revascularization for reduction of symptoms.
It is possible that for carefully selected patients, revascularization in addition to lifestyle modification and medical therapy may improve survival.
Ischemic heart disease, an inability to provide adequate blood supply to the myocardium, is primarily caused by atherosclerosis of the epicardial coronary arteries. For this reason the terms ischemic heart disease, chronic coronary syndrome, coronary heart disease, and coronary artery disease are often used interchangeably, although the true pathophysiology is more complex.
Complications of ischemic heart disease include myocardial infarction, ischemic cardiomyopathy, and sudden cardiac death. Exertional angina is the classic symptom of ischemic heart disease, but patients may have atypical or no symptoms. Although routine screening is discouraged, testing may reveal ischemic heart disease in patients without symptoms or complications.
Ischemic heart disease is said to be stable when symptoms, if any, are manageable and not rapidly progressive; there must also be no recent infarction, procedural intervention, or signs of significant ongoing cardiac necrosis. Stable ischemic heart disease (SIHD) stands in contrast to acute coronary syndrome (ACS), a term that encompasses unstable angina, ST-elevation myocardial infarction, and non-ST-elevation myocardial infarction. Although ACS is a manifestation of the same general disease process as SIHD, risk stratification, diagnostic testing, and medical and procedural management usually differ significantly between the two conditions. In some circumstances patients with low-risk unstable angina may be managed similarly to patients with SIHD.
History and exam
Key diagnostic factors
- typical angina symptoms
- atypical angina symptoms
- symptoms of low-risk unstable angina
- normal exam
Other diagnostic factors
- known medical history of exacerbating factor
- nonanginal chest pain
- epigastric discomfort
- jaw pain
- arm pain
- dyspnea on exertion
- perspiration (diaphoresis)
- mitral regurgitation murmur
- bibasilar rales
- aortic outflow murmur
- carotid bruit
- diminished peripheral pulses
- signs of abdominal aortic aneurysm
- retinopathy seen on fundoscopic examination
- xanthomas or xanthelasma
- advancing age
- elevated LDL cholesterol
- isolated low HDL cholesterol
- illicit drug use
- male sex
- family history of ischemic heart disease
- mental stress/depression
- plasma biomarkers
- polluted air
1st investigations to order
- resting ECG
- lipid profile
- fasting blood glucose or HbA1c
Investigations to consider
- exercise ECG (without imaging)
- exercise or pharmacologic stress with imaging
- coronary CT angiography (CCTA)
- invasive coronary angiography
- thyroid-stimulating hormone
- rest echocardiography
- CT myocardial perfusion (CTP) and fractional flow reserve CT (FFRCT)
- coronary artery calcium (CAC) scoring
- tests for vasospasm and microcirculatory dysfunction
- Aortic dissection
- Pulmonary embolism
- ACR appropriateness criteria: chronic chest pain - high probability of coronary artery disease
- Guidelines for performance, interpretation, and application of stress echocardiography in ischemic heart disease
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