Stable ischemic heart disease

Last reviewed: December 2018

Last updated: October 2018

Summary

Initial assessment 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.

A stepwise addition of beta-blockers, calcium-channel antagonists, and/or long-acting nitrates should be provided to patients with chronic anginal symptoms.

Patients with persistent angina despite lifestyle modification and guideline-directed medical therapy may warrant revascularization for reduction of symptoms.

Additionally, patients with high risk of ischemia may benefit from revascularization concurrent with initiation of lifestyle modification and medical therapy.

Definition

Stable ischemic heart disease (SIHD) and low-risk unstable angina are most commonly caused by atheromatous plaques in the coronary arteries that obstruct blood flow. Anginal symptoms are a clinical manifestation of ischemia. Key contributory factors to progression of atheromatous disease include smoking, hypertension, hyperlipidemia, diabetes, and obesity. In a substantial number of patients, especially women, ischemia may also be caused by vascular dysfunction of smaller myocardial vessels without significant obstruction of large epicardial vessels. The pathology of this process may differ from that of atheroma formation. Chest discomfort in the setting of exertion or emotional stress is the predominant clinical presentation of chronic stable angina. Atypical presentations, including pain in the epigastrium, jaw, neck, or arms are also common, particularly in women, people with diabetes, and older people. Associated symptoms for typical and atypical angina, or "ischemic equivalents," include dyspnea, nausea, vomiting, perspiration, lightheadedness, and fatigue. [1]

The guidelines described here specifically address the clinical syndrome of SIHD, which is defined by the presence of confirmed obstructive coronary artery disease without recent (<1 year) acute coronary syndrome or percutaneous intervention. [2] This clinical syndrome includes patients with stable angina pain syndromes and patients with low-risk unstable angina. Angina is considered unstable if it occurs at rest, is new in onset, and is severe (occurs with walking 1 flight of stairs, or <2 blocks on even ground), or if it is increasing in severity or frequency requiring markedly less provocation in patients with previous angina. Features of low-risk unstable angina include pain from exertion lasting less than 20 minutes, pain not rapidly increasing, and normal/unchanged ECG. Patients with more severe symptoms consistent with intermediate or high-risk unstable angina or acute coronary syndrome are at increased short-term risk of death or nonfatal myocardial infarction, and should be evaluated urgently. [3]

History and exam

Key diagnostic factors

typical angina symptoms
atypical angina symptoms
symptoms of low-risk unstable angina
normal exam

Full details

Other diagnostic factors

known medical history of exacerbating factor
nonanginal chest pain
epigastric discomfort
jaw pain
arm pain
dyspnea on exertion
nausea/vomiting
perspiration (diaphoresis)
fatigue
hypoxia
tachycardia
S3
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

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Risk factors

advancing age
smoking
hypertension
elevated LDL cholesterol
isolated low HDL cholesterol
hypertriglyceridemia
diabetes
inactivity
obesity
family history of premature ischemic heart disease
illicit drug use
male sex
mental stress/depression
plasma biomarkers
polluted air

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Diagnostic investigations

1st investigations to order

resting ECG
hemoglobin
fasting lipid profile
fasting blood glucose or HbA1c

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Investigations to consider

thyroid-stimulating hormone
stress exercise ECG without imaging
stress single photon emission computed tomography (SPECT), stress echocardiography, stress cardiac magnetic resonance (CMR), stress positron emission tomography (PET)
cardiac computed tomographic angiography (CCTA)
invasive coronary angiography

Full details

Emerging tests

coronary artery calcium (CAC) scoring
fractional flow reserve (FFR)-CT and FFR-MRI

Full details

Treatment algorithm

ONGOING

all patients

Contributors

Authors VIEW ALL 

Douglas Berger, MD, MLitt

General Medicine Service

Veterans Affairs (VA) Puget Sound Health Care System

Assistant Professor

University of Washington

Seattle

Disclosures

DB declares that he has no competing interests.

Acknowledgements

Dr Douglas Berger would like to gratefully acknowledge Dr Stephan D. Fihn, Dr Karen E. Segerson, Dr Mark C. Zaros, Dr Joy Bucher, and Dr Steven M. Bradley, previous contributors to this topic. SDF, KES, MCZ, JB, and SMB declare that they have no competing interests.

Peer reviewers VIEW ALL 

Syed Wamique Yusuf, MD, MRCPI, FACC

Associate Professor

University of Texas MD Anderson Cancer Center

Department of Cardiology

Houston

Disclosures

SWY declares that he has no competing interests.

John R. Charpie, MD, PhD

Associate Professor of Pediatrics

Medical Director

Pediatric Cardiothoracic Intensive Care Unit

University of Michigan Congenital Heart Center

C.S. Mott Children's Hospital

Ann Arbor

Disclosures

JRC declares that he has no competing interests.

Michael A. Spinelli, MD

Fellow

Albert Einstein College of Medicine

Montefiore Medical Center

Bronx

Disclosures

MAS declares that he has no competing interests.

Katherine Wu, MD

Associate Professor of Medicine

Division of Cardiology

Johns Hopkins Medical Institutions

Baltimore

Disclosures

KW declares that she has no competing interests.

Daniel Lenihan, MD

Professor of Cardiovascular Medicine

Director of Clinical Research

Vanderbilt University

Nashville

Disclosures

DL declares that he has no competing interests.

Gianluca Rigatelli, MD, PhD, FACP, FACC, FESC, FSCAI

Director

Section of Transcatheter Treatment of Congenital Heart Disease in the Adult

Rovigo General Hospital

Rovigo

Italy

Disclosures

GR declares that he has no competing interests.

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Stable ischemic heart disease

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Emerging tests

Treatment algorithm

all patients

Contributors

Authors VIEW ALL 

Douglas Berger, MD, MLitt

Disclosures

Acknowledgements

Peer reviewers VIEW ALL 

Syed Wamique Yusuf, MD, MRCPI, FACC

Disclosures

John R. Charpie, MD, PhD

Disclosures

Michael A. Spinelli, MD

Disclosures

Katherine Wu, MD

Disclosures

Daniel Lenihan, MD

Disclosures

Gianluca Rigatelli, MD, PhD, FACP, FACC, FESC, FSCAI

Disclosures

Differentials

Guidelines

Patient leaflets

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