Stable ischemic heart disease

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.

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]Abrams J. Clinical practice. Chronic stable angina. N Engl J Med. 2005 Jun 16;352(24):2524-33. http://www.ncbi.nlm.nih.gov/pubmed/15958808?tool=bestpractice.com

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]Fihn SD, Blankenship JC, Alexander KP, et al. 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol. 2014 Nov 4;64(18):1929-49. http://www.onlinejacc.org/content/64/18/1929 http://www.ncbi.nlm.nih.gov/pubmed/25077860?tool=bestpractice.com  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]O'Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013 Jan 29;127(4):e362-425. https://www.ahajournals.org/doi/10.1161/CIR.0b013e3182742cf6 http://www.ncbi.nlm.nih.gov/pubmed/23247304?tool=bestpractice.com