Stable ischemic heart disease

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.[1]Marzilli M, Merz CN, Boden WE, et al. Obstructive coronary atherosclerosis and ischemic heart disease: an elusive link! J Am Coll Cardiol. 2012 Sep 11;60(11):951-6. https://www.sciencedirect.com/science/article/pii/S0735109712022929?via%3Dihub http://www.ncbi.nlm.nih.gov/pubmed/22954239?tool=bestpractice.com [2]Pepine CJ, Douglas PS. Rethinking stable ischemic heart disease: is this the beginning of a new era? J Am Coll Cardiol. 2012 Sep 11;60(11):957-9. https://www.sciencedirect.com/science/article/pii/S0735109712022930?via%3Dihub http://www.ncbi.nlm.nih.gov/pubmed/22954240?tool=bestpractice.com

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.[3]Fihn SD, Gardin JM, Abrams J, et al; American College of Cardiology Foundation/American Heart Association Task Force. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. Circulation. 2012 Dec 18;126(25):e354-471. https://www.ahajournals.org/doi/10.1161/CIR.0b013e318277d6a0 http://www.ncbi.nlm.nih.gov/pubmed/23166211?tool=bestpractice.com [4]Knuuti J, Wijns W, Saraste A, et al. 2019 ESC guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J. 2020 Jan 14;41(3):407-77. https://academic.oup.com/eurheartj/article/41/3/407/5556137 http://www.ncbi.nlm.nih.gov/pubmed/31504439?tool=bestpractice.com