2012 ACCF/AHA/ACP/AATS/PCNA/ SCAI/STS Guideline for the Diagnosis and

2012 ACCF/AHA/ACP/AATS/PCNA/ SCAI/STS Guideline for the Diagnosis and

2012 ACCF/AHA/ACP/AATS/PCNA/ SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease Developed in Partnership with American College of Cardiology Foundation, American Heart Association, American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. American College of Cardiology Foundation and American Heart Association, Inc. Citation This slide set is adapted from the 2012

ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients with Stable Ischemic Heart Disease (Journal of the American College of Cardiology). Published ahead-of print on November 19, 2012], available at: http://content.onlinejacc.org/article.aspx?doi=10.1016/j. jacc.2012.07.013 and http://circ.ahajournals.org/lookup/doi/10.1161/CIR.0b01 3e318277d6a0 The full-text guidelines are also available on the following Web sites: ACC (www.cardiosource.org) and AHA (my.americanheart.org).

Special Thanks To Slide Set Editor Stephan D. Fihn, MD, MPH The SIHD Guideline Writing Committee Members Stephan D. Fihn, MD, MPH, Chair Julius M. Gardin, MD, Vice Chair Jonathan Abrams, MD Kathleen Berra, MSN, ANP James C. Blankenship, MD Paul Dallas, MD Pamela S. Douglas, MD JoAnne M. Foody, MD

Thomas Gerber, MD, PhD Alan L. Hinderliter, MD Spencer B. King, III, MD Paul D. Kligfield, MD Harlan M. Krumholz, MD Raymond Y.K. Kwong, MD Michael J. Lim, MD Jane Linderbaum, MS, CNP-BC Michael J. Mack, MD# Mark A. Munger, PharmD Richard L. Prager, MD# Joseph F. Sabik MD**

Leslee J. Shaw, PhD Joanna D. Sikkema, MSN, ANP-BC Craig R. Smith, Jr, MD** Sidney C. Smith, Jr, MD John A. Spertus, MD, MPH Sankey V. Williams, MD ACP Representative; ACCF/AHA Representative; PCNA Representative; SCAI Representative; Critical care nursing expertise; #STS Representative; **AATS Representative; ACCF/AHA Task Force on Practice Guidelines Liaison; ACCF/AHA Task Force on Performance Measures Liaison. Classification of Recommendations and Levels of Evidence A recommendation with

Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Although randomized trials are unavailable, there may be a very clear clinical consensus that a particular test or therapy

is useful or effective. *Data available from clinical trials or registries about the usefulness/ efficacy in different subpopulations, such as sex, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use. For comparative effectiveness

recommendations (Class I and IIa; Level of Evidence A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated. Key Guideline Messages Management of SIHD should be based on strong scientific evidence and the patients preferences.

Patients presenting with angina should be categorized as stable vs. unstable. Those at moderate or high risk should be treated emergently for acute coronary syndrome. A standard exercise test is the first choice to diagnose IHD for patients with an interpretable ECG and able to exercise, especially if the likelihood is intermediate (10-90%). Those who have an uninterpretable ECG and can exercise, should undergo exercise stress test with nuclear MPI or echocardiography, particularly if likelihood of IHD is >10%. If unable to exercise, MPI or echocardiography with pharmacologic stress is recommended. Key Guideline Messages Patients diagnosed with SIHD should undergo

assessment of risk for death or complications. For patients with an interpretable ECG and who are able to exercise, a standard exercise test is also the preferred choice for risk assessment. Those who have an uninterpretable ECG and are able to exercise, should undergo an exercise stress with nuclear MPI or echocardiography, while for patients unable to exercise, nuclear MPI or echocardiography with pharmacologic stress is recommended. Key Guideline Messages Patients with SIHD should generally receive a package of GDMT that include lifestyle interventions and

medications shown to improve outcomes which includes (as appropriate): Diet, weight loss and regular physical activity; If a smoker, smoking cessation; Aspirin 75-162mg daily; A statin medication in moderate dosage; If hypertensive, antihypertensive medication to achieve a BP

<140/90; If diabetic, appropriate glycemic control. Key Guideline Messages Patients with angina should receive sublingual nitroglycerin and a beta blocker. When these are not tolerated or are ineffective, a calcium-channel blocker or long-acting nitrate may be substituted or added. Coronary arteriography should be considered for patients with SIHD whose clinical characteristics and results of noninvasive testing indicate a high likelihood of severe IHD and when the benefits are deemed to exceed risk. Key Guideline Messages

The relatively small proportion of patients who have high-risk anatomy (e.g., >50% stenosis of the left main coronary artery), revascularization of with CABG should be considered to potentially improve survival. Most data showing improved survival with surgery compared to medical therapy are several decades old and based on surgical techniques and medical therapies that have advanced considerably. There are no conclusive data demonstrating improved survival following PCI. Key Guideline Messages Most patients should have a trial of GDMT before considering revascularization to improve symptoms.

Deferring revascularization is not associated with worse outcomes. Prior to revascularization to improve symptoms, coronary anatomy should be correlated with functional studies to ensure lesions responsible for symptoms are targeted. Patients with SIHD should be carefully followed to monitor progression of disease, complications and adherence. Exercise and imaging studies should generally be repeated only when there is a change in clinical status (not annually). Guideline for SIHD

Introduction Spectrum of IHD Guidelines relevant to the spectrum of IHD are in parentheses Introduction Vital Importance of Involvement by an Informed Patient

Vital Importance of Involvement by an Informed Patient I IIa IIb III Choices regarding diagnostic and therapeutic options should be made through a process of shared decision-making involving the patient and provider, explaining information about risks, benefits, and costs to the patient. (Level of Evidence: C) Guideline for SIHD

Diagnosis of SIHD Diagnosis Clinical Evaluation of Patients With Chest Pain Clinical Evaluation of Patients With Chest Pain I IIa IIb III Patients with chest pain should receive a thorough

history and physical examination to assess the probability of IHD prior to additional testing. I IIa IIb III Patients who present with acute angina should be categorized as stable or unstable; patients with UA should be further categorized as high, moderate or low risk. Diagnosis of Patients with Suspected Ischemic Heart Disease

Clinical Classification of Chest Pain Pretest Likelihood of CAD in Symptomatic Patients According to Age and Sex* (Combined Diamond/Forrester and CASS Data) *Each value represents the percent with significant CAD on catheterization. Comparing Pretest Likelihood of CAD

in Low-Risk Symptomatic Patients With High-Risk Symptomatic Patients (Duke Database) Each value represents the percentage with significant CAD. The first is the percentage for a lowrisk, mid-decade patient without diabetes mellitus, smoking, or hyperlipidemia. The second is that of a patient of the same age with diabetes mellitus, smoking, and hyperlipidemia. Both highand low-risk patients have normal resting ECGs. If ST-T-wave changes or Q waves had been present, the likelihood of CAD would be higher in each entry of the table. Diagnosis Electrocardiography Diagnosis

Resting Electrocardiography to Assess Risk Resting Electrocardiography to Assess Risk I IIa IIb III A resting ECG is recommended in patients without an obvious, noncardiac cause of chest pain.

Diagnosis Stress Testing and Advanced Imaging for Initial Diagnosis in Patients With Suspected SIHD Who Require Noninvasive Testing Diagnosis Able to Exercise Able to Exercise

I IIa IIb III I IIa IIb III Standard exercise ECG testing is recommended for patients with an intermediate pretest probability of IHD who have an interpretable ECG and at least moderate physical functioning or no disabling comorbidity. Exercise stress with nuclear MPI or echocardiography is recommended for patients with an intermediate to high pretest probability of IHD who have an uninterpretable ECG and at least moderate physical

functioning or no disabling comorbidity. Able to Exercise (cont.) I IIa IIb III I IIa IIb III For patients with a low pretest probability of obstructive IHD who do require testing, standard exercise ECG testing can be useful, provided the patient has an interpretable ECG and at least moderate physical functioning or no disabling comorbidity. Exercise stress with nuclear MPI or echocardiography is

reasonable for patients with an intermediate to high pretest probability of obstructive IHD who have an interpretable ECG and at least moderate physical functioning or no disabling comorbidity. Able to Exercise (cont.) I IIa IIb III Pharmacological stress with CMR can be useful for patients with an intermediate to high pretest probability of obstructive IHD who have an uninterpretable ECG and at least moderate physical functioning or no disabling comorbidity.

I IIa IIb III CCTA might be reasonable for patients with an intermediate pretest probability of IHD who have at least moderate physical functioning or no disabling comorbidity. I IIa IIb III For patients with a low pretest probability of obstructive IHD who do require testing, standard exercise stress echocardiography might be reasonable, provided the patient has an interpretable ECG and at least moderate

physical functioning or no disabling comorbidity. Able to Exercise (cont.) I IIa IIb III No Benefit I IIa IIb III No Benefit Pharmacological stress with nuclear MPI, echocardiography, or CMR is not recommended for

patients who have an interpretable ECG and at least moderate physical functioning or no disabling comorbidity. Exercise stress with nuclear MPI is not recommended as an initial test in low-risk patients who have an interpretable ECG and at least moderate physical functioning or no disabling comorbidity. Diagnosis Unable to Exercise

Unable to Exercise I IIa IIb III Pharmacological stress with nuclear MPI or echocardiography is recommended for patients with an intermediate to high pretest probability of IHD who are incapable of at least moderate physical functioning or have disabling comorbidity. I IIa IIb III Pharmacological stress echocardiography is reasonable for patients with a low pretest probability of IHD who

require testing and are incapable of at least moderate physical functioning or have disabling comorbidity. I IIa IIb III CCTA is reasonable for patients with a low to intermediate pretest probability of IHD who are incapable of at least moderate physical functioning or have disabling comorbidity. Unable to Exercise (cont.) I IIa IIb III

Pharmacological stress CMR is reasonable for patients with an intermediate to high pretest probability of IHD who are incapable of at least moderate physical functioning or have disabling comorbidity. I IIa IIb III Standard exercise ECG testing is not recommended for patients who have an uninterpretable ECG or are incapable of at least moderate physical functioning or have disabling comorbidity.

No Benefit Other I IIa IIb III CCTA is reasonable for patients with an intermediate pretest probability of IHD who a) have continued symptoms with prior normal test findings, or b) have inconclusive results from prior exercise or pharmacological stress testing, or c) are unable to undergo stress with nuclear MPI or echocardiography.

I IIa IIb III For patients with a low to intermediate pretest probability of obstructive IHD, noncontrast cardiac CT to determine the CAC score may be considered. Guideline for SIHD Risk Assessment Risk Assessment

Advanced Testing: Resting and Stress Noninvasive Testing Risk Assessment Resting Imaging to Assess Cardiac Structure and Function Resting Imaging to Assess Cardiac Structure and Function

I IIa IIb III Assessment of resting LV systolic and diastolic ventricular function and evaluation for abnormalities of myocardium, heart valves, or pericardium are recommended with the use of Doppler echocardiography in patients with known or suspected IHD and a prior MI, pathological Q waves, symptoms or signs suggestive of heart failure, complex ventricular arrhythmias, or an undiagnosed heart murmur. Resting Imaging to Assess

Cardiac Structure and Function (cont.) I IIa IIb III Assessment of cardiac structure and function with resting echocardiography may be considered in patients with hypertension or diabetes mellitus and an abnormal ECG. I IIa IIb III Measurement of LV function with radionuclide imaging may be considered in patients with a prior

MI or pathological Q waves, provided there is no need to evaluate symptoms or signs suggestive of heart failure, complex ventricular arrhythmias, or an undiagnosed heart murmur. Resting Imaging to Assess Cardiac Structure and Function (cont.) I IIa IIb III No Benefit I IIa IIb III

No Benefit Echocardiography, radionuclide imaging, CMR, and cardiac CT are not recommended for routine assessment of LV function in patients with a normal ECG, no history of MI, no symptoms or signs suggestive of heart failure, and no complex ventricular arrhythmias. Routine reassessment (<1 year) of LV function with technologies such as echocardiography radionuclide imaging, CMR, or cardiac CT is not recommended in patients with no change in clinical status and for whom

no change in therapy is contemplated. Risk Assessment Stress Testing and Advanced Imaging in Patients With Known SIHD Who Require Noninvasive Testing for Risk Assessment Risk Assessment Risk Assessment in Patients

Able to Exercise Risk Assessment in Patients Able to Exercise I IIa IIb III Standard exercise ECG testing is recommended for risk assessment in patients with SIHD who are able to exercise to an adequate workload and have an interpretable ECG. I IIa IIb III

The addition of either nuclear MPI or echocardiography to standard exercise ECG testing is recommended for risk assessment in patients with SIHD who are able to exercise to an adequate workload but have an uninterpretable ECG not due to LBBB or ventricular pacing. Risk Assessment in Patients Able to Exercise (cont.) I IIa IIb III The addition of either nuclear MPI or echocardiography to standard exercise ECG

testing is reasonable for risk assessment in patients with SIHD who are able to exercise to an adequate workload and have an interpretable ECG. I IIa IIb III CMR with pharmacological stress is reasonable for risk assessment in patients with SIHD who are able to exercise to an adequate workload but have an uninterpretable ECG. Risk Assessment in Patients

Able to Exercise (cont.) I IIa IIb III CCTA may be reasonable for risk assessment in patients with SIHD who are able to exercise to an adequate workload but have an uninterpretable ECG. I IIa IIb III Pharmacological stress imaging (nuclear MPI, echocardiography, or CMR) or CCTA is not recommended for risk assessment in patients with

SIHD who are able to exercise to an adequate workload and have an interpretable ECG. No Benefit Risk Assessment Risk Assessment in Patients Unable to Exercise Risk Assessment in Patients Unable to Exercise I IIa IIb III

Pharmacological stress with either nuclear MPI or echocardiography is recommended for risk assessment in patients with SIHD who are unable to exercise to an adequate workload regardless of interpretability of ECG. I IIa IIb III Pharmacological stress CMR is reasonable for risk assessment in patients with SIHD who are unable to exercise to an adequate workload regardless of interpretability of ECG .

I IIa IIb III CCTA can be useful as a first-line test for risk assessment in patients with SIHD who are unable to exercise to an adequate workload regardless of interpretability of ECG. Risk Assessment Risk Assessment Regardless of Patients Ability to Exercise Risk Assessment

Regardless of Patients Ability to Exercise I IIa IIb III Pharmacological stress with either nuclear MPI or echocardiography is recommended for risk assessment in patients with SIHD who have LBBB on ECG, regardless of ability to exercise to an adequate workload. I IIa IIb III

Either exercise or pharmacological stress with imaging (nuclear MPI, echocardiography, or CMR) is recommended for risk assessment in patients with SIHD who are being considered for revascularization of known coronary stenosis of unclear physiological significance. Risk Assessment Regardless of Patients Ability to Exercise (cont.)

CCTA can be useful for risk assessment in patients with I IIa IIb III SIHD who have an indeterminate result from functional testing . I IIa IIb III CCTA might be considered for risk assessment in patients with SIHD unable to undergo stress imaging or as an alternative to invasive coronary angiography when functional testing indicates a moderate- to high-risk result and knowledge of angiographic coronary anatomy is unknown. I IIa IIb III

A request to perform either a) more than 1 stress imaging study or b) a stress imaging study and a CCTA at the same time is not recommended for risk assessment in patients with SIHD. No Benefit Noninvasive Risk Stratification *Although the published data are limited; patients with these findings will probably not be at low risk in the presence of either a high-risk treadmill score or severe resting LV dysfunction (LVEF <35%).

Algorithm for Risk Assessment of Patients With SIHD* *Colors correspond to the ACCF/AHA Classification of Recommendations and Levels of Evidence Table. Algorithm for Risk Assessment of Patients With SIHD (cont.)* *Colors correspond to the ACCF/AHA Classification of Recommendations and Levels of Evidence Table.

Risk Assessment Coronary Angiography Risk Assessment Coronary Angiography as an Initial Testing Strategy to Assess Risk Coronary Angiography as an Initial Testing Strategy to Assess Risk

I IIa IIb III Patients with SIHD who have survived sudden cardiac death or potentially life-threatening ventricular arrhythmia should undergo coronary angiography to assess cardiac risk. I IIa IIb III Patients with SIHD who develop symptoms and signs of heart failure should be evaluated to determine whether coronary angiography should be performed for risk assessment.

CAD Prognostic Index *Assuming medical treatment only. Risk Assessment Coronary Angiography to Assess Risk After Initial Workup With Noninvasive Testing Coronary Angiography to Assess

Risk After Initial Workup With Noninvasive Testing I IIa IIb III Coronary arteriography is recommended for patients with SIHD whose clinical characteristics and results of noninvasive testing indicate a high likelihood of severe IHD and when the benefits are deemed to exceed risk. I IIa IIb III Coronary angiography is reasonable to further assess risk in patients with SIHD who have depressed LV

function (EF <50%) and moderate risk criteria on noninvasive testing with demonstrable ischemia. Coronary Angiography to Assess Risk After Initial Workup With Noninvasive Testing (cont.) I IIa IIb III Coronary angiography is reasonable to further assess risk in patients with SIHD and inconclusive prognostic information after noninvasive testing or in patients for whom noninvasive testing is contraindicated or inadequate.

I IIa IIb III Coronary angiography for risk assessment is reasonable for patients with SIHD who have unsatisfactory quality of life due to angina, have preserved LV function (EF >50%), and have intermediate risk criteria on noninvasive testing. Coronary Angiography to Assess Risk After Initial Workup With Noninvasive Testing (cont.) I IIa IIb III

No Benefit I IIa IIb III No Benefit Coronary angiography for risk assessment is not recommended in patients with SIHD who elect not to undergo revascularization or who are not candidates for revascularization because of comorbidities or individual preferences . Coronary angiography is not recommended to

further assess risk in patients with SIHD who have preserved LV function (EF >50%) and lowrisk criteria on noninvasive testing. Coronary Angiography to Assess Risk After Initial Workup With Noninvasive Testing (cont.) I IIa IIb III No Benefit I IIa IIb III No Benefit

Coronary angiography is not recommended to assess risk in patients who are at low risk according to clinical criteria and who have not undergone noninvasive risk testing. Coronary angiography is not recommended to assess risk in asymptomatic patients with no evidence of ischemia on noninvasive testing. Guideline for SIHD Treatment Treatment

Patient Education Patient Education I IIa IIb III Patients with SIHD should have an individualized education plan to optimize care and promote wellness, including: a.education on the importance of medication adherence for managing symptoms and retarding disease progression ; I IIa IIb III

b. an explanation of medication management and cardiovascular risk reduction strategies in a manner that respects the patients level of understanding, reading comprehension, and ethnicity; I IIa IIb III c. comprehensive review of all therapeutic options; Patient Education (cont.) Patients with SIHD should have an individualized education plan to optimize care and promote wellness, including: I IIa IIb III

d. a description of appropriate levels of exercise, with encouragement to maintain recommended levels of daily physical activity; I IIa IIb III e. introduction to self-monitoring skills; and I IIa IIb III f. information on how to recognize worsening cardiovascular symptoms and take appropriate action. Patient Education (cont.)

I IIa IIb III Patients with SIHD should be educated about the following lifestyle elements that could influence prognosis: weight control, maintenance of a BMI of 18.5 to 24.9 kg/m2, and maintenance of a waist circumference less than 102 cm (40 inches) in men and less than 88 cm (35 inches) in women (less for certain racial groups); lipid management; BP control; smoking cessation and avoidance of exposure to secondhand smoke; and individualized medical, nutrition, and life-style changes for patients with diabetes mellitus to supplement diabetes treatment

goals and education. Patient Education (cont.) It is reasonable to educate patients with SIHD about: I IIa IIb III a. adherence to a diet that is low in saturated fat, cholesterol, and trans fat; high in fresh fruits, whole grains, and vegetables; and reduced in sodium intake, with cultural and ethnic preferences incorporated; I IIa IIb III

b. common symptoms of stress and depression to minimize stress related angina symptoms; Patient Education (cont.) It is reasonable to educate patients with SIHD about: I IIa IIb III c. comprehensive behavioral approaches for the management of stress and depression; and I IIa IIb III d. evaluation and treatment of major depressive

disorder when indicated. Treatment Guideline-Directed Medical Therapy Treatment Risk Factor Modification Treatment

Lipid Management Lipid Management I IIa IIb III Lifestyle modifications, including daily physical activity and weight management, are strongly recommended for all patients with SIHD. I IIa IIb III Dietary therapy for all patients should include reduced intake of saturated fats (to <7% of total

calories), trans fatty acids (to <1% of total calories), and cholesterol (to <200 mg/d). Lipid Management (cont.) I IIa IIb III In addition to therapeutic lifestyle changes, a moderate or high dose of a statin therapy should be prescribed, in the absence of contraindications or documented adverse effects. I IIa IIb III

For patients who do not tolerate statins, LDL cholesterollowering therapy with bile acid sequestrants,* niacin, or both is reasonable. *The use of bile acid sequestrant is relatively contraindicated when triglycerides are 200 mg/dL and is contraindicated when triglycerides are 500 mg/dL. Dietary supplement niacin must not be used as a substitute for prescription niacin. Treatment Blood Pressure Management

Blood Pressure Management I IIa IIb III All patients should be counseled about the need for lifestyle modification: weight control; increased physical activity; alcohol moderation; sodium reduction; and emphasis on increased consumption of fresh fruits, vegetables, and lowfat dairy products. I IIa IIb III In patients with SIHD with BP 140/90 mm Hg or higher,

antihypertensive drug therapy should be instituted in addition to or after a trial of lifestyle modifications. I IIa IIb III The specific medications used for treatment of high BP should be based on specific patient characteristics and may include ACE inhibitors and/or beta blockers, with addition of other drugs, such as thiazide diuretics or calcium channel blockers, if needed to achieve a goal BP of less than 140/90 mm Hg. Treatment

Diabetes Management Diabetes Management I IIa IIb III For selected individual patients, such as those with a short duration of diabetes mellitus and a long life expectancy, a goal HbA1c of 7% or less is reasonable. I IIa IIb III

A goal HbA1c between 7% and 9% is reasonable for certain patients according to age, history of hypoglycemia, presence of microvascular or macrovascular complications, or presence of coexisting medical conditions. Diabetes Management (cont.) I IIa IIb III Initiation of pharmacotherapy interventions to achieve target HbA1c might be reasonable.

I IIa IIb III Therapy with rosiglitazone should not be initiated in patients with SIHD. Harm Treatment Physical Activity Physical Activity I IIa IIb III

For all patients, the clinician should encourage 30 to 60 minutes of moderate-intensity aerobic activity, such as brisk walking, at least 5 days and preferably 7 days per week, supplemented by an increase in daily lifestyle activities (e.g., walking breaks at work, gardening, household work) to improve cardiorespiratory fitness and move patients out of the least-fit, least-active, high-risk cohort (bottom 20%). I IIa IIb III For all patients, risk assessment with a physical

activity history and/or an exercise test is recommended to guide prognosis and prescription. Physical Activity (cont.) I IIa IIb III Medically supervised programs (cardiac rehabilitation) and physician-directed, home-based programs are recommended for at-risk patients at first diagnosis. I IIa IIb III

It is reasonable for the clinician to recommend complementary resistance training at least 2 days per week. Treatment Weight Management Weight Management I IIa IIb III BMI and/or waist circumference should be assessed at every visit, and the clinician should consistently encourage

weight maintenance or reduction through an appropriate balance of lifestyle physical activity, structured exercise, caloric intake, and formal behavioral programs when indicated to maintain or achieve a BMI between 18.5 and 24.9 kg/m2 and a waist circumference less than 102 cm (40 inches) in men and less than 88 cm (35 inches) in women (less for certain racial groups). I IIa IIb III The initial goal of weight loss therapy should be to reduce body weight by approximately 5% to 10% from baseline. With success, further weight loss can be attempted if

indicated. Treatment Smoking Cessation Counseling Smoking Cessation Counseling I IIa IIb III Smoking cessation and avoidance of exposure to environmental tobacco smoke at work and home

should be encouraged for all patients with SIHD. Follow-up, referral to special programs, and pharmacotherapy are recommended, as is a stepwise strategy for smoking cessation (Ask, Advise, Assess, Assist, Arrange, Avoid). Treatment Management of Psychological Factors Management of Psychological Factors

I IIa IIb III It is reasonable to consider screening SIHD patients for depression and to refer or treat when indicated. I IIa IIb III Treatment of depression has not been shown to improve cardiovascular disease outcomes but might be reasonable for its other clinical benefits. Treatment

Alcohol Consumption Alcohol Consumption I IIa IIb III In patients with SIHD who use alcohol, it might be reasonable for nonpregnant women to have 1 drink (4 ounces of wine, 12 ounces of beer, or 1 ounce of spirits) a day and for men to have 1 or 2 drinks a day, unless alcohol is contraindicated (such as in patients with a history of alcohol abuse or dependence or with liver disease).

Treatment Avoiding Exposure to Air Pollution Avoiding Exposure to Air Pollution I IIa IIb III It is reasonable for patients with SIHD to avoid exposure to increased air pollution to reduce the risk of cardiovascular events.

Treatment Additional Medical Therapy to Prevent MI and Death Treatment Antiplatelet Therapy Antiplatelet Therapy I IIa IIb III

Treatment with aspirin 75 to 162 mg daily should be continued indefinitely in the absence of contraindications in patients with SIHD. I IIa IIb III Treatment with clopidogrel is reasonable when aspirin is contraindicated in patients with SIHD . Antiplatelet Therapy (cont.) I IIa IIb III Treatment with aspirin 75 to 162 mg daily and

clopidogrel 75 mg daily might be reasonable in certain high-risk patients with SIHD. I IIa IIb III Dipyridamole is not recommended as antiplatelet therapy for patients with SIHD. No Benefit Treatment Beta-Blocker Therapy

Beta-Blocker Therapy I IIa IIb III Beta-blocker therapy should be started and continued for 3 years in all patients with normal LV function after MI or ACS. I IIa IIb III Beta-blocker therapy should be used in all patients with LV systolic dysfunction (EF 40%) with heart failure or prior MI, unless contraindicated. (Use should be limited

to carvedilol, metoprolol succinate, or bisoprolol, which have been shown to reduce risk of death.) I IIa IIb III Beta blockers may be considered as chronic therapy for all other patients with coronary or other vascular disease. Treatment Renin-AngiotensinAldosterone Blocker Therapy

Renin-AngiotensinAldosterone Blocker Therapy I IIa IIb III ACE inhibitors should be prescribed in all patients with SIHD who also have hypertension, diabetes mellitus, LVEF 40% or less, or CKD, unless contraindicated. I IIa IIb III ARBs are recommended for patients with SIHD

who have hypertension, diabetes mellitus, LV systolic dysfunction, or CKD and have indications for, but are intolerant of, ACE inhibitors. I IIa IIb III I IIa IIb III Renin-AngiotensinAldosterone Blocker Therapy (cont.) Treatment with an ACE inhibitor is reasonable in patients with both SIHD and other vascular disease.

It is reasonable to use ARBs in other patients who are ACE inhibitor intolerant. Indications for Individual Drug Classes in the Treatment of Hypertension in Patients With SIHD* *Table indicates drugs that should be considered and does not indicate that all drugs should necessarily be prescribed in an individual patient (e.g., ACE inhibitors and ARB typically are not prescribed together). Treatment

Influenza Vaccination Influenza Vaccination I IIa IIb III An annual influenza vaccine is recommended for patients with SIHD. Treatment Additional Therapy to

Reduce Risk of MI and Death Additional Therapy to Reduce Risk of MI and Death Estrogen therapy is not recommended in postmenopausal I IIa IIb III women with SIHD with the intent of reducing cardiovascular risk or improving clinical outcomes. No Benefit I IIa IIb III

No Benefit I IIa IIb III No Benefit Vitamin C, vitamin E, and beta-carotene supplementation are not recommended with the intent of reducing cardiovascular risk or improving clinical outcomes in patients with SIHD. Treatment of elevated homocysteine with folate or vitamins B6 and B12 is not recommended with the intent of reducing cardiovascular risk or improving clinical outcomes in patients with SIHD.

Additional Therapy to Reduce Risk of MI and Death (cont.) I IIa IIb III No Benefit I IIa IIb III No Benefit Chelation therapy is not recommended with the intent of improving symptoms or reducing

cardiovascular risk in patients with SIHD. Treatment with garlic, coenzyme Q10, selenium, or chromium is not recommended with the intent of reducing cardiovascular risk or improving clinical outcomes in patients with SIHD. Treatment Medical Therapy for Relief of Symptoms Treatment

Use of Anti-Ischemic Medications I IIa IIb III Use of Anti-Ischemic Medications Beta blockers should be prescribed as initial therapy for relief of symptoms in patients with SIHD. I IIa IIb III

Calcium channel blockers or long-acting nitrates should be prescribed for relief of symptoms when beta blockers are contraindicated or cause unacceptable side effects in patients with SIHD. I IIa IIb III Calcium channel blockers or long-acting nitrates, in combination with beta blockers, should be prescribed for relief of symptoms when initial treatment with beta blockers is unsuccessful in patients with SIHD. Use of Anti-Ischemic

Medications (cont.) I IIa IIb III Sublingual nitroglycerin or nitroglycerin spray is recommended for immediate relief of angina in patients with SIHD. I IIa IIb III Treatment with a long-acting nondihydropyridine calcium channel blocker (verapamil or diltiazem) instead of a beta blocker as initial therapy for relief of symptoms is reasonable in patients with SIHD.

I IIa IIb III Ranolazine can be useful when prescribed as a substitute for beta blockers for relief of symptoms in patients with SIHD if initial treatment with beta blockers leads to unacceptable side effects or is ineffective or if initial treatment with beta blockers is contraindicated. Use of Anti-Ischemic Medications (cont.) I IIa IIb III

Ranolazine in combination with beta blockers can be useful when prescribed for relief of symptoms when initial treatment with beta blockers is not successful in patients with SIHD. Algorithm for Guideline-Directed Medical Therapy for Patients With SIHD* *Colors correspond to the ACCF/AHA Classification of Recommendations and Levels of Evidence Table. Algorithm for Guideline-Directed

Medical Therapy for Patients With SIHD* (cont.) *Colors correspond to the ACCF/AHA Classification of Recommendations and Levels of Evidence Table. Algorithm for Guideline-Directed Medical Therapy for Patients With SIHD* (cont.) *Colors correspond to the ACCF/AHA Classification of Recommendations and Levels

of Evidence Table. The use of bile acid sequestrant is relatively contraindicated when triglycerides are 200 mg/dL and is contraindicated when triglycerides are 500 mg/dL. Dietary supplement niacin must not be used as a substitute for prescription niacin. Treatment

Alternative Therapies for Relief of Symptoms in Patients With Refractory Angina Alternative Therapies for Relief of Symptoms in Patients with Refractory Angina I IIa IIb III EECP may be considered for relief of refractory angina in patients with SIHD.

I IIa IIb III Spinal cord stimulation may be considered for relief of refractory angina in patients with SIHD. Alternative Therapies for Relief of Symptoms in Patients with Refractory Angina (cont.) I IIa IIb III TMR may be considered for relief of refractory

angina in patients with SIHD. I IIa IIb III Acupuncture should not be used for the purpose of improving symptoms or reducing cardiovascular risk in patients with SIHD. No Benefit SIHD Guideline CAD Revascularization

CAD Revascularization Heart Team Approach to Revascularization Decisions Heart Team Approaches to Revascularization Decisions I IIa IIb III A Heart Team approach to revascularization is recommended in patients with unprotected left main or complex CAD.

I IIa IIb III Calculation of the STS and SYNTAX scores is reasonable in patients with unprotected left main and complex CAD. CAD Revascularization Revascularization to Improve Survival CAD Revascularization

Left Main CAD Revascularization I IIa IIb III Left Main CAD Revascularization CABG to improve survival is recommended for patients with significant (50% diameter stenosis) left main coronary artery stenosis. I IIa IIb III

PCI to improve survival is reasonable as an alternative to CABG in selected stable patients with significant (50% diameter stenosis) unprotected left main CAD with: 1) anatomic conditions associated with a low risk of PCI procedural complications and a high likelihood of good long-term outcome (e.g., a low SYNTAX score [22], ostial or trunk left main CAD); and 2) clinical characteristics that predict a significantly increased risk of adverse surgical outcomes (e.g., STS-predicted risk of operative mortality 5%). Left Main CAD Revascularization (cont.)

I IIa IIb III PCI to improve survival is reasonable in patients with UA/NSTEMI when an unprotected left main coronary artery is the culprit lesion and the patient is not a candidate for CABG. I IIa IIb III PCI to improve survival is reasonable in patients with acute STEMI when an unprotected left main coronary artery is the culprit lesion, distal coronary flow is less than TIMI grade 3, and PCI can be performed more rapidly and safely than

CABG. Left Main CAD Revascularization (cont.) I IIa IIb III PCI to improve survival may be reasonable as an alternative to CABG in selected stable patients with significant (50% diameter stenosis) unprotected left main CAD with: a) anatomic conditions associated with a low to intermediate risk of PCI procedural complications and an intermediate to high likelihood of good long-term outcome (e.g., lowintermediate

SYNTAX score of <33, bifurcation left main CAD); and b) clinical characteristics that predict an increased risk of adverse surgical outcomes (e.g., moderatesevere chronic obstructive pulmonary disease, disability from previous stroke, or previous cardiac surgery; STSpredicted risk of operative mortality >2%). Left Main CAD Revascularization (cont.) I IIa IIb III Harm PCI to improve survival should not be performed

in stable patients with significant (50% diameter stenosis) unprotected left main CAD who have unfavorable anatomy for PCI and who are good candidates for CABG. CAD Revascularization NonLeft Main CAD Revascularization Non-Left Main CAD Revascularization I IIa IIb III

CABG I IIa IIb III PCI I IIa IIb III CABG to improve survival is beneficial in patients with significant (70% diameter) stenoses in 3 major coronary arteries (with or without involvement of the proximal LAD artery) or in the proximal LAD artery

plus 1 other major coronary artery. CABG or PCI to improve survival is beneficial in survivors of sudden cardiac death with presumed ischemia-mediated ventricular tachycardia caused by significant (70% diameter) stenosis in a major coronary artery. Non-Left Main CAD Revascularization (cont.) I IIa IIb III CABG to improve survival is reasonable in patients with significant (70% diameter) stenoses in 2 major coronary

arteries with severe or extensive myocardial ischemia (e.g., high-risk criteria on stress testing, abnormal intracoronary hemodynamic evaluation, or >20% perfusion defect by myocardial perfusion stress imaging) or target vessels supplying a large area of viable myocardium. I IIa IIb III CABG to improve survival is reasonable in patients with mildmoderate LV systolic dysfunction (EF 35% to 50%) and significant (70% diameter stenosis) multivessel CAD or proximal LAD coronary artery stenosis, when viable myocardium is present in the region of intended

revascularization. Non-Left Main CAD Revascularization (cont.) I IIa IIb III CABG with a LIMA graft to improve survival is reasonable in patients with significant (70% diameter) stenosis in the proximal LAD artery and evidence of extensive ischemia. I IIa IIb III It is reasonable to choose CABG over PCI to improve

survival in patients with complex 3-vessel CAD (e.g., SYNTAX score >22), with or without involvement of the proximal LAD artery who are good candidates for CABG. I IIa IIb III CABG is probably recommended in preference to PCI to improve survival in patients with multivessel CAD and diabetes mellitus, particularly if a LIMA graft can be anastomosed to the LAD artery. Non-Left Main CAD Revascularization (cont.)

I IIa IIb III The usefulness of CABG to improve survival is uncertain in patients with significant (70%) diameter stenoses in 2 major coronary arteries not involving the proximal LAD artery and without extensive ischemia. I IIa IIb III The usefulness of PCI to improve survival is uncertain in patients with 2- or 3-vessel CAD (with or without involvement of the proximal LAD artery) or 1-vessel proximal LAD disease.

I IIa IIb III CABG might be considered with the primary or sole intent of improving survival in patients with SIHD with severe LV systolic dysfunction (EF <35%) whether or not viable myocardium is present. Non-Left Main CAD Revascularization (cont.) I IIa IIb III The usefulness of CABG or PCI to improve survival is

uncertain in patients with previous CABG and extensive anterior wall ischemia on noninvasive testing. I IIa IIb III CABG or PCI should not be performed with the primary or sole intent to improve survival in patients with SIHD with 1 or more coronary stenoses that are not anatomically or functionally significant (e.g., <70% diameter nonleft main coronary artery stenosis, FFR >0.80, no or only mild ischemia on noninvasive testing), involve only the left circumflex or right coronary artery, or subtend only a small area of viable myocardium.

Harm Revascularization to Improve Symptoms With Significant Anatomic (50% Left Main or 70% Non-Left Main CAD) or Physiological (FFR 0.80) Coronary Stenoses Algorithm for Revascularization to Improve Survival of Patients With SIHD*

*Colors correspond to the ACCF/AHA Classification of Recommendations and Levels of Evidence Table. Algorithm for Revascularization to Improve Survival of Patients With SIHD (cont.)* *Colors correspond to the ACCF/AHA Classification of Recommendations and Levels of Evidence Table.

CAD Revascularization Revascularization to Improve Symptoms Revascularization to Improve Symptoms I IIa IIb III CABG or PCI to improve symptoms is beneficial in patients with 1 or more significant (70% diameter) coronary artery stenoses amenable to revascularization and unacceptable angina despite

GDMT. I IIa IIb III CABG or PCI to improve symptoms is reasonable in patients with 1 or more significant (70% diameter) coronary artery stenoses and unacceptable angina for whom GDMT cannot be implemented because of medication contraindications, adverse effects, or patient preferences. Revascularization to Improve Symptoms (cont.)

I IIa IIb III PCI to improve symptoms is reasonable in patients with previous CABG, 1 or more significant (70% diameter) coronary artery stenoses associated with ischemia, and unacceptable angina despite GDMT. I IIa IIb III It is reasonable to choose CABG over PCI to improve symptoms in patients with complex 3vessel CAD (e.g., SYNTAX score >22), with or without involvement of the proximal LAD artery,

who are good candidates for CABG. Revascularization to Improve Symptoms (cont.) I IIa IIb III CABG to improve symptoms might be reasonable for patients with previous CABG, 1 or more significant (70% diameter) coronary artery stenoses not amenable to PCI, and unacceptable angina despite GDMT. I IIa IIb III

TMR performed as an adjunct to CABG to improve symptoms may be reasonable in patients with viable ischemic myocardium that is perfused by arteries that are not amenable to grafting. I IIa IIb III CABG or PCI to improve symptoms should not be performed in patients who do not meet anatomic (50% diameter left main or 70% nonleft main stenosis diameter) or physiological (e.g., abnormal FFR) criteria for revascularization.

Harm Algorithm for Revascularization to Improve Symptoms of Patients With SIHD* *Colors correspond to the ACCF/AHA Classification of Recommendations and Levels of Evidence Table.

Algorithm for Revascularization to Improve Symptoms of Patients With SIHD (cont.)* *Colors correspond to the ACCF/AHA Classification of Recommendations and Levels of Evidence Table. CAD Revascularization

Dual Antiplatelet Therapy Compliance and Stent Thrombosis Dual Antiplatelet Therapy Compliance and Stent Thrombosis I IIa IIb III PCI with coronary stenting (BMS or DES) should Harm not be performed if the patient is not likely to be able to tolerate and comply with DAPT for the

appropriate duration of treatment based on the type of stent implanted. CAD Revascularization Hybrid Coronary Revascularization I IIa IIb III Hybrid Coronary Hybrid coronary revascularization (defined as the planned Revascularization

combination of LIMA-to-LAD artery grafting and PCI of 1 nonLAD coronary arteries) is reasonable in patients with 1 or more of the following: a.Limitations to traditional CABG, such as heavily calcified proximal aorta or poor target vessels for CABG (but amenable to PCI); b.Lack of suitable graft conduits; c.Unfavorable LAD artery for PCI (i.e., excessive vessel tortuosity or chronic total occlusion). I IIa IIb III Hybrid coronary revascularization (defined as the planned combination of LIMA-to-LAD artery grafting and PCI of 1 nonLAD coronary arteries) may be reasonable as an alternative to

multivessel PCI or CABG in an attempt to improve the overall riskbenefit ratio of the procedures. Guideline for SIHD Patient Follow-Up: Monitoring of Symptoms and Antianginal Therapy Patient Follow-Up: Monitoring of Symptoms and Antianginal Therapy

Clinical Evaluation, Echocardiography During Routine, Periodic Follow-Up Clinical Evaluation, Echocardiography During Routine, Periodic Follow-Up I IIa IIb III Patients with SIHD should receive periodic follow-up, at least annually, that includes all of the following: a.Assessment of symptoms and clinical function;

b.Surveillance for complications of SIHD, including heart failure and arrhythmias; c.Monitoring of cardiac risk factors; and d.Assessment of the adequacy of and adherence to recommended lifestyle changes and medical therapy. I IIa IIb III Assessment of LVEF and segmental wall motion by echocardiography or radionuclide imaging is recommended in patients with new or worsening heart failure or evidence of intervening MI by history or ECG. Clinical Evaluation,

Echocardiography During Routine, Periodic Follow-Up (cont.) Periodic screening for important comorbidities that are I IIa IIb III prevalent in patients with SIHD, including diabetes mellitus, depression, and CKD, might be reasonable. I IIa IIb III A resting 12-lead ECG at 1-year or longer intervals between

studies in patients with stable symptoms might be reasonable. I IIa IIb III Measurement of LV function with a technology such as echocardiography or radionuclide imaging is not recommended for routine periodic reassessment of patients who have not had a change in clinical status or who are at low risk of adverse cardiovascular events. No Benefit

Patient Follow-Up: Monitoring of Symptoms and Antianginal Therapy Noninvasive Testing in Known SIHD Patient Follow-Up: Monitoring of Symptoms and Antianginal Therapy Follow-Up Noninvasive Testing in Patients With

Known SIHD: New, Recurrent or Worsening Symptoms, Not Consistent With Unstable Angina Patient Follow-Up: Monitoring of Symptoms and Antianginal Therapy Patients Able to Exercise Patients Able to Exercise I IIa IIb III

Standard exercise ECG testing is recommended in patients with known SIHD who have new or worsening symptoms not consistent with UA and who have a) at least moderate physical functioning and no disabling comorbidity and b) an interpretable ECG. I IIa IIb III Exercise with nuclear MPI or echocardiography is recommended in patients with known SIHD who have new or worsening symptoms not consistent with UA and who have a) at least moderate physical

functioning or no disabling comorbidity but b) an uninterpretable ECG. Patients Able to Exercise (cont.) Exercise with nuclear MPI or echocardiography is I IIa IIb III reasonable in patients with known SIHD who have new or worsening symptoms not consistent with UA and who have a) at least moderate physical functioning and no disabling comorbidity, b) previously required imaging with exercise stress, or c) known multivessel

disease or high risk for multivessel disease. I IIa IIb III No Benefit Pharmacological stress imaging with nuclear MPI, echocardiography, or CMR is not recommended in patients with known SIHD who have new or worsening symptoms not consistent with UA and who are capable of at least moderate physical functioning or have no disabling comorbidity. Patient Follow-Up: Monitoring of

Symptoms and Antianginal Therapy Patients Unable to Exercise Patients Unable to Exercise I IIa IIb III Pharmacological stress imaging with nuclear MPI or echocardiography is recommended in patients with known SIHD who have new or worsening symptoms not consistent with UA and who are incapable of at least moderate physical functioning or have disabling comorbidity.

I IIa IIb III Pharmacological stress imaging with CMR is reasonable in patients with known SIHD who have new or worsening symptoms not consistent with UA and who are incapable of at least moderate physical functioning or have disabling comorbidity. I IIa IIb III Standard exercise ECG testing should not be performed in patients with known SIHD who have new or worsening

symptoms not consistent with UA and who a) are incapable of at least moderate physical functioning or have disabling comorbidity or b) have an uninterpretable ECG. No Benefit Patient Follow-Up: Monitoring of Symptoms and Antianginal Therapy Irrespective of Ability to Exercise

Irrespective of Ability to CCTA for assessment of patency of CABG or of coronary I IIa IIb III Exercise stents 3 mm or larger in diameter might be reasonable in patients with known SIHD who have new or worsening symptoms not consistent with UA, irrespective of ability to exercise. I IIa IIb III CCTA might be reasonable in patients with known SIHD who have new or worsening symptoms not consistent with UA, irrespective of ability to exercise, in the absence of known

moderate or severe calcification or if the CCTA is intended to assess coronary stents less than 3 mm in diameter. I IIa IIb III CCTA should not be performed for assessment of native coronary arteries with known moderate or severe calcification or with coronary stents less than 3 mm in diameter in patients with known SIHD who have new or worsening symptoms not consistent with UA, irrespective of ability to exercise. No Benefit

Patient Follow-Up: Monitoring of Symptoms and Antianginal Therapy Noninvasive Testing in Known SIHDAsymptomatic (or Stable Symptoms) Noninvasive Testing in Known SIHDAsymptomatic (or Stable Nuclear MPI, echocardiography, or CMR with either exercise I IIa IIb III

Symptoms) or pharmacological stress can be useful for follow-up assessment at 2-year or longer intervals in patients with SIHD with prior evidence of silent ischemia or who are at high risk for a recurrent cardiac event and a) are unable to exercise to an adequate workload, b) have an uninterpretable ECG, or c) have a history of incomplete coronary revascularization I IIa IIb III Standard exercise ECG testing performed at 1-year or longer intervals might be considered for follow-up assessment in

patients with SIHD who have had prior evidence of silent ischemia or are at high risk for a recurrent cardiac event and are able to exercise to an adequate workload and have an interpretable ECG. Noninvasive Testing in Known SIHD Asymptomatic Stable In patients who have noSymptoms) new or worsening symptoms or no I IIa IIb III (or

prior evidence of silent ischemia and are not at high risk for (cont.) a recurrent cardiac event, the usefulness of annual surveillance exercise ECG testing is not well established. I IIa IIb III No Benefit Nuclear MPI, echocardiography, or CMR, with either exercise or pharmacological stress or CCTA, is not recommended for follow-up assessment in patients with SIHD, if performed more frequently than at a) 5-year

intervals after CABG or b) 2-year intervals after PCI. Follow-Up Noninvasive Testing in Patients With Known SIHD: New, Recurrent, or Worsening Symptoms Not Consistent with UA*Patients are candidates for exercise testing if they are capable of performing at least moderate physical functioning (i.e., moderate

household, yard, or recreational work and most activities of daily living) and have no disabling comorbidity. Patients should be able to achieve 85% of age-predicted maximum heart rate.

Noninvasive Testing in Known SIHD: Asymptomatic (or Stable Symptoms) *Patients are candidates for exercise testing if they are capable of performing at least moderate physical functioning (i.e., moderate household, yard, or recreational work and most activities of daily living) and have no disabling comorbidity. Patients should be able to achieve 85% of age-predicted maximum heart rate.

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