Guideline for Treating Stable Ischemic Heart Disease
In July 2014 the American College of Cardiology, the American Heart Association and other cardiovascular organizations updated standards on the evaluation and treatment of stable ischemic heart disease. These guidelines apply to most patients, but also give your doctor the flexibility to tailor treatment to your specific clinical needs. Below is a summary of key information and recommendations.
Print this document and bring it with you to your next doctor visit so that you can ask questions and have a record of your treatment.
What You Should Know
Ischemic heart disease means that the heart muscle is being deprived of the oxygen-rich blood it needs to function, as a result of clogged coronary arteries.
More than 13 million people in the United States have coronary artery disease, and nearly 9 million have chest pain (angina).
If you have ischemic heart disease you may experience chest pain when you put extra demands on your heart, such as during exercise or stress. However, arm pain during exercise and shortness of breath are also symptoms of ischemia.
The right treatment for you will depend on how high-risk your heart disease is and other factors, such as your age, other medical conditions, and personal preferences. It is essential that you play an active role in learning about your condition and weighing the treatment options your doctor will discuss with you.
The Initial Evaluation
In order to get a clear understanding about your heart disease and begin to estimate your risk of serious complications such as a heart attack, your doctor may:
- Ask you questions about your chest pain and other heart-related symptoms, overall health, lifestyle, and family history.
- Order blood tests to check your cholesterol levels, blood sugar, kidney function, and several other important health indicators.
- Run a resting electrocardiogram (ECG or EKG) to check your heart’s rhythm and electrical system.
- Order a stress test to see how your heart responds when it is beating rapidly. The stress test will help determine whether you have ischemic heart disease. It may also show what part and how large an area of heart muscle is being deprived of oxygen-rich blood. This will help determine how high your cardiac risk is. The type of stress test your doctor orders will depend on many things, including whether you can exercise strenuously and how high your cardiac risk is estimated to be before the test. The most common option is ECG exercise stress testing, but your doctor may also order a stress test that uses echocardiography (ultrasound for the heart) or nuclear scanning. If you can’t exercise vigorously your doctor will order a stress test that uses medication to make your heart beat faster, paired with echocardiography, nuclear scanning, or cardiac magnetic resonance imaging. Your doctor may also choose cardiac computed tomographic angiography (CCTA) to examine your heart and blood vessels.
- Order an imaging test—usually echocardiography—to be done while you rest quietly, to check your heart’s size and shape, how well it is pumping, and the motion of your heart valves. This resting test is usually done for patients who have previously had a heart attack, have signs of heart failure, have a complex arrhythmia, or a heart murmur. Resting tests may also be done using nuclear imaging.
- Refer you to an invasive cardiologist for cardiac catheterization (angiography). In this test, dye is injected into the arteries of your heart so that blockages can be seen on X-rays. This test is usually done only for patients who have high-risk results on their stress test, or have other high-risk problems such as cardiac arrest, a serious disturbance in the heart’s rhythm, or signs of heart failure.
Your Treatment Plan
To keep you healthy, your doctor may recommend:
Participation in a cardiac rehabilitation program, to support you in making healthy lifestyle changes and in managing medications.
A non-invasive therapy called enhanced external counterpulsation may also be used to relieve chest pain in certain patients. However, this therapy is not recommended for certain patients, including those with peripheral artery disease, severe heart failure and severe aortic regurgitation.
A procedure to restore good blood flow to your heart. This may be necessary if the build-up of cholesterol plaque (atherosclerosis) is causing severe and dangerous blockages in your arteries, or if medication alone is not enough to control your symptoms. The choice typically is between open-chest coronary artery bypass graft surgery (CABG) and minimally invasive percutaneous coronary intervention (PCI, also called angioplasty and stenting). CABG is recommended over PCI in patients with diabetes and complex multivessel disease and in some patients, doctors may use a “hybrid” combination of the two procedures to improve blood flow to the heart. The best approach will depend on where the blockages are, how severe they are, how many arteries are involved, and your overall health.
Healthy lifestyle habits that include:
- Eating a diet that is low in cholesterol, saturated fats, trans fats, and salt, and that includes lots of fresh fruits and vegetables, and whole grains.
- Maintaining a healthy body weight.
- Exercising 30 to 60 minutes at moderate intensity, such as brisk walking, at least 5 days a week.
- Taking steps to reduce stress and relieve depression.
- Stopping smoking and avoiding second-hand smoke.
- Limiting alcohol intake to 1 to 2 drinks a day for men and 1 drink a day for women.
- Getting an annual flu shot.
- Keep blood levels of cholesterol and other lipids under control (usually statins).
- Lower blood pressure to less than 140/90 mmHg (lower if you have diabetes or heart failure).
- Prevent heart attack, including daily low-dose aspirin (75 to 162 mg), clopidogrel (Plavix) if you are at high risk, beta blockers, and angiotensin-converting-enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs).
- Relieve chest pain and other symptoms, including beta blockers and nitroglycerin tablets to put under your tongue in case you suddenly develop chest pain. Some patients may need calcium-channel blockers or long-acting nitrates instead.
- Achieve good diabetes control, including keeping the hemoglobin A1c at 7% or less for most people.
Your doctor and heart care team will present all your options, and you will play a key role in making this important decision. This heart care team typically includes an interventional cardiologist and a cardiac surgeon who work with you to review your medical history and health status, discuss possible treatment options and select the best treatment strategy for you.
To help you stay healthy over the long run, your doctor may:
- Talk to you about your symptoms and ability to participate in daily activities.
- Watch for any complications, including heart failure or arrhythmias.
- Keep an eye on risk factors, such as cholesterol levels, blood pressure, and diabetes control.
- Encourage you to continue healthy lifestyle changes.
- Make sure you are following your medication plan.
- Order a stress test if you are having problems with new or worsening symptoms, such as chest pain or shortness of breath.
Read the full guidelines in the Journal of the American College of Cardiology