Updated Stable Ischemic Heart Disease Guidelines Add Advice on Diagnostic Cath

Guidelines for the diagnosis and management of patients with stable ischemic heart disease have been updated to include a new section on diagnostic coronary angiography and a definition of ‘optimal care’ for diabetic patients. The paper, published online July 28, 2014, ahead of print in Circulation and the Journal of the American College of Cardiology, was jointly created by 6 professional societies including the American College of Cardiology and the American Heart Association. 

Writing Committee Chair Stephan D. Fihn, MD, MPH, of the University of Washington (Seattle, WA), told TCTMD in a telephone interview that the current document builds off of the last update, published in November 2012.

“The original guidelines did not have a section on invasive catheterization for diagnostics or risk stratification, so this just reaffirms that cath is really useful in patients with mostly high-risk findings on stress imaging where there's a reasonable likelihood that revascularization would be undertaken based on patient symptoms, noninvasive studies, and their preference,” he said.

Additionally, Ajay J. Kirtane, MD, SM, of Columbia University Medical Center (New York, NY), said the new section can inform management of very high-risk patients. “There was [previously] discordance between the appropriate use criteria and the guidelines,” he told TCTMD in a telephone interview. In the previous update, “you get a sense that it was almost as if the guidelines committee forgot about coronary angiography as a diagnostic test.”

‘Heart Team’ Enhances Treatment of Challenging Subgroups

Dr. Fihn said the other big shift relates to diabetic patients. In 2012, CABG was stated as being “probably recommended” over PCI in this subgroup in a class IIa recommendation, while now it is “generally recommended” with a class I recommendation.

A heart team approach is fast “becoming widely accepted,” he said, noting that it helps avoid the “knee-jerk” reaction of stenting diabetic patients who are found midangiography to have extensive disease. Rather, operators should “evaluate what is the best approach to revascularization in that individual patient based on their anatomy and the opinions from cardiology, surgery, the patient and [his/her] preferences, and all the other factors that would go into making that decision,” according to Dr. Fihn.

The advantage of CABG in this population is improved survival, he added. “We've seen initial great enthusiasm for PCI [in diabetic patients] because it's certainly less invasive than surgery  and can also be combined with the diagnostic approach. But I think we're now sort of seeing that it may not always be the optimal course for a given patient.”

Dr. Kirtane commented that when complex multivessel disease is found during angiography in the general population, patients, unless they are unstable, “should be taken off the table to discuss options.”

A controversial issue within the writing committee was the role of catheterization in patients with stable disease or mild but worsening symptoms who do not have ACS, Dr. Fihn reported, citing “the increasing recognition that medical therapy may not be inferior to revascularization in many patients.”

ISCHEMIA Trial Speaks to Role of Diagnostic Angiography

The new guidelines maintain “a level of justified conservatism” in the diagnosis and revascularization of patients with stable ischemic heart disease, commented Dr. Fihn, highlighting the currently enrolling ISCHEMIA trial.

Dr. Kirtane said the trial, designed to test whether angiography is needed in approximately 8,000 patients with high-risk noninvasive stress tests, will hopefully cement the issue one way or the other.

But according to Dr. Fihn, “the data to date still do not indicate that PCI, really under any circumstance outside of acute coronary syndromes, prolongs life, and therefore I think [it’s important to emphasize] a more conservative approach…. What's happening in practice got a bit ahead of the evidence.”

Future research apart from ISCHEMIA should focus on finding better ways to risk stratify patients with stable ischemic heart disease and identify who will actually benefit from revascularization over medical therapy, he suggested.

Choosing the Proper Candidate

According to the guidelines, “[C]oronary angiography is appropriate only when the information derived from the procedure will significantly influence patient management and if the risks and benefits of the procedure have been carefully considered and understood by the patient. Coronary angiography to assess coronary anatomy for revascularization is appropriate only when it is determined beforehand that the patient is amenable to, and a candidate for, percutaneous or surgical revascularization.”

Yet Dr. Kirtane cautioned that the situation is not static.

“A lot of times patients’ decisions about revascularization are based upon what happened at the time of the angiogram,” he said. “So there may be people who are reluctant to undergo angiography, but when they see complex multivessel disease, they then change their minds, and the physicians change their minds.”

Making assumptions about who might—or might not—be a candidate for revascularization before knowing the anatomy is a dangerous game, Dr. Kirtane stressed. “The key thing is there should be dissociation between the angiogram, which is a diagnostic test, and the revascularization, which is a therapeutic one,” he explained, adding that many patients will undergo diagnosis but not invasive treatment.

Source:

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: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2014;Epub ahead of print.

Disclosures:

• Dr. Fihn reports no relevant conflicts of interest.
• Dr. Kirtane reports serving as a reviewer of the guidelines and participating in studies through his institution, which receives institutional research support from Abbott Vascular, Abiomed, Boston Scientific, Medtronic, and St. Jude Medical.

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