2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease: Executive Summary: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons FREE

Jeffrey L. Anderson, MD, FACC, FAHA, Chair

Jonathan L. Halperin, MD, FACC, FAHA, Chair-Elect

Alice K. Jacobs, MD, FACC, FAHA, Immediate Past Chair 2009–2011§§Former Task Force member during this writing effort.

Sidney C. Smith, Jr, MD, FACC, FAHA, Past Chair 2006–2008§§

Cynthia D. Adams, MSN, APRN-BC, FAHA§§

Nancy M. Albert, PhD, CCNS, CCRN, FAHA

Ralph G. Brindis, MD, MPH, MACC

Christopher E. Buller, MD, FACC§§

Mark A. Creager, MD, FACC, FAHA

David DeMets, PhD

Steven M. Ettinger, MD, FACC§§

Robert A. Guyton, MD, FACC

Judith S. Hochman, MD, FACC, FAHA

Sharon Ann Hunt, MD, FACC, FAHA§§

Richard J. Kovacs, MD, FACC, FAHA

Frederick G. Kushner, MD, FACC, FAHA§§

Bruce W. Lytle, MD, FACC, FAHA§§

Rick A. Nishimura, MD, FACC, FAHA§§

E. Magnus Ohman, MD, FACC

Richard L. Page, MD, FACC, FAHA§§

Barbara Riegel, DNSc, RN, FAHA§§

William G. Stevenson, MD, FACC, FAHA

Lynn G. Tarkington, RN§§

Clyde W. Yancy, MD, FACC, FAHA

• Preamble…...2566

• 1Introduction…...2568
  • 1.1Methodology and Evidence Overview…...2568
  • 1.2Organization of the Writing Committee…...2569
  • 1.3Document Review and Approval…...2569
  • 1.4Scope of the Guideline…...2569
  • 1.5General Approach and Overlap With Other Guidelines or Statements…...2571
  • 1.6Magnitude of the Problem…...2571
  • 1.7Organization of the Guideline…...2571
  • 1.8Vital Importance of Involvement by an Informed Patient: Recommendation…...2572
• 2Diagnosis of SIHD: Recommendations…...2572
  • 2.1Clinical Evaluation of Patients With Chest Pain…...2572
    • 2.1.1Clinical Evaluation in the Initial Diagnosis of SIHD in Patients With Chest Pain…...2572
    • 2.1.2Electrocardiography…...2572
      • 2.1.2.1Resting Electrocardiography to Assess Risk…...2572
    • 2.1.3Stress Testing and Advanced Imaging for Initial Diagnosis in Patients With Suspected SIHD Who Require Noninvasive Testing…...2572
      • 2.1.3.1Able to Exercise…...2572
      • 2.1.3.2Unable to Exercise…...2572
      • 2.1.3.3Other…...2574
• 3Risk Assessment: Recommendations…...2574
  • 3.1Advanced Testing: Resting and Stress Noninvasive Testing…...2574
    • 3.1.1Resting Imaging to Assess Cardiac Structure and Function…...2574
    • 3.1.2Stress Testing and Advanced Imaging in Patients With Known SIHD Who Require Noninvasive Testing for Risk Assessment…...2575
      • 3.1.2.1Risk Assessment in Patients Able to Exercise…...2575
      • 3.1.2.2Risk Assessment in Patients Unable to Exercise…...2576
      • 3.1.2.3Risk Assessment Regardless of Patients' Ability to Exercise…...2577
  • 3.2Coronary Angiography…...2578
    • 3.2.1Coronary Angiography as an Initial Testing Strategy to Assess Risk…...2578
    • 3.2.2Coronary Angiography to Assess Risk After Initial Workup With Noninvasive Testing…...2578
• 4Treatment: Recommendations…...2579
  • 4.1Patient Education…...2579
  • 4.2Guideline-Directed Medical Therapy…...2580
    • 4.2.1Risk Factor Modification…...2580
      • 4.2.1.1Lipid Management…...2580
      • 4.2.1.2Blood Pressure Management…...2580
      • 4.2.1.3Diabetes Management…...2580
      • 4.2.1.4Physical Activity…...2580
      • 4.2.1.5Weight Management…...2580
      • 4.2.1.6Smoking Cessation Counseling…...2580
      • 4.2.1.7Management of Psychological Factors…...2581
      • 4.2.1.8Alcohol Consumption…...2581
      • 4.2.1.9Avoiding Exposure to Air Pollution…...2581
    • 4.2.2Additional Medical Therapy to Prevent MI and Death…...2581
      • 4.2.2.1Antiplatelet Therapy…...2581
      • 4.2.2.2Beta-Blocker Therapy…...2581
      • 4.2.2.3Renin-Angiotensin-Aldosterone Blocker Therapy…...2581
      • 4.2.2.4Influenza Vaccination…...2581
      • 4.2.2.5Additional Therapy to Reduce Risk of MI and Death…...2581
    • 4.2.3Medical Therapy for Relief of Symptoms…...2581
      • 4.2.3.1Use of Anti-ischemic Medications…...2581
    • 4.2.4Alternative Therapies for Relief of Symptoms in Patients With Refractory Angina…...2582
• 5CAD Revascularization: Recommendations…...2582
  • 5.1Heart Team Approach to Revascularization Decisions…...2582
  • 5.2Revascularization to Improve Survival…...2582
  • 5.3Revascularization to Improve Symptoms…...2584
  • 5.4Dual Antiplatelet Therapy Compliance and Stent Thrombosis…...2585
  • 5.5Hybrid Coronary Revascularization…...2585
• 6Patient Follow-Up: Monitoring of Symptoms and Antianginal Therapy: Recommendations…...2585
  • 6.1Clinical Evaluation, Echocardiography During Routine, Periodic Follow-Up…...2585
  • 6.2Noninvasive Testing in Known SIHD…...2586
    • 6.2.1Follow-Up Noninvasive Testing in Patients With Known SIHD: New, Recurrent or Worsening Symptoms, Not Consistent With Unstable Angina…...2586
      • 6.2.1.1Patients Able to Exercise…...2586
      • 6.2.1.2Patients Unable to Exercise…...2586
      • 6.2.1.3Irrespective of Ability to Exercise…...2587
    • 6.2.2Noninvasive Testing in Known SIHD—Asymptomatic (or Stable Symptoms)…...2587

• Appendix 1. Author Relationships With Industry and Other Entities (Relevant)…...2599

• Appendix 2. Reviewer Relationships With Industry and Other Entities (Relevant)…...2601

The medical profession should play a central role in evaluating the evidence related to drugs, devices, and procedures for the detection, management, and prevention of disease. When properly applied, expert analysis of available data on the benefits and risks of these therapies and procedures can improve the quality of care, optimize patient outcomes, and favorably affect costs by focusing resources on the most effective strategies. An organized and directed approach to a thorough review of evidence has resulted in the production of clinical practice guidelines that assist physicians in selecting the best management strategy for an individual patient. Moreover, clinical practice guidelines can provide a foundation for other applications, such as performance measures, appropriate use criteria, and both quality improvement and clinical decision support tools.

The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have jointly produced guidelines in the area of cardiovascular disease since 1980. The ACCF/AHA Task Force on Practice Guidelines (Task Force), charged with developing, updating, and revising practice guidelines for cardiovascular diseases and procedures, directs and oversees this effort. Writing committees are charged with regularly reviewing and evaluating all available evidence to develop balanced, patient-centric recommendations for clinical practice.

Experts in the subject under consideration are selected by the ACCF and AHA to examine subject-specific data and write guidelines in partnership with representatives from other medical organizations and specialty groups. Writing committees are asked to perform a literature review; weigh the strength of evidence for or against particular tests, treatments, or procedures; and include estimates of expected outcomes where such data exist. Patient-specific modifiers, comorbidities, and issues of patient preference that may influence the choice of tests or therapies are considered. When available, information from studies on cost is considered, but data on efficacy and outcomes constitute the primary basis for the recommendations contained herein.

In analyzing the data and developing recommendations and supporting text, the writing committee uses evidence-based methodologies developed by the Task Force (1). The Class of Recommendation (COR) is an estimate of the size of the treatment effect, with consideration given to risks versus benefits in addition to evidence and/or agreement that a given treatment or procedure is or is not useful/effective or in some situations may cause harm. The Level of Evidence (LOE) is an estimate of the certainty or precision of the treatment effect. The writing committee reviews and ranks evidence supporting each recommendation, with the weight of evidence ranked as LOE A, B, or C according to specific definitions that are included in (Table 1). Studies are identified as observational, retrospective, prospective, or randomized as appropriate. For certain conditions for which inadequate data are available, recommendations are based on expert consensus and clinical experience and are ranked as LOE C. When recommendations at LOE C are supported by historical clinical data, appropriate references (including clinical reviews) are cited if available. For issues for which sparse data are available, a survey of current practice among the clinicians on the writing committee is the basis for LOE C recommendations, and no references are cited. The schema for COR and LOE is summarized in (Table 1), which also provides suggested phrases for writing recommendations within each COR. A new addition to this methodology is separation of the Class III recommendations to delineate whether the recommendation is determined to be of “no benefit” or is associated with “harm” to the patient. In addition, in view of the increasing number of comparative effectiveness studies, comparator verbs and suggested phrases for writing recommendations for the comparative effectiveness of one treatment or strategy versus another have been added for COR I and IIa, LOE A or B only.

In view of the advances in medical therapy across the spectrum of cardiovascular diseases, the Task Force has designated the term guideline-directed medical therapy (GDMT) to represent optimal medical therapy as defined by ACCF/AHA guideline-recommended therapies (primarily Class I). This new term, GDMT, will be used herein and throughout all future guidelines.

Because the ACCF/AHA practice guidelines address patient populations (and healthcare providers) residing in North America, drugs that are not currently available in North America are discussed in the text without a specific COR. For studies performed in large numbers of subjects outside North America, each writing committee reviews the potential influence of different practice patterns and patient populations on the treatment effect and relevance to the ACCF/AHA target population to determine whether the findings should inform a specific recommendation.

The ACCF/AHA practice guidelines are intended to assist healthcare providers in clinical decision making by describing a range of generally acceptable approaches to the diagnosis, management, and prevention of specific diseases or conditions. The guidelines attempt to define practices that meet the needs of most patients in most circumstances. The ultimate judgment about care of a particular patient must be made by the healthcare provider and patient in light of all the circumstances presented by that patient. As a result, situations may arise in which deviations from these guidelines might be appropriate. Clinical decision making should involve consideration of the quality and availability of expertise in the area where care is provided. When these guidelines are used as the basis for regulatory or payer decisions, the goal should be improvement in quality of care. The Task Force recognizes that situations arise in which additional data are needed to inform patient care more effectively; these areas will be identified within each respective guideline when appropriate.

Prescribed courses of treatment in accordance with these recommendations are effective only if followed. Because lack of patient understanding and adherence may adversely affect outcomes, physicians and other healthcare providers should make every effort to engage the patient's active participation in prescribed medical regimens and lifestyles. In addition, patients should be informed of the risks, benefits, and alternatives to a particular treatment and should be involved in shared decision making whenever feasible, particularly for COR IIa and IIb, for which the benefit-to-risk ratio may be lower.

The Task Force makes every effort to avoid actual, potential, or perceived conflicts of interest that may arise as a result of industry relationships or personal interests among the members of the writing committee. All writing committee members and peer reviewers of this guideline were required to disclose all such current healthcare-related relationships, as well as those existing 24 months (from 2005) before initiation of the writing effort. The writing committee chair may not have any relevant relationships with industry or other entities (RWI); however, RWI are permitted for the vice chair position. In December 2009, the ACCF and AHA implemented a new policy that requires a minimum of 50% of the writing committee have no relevant RWI; in addition, the disclosure term was changed to 12 months before writing committee initiation. The present guideline was developed during the transition in RWI policy and occurred over an extended period of time. In the interest of transparency, we provide full information on RWI existing over the entire period of guideline development, including delineation of relationships that expired more than 24 months before the guideline was finalized. This information is included in Appendix 1. These statements are reviewed by the Task Force and all members during each conference call and meeting of the writing committee and are updated as changes occur. All guideline recommendations require a confidential vote by the writing committee and must be approved by a consensus of the voting members. Members who recused themselves from voting are indicated in the list of writing committee members, and section recusals are noted in Appendix 1. Authors' and peer reviewers' RWI pertinent to this guideline are disclosed in Appendixes (11) and (12), respectively. Comprehensive disclosure information for the Task Force is also available online at http://www.cardiosource.org/ACC/About-ACC/Who-We-Are/Leadership/Guidelines-and-Documents-Task-Forces.aspx. The work of the writing committee is supported exclusively by the ACCF, AHA, American College of Physicians (ACP), American Association for Thoracic Surgery (AATS), Preventive Cardiovascular Nurses Association (PCNA), Society for Cardiovascular Angiography and Interventions (SCAI), and Society of Thoracic Surgeons (STS), without commercial support. Writing committee members volunteered their time for this activity.

The recommendations in this guideline are considered current until they are superseded by a focused update or the full-text guideline is revised. The reader is encouraged to consult the full-text guideline (2) for additional guidance and details about stable ischemic heart disease since the Executive Summary contains only the recommendations. Guidelines are official policy of both the ACCF and AHA.

Jeffrey L. Anderson, MD, FACC, FAHA Chair, ACCF/AHA Task Force on Practice Guidelines