What is the management algorithm for Ischemic Heart Disease (IHD)?

Management Algorithm for Ischemic Heart Disease (IHD)

The management of ischemic heart disease should follow a structured approach that includes risk assessment, guideline-directed medical therapy, and consideration for revascularization based on symptom severity and coronary anatomy. 1

Initial Assessment and Risk Stratification

• Assess severity of symptoms using the Canadian Cardiovascular Society classification system 2
• Perform resting 12-lead ECG for all patients with suspected IHD 1
• Evaluate left ventricular function with echocardiography in patients with known or suspected IHD who have prior MI, pathological Q waves, symptoms of heart failure, complex ventricular arrhythmias, or undiagnosed heart murmur 1
• Stratify patients into low, intermediate, or high risk categories based on clinical features and diagnostic testing results 1

Diagnostic Testing

For Patients Able to Exercise:

• Standard exercise ECG testing is recommended for patients with intermediate pretest probability who have an interpretable ECG and adequate exercise capacity 1
• Exercise stress with nuclear MPI or echocardiography for patients with intermediate to high pretest probability who have an uninterpretable ECG 1

For Patients Unable to Exercise:

• Pharmacological stress with nuclear MPI or echocardiography for patients with intermediate to high pretest probability who cannot exercise 1
• Coronary CT angiography (CCTA) is reasonable for patients with low to intermediate pretest probability who cannot exercise 1

Guideline-Directed Medical Therapy (GDMT)

Antiplatelet Therapy

• Aspirin 75-162 mg daily for all patients with IHD 3
• Consider clopidogrel 75 mg daily (after 300 mg loading dose) in patients with acute coronary syndrome or those intolerant to aspirin 3

Anti-Ischemic Medications

• Beta-blockers are first-line therapy for symptom relief and improved survival, particularly in patients with prior MI or reduced ejection fraction 2, 4
• Nitrates for symptom relief, used as needed or in long-acting formulations 2
• Calcium channel blockers (CCBs) when beta-blockers are contraindicated or inadequate for symptom control; non-dihydropyridine CCBs (diltiazem, verapamil) should be avoided in patients with LV dysfunction 1, 4
• Consider ranolazine for patients with refractory angina despite optimal therapy with other anti-anginal medications 5

Risk Factor Modification

Lipid Management

• Moderate to high-intensity statin therapy for all patients with IHD 1
• Consider bile acid sequestrants or niacin for patients who cannot tolerate statins 1
• Target LDL-cholesterol reduction rather than specific numerical goals 1

Blood Pressure Management

• Target BP <130/80 mmHg for patients with established CAD 4
• Consider lower targets (<120/80 mmHg) for patients with left ventricular dysfunction 4
• Exercise caution when lowering diastolic BP below 60 mmHg, especially in elderly patients or those with diabetes 4
• First-line agents: beta-blockers and ACE inhibitors/ARBs 4
• Add thiazide diuretics if needed for BP control 4

Lifestyle Modifications

• Daily physical activity and weight management 1
• Dietary therapy with reduced intake of saturated fats (<7% of total calories), trans fats (<1% of total calories), and cholesterol (<200 mg/day) 1
• Smoking cessation and avoidance of secondhand smoke 1
• Sodium reduction and increased consumption of fresh fruits, vegetables, and low-fat dairy products 1

Revascularization Strategy

Indications for Coronary Angiography

• High-likelihood of severe IHD based on clinical characteristics and noninvasive testing 1
• Depressed LV function (ejection fraction <50%) with moderate risk criteria on noninvasive testing 1
• Unsatisfactory quality of life due to angina despite medical therapy 1

Revascularization Decision-Making

• Consider coronary artery bypass grafting (CABG) for:

  • Left main disease (≥50% stenosis) 1
  • Three-vessel disease, especially with reduced LV function 1
  • Two-vessel disease with proximal LAD involvement 2
  • Diabetes with multivessel disease 1

• Consider percutaneous coronary intervention (PCI) for:

  • Single-vessel disease with persistent symptoms despite optimal medical therapy 1
  • Multivessel disease with low SYNTAX score (0-22) 1
  • Patients who are not candidates for CABG 1

Follow-Up and Monitoring

• Regular assessment of angina frequency, severity, and response to therapy 2
• Monitor for signs of worsening ischemia or heart failure 2
• Consider repeat stress testing or coronary angiography if symptoms worsen despite optimal medical therapy 2

Special Considerations

• In patients with both heart failure and angina, strong consideration should be given to coronary revascularization 2
• For women with nonobstructive CAD and demonstrable ischemia, consider anti-ischemic therapy even with mild coronary stenosis (>0% but <50%) 1
• Avoid rosiglitazone in patients with IHD 1
• Avoid combining beta-blockers with non-dihydropyridine CCBs due to increased risk of bradyarrhythmias and heart failure 4