What is the recommended approach for cardiac assessment and management?

Recommended Approach for Cardiac Assessment and Management

The recommended approach for cardiac assessment begins with non-invasive functional imaging for myocardial ischemia or coronary CTA as the initial test for diagnosing CAD in symptomatic patients in whom obstructive CAD cannot be excluded by clinical assessment alone. 1

Initial Diagnostic Evaluation

• A resting 12-lead ECG is recommended in all patients with chest pain without obvious non-cardiac cause 1

• Basic biochemistry testing should include:

  • Full blood count (including hemoglobin) 1
  • Creatinine measurement and estimation of renal function 1
  • Lipid profile (including LDL-C) 1
  • Screening for type 2 diabetes mellitus with HbA1c and fasting plasma glucose measurements 1

• Resting transthoracic echocardiography is recommended in all patients to:

  • Exclude alternative causes of angina 1
  • Identify regional wall motion abnormalities suggestive of CAD 1
  • Measure LVEF for risk-stratification purposes 1
  • Evaluate diastolic function 1

• Chest X-ray is recommended for patients with an atypical presentation, signs and symptoms of heart failure, or suspicion of pulmonary disease 1

Selection of Diagnostic Tests

• Selection of the initial non-invasive diagnostic test should be based on:

  • Clinical likelihood of CAD 1
  • Patient characteristics that influence test performance 1
  • Local expertise and availability of tests 1

• Coronary CTA is not recommended when extensive coronary calcification, irregular heart rate, significant obesity, inability to cooperate with breath-hold commands, or any other conditions make good image quality unlikely 1

• Exercise ECG is recommended for assessment of exercise tolerance, symptoms, arrhythmias, BP response, and event risk in selected patients 1

Risk Stratification

• Risk stratification should be based on clinical assessment and the result of the diagnostic test initially employed to make a diagnosis of CAD 1

• For patients with new or worsening symptoms, risk stratification is recommended, preferably using stress imaging or, alternatively, exercise stress ECG 1

• In symptomatic patients with a high-risk clinical profile, invasive coronary angiography (ICA) complemented by invasive physiological guidance (FFR) is recommended, particularly if symptoms are inadequately responding to medical treatment 1

• ICA is not recommended solely for risk stratification 1

Management Approach

• Medical treatment of symptomatic patients requires one or more drugs for angina/ischemia relief in association with drugs for event prevention 1

• For angina/ischemia relief:

  • Short-acting nitrates are recommended for immediate relief of effort angina 1
  • First-line treatment should include beta-blockers and/or calcium channel blockers to control heart rate and symptoms 1

• For event prevention:

  • Aspirin 75-100 mg daily is recommended in patients with a previous MI or revascularization 1
  • Clopidogrel 75 mg daily is recommended as an alternative in patients with aspirin intolerance 1

• In hypertensive patients with CAD:

  • Office BP should be controlled to target values: systolic BP 120-130 mmHg in general and 130-140 mmHg in older patients (>65 years) 1
  • In patients with recent MI, beta-blockers and RAS blockers are recommended 1

Lifestyle Management

• Improvement of lifestyle factors in addition to appropriate pharmacological management is recommended 1
• Exercise-based cardiac rehabilitation is recommended as an effective means for patients with chronic coronary syndromes to achieve a healthy lifestyle and manage risk factors 1
• Annual influenza vaccination is recommended for patients with chronic coronary syndromes, especially in the elderly 1

Follow-up Assessment

• Periodic visits to a cardiovascular healthcare professional are recommended to reassess potential changes in risk status, including clinical evaluation of lifestyle modifications, adherence to targets of cardiovascular risk factors, and development of comorbidities 1

• For symptomatic patients with worsening symptoms:

  • Reassessment of CAD status is recommended in patients with deteriorating LV systolic function 1
  • Patients with significant worsening of symptoms should be expeditiously referred for evaluation 1
  • ICA with FFR/iwFR when necessary is recommended for risk stratification in patients with severe CAD, particularly if symptoms are refractory to medical treatment 1

Special Considerations

• In patients with valvular disease, ICA is recommended before valve surgery in patients with history of CVD, suspected myocardial ischemia, LV systolic dysfunction, in men aged >40 years and post-menopausal women, or one or more cardiovascular risk factors 1

• For patients with active cancer, treatment decisions should be based on life expectancy, additional comorbidities, and potential interactions between drugs used in CAD management and antineoplastic agents 1

• In patients with diabetes mellitus and CAD:

  • Risk factor control (BP, LDL-C, and HbA1c) to targets is recommended 1
  • In asymptomatic patients, a periodic resting ECG is recommended for detection of conduction abnormalities, AF, and silent MI 1

Common Pitfalls and Caveats

• Relying solely on symptom presentation for risk assessment can be misleading, as typicality of symptoms is not closely associated with higher baseline risk 2

• Coronary calcium detection by computed tomography is not recommended to identify individuals with obstructive CAD 1

• In severe valvular heart disease, stress testing should not be routinely used to detect CAD because of low diagnostic yield and potential risks 1

• The combination of ACE inhibitors and an ARB is not recommended in hypertensive patients with CAD 1