Canadian Cardiovascular Society Guidelines for the Diagnosis and Management of Stable Ischemic Heart Disease

doi:10.1016/j.cjca.2014.05.013

Canadian Journal of Cardiology

Volume 30, Issue 8, August 2014, Pages 837-849

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https://doi.org/10.1016/j.cjca.2014.05.013 Get rights and content

Abstract

This overview provides a guideline for the management of stable ischemic heart disease. It represents the work of a primary and secondary panel of participants from across Canada who achieved consensus on behalf of the Canadian Cardiovascular Society. The suggestions and recommendations are intended to be of relevance to primary care and specialist physicians with an emphasis on rational deployment of diagnostic tests, expedited implementation of long- and short-term medical therapy, timely consideration of revascularization, and practical follow-up measures.

Résumé

Cette vue d’ensemble offre des recommandations sur la prise en charge de la cardiopathie ischémique stable. Elle représente le travail d’un panel principal et d’un panel secondaire de participants de l’ensemble du Canada qui ont atteint un consensus au nom de la Société canadienne de cardiologie. Les suggestions et les recommandations doivent avoir rapport avec les soins primaires et les médecins spécialistes tout en insistant sur l’utilisation rationnelle des examens diagnostiques, la mise en œuvre rapide d’un traitement médical à court et à long terme, la prise en considération en temps opportun de la revascularisation et les mesures concrètes de suivi.

Section snippets

Establishing Diagnosis and Prognosis

In patients with symptoms suggestive of SIHD, the probability of having obstructive coronary artery disease (CAD) is primarily obtained using a thorough history. Classically, angina is described as a dull retrosternal discomfort/ache/heaviness that might or might not radiate to the jaw, neck, shoulders or arms, is provoked by exertion or emotional stress, and is relieved within 5 minutes of rest or nitroglycerine use.² However, nonclassical symptoms are common, particularly among diabetic

Initiation of Medical Treatment in Patients With Established CAD

Therapy for SIHD involves a combination of approaches to improve quality of life by minimizing or abolishing symptoms, and to improve prognosis by preventing myocardial infarction (MI) and premature death. Medical management can be implemented more expeditiously in most settings than can the steps required in anticipation of possible revascularization. However, expeditious revascularization therapy might be considered in parallel based on prognostic features of the diagnostic tests as discussed

Consideration of Revascularization Therapy

Revascularization therapy is also indicated to improve symptoms or quality of life and/or to reduce the risk of MI and premature death. There is no controversy regarding the need to explore revascularization in SIHD patients with inadequate symptom relief, suboptimal quality of life, or emergence of acute chest pain syndromes while using medical therapy. However, because of the success of available medical therapy, and new forms of medical and revascularization therapies, categorical statements

Provision of Appropriate Clinical Follow-up

The most appropriate clinical follow-up in patients with SIHD is difficult to clearly define because of the paucity of robust research. However, there is a need for regular communication between primary care practitioners and specialists expert in the provision of chronic disease care for such patients.³ Follow-up visits should include a focused history, physical examination, and clinically appropriate laboratory testing, with an emphasis on ensuring optimal risk factor control. The history

Summary

SIHD is common, requires expeditious diagnosis, implementation of medical therapies, correction of CV risk factors, timely consideration of revascularization options, and appropriate follow-up. This Canadian perspective provides a practical approach applicable in most practice settings for optimization of longevity and quality of life, with ample regard for rational resource utilization.

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Cited by (126)

Comparing Costs of Noninvasive Cardiac Diagnostic Tests—a Population-Based Study
2024, Journal of the American Society of Echocardiography
Noninvasive cardiac diagnostic tests (NITs) for the diagnosis of coronary artery disease have been estimated to cost >$3 billion annually in the United States alone and have recently undergone scrutiny over concerns of overuse. Consequently, comparing costs of different NIT testing strategies is of urgent importance to health care planning.
We utilized population-based administrative and clinical data from Ontario, Canada, to compare downstream costs between 4 available NIT testing strategies (graded exercise stress testing [GXT], stress echocardiography, cardiac computed tomography angiography [CCTA], and myocardial perfusion imaging [MPI] as well as no testing), among patients evaluated for chest pain. To compare costs among the tested (overall and by testing strategy) and nontested groups, we used a log-gamma generalized linear model to account for the skewed distribution of health care cost data, adjusting for relevant clinical covariates.
A total of 2,340,699 patients were included in our cohort, of whom 481,170 (21%) patients received 1 of the 4 NITs. Among patients who received a NIT, 254,492 (53%) received a GXT as their initial test, 154,137 (32%) received MPI, 69,160 (14%) received a stress echo, and 3,381 (<1%) received a CCTA. After adjustment for differences in baseline patient characteristics, receipt of any NIT was associated with an approximate 12% reduction in downstream 1-year mean costs (cost ratio = 0.88; 95% CI, 0.87, 0.89) compared with those without any testing. Comparing the different testing strategies with no testing, both GXT (cost ratio = 0.80; 95% CI, 0.79-0.81) and stress echocardiography (cost ratio = 0.82; 95% CI, 0.81-0.83) were associated with the lower downstream costs, while both MPI (cost ratio = 1.26; 95% CI, 1.25, 1.27) and CCTA (cost ratio = 1.29; 95% CI, 1.23, 1.35) were associated with higher downstream costs.
In a large population-based cohort consisting of >2 million people evaluated for chest pain, we report that receipt of noninvasive testing was associated with a 12% reduction in downstream costs when compared with no testing. Graded exercise stress testing and stress echocardiography were associated with the least downstream costs, whereas CCTA and MPI were associated with higher costs when compared with no testing. These findings may help inform testing decisions in chest pain patients.
The Canadian Women's Heart Health Alliance ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women — Chapter 8: Knowledge Gaps and Status of Existing Research Programs in Canada
2024, CJC Open
Despite significant progress in medical research and public health efforts, gaps in knowledge of women’s heart health remain across epidemiology, presentation, management, outcomes, education, research, and publications. Historically, heart disease was viewed primarily as a condition in men and male individuals, leading to limited understanding of the unique risks and symptoms that women experience. These knowledge gaps are particularly problematic because globally heart disease is the leading cause of death for women. Until recently, sex and gender have not been addressed in cardiovascular research, including in preclinical and clinical research. Recruitment was often limited to male participants and individuals identifying as men, and data analysis according to sex or gender was not conducted, leading to a lack of data on how treatments and interventions might affect female patients and individuals who identify as women differently. This lack of data has led to suboptimal treatment and limitations in our understanding of the underlying mechanisms of heart disease in women, and is directly related to limited awareness and knowledge gaps in professional training and public education. Women are often unaware of their risk factors for heart disease or symptoms they might experience, leading to delays in diagnosis and treatments. Additionally, health care providers might not receive adequate training to diagnose and treat heart disease in women, leading to misdiagnosis or undertreatment. Addressing these knowledge gaps requires a multipronged approach, including education and policy change, built on evidence-based research. In this chapter we review the current state of existing cardiovascular research in Canada with a specific focus on women.
En dépit des avancées importantes de la recherche médicale et des efforts en santé publique, il reste des lacunes dans les connaissances sur la santé cardiaque des femmes sur les plans de l’épidémiologie, du tableau clinique, de la prise en charge, des résultats, de l’éducation, de la recherche et des publications. Du point de vue historique, la cardiopathie a d’abord été perçue comme une maladie qui touchait les hommes et les individus de sexe masculin. De ce fait, la compréhension des risques particuliers et des symptômes qu’éprouvent les femmes est limitée. Ces lacunes dans les connaissances posent particulièrement problème puisqu’à l’échelle mondiale la cardiopathie est la cause principale de décès chez les femmes. Jusqu’à récemment, la recherche en cardiologie, notamment la recherche préclinique et clinique, ne portait pas sur le sexe et le genre. Le recrutement souvent limité aux participants masculins et aux individus dont l’identité de genre correspond au sexe masculin et l’absence d’analyses de données en fonction du sexe ou du genre ont eu pour conséquence un manque de données sur la façon dont les traitements et les interventions nuisent aux patientes féminines et aux individus dont l’identité de genre correspond au sexe féminin, et ce, de façon différente. Cette absence de données a mené à un traitement sous-optimal et à des limites de notre compréhension des mécanismes sous-jacents de la cardiopathie chez les femmes, et est directement reliée à nos connaissances limitées, et à nos lacunes en formation professionnelle et en éducation du public. Le fait que les femmes ne connaissent souvent pas leurs facteurs de risque de maladies du cœur ou les symptômes qu’elles peuvent éprouver entraîne des retards de diagnostic et de traitements. De plus, le fait que les prestataires de soins de santé ne reçoivent pas la formation adéquate pour poser le diagnostic et traiter la cardiopathie chez les femmes les mène à poser un mauvais diagnostic ou à ne pas traiter suffisamment. Pour pallier ces lacunes de connaissances, il faut une approche à plusieurs volets, qui porte notamment sur l’éducation et les changements dans les politiques, et qui repose sur la recherche fondée sur des données probantes. Dans ce chapitre, nous passons en revue l’état actuel de la recherche existante sur les maladies cardiovasculaires au Canada, plus particulièrement chez les femmes.
The Development of a Chest-Pain Protocol for Women Presenting to the Emergency Department
2024, CJC Open
Cardiovascular disease (CVD) is the leading cause of death in women worldwide, and of premature death in women in Canada. Despite improvements in cardiovascular care over the past 15-20 years, acute coronary syndrome (ACS) and CVD mortality continue to increase among women in Canada. Chest pain is a common symptom leading to emergency department visits for both men and women. However, women with ACS experience worse outcomes. compared with those of men, due to misdiagnosis or lack of diagnosis resulting in delayed care and underuse of guideline-directed medical therapies. CVD mortality rates are highest in Indigenous and racialized women and those with a disproportionately high number of adverse social determinants of health. CVD remains underrecognized, underdiagnosed, undertreated, and underresearched in women. Moreover, a lack of awareness of unique symptoms, clinical presentations, and sex-and-gender specific CVD risk factors, by healthcare professionals, leads to outcome disparities. In response to this knowledge gap, in acute recognition and management of chest-pain syndromes in women, the Canadian Women’s Heart Health Alliance performed a needs assessment and review of CVD risk factors and ACS pathophysiology, through a sex and gender lens, and then developed a unique chest-pain assessment protocol utilizing modified dynamic programming algorithmic methodology. The resulting algorithmic protocol is presented. The output is intended as a quick reference algorithm that could be posted in emergency departments and other acute-care settings. Next steps include protocol implementation evaluation and impact assessment on CVD outcomes in women.
Les maladies cardiovasculaires (MCV) sont la principale cause de décès chez les femmes dans le monde et de décès prématuré chez les femmes au Canada. Malgré les progrès réalisés dans le domaine des soins cardiovasculaires au cours des 15 à 20 dernières années, les taux de syndrome coronarien aigu (SCA) et de mortalité due aux MCV continuent d’augmenter chez les femmes au Canada. La douleur thoracique est un symptôme fréquent qui pousse les hommes et les femmes à se rendre aux urgences. Toutefois, les femmes atteintes d’un SCA présentent de moins bons résultats cliniques que les hommes, en raison d’erreurs de diagnostic ou d’une absence de diagnostic causant des retards dans les soins prodigués et une sous-utilisation des traitements médicaux préconisés dans les lignes directrices. Les taux de mortalité liée aux MCV sont les plus élevés chez les femmes autochtones et les femmes racialisées ainsi que chez celles qui présentent un nombre particulièrement élevé de déterminants sociaux de la santé défavorables. Les MCV continuent d’être sous-estimées, sous-diagnostiquées et sous-traitées chez les femmes et ne sont pas suffisamment étudiées dans cette population. De plus, la méconnaissance par les professionnels de la santé des symptômes, des tableaux cliniques et des facteurs de risque de MCV selon le sexe et le genre entraînent des disparités dans les résultats cliniques. Pour combler ces lacunes dans les connaissances en matière de reconnaissance et de prise en charge des symptômes de douleur thoracique chez les femmes, l’Alliance canadienne de la santé cardiaque des femmes a réalisé une évaluation des besoins et un examen des facteurs de risque de MCV et de la physiopathologie du SCA en tenant compte des particularités liées au sexe et au genre, et a ensuite élaboré un protocole unique d’évaluation de la douleur thoracique faisant appel à une méthodologie algorithmique par programmation dynamique modifiée. Nous présentons le protocole algorithmique qui en est issu. Ce résultat se veut un algorithme de référence rapide pouvant être diffusé dans les services d’urgences et les autres services de soins de courte durée. Les prochaines étapes de notre travail seront d’évaluer la mise en œuvre du protocole et son incidence sur les issues cardiovasculaires chez les femmes.
Evaluation of the efficacy and safety of Suxiao Jiuxin Pill in the treatment of stable angina: A randomized, double-blind, placebo-controlled, multi-center clinical trial
2024, Journal of Ethnopharmacology
The Suxiao Jiuxin Pill (SJP) has been used for treating chronic stable angina (SA) for more than 40 years in China. SJP is composed of two Chinese herbs and has the effect of activating blood and promoting qi, according to traditional Chinese medicine (TCM) theory.
The study aims to determine the effects of adjunct SJP on conventional therapy in patients with SA which provides a complementary choice and its evidence for clinical medication for treating SA.
Participants with SA were recruited and randomized 1:1 to either the SJP group or the control group for 24 weeks. Both groups received conventional treatment according to local tertiary hospital protocols, and the participants received additional SJP (composed of Ligusticum wallichii and Borneol) or placebo in treatment and control groups respectively. The primary outcome was the curative efficacy rate at week 4. Secondary outcomes are the curative efficacy rate, the total score of angina pectoris symptoms, CCS Angina Classification improvement, Seattle Angina Questionnaire (SAQ) score, TCM syndrome scores (TCMSS), and the curative efficacy rate of TCMSS. Adverse events and adverse drug reactions were observed and recorded for safety analysis.
A total of 324 participants with SA from 13 hospitals in China were enrolled in this trial. Compared with the control group, the curative efficacy rate of SA, the curative efficacy rate of TCMSS significantly increased, and the total score of angina pectoris symptoms and TCMSS significantly reduced in the SJP group at week 4, 12, and 24, accompanied by the statistically significant improvement in the curative efficacy rate based on CCS grade reduction (all P < 0.05). Furthermore, the SAQ score (physical limitation, angina stability, and treatment satisfaction) was evaluated as the quality of life significantly improved after treatment (P < 0.05). The medication compliance, concomitant medication, and rates of adverse events were similar between the two groups (P > 0.05).
The present prospective, multicenter, randomized, double-blind, placebo-controlled, clinical trial confirms that adjunct SJP to conventional treatment increased the curative efficacy and life quality of SA patients with no significant adverse drug reactions during the clinical application.
(ID, ChiCTR1900021876, URL = http://www.chictr.org.cn/showproj.aspx?proj=34955).
Usefulness of Carotid Ultrasound Screening in Primary Cardiovascular Prevention: A Systematic Review
2024, Current Problems in Cardiology
Cardiovascular disease (CVD) is the leading cause of morbidity and mortality worldwide, and its prevention is more cost-effective than the treatment of its complications. Although cardiovascular (CV) risk assessment based on conventional risk factors is the general recommendation, a significant percentage of the population, irrespective of these risk factors, present with subclinical atherosclerosis during carotid Doppler ultrasound (US) imaging. Subclinical atherosclerotic lesions at the carotid bifurcations may be related to the incidence of future CV events and occult atherosclerotic coronary disease. Such patients might benefit from preventive measures if the carotid Doppler US is allowed as a screening tool to detect the extent of carotid stenosis. We aimed to conduct a comprehensive and systematic evaluation of the impact of carotid US screening on CV risk stratification.
We searched PubMed, Scopus, and ScienceDirect from inception until July 2023. We included literature that examined the impact of carotid US screening on cardiovascular risk factor (CVRF) prevention, CV events, and mortality in adults of all age groups free of symptomatic carotid artery disease.
We identified 2 randomized controlled trials (RCTs) and 9 observational studies, including 21,046 participants. The mean age of the participants was 49, and 53% were female. Two RCTs, with 7,064 participants, examined the impact of pictorial knowledge about subclinical carotid atherosclerosis using carotid US versus traditional CVD risk evaluation without any US evidence in primary cardiovascular prevention. Both studies reported remarkable improvement in medication adherence at 1 to 3-year follow-up after carotid US screening with a decrease in Framingham risk score (FRS). Nine observational studies with 13, 982 participants analyzed the evidence of atherosclerosis on carotid US screening and demonstrated that it is a beneficial tool in the early identification of subclinical atherosclerosis and effective therapeutic intervention.
This systematic review found that pictorial presentation of silent atherosclerosis using carotid US screening has a contributory role in CV risk stratification and prevention of CVD.
Chest Pain Evaluation: Diagnostic Testing
2023, CJC Open
Chest pain/discomfort (CP) is a common symptom and can be a diagnostic dilemma for many clinicians. The misdiagnosis of an acute or progressive chronic cardiac etiology may carry a significant risk of morbidity and mortality. This review summarizes the different options and modalities for establishing the diagnosis and severity of coronary artery disease. An effective test selection algorithm should be individually tailored to each patient to maximize diagnostic accuracy in a timely fashion, determine short- and long-term prognosis, and permit implementation of evidence-based treatments in a cost-effective manner. Through collaboration, a decision algorithm was developed (www.chowmd.ca/cadtesting) that could be adopted widely into clinical practice.
La douleur ou la gêne thoracique sont des symptômes fréquents qui peuvent poser un dilemme diagnostique pour de nombreux médecins. Les erreurs de diagnostic d’une cause aiguë ou chronique progressive d’origine cardiaque peuvent d'ailleurs entraîner un risque considérable de morbidité et de mortalité. La présente synthèse porte sur les différentes options et modalités d’établissement du diagnostic et de la gravité d’une coronaropathie. Un algorithme efficace pour le choix des tests doit être adapté à chaque patient afin de maximiser l’exactitude diagnostique dans les plus brefs délais, de déterminer le pronostic à court et à long terme, et de permettre une mise en œuvre de traitements fondés sur des données probantes tout en tenant compte des coûts. Un algorithme décisionnel a donc été conjointement mis au point (www.chowmd.ca/cadtesting) et pourrait être largement adopté dans la pratique clinique.

View all citing articles on Scopus

: The disclosure information of the authors and reviewers is available from the CCS on their guidelines library at www.ccs.ca.

: This statement was developed following a thorough consideration of medical literature and the best available evidence and clinical experience. It represents the consensus of a Canadian panel comprised of multidisciplinary experts on this topic with a mandate to formulate disease-specific recommendations. These recommendations are aimed to provide a reasonable and practical approach to care for specialists and allied health professionals obliged with the duty of bestowing optimal care to patients and families, and can be subject to change as scientific knowledge and technology advance and as practice patterns evolve. The statement is not intended to be a substitute for physicians using their individual judgment in managing clinical care in consultation with the patient, with appropriate regard to all the individual circumstances of the patient, diagnostic and treatment options available and available resources. Adherence to these recommendations will not necessarily produce successful outcomes in every case.

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Society GuidelinesCanadian Cardiovascular Society Guidelines for the Diagnosis and Management of Stable Ischemic Heart Disease

Abstract

Résumé

Section snippets

Establishing Diagnosis and Prognosis

Initiation of Medical Treatment in Patients With Established CAD

Consideration of Revascularization Therapy

Provision of Appropriate Clinical Follow-up

Summary

Can J Cardiol

Can J Cardiol

Can J Cardiol

Can J Cardiol

Am J Cardiol

Ann Emerg Med

Atherosclerosis

J Am Coll Cardiol

Can J Cardiol

J Am Coll Cardiol

Am Heart J

J Am Coll Cardiol Interv

J Am Coll Cardiol

Can J Cardiol

Can J Cardiol

Lancet

J Am Coll Cardiol

Lancet

Am J Cardiol

Can J Cardiol

Am Heart J

J Thorac Cardiovasc Surg

Ann Thorac Surg

Lancet Diabetes Endocrinol

Int J Cardiol

J Am Coll Cardiol

Lancet

J Thorac Cardiovasc Surg

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

2000 revision of the Canadian Cardiovascular Society 1997 Consensus Conference on the evaluation and management of chronic ischemic heart disease

Can J Cardiol

Circulation

2013 ESC guidelines on the management of stable coronary artery disease

Eur Heart J

Assessment and manangement of acute coronary syndromes (ACS): a Canadian perspective on current guideline-recommended treatment – Part 1: non-ST-segment elevation ACS

Can J Cardiol

Management of patients with refractory angina: Canadian Cardiovascular Society/Canadian Pain Society joint guidelines

Can J Cardiol

Canadian Cardiovascular Society 1999 consensus conference

Can J Cardiol

Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada

Can J Diabetes

Chest pain relief by nitroglycerin does not predict active coronary artery disease

Ann Intern Med

Value of the history and physical in identifying patients at increased risk for coronary-artery disease

Ann Intern Med

ACC/AHA 2002 guideline update for the management of patients with chronic stable angina—summary article: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on the Management of Patients With Chronic Stable Angina)

Circulation

Analysis of probability as an aid in the clinical-diagnosis of coronary-artery disease

N Engl J Med

Angiographic prevalence of high-risk coronary-artery disease in patient subsets (CASS)

Circulation

Circulation

Society Guidelines
Canadian Cardiovascular Society Guidelines for the Diagnosis and Management of Stable Ischemic Heart Disease