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Stable Ischemic Heart Disease (SIHD) Guidelines Published
James B. Groce III, Pharm.D., CACP
For the first time since 2002 a full-scale revision of the guidelines for patients with stable ischemic heart disease (SIHD) has been published first on-line in November 2012 in the Annals of Internal Medicine 1,2 and subsequently in the Journal of American College of Cardiology3.
With 1 in 3 adults in the United States (about 71 million patients) having some form of cardiovascular disease — 15% of women and 23% of men aged 60 to 79 and rising after age 80 to 22% of women and 33% of men — these new guidelines are both timely and important for mitigating the potential morbidity and mortality associated with SIHD3.
Management of SIHD should be based on strong scientific evidence and the patient’s preferences. The new guidelines are indeed evidence-based, well written, carefully vetted by a process of review and encompassing of input by physicians, cardiovascular interventionalists, surgeons, general internists, imagers, nurses, and pharmacists.
The guidelines include 48 specific recommendations emphasizing patient education, managing cardiovascular risk factors, the use of medical therapy to prevent MI and death and to relieve angina symptoms, and patient follow-up. As pharmacists—this strong emphasis on medical therapy as the first-line treatment for patients with SIHD gives pause to reflect upon the ever present and growing role of the pharmacist in management of such patients. The choices given within the new guidelines regarding therapeutic options is best made through a process of shared decision-making involving the patient, provider—and certainly the role of the pharmacist—as drug information experts, to explain information about risks, benefits and costs to our patients.
The approach of the new SIHD guidelines offer guideline-directed medical therapy (GDMT) to represent optimal medical therapy as defined by ACCF/AHA guideline-recommended therapies (primarily Class I recommendations).Patients with SIHD should generally receive a “package” of GDMT that include lifestyle interventions and medications shown to improve outcomes which includes (as appropriate):
- Risk factor modification to include diet, weight loss and regular physical activity 30 to 60 minutes per day for minimally 5 days per week; and smoking cessation. In addition to therapeutic life style changes that encompass an appropriate diet.
- Lipid management with a moderate or high dose of a statin therapy should be prescribed. For patients who do not tolerate statins, LDL cholesterol–lowering therapy with bile acid sequestrants, niacin, or both is reasonable.
- Anti-ischemic and blood pressure management in patients with SIHD with BP 140/90 mm Hg or higher. Antihypertensive drug therapy should be instituted in addition to or after a trial of lifestyle modifications. Beta blockers should be prescribed as initial therapy for relief of symptoms in patients with SIHD—use should be limited to carvedilol, metoprolol succinate or bisoprolol which have been shown to reduce mortality. Calcium channel blockers or long-acting nitrates should be prescribed for relief of symptoms when beta blockers are contraindicated or cause unacceptable side effects in patients with SIHD. Calcium channel blockers or long-acting nitrates, in combination with beta blockers, should be prescribed for relief of symptoms when initial treatment with beta blockers is unsuccessful in patients with SIHD. Blood pressure management may include ACE inhibitors in all patients with SIHD who also have diabetes mellitus, LVEF 40% or less, or CKD, unless contraindicated. ARBs are recommended for patients with SIHD who have hypertension, diabetes mellitus, LV systolic dysfunction, or CKD and have indications for, but are intolerant of, ACE inhibitors.
- Antiplatelet drug therapy with aspirin 75 to 162 mg daily should be continued indefinitely in the absence of contraindications in patients with SIHD. Treatment with clopidogrel is reasonable when aspirin is contraindicated in patients with SIHD.
Patients with SIHD should have an individualized education plan to optimize care and promote wellness, including: education on the importance of medication adherence for managing symptoms and retarding disease progression; an explanation of medication management and cardiovascular risk reduction strategies in a manner that respects the patient’s level of understanding, reading comprehension, and ethnicity; comprehensive review of all therapeutic options; a description of appropriate levels of exercise, with encouragement to maintain recommended levels of daily physical activity; introduction to self-monitoring skills; and information on how to recognize worsening cardiovascular symptoms and take appropriate action.
Assuring implementation of the new guidelines focusing on drug therapy is a logical extension for the role of the pharmacist in improving outcomes of efficacy, safety, and prevention of unnecessary 30-day readmissions to our hospitals—all while improving the quality of life for our patients.
- Qaseen A, Fihn SD, Dallas P, et al. Management of stable ischemic heart disease: summary of a clinical practice guideline from the American College of Physicians/American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med. 2012 Nov 20;157(10):735-43. doi: 10.7326/0003-4819-157-10-201211200-00011.
- Qaseen A, Fihn SD, Williams S, et al. Diagnosis of stable ischemic heart disease: summary of a clinical practice guideline from the American College of Physicians/American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med. 2012 Nov 20;157(10):729-34. doi: 10.7326/0003-4819-157-10-201211200-00010.
- Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease. Am Coll Cardiol. 2012;60(24):2564-2603.
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