First chronic stable angina guides published
Three organizations combine for in-depth review
For the first time, comprehensive guidelines for the treatment of chronic stable angina have been compiled and published as one source by a panel of the American College of Cardiology, American Heart Association, and the American College of Physicians-American Society of Internal Medicine.
Cardiologist Raymond Gibbons, who chaired the guidelines panel, says the effort was done for two reasons: to chronicle up-to-date information on what works and what doesn’t in a field with constantly expanding treatments.
As one example, Gibbons cites lipid-lowering trials, which have shown reduction in mortality and heart attacks. "Physicians need to recognize that lipid-lowering therapy is now clearly proven to improve patient outcome," he says.
On the other hand, he adds, "although there’s been a wave of enthusiasm for vitamins E and C, the panel felt current evidence doesn’t support their use in routine therapy." Same for electron beam computed tomography, which Gibbons says also lacks documented clinical benefits despite its recent popularity.
The guidelines are divided into four sections: diagnosis, risk stratification, treatment, and patient follow-up. Each offers patient conditions as treatment factors, the pros and cons of treatment regimens, and recommendations for combination or monotherapies among other topics.
The guidelines apply to "adult patients with stable chest pain syndromes and known or suspected ischemic heart disease" as well as patients with "ischemic equivalents such as dyspnea on exertion or arm pain with exertion." Recommen dations on how to assess coronary artery disease (CAD) also are included.
The diagnosis section includes recommendations for lab tests and test result evaluations of hemoglobin, fasting glucose and fasting lipid panels, and chest X-rays and stress imaging toward the evaluation of the extent of ischemia. Other diagnosis recommendations include using adenosine or dipyridamole myocardial perfusion imaging and invasive diagnosis by way of coronary angiography. Throughout all of the diagnosis routines, medication uses and levels are spelled out.
The risk stratification section deals with patient demographics and medical history with a focus on hypertension, diabetes, hypercholesterolemia, peripheral arterial disease, and previous myocardial infarction, along with factors such as exercise testing and following EKG results and the presence of comorbidities that could limit life expectancy or revascularization.
The treatment section, which is the largest entry, "Recommendations for Pharmacotherapy to Prevent MI and Death and Reduce Symp toms," is of particular interest to pharmacists. The latest clinical trial assessments of the use of aspirin, beta-blockers, calcium antagonists, nitrates, lipid-lowering therapies, clopidogrel, nondihydropyridine calcium antagonists, and warfarin are included, again in terms of monotherapies and combination therapies as well as each drug’s pros and cons.
The patient follow-up section outlines recommendations for ongoing drug therapy, echocardiography, exercise testing, stress imaging, and coronary angiography.
The guidelines’ text is supplemented by graphics, including diagnostic and treatment flowcharts, symptomatic CAD prediction charts, and plotting of survival ratios and nomogram variations, among others.
[For a copy of the guidelines, contact the American College of Cardiology, 9111 Old Georgetown Road, Bethesda, MD 20814. Telephone: (301) 897-5400.]
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