MY APPROACH to managing stable ischemic heart disease

Abstract

Stable ischemic heart disease (SIHD) is the leading cause of morbidity and mortality worldwide. Among the estimated 15 million patients in the US with coronary artery disease (CAD), 52% are categorized as having SIHD, making this the most prevalent expression of CAD seen in clinical practice. As such, the management of patients with SIHD is of paramount importance to cardiologists, internists, and primary care physicians. Unlike CAD patients who present with acute coronary syndrome (ACS), where data obtained from both multiple randomized trials and observational studies support the clinical benefit of a routine early invasive diagnostic approach and myocardial revascularization as the most appropriate treatment intervention, the same unanimity of scientific evidence and clinical decision-making does not underlie the management of patients with SIHD. For this reason, it is important for the cardiovascular practitioner to consider a more pluralistic approach to managing SIHD patients. Current clinical practice guidelines from both the ACC/AHA and ESC advocate an initial management strategy that embraces the important role of lifestyle intervention and cardiac risk factor modification, coupled with intensive, multifaceted secondary prevention and the use of anti-ischemic pharmacotherapy. In the aggregate, this approach is widely known as “optimal medical therapy” (OMT). Over the past 2 decades, the evidence base regarding the potential added benefit of combining an early revascularization strategy with OMT in SIHD patients has grown substantially. Landmark trials, including COURAGE, BARI 2D, and