Stable Ischemic Heart Disease Guidelines: Summary
Revascularization to improve mortality:
- Left Main >50% (CABG Class I, PCI Class IIa)- CASS, VA Co-op Study, MASS II
- 3 vessel disease or pLAD and one other (CABG, Class I)- CASS, VA Co-op Study, MASS II
- 2 major coronary arteries with significant ischemia (CABG, Class IIa)
- LVSD 35-50% EF when viable myocardium present (Class IIa)
- SCD in presumed ischemia related VT (CABG/PCI, Class I)
Revascularization options:
- CABG vs BMS:
o No difference at 5 years, single or multi-vessel disease
o Procedural stroke CABG>PCI
o Angina relief CABG>PCI
o Repeat revascularization PCI>CABG
- CABG vs DES
o MACE and mortality: PCI>CABG at 3 years in higher syntax scores >22 (<22, no difference)
Special groups
- Left main (selected patients- ostium or trunk)
o Mortality, MI and stroke at 1 and 2 years, PCI=CABG (syntax >33, higher mortality)
o TVR at 1, 2 and 3 years, PCI>CABG
- PLAD
o (PCI =CABG) >medical therapy
- LV systolic dysfunction
o LVEF <35%, CABG = GDMT at 5 years- STICH
- Diabetes
o Survival: CABG >PCI – BARI, FREEDOM
Medical therapy of angina:
- Beta blockers
o For patients with PAD/ Prinzmetal’s angina: labetalol/carvedilol (alpha adrenergic blocking) or nebivolol (direct vasodilator)
- CCBs: verapamil or diltiazem
- Long acting nitrates
- Ranolazine: contraindicated in significant hepatic impairment. 500mg BID max dose with diltiazem and verapamil. Increases plasma concentration of simvastatin 2 fold.
