Treatment for chronic stable angina: A guidelines-based approach

Quality care in clinical cardiology, as in all of medicine, relies on the incorporation of evidence from clinical trials to help inform and drive management of patients. Stable ischemic heart disease (SIHD) presenting with stable angina is a common clinical scenario seen by internists and clinical cardiologists in multiple settings. The management of patients with chronic stable angina requires consideration of risk factors, comorbidities, symptoms, coronary anatomy, and ischemic burden. The physician has a variety of tools at his or her disposal, ranging from lifestyle modification and pharmacotherapy, to percutaneous and surgical procedures. The past two decades have witnessed an explosion in the amount of evidence that is currently available to inform the clinical care of these patients, which has led to the development and dissemination of clinical guidelines that have systematically assessed the different lifestyle, pharmacologic, and revascularization strategies in patients with SIHD. Patients with SIHD demonstrate higher rates of cardiovascular morbidity and mortality and, therefore, their management includes two distinct goals: to mitigate major cardiovascular mortality and morbidity and to reduce symptom burden. This article reviews the intersection of two of these guidelines: the recently published 2012 SIHD guidelines and the Appropriate Use Criteria for Revascularization, first published in 2009 and recently revised in 2012. The overlap between the two guidelines is discussed, as well as the gaps within them, particularly as they relate to the role of pharmacologic therapies, in an effort to build a case for evidence-based management of patients with SIHD.