Guidelines For Management of Stable Ischemic Heart Disease

Journal of the American College of Cardiology Vol. 60, No.
24, 2012
2012 by the American College of Cardiology Foundation and the American Heart Association, Inc. ISSN 0735-1097/$36.00
Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jacc.2012.07.012
PRACTICE GUIDELINE
2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline

for the Diagnosis and Management of Patients With
Stable Ischemic Heart Disease: Executive Summary
A Report of the American College of Cardiology Foundation/American Heart Association Task Force on
Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery,
Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions,
and Society of Thoracic Surgeons
Writing Stephan D. Fihn, MD, MPH, Chair Michael J. Mack, MD*#

Committee Julius M. Gardin, MD, Vice Chair* Mark A. Munger, PHARMD*
Members*
Richard L. Prager, MD#
Jonathan Abrams, MD Joseph F. Sabik, MD***
Kathleen Berra, MSN, ANP* Leslee J. Shaw, PHD*
James C. Blankenship, MD* Joanna D. Sikkema, MSN, ANP-BC*
Apostolos P. Dallas, MD* Craig R. Smith, JR, MD**
Pamela S. Douglas, MD* Sidney C. Smith, JR, MD*
JoAnne M. Foody, MD* John A. Spertus, MD, MPH*
Thomas C. Gerber, MD, PHD Sankey V. Williams, MD*
Alan L. Hinderliter, MD
Spencer B. King III, MD* *Writing committee members are required to recuse themselves from
Paul D. Kligfield, MD voting on sections to which their specific relationship could apply; see
Appendix 1 for detailed information. ACP Representative. ACCF/
Harlan M. Krumholz, MD AHA Representative. PCNA Representative. SCAI Representative.
Raymond Y. K. Kwong, MD Critical care nursing expertise. #STS Representative. **AATS Repre-
sentative. ACCF/AHA Task Force on Practice Guidelines Liaison.
Michael J. Lim, MD*
ACCF/AHA Task Force on Performance Measures Liaison.
Jane A. Linderbaum, MS, CNP-BC
Full-text guideline available at: J Am Coll Cardiol 2012;60:e44 164; doi:10.1016/ Williams SV. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the
j.jacc.2012.07.013. diagnosis and management of patients with stable ischemic heart disease: a report of
The writing committee gratefully acknowledges the memory of James T. Dove, the American College of Cardiology Foundation/American Heart Association Task
MD, who died during the development of this document but contributed immensely Force on Practice Guidelines, and the American College of Physicians, American
to our understanding of stable ischemic heart disease. Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association,
This document was approved by the American College of Cardiology Foun- Society for Cardiovascular Angiography and Interventions, and Society of Thoracic
dation Board of Trustees, American Heart Association Science Advisory and Surgeons. J Am Coll Cardiol 2012;60:2564 603.
Coordinating Committee, American College of Physicians, American Association This article is copublished in Circulation.
for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Copies: This document is available on the World Wide Web sites of the American
Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons College of Cardiology (www.cardiosource.org) and American Heart Association
in July 2012. (my.americanheart.org). For copies of this document, please contact Elsevier Inc.
The American College of Cardiology Foundation requests that this document be Reprint Department, fax (212) 633-3820, e-mail reprints@elsevier.com.
cited as follows: Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas Permissions: Modification, alteration, enhancement and/or distribution of this
AP, Douglas PS, Foody JM, Gerber TC, Hinderliter AL, King SB III, Kligfield PD, document are not permitted without the express permission of the American College
Krumholz HM, Kwong RYK, Lim MJ, Linderbaum JA, Mack MJ, Munger MA, of Cardiology Foundation. Please contact Elseviers permission department:
Prager RL, Sabik JF, Shaw LJ, Sikkema JD, Smith CR Jr, Smith SC Jr, Spertus JA, healthpermissions@elsevier.com/.
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JACC Vol. 60, No. 24, 2012 Fihn et al. 2565
December 18, 2012:2564603 Stable Ischemic Heart Disease: Executive Summary
ACCF/AHA Jeffrey L. Anderson, MD, FACC, FAHA, Steven M. Ettinger, MD, FACC
Task Force Chair Robert A. Guyton, MD, FACC
Members
Jonathan L. Halperin, MD, FACC, FAHA, Judith S. Hochman, MD, FACC, FAHA
Chair-Elect Sharon Ann Hunt, MD, FACC, FAHA
Alice K. Jacobs, MD, FACC, FAHA, Richard J. Kovacs, MD, FACC, FAHA
Immediate Past Chair 2009 2011 Frederick G. Kushner, MD, FACC, FAHA
Sidney C. Smith, Jr, MD, FACC, FAHA, Bruce W. Lytle, MD, FACC, FAHA
Past Chair 2006 2008 Rick A. Nishimura, MD, FACC, FAHA
E. Magnus Ohman, MD, FACC
Cynthia D. Adams, MSN, APRN-BC, Richard L. Page, MD, FACC, FAHA
FAHA Barbara Riegel, DNSC, RN, FAHA
Nancy M. Albert, PHD, CCNS, CCRN, William G. Stevenson, MD, FACC, FAHA
FAHA Lynn G. Tarkington, RN
Ralph G. Brindis, MD, MPH, MACC Clyde W. Yancy, MD, FACC, FAHA
Christopher E. Buller, MD, FACC
Former Task Force member during this writing effort.
Mark A. Creager, MD, FACC, FAHA
David DeMets, PHD
3.1.1. Resting Imaging to Assess Cardiac Structure

TABLE OF CONTENTS and Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2574
3.1.2. Stress Testing and Advanced Imaging in Patients
Preamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2566
With Known SIHD Who Require Noninvasive
Testing for Risk Assessment . . . . . . . . . . . . . . . . . . .2575
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2568 3.1.2.1. RISK ASSESSMENT IN PATIENTS ABLE
TO EXERCISE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2575
1.1. Methodology and Evidence Overview . . . . . . . . . . . .2568 3.1.2.2. RISK ASSESSMENT IN PATIENTS UNABLE TO
1.2. Organization of the Writing Committee . . . . . . . . . .2569 EXERCISE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2576

3.1.2.3. RISK ASSESSMENT REGARDLESS OF
1.3. Document Review and Approval . . . . . . . . . . . . . . . . . .2569
PATIENTS ABILITY TO EXERCISE . . . . . . . . . . . . . . . . .2577
1.4. Scope of the Guideline . . . . . . . . . . . . . . . . . . . . . . . . . . . .2569
1.5. General Approach and Overlap With Other 3.2. Coronary Angiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2578
Guidelines or Statements . . . . . . . . . . . . . . . . . . . . . . . . .2571 3.2.1. Coronary Angiography as an Initial Testing
1.6. Magnitude of the Problem. . . . . . . . . . . . . . . . . . . . . . . . .2571 Strategy to Assess Risk . . . . . . . . . . . . . . . . . . . . . . . . .2578
1.7. Organization of the Guideline . . . . . . . . . . . . . . . . . . . . .2571 3.2.2. Coronary Angiography to Assess Risk After
1.8. Vital Importance of Involvement by an Initial Workup With Noninvasive Testing . . . . .2578
Informed Patient: Recommendation. . . . . . . . . . . . . .2572
4. Treatment: Recommendations . . . . . . . . . . . . . . . . . . . . . . .2579
2. Diagnosis of SIHD: Recommendations . . . . . . . . . . . . .2572
4.1. Patient Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2579

2.1. Clinical Evaluation of Patients With Chest
4.2. Guideline-Directed Medical Therapy . . . . . . . . . . . . . .2580
Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2572
4.2.1. Risk Factor Modification . . . . . . . . . . . . . . . . . . . . . . .2580
2.1.1. Clinical Evaluation in the Initial Diagnosis of 4.2.1.1. LIPID MANAGEMENT . . . . . . . . . . . . . . . . . . . . . . . . . .2580
SIHD in Patients With Chest Pain . . . . . . . . . . . .2572 4.2.1.2. BLOOD PRESSURE MANAGEMENT . . . . . . . . . . . . . . . .2580
2.1.2. Electrocardiography . . . . . . . . . . . . . . . . . . . . . . . . . . . .2572 4.2.1.3. DIABETES MANAGEMENT . . . . . . . . . . . . . . . . . . . . . .2580
2.1.2.1. RESTING ELECTROCARDIOGRAPHY
4.2.1.4. PHYSICAL ACTIVITY . . . . . . . . . . . . . . . . . . . . . . . . . . .2580
TO ASSESS RISK . . . . . . . . . . . . . . . . . . . . . . . . . . . .2572
2.1.3. Stress Testing and Advanced Imaging for 4.2.1.5. WEIGHT MANAGEMENT . . . . . . . . . . . . . . . . . . . . . . . .2580
Initial Diagnosis in Patients With Suspected 4.2.1.6. SMOKING CESSATION COUNSELING. . . . . . . . . . . . . . .2580
SIHD Who Require Noninvasive Testing . . . . . .2572 4.2.1.7. MANAGEMENT OF PSYCHOLOGICAL FACTORS . . . . . . .2581
2.1.3.1. ABLE TO EXERCISE . . . . . . . . . . . . . . . . . . . . . . . . . . .2572 4.2.1.8. ALCOHOL CONSUMPTION . . . . . . . . . . . . . . . . . . . . . .2581
2.1.3.2. UNABLE TO EXERCISE . . . . . . . . . . . . . . . . . . . . . . . . .2572 4.2.1.9. AVOIDING EXPOSURE TO AIR POLLUTION . . . . . . . . . .2581
2.1.3.3. OTHER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2574 4.2.2. Additional Medical Therapy to Prevent MI
and Death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2581
3. Risk Assessment: Recommendations . . . . . . . . . . . . . .2574 4.2.2.1. ANTIPLATELET THERAPY . . . . . . . . . . . . . . . . . . . . . . .2581
4.2.2.2. BETA-BLOCKER THERAPY . . . . . . . . . . . . . . . . . . . . . .2581
3.1. Advanced Testing: Resting and 4.2.2.3. RENIN-ANGIOTENSIN-ALDOSTERONE BLOCKER
Stress Noninvasive Testing . . . . . . . . . . . . . . . . . . . . . . .2574 THERAPY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2581

2566 Fihn et al. JACC Vol. 60, No. 24, 2012
Stable Ischemic Heart Disease: Executive Summary December 18, 2012:2564603
4.2.2.4. INFLUENZA VACCINATION . . . . . . . . . . . . . . . . . . . . . .2581 jointly produced guidelines in the area of cardiovascular
4.2.2.5. ADDITIONAL THERAPY TO REDUCE RISK OF MI
AND DEATH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2581
disease since 1980. The ACCF/AHA Task Force on
4.2.3. Medical Therapy for Relief of Symptoms . . . . . .2581 Practice Guidelines (Task Force), charged with developing,
4.2.3.1. USE OF ANTI-ISCHEMIC MEDICATIONS . . . . . . . . . . . . .2581 updating, and revising practice guidelines for cardiovascular
4.2.4. Alternative Therapies for Relief of Symptoms in
diseases and procedures, directs and oversees this effort. Writ-
Patients With Refractory Angina . . . . . . . . . . . . . . .2582
ing committees are charged with regularly reviewing and
5. CAD Revascularization: Recommendations . . . . . . . .2582 evaluating all available evidence to develop balanced, patient-
centric recommendations for clinical practice.
5.1. Heart Team Approach to Revascularization
Decisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2582 Experts in the subject under consideration are selected by
5.2. Revascularization to Improve Survival . . . . . . . . . . .2582
the ACCF and AHA to examine subject-specific data and
write guidelines in partnership with representatives from
5.3. Revascularization to Improve Symptoms . . . . . . . .2584
other medical organizations and specialty groups. Writing
5.4. Dual Antiplatelet Therapy Compliance and
Stent Thrombosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2585 committees are asked to perform a literature review; weigh
the strength of evidence for or against particular tests,
5.5. Hybrid Coronary Revascularization . . . . . . . . . . . . . . .2585
treatments, or procedures; and include estimates of ex-
6. Patient Follow-Up: Monitoring of Symptoms pected outcomes where such data exist. Patient-specific
and Antianginal Therapy: Recommendations . . . . . .2585
modifiers, comorbidities, and issues of patient preference
that may influence the choice of tests or therapies are consid-
6.1. Clinical Evaluation, Echocardiography During
Routine, Periodic Follow-Up . . . . . . . . . . . . . . . . . . . . . . .2585 ered. When available, information from studies on cost is
6.2. Noninvasive Testing in Known SIHD . . . . . . . . . . . . . .2586 considered, but data on efficacy and outcomes constitute the
6.2.1. Follow-Up Noninvasive Testing in Patients With primary basis for the recommendations contained herein.
Known SIHD: New, Recurrent or Worsening In analyzing the data and developing recommendations
Symptoms, Not Consistent With Unstable and supporting text, the writing committee uses evidence-
Angina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2586
6.2.1.1. PATIENTS ABLE TO EXERCISE . . . . . . . . . . . . . . . . . . .2586 based methodologies developed by the Task Force (1). The
6.2.1.2. PATIENTS UNABLE TO EXERCISE . . . . . . . . . . . . . . . . .2586 Class of Recommendation (COR) is an estimate of the size
6.2.1.3. IRRESPECTIVE OF ABILITY TO EXERCISE . . . . . . . . . . .2587 of the treatment effect, with consideration given to risks
6.2.2. Noninvasive Testing in Known
versus benefits in addition to evidence and/or agreement
SIHDAsymptomatic (or Stable Symptoms) . .2587
that a given treatment or procedure is or is not useful/
effective or in some situations may cause harm. The Level of
Appendix 1. Author Relationships With Industry Evidence (LOE) is an estimate of the certainty or precision
and Other Entities (Relevant) . . . . . . . . . . . . . . . . . . . . . . . . . . . .2599 of the treatment effect. The writing committee reviews and
ranks evidence supporting each recommendation, with the
Appendix 2. Reviewer Relationships With Industry weight of evidence ranked as LOE A, B, or C according to
and Other Entities (Relevant) . . . . . . . . . . . . . . . . . . . . . . . . . . . .2601
specific definitions that are included in Table 1. Studies are
identified as observational, retrospective, prospective, or
randomized as appropriate. For certain conditions for which
Preamble inadequate data are available, recommendations are based
on expert consensus and clinical experience and are ranked
The medical profession should play a central role in evalu- as LOE C. When recommendations at LOE C are sup-
ating the evidence related to drugs, devices, and procedures ported by historical clinical data, appropriate references
for the detection, management, and prevention of disease. (including clinical reviews) are cited if available. For issues
When properly applied, expert analysis of available data on for which sparse data are available, a survey of current
the benefits and risks of these therapies and procedures can practice among the clinicians on the writing committee is
improve the quality of care, optimize patient outcomes, and the basis for LOE C recommendations, and no references
favorably affect costs by focusing resources on the most are cited. The schema for COR and LOE is summarized in
effective strategies. An organized and directed approach to a Table 1, which also provides suggested phrases for writing
thorough review of evidence has resulted in the production recommendations within each COR. A new addition to this
of clinical practice guidelines that assist physicians in select- methodology is separation of the Class III recommendations to
ing the best management strategy for an individual patient. delineate whether the recommendation is determined to be of
Moreover, clinical practice guidelines can provide a foun- no benefit or is associated with harm to the patient. In
dation for other applications, such as performance measures, addition, in view of the increasing number of comparative
appropriate use criteria, and both quality improvement and effectiveness studies, comparator verbs and suggested phrases
clinical decision support tools. for writing recommendations for the comparative effectiveness
The American College of Cardiology Foundation of one treatment or strategy versus another have been added for
(ACCF) and the American Heart Association (AHA) have COR I and IIa, LOE A or B only.

Table 1. Applying Classification of Recommendations and Level of Evidence
A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials.
Although randomized trials are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.
Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as sex, age, history of diabetes, history of prior myocardial infarction, history of heart
failure, and prior aspirin use. For comparative effectiveness recommendations (Class I and IIa; Level of Evidence A and B only), studies that support the use of comparator verbs should involve direct
comparisons of the treatments or strategies being evaluated.
In view of the advances in medical therapy across the populations on the treatment effect and relevance to the
spectrum of cardiovascular diseases, the Task Force has ACCF/AHA target population to determine whether the
designated the term guideline-directed medical therapy findings should inform a specific recommendation.
(GDMT) to represent optimal medical therapy as defined by The ACCF/AHA practice guidelines are intended to assist
ACCF/AHA guideline-recommended therapies (primarily healthcare providers in clinical decision making by describing a
Class I). This new term, GDMT, will be used herein and range of generally acceptable approaches to the diagnosis,
throughout all future guidelines. management, and prevention of specific diseases or conditions.
Because the ACCF/AHA practice guidelines address The guidelines attempt to define practices that meet the needs
patient populations (and healthcare providers) residing in of most patients in most circumstances. The ultimate judg-
North America, drugs that are not currently available in ment about care of a particular patient must be made by the
North America are discussed in the text without a specific healthcare provider and patient in light of all the circumstances
COR. For studies performed in large numbers of subjects presented by that patient. As a result, situations may arise in
outside North America, each writing committee reviews the which deviations from these guidelines might be appropriate.
potential influence of different practice patterns and patient Clinical decision making should involve consideration of the

quality and availability of expertise in the area where care is ation for Thoracic Surgery (AATS), Preventive Cardiovascular
provided. When these guidelines are used as the basis for Nurses Association (PCNA), Society for Cardiovascular An-
regulatory or payer decisions, the goal should be improvement giography and Interventions (SCAI), and Society of Thoracic
in quality of care. The Task Force recognizes that situations Surgeons (STS), without commercial support. Writing commit-
arise in which additional data are needed to inform patient care tee members volunteered their time for this activity.
more effectively; these areas will be identified within each The recommendations in this guideline are considered
respective guideline when appropriate. current until they are superseded by a focused update or the
Prescribed courses of treatment in accordance with full-text guideline is revised. The reader is encouraged to
these recommendations are effective only if followed. consult the full-text guideline (2) for additional guidance
Because lack of patient understanding and adherence may and details about stable ischemic heart disease since the
adversely affect outcomes, physicians and other health- Executive Summary contains only the recommendations.
care providers should make every effort to engage the Guidelines are official policy of both the ACCF and AHA.
patients active participation in prescribed medical regi-
mens and lifestyles. In addition, patients should be Jeffrey L. Anderson, MD, FACC, FAHA
informed of the risks, benefits, and alternatives to a Chair, ACCF/AHA Task Force on Practice Guidelines
particular treatment and should be involved in shared
decision making whenever feasible, particularly for COR IIa 1. Introduction
and IIb, for which the benefit-to-risk ratio may be lower.
The Task Force makes every effort to avoid actual,
1.1. Methodology and Evidence Overview
potential, or perceived conflicts of interest that may arise as
a result of industry relationships or personal interests among The recommendations listed in this document are, when-
the members of the writing committee. All writing com- ever possible, evidence based. An extensive evidence review
mittee members and peer reviewers of this guideline were was conducted as the document was compiled through
required to disclose all such current healthcare-related December 2008. Repeated literature searches were per-
relationships, as well as those existing 24 months (from formed by the guideline development staff and writing
2005) before initiation of the writing effort. The writing committee members as new issues were considered. When
committee chair may not have any relevant relationships available, current and credible meta-analyses were used
with industry or other entities (RWI); however, RWI are instead of conducting a systematic review of all primary
permitted for the vice chair position. In December 2009, the literature. New clinical trials published in peer-reviewed
ACCF and AHA implemented a new policy that requires a journals and articles through December 2011 were also
minimum of 50% of the writing committee have no relevant reviewed and incorporated when relevant. Furthermore,
RWI; in addition, the disclosure term was changed to 12 because of the extended development time period for this
months before writing committee initiation. The present guideline, peer review comments indicated that the sections
guideline was developed during the transition in RWI focused on imaging technologies required additional updat-
policy and occurred over an extended period of time. In the ing, which occurred during 2011. Therefore, the evidence
interest of transparency, we provide full information on review for the imaging sections includes published literature
RWI existing over the entire period of guideline develop- through December 2011.
ment, including delineation of relationships that expired Searches were limited to studies, reviews, and other
more than 24 months before the guideline was finalized. evidence in human subjects and published in English.
This information is included in Appendix 1. These state- Key search words included, but were not limited to:
ments are reviewed by the Task Force and all members accuracy, angina, asymptomatic patients, cardiac magnetic
during each conference call and meeting of the writing resonance (CMR), cardiac rehabilitation, chest pain, chronic
committee and are updated as changes occur. All guideline angina, chronic coronary occlusions, chronic ischemic heart
recommendations require a confidential vote by the writing disease (IHD), chronic total occlusion, connective tissue
committee and must be approved by a consensus of the disease, coronary artery bypass graft (CABG) versus medical
voting members. Members who recused themselves from therapy, coronary artery disease (CAD) and exercise, coro-
voting are indicated in the list of writing committee mem- nary calcium scanning, cardiac/coronary computed tomogra-
bers, and section recusals are noted in Appendix 1. Authors phy angiography (CCTA), CMR angiography, CMR imag-
and peer reviewers RWI pertinent to this guideline are ing, coronary stenosis, death, depression, detection of CAD in
disclosed in Appendixes 1 and 2, respectively. Comprehen- symptomatic patients, diabetes, diagnosis, dobutamine stress
sive disclosure information for the Task Force is also echocardiography, echocardiography, elderly, electrocardio-
available online at http://www.cardiosource.org/ACC/ gram (ECG) and chronic stable angina, emergency depart-
About-ACC/Who-We-Are/Leadership/Guidelines-and- ment, ethnic, exercise, exercise stress testing, follow-up test-
Documents-Task-Forces.aspx. The work of the writing ing, gender, glycemic control, hypertension, intravascular
committee is supported exclusively by the ACCF, AHA, ultrasound, fractional flow reserve, invasive coronary an-
American College of Physicians (ACP), American Associ- giography, kidney disease, low-density lipoprotein lowering,

magnetic resonance imaging (MRI), medication adherence, Lastly, the imaging sections were also peer reviewed separately,
minority groups, mortality, myocardial infarction (MI), after an update to that evidence base.
noninvasive testing and mortality, nuclear myocardial per- This document was approved for publication by the
fusion, nutrition, obesity, outcomes, patient follow-up, pa- governing bodies of the ACCF, AHA, ACP, AATS,
tient education, prognosis, proximal left anterior descending PCNA, SCAI, and STS.
(LAD) disease, physical activity, reoperation, risk stratifica-
tion, smoking, stable ischemic heart disease (SIHD), stable 1.4. Scope of the Guideline
angina and reoperation, stable angina and revasculariza- These guidelines are intended to apply to adult patients with
tion, stress echocardiography, radionuclide stress testing, stable known or suspected IHD, including new-onset chest
stenting versus CABG, unprotected left main, weight reduc- pain (i.e., low-risk unstable angina [UA]), or to adult
tion, and women. patients with stable pain syndromes (Figure 1). Patients
1.2. Organization of the Writing Committee who have ischemic equivalents, such as dyspnea or arm
The writing committee was composed of physicians, car- pain with exertion, are included in the latter group. Many
diovascular interventionalists, surgeons, general internists, patients with IHD can become asymptomatic with appro-
imagers, nurses, and pharmacists. The writing committee priate therapy. Accordingly, the follow-up sections of this
included representatives from the ACP, AATS, PCNA, guideline pertain to patients who were previously symptom-
SCAI, and STS. atic, including those who have undergone percutaneous
coronary intervention (PCI) or CABG.
1.3. Document Review and Approval This guideline also addresses the initial diagnostic approach
This document was reviewed by 2 external reviewers nom- to patients who present with symptoms that suggest
inated by both the ACCF and the AHA; 2 reviewers IHD, such as anginal-type chest pain, but who are not
nominated by the ACP, AATS, PCNA, SCAI, and STS; known to have IHD. In this circumstance, it is essential
and 19 content reviewers, including representatives from the that the practitioner ascertain whether such symptoms
ACCF Imaging Council, ACCF Interventional Scientific represent the initial clinical recognition of chronic stable
Council, and the AHA Council on Clinical Cardiology. All angina, reflecting gradual progression of obstructive CAD or
reviewer RWI information was collected and distributed to an increase in supply/demand mismatch precipitated by a
the writing committee and is published in this document change in activity or concurrent illness (such as anemia or
(Appendix 2). Because extensive peer review comments re- infection), or whether they represent an acute coronary
sulted in substantial revision, the guideline was subjected to a syndrome (ACS), most likely due to an unstable plaque
second peer review by all official and organizational reviewers. causing acute thrombosis. For patients with newly diagnosed
Noninvasive Asymptomatic
Testing
(SIHD)
*Features of low risk unstable angina:
Age, 70 y
Exertional pain lasting <20 min.
Pain not rapidly accelerating
Normal or unchanged ECG
No elevation of cardiac markers
Stable Angina
Asymptomatic New Onset
or Low-Risk
Persons Chest Pain
UA* Patients
(SIHD; UA/NSTEMI; STEMI)
Without (SIHD; PCI/CABG) with
Known IHD Known IHD
(CV Risk)
Noncardiac Acute Coronary
Chest Pain Syndromes
(UA/NSTEMI; STEMI;
PCI/CABG)
Sudden Cardiac Death
(VA-SCD)
Figure 1. Spectrum of IHD
Guidelines relevant to the spectrum of IHD are in parentheses.
CABG indicates coronary artery bypass graft; CV, cardiovascular; ECG, electrocardiogram; IHD, ischemic heart disease; PCI, percutaneous coronary intervention; SCD, sudden
cardiac death; SIHD, stable ischemic heart disease; STEMI, ST-elevation myocardial infarction; UA, unstable angina; UA/NSTEMI, unstable angina/nonST-elevation myocar-
dial infarction; and VA, ventricular arrhythmia.

stable angina, this guideline should be used. For patients with Additionally, this guideline addresses the approach to
acute MI, the reader is referred to the ACCF/AHA guidelines asymptomatic patients with SIHD that has been diagnosed
for the management of patients with ST-elevation MI (3,4), solely on the basis of an abnormal screening study, rather than
and for patients with UA, the reader is referred to the on the basis of clinical symptoms or events such as anginal
ACCF/AHA Guidelines for the Management of Patients symptoms or ACS. Multiple ACCF/AHA guidelines and
With Unstable Angina/NonST-Elevation Myocardial In- scientific statements have discouraged the use of ambulatory
farction (5,5a). There are, however, patients with UA who can monitoring, treadmill testing, stress echocardiography, stress
be categorized as low risk and are addressed in this guideline myocardial perfusion imaging (MPI), and computed tomog-
(Table 2). raphy scoring of coronary calcium or coronary angiography as
A key premise of this guideline is that once a diagnosis of routine screening tests in asymptomatic individuals.
IHD is established, it is necessary in most patients to assess When patients with documented IHD develop recurrent
their risk of subsequent complications, such as acute myo- chest pain, the symptoms still could be attributable to
cardial infarction or death. Because the approach to diag- another condition. Such patients are included in this guide-
nosis of suspected IHD and the assessment of risk in a line if there is sufficient suspicion that their heart disease is
patient with known IHD are conceptually different and are a likely source of symptoms to warrant cardiac evaluation.
based on different literature, these issues are addressed Just as in the case of patients with new-onset chest pain, if
separately. A clinician might, however, select a procedure for the pain seems to be cardiac in origin, the clinician must
a patient with a moderate to high pretest likelihood of IHD to determine whether such recurrent or worsening pain is
provide information for both diagnosis and risk assessment, consistent with ACS or simply represents symptoms more
whereas in a patient with a low likelihood of IHD, it could be consistent with chronic stable angina that do not require
sensible to select a test simply for diagnostic purposes without emergent attention.
regard to risk assessment. The purpose of this dichotomy is to The approach to screening and management of asymp-
promote the sensible application of appropriate testing rather tomatic patients who are at risk for IHD but who are not
than routine use of the most expensive or complex tests known to have IHD is beyond the scope of this guideline,
whether warranted or not. but it is addressed in the ACCF/AHA Guideline for
Table 2. Short-Term Risk of Death or Nonfatal MI in Patients With UA/NSTEMI

High Risk Intermediate Risk Low Risk
No high- or intermediate-risk
At least 1 of the following features must No high-risk features are present, but patient features are present, but patient
Feature be present: must have 1 of the following: may have any of the following:
History Accelerating tempo of ischemic symptoms Prior MI, peripheral or cerebrovascular disease, N/A
in preceding 48 h or CABG
Prior aspirin use
Characteristics of pain Prolonged ongoing (20 min) rest pain Prolonged (20 min) rest angina, now resolved, Increased angina frequency, severity,
with moderate or high likelihood of CAD or duration
Rest angina (20 min) or relieved with rest or Angina provoked at a lower
sublingual NTG threshold
Nocturnal angina New-onset angina with onset 2 wk to
New-onset or progressive CCS Class III or IV 2 mo before presentation
angina in previous 2 wk without prolonged
(20 min) rest pain but with intermediate or
high likelihood of CAD
Clinical findings Pulmonary edema, most likely due to Age 70 y N/A
ischemia
New or worsening mitral regurgitation
murmur
S3 or new/worsening rales
Hypotension, bradycardia, or tachycardia
Age 75 y
ECG Angina at rest with transient ST-segment T-wave changes Normal or unchanged ECG
changes 0.5 mm Pathological Q waves or resting ST-depression
Bundle-branch block, new or presumed new 1 mm in multiple lead groups (anterior,
Sustained ventricular tachycardia inferior, lateral)
Cardiac markers Elevated cardiac TnT, TnI, or CK-MB Slightly elevated cardiac TnT, TnI, or CK-MB Normal
(i.e., TnT or TnI 0.1 ng/mL) (i.e., TnT 0.01 but 0.1 ng/mL)
Estimation of the short-term risks of death and nonfatal cardiac ischemic events in UA or NSTEMI is a complex multivariable problem that cannot be fully specified in a table such as this. Therefore,
the table is meant to offer general guidance and illustration rather than rigid algorithms.
CABG indicates coronary artery bypass graft; CAD, coronary artery disease; CCS, Canadian Cardiovascular Society; CK-MB, creatine kinase-MB fraction; ECG, electrocardiogram; MI, myocardial
infarction; NTG, nitroglycerin; N/A, not available; TnI, troponin I; TnT, troponin T; and UA/NSTEMI, unstable angina/nonST-elevation myocardial infarction.
Modified from Braunwald et al. (7).

Assessment of Cardiovascular Risk in Asymptomatic age, approximately 23% of men and 15% of women have
Adults (6). Similarly, the present guideline does not prevalent IHD, and these figures rise to 33% and 22%
apply to patients with chest pain symptoms early after among men and women 80 years of age, respectively (27).
revascularization, that is, within 6 months of revascular- Although the survival rate of patients with IHD has been
ization. steadily improving (28), it was still responsible for nearly
1.5. General Approach and Overlap With
380,000 deaths in the United States in 2010, with an
Other Guidelines or Statements
age-adjusted mortality rate of 113 per 100,000 population
(29). Although IHD is widely known to be the number 1
This guideline overlaps with numerous clinical practice cause of death in men, this is also the case for women,
guidelines published by the ACCF/AHA Task Force on among whom this condition accounts for 27% of deaths
Practice Guidelines; the National Heart, Lung, and Blood (compared with 22% due to cancer) (30). IHD also accounts
Institute; and the ACP (Table 3). To maintain consistency, for the vast majority of the mortality and morbidity of
the writing committee worked with members of other cardiac disease. Each year, 1.5 million patients have an
committees to harmonize recommendations and eliminate MI. Many more are hospitalized for UA and evaluation and
discrepancies. treatment of stable chest pain syndromes. Patients who have
This document recommends a combination of lifestyle had ACS, such as acute MI, remain at risk for recurrent
modifications and medications that constitute GDMT. events even if they have no, or limited, symptoms, and they
Recommendations for risk reduction are consistent with the should be considered to have SIHD.
AHA/ACCF Secondary Prevention and Risk Reduction In approximately 50% of patients, angina pectoris is the
Therapy for Patients With Coronary and Other Vascular initial manifestation of IHD (27). The incidence of angina
Disease: 2011 Update (8). Recommendations related to rises continuously with age in women, whereas the inci-
revascularization are the result of collaboration discussions dence of angina in men peaks between 55 and 65 years of
among several writing committees, including those address- age before declining (27). It has been estimated that there
ing SIHD, PCI, CABG, and unstable angina/nonST- are 30 patients with stable angina for every patient hospi-
elevation MI. To the fullest extent possible, these guidelines
talized with infarction, and symptoms in many of these
are consistent with the appropriate use criteria documents
patients are poorly controlled (3133). The direct and
for imaging testing, diagnostic catheterization, and coronary
indirect costs of caring for patients with IHD are estimated
revascularization that are also sponsored by the ACCF
to exceed $150 billion in the United States.
(9 14).
1.6. Magnitude of the Problem 1.7. Organization of the Guideline
It is estimated that 1 in 3 adults in the United States (about The overarching framework adopted in this guideline re-
71 million) has some form of cardiovascular disease, includ- flects the complementary goals of treating patients with
ing 13 million with CAD and nearly 9 million with known SIHD, alleviating or improving symptoms, and
angina pectoris (26,27). Among persons 60 to 79 years of prolonging life. This guideline is divided into 4 basic
Table 3. Associated Guidelines and Statements

Publication
Document Reference(s) Organization Year
Guidelines
Chronic Stable Angina: 2007 Focused Update (15) ACCF/AHA 2007
Valvular Heart Disease (16) ACCF/AHA 2008
Heart Failure: 2009 Update (17) ACCF/AHA 2009
STEMI (3,4,18) ACCF/AHA 2009
Assessment of Cardiovascular Risk in Asymptomatic Adults (6) ACCF/AHA 2010
Coronary Artery Bypass Graft Surgery (19) ACCF/AHA 2011
Percutaneous Coronary Intervention (20) ACCF/AHA/SCAI 2011
Secondary Prevention and Risk Reduction Therapy for Patients With Coronary and (8) AHA/ACCF 2011
Other Atherosclerotic Vascular Disease
UA/NSTEMI: 2007 and 2012 Updates (5,5a) ACCF/AHA 2012
Statements
NCEP ATP III Implications of Recent Clinical Trials (22,23) NHLBI 2004
National Hypertension Education Program (JNC VII) (24) NHLBI 2004
Referral, Enrollment, and Delivery of Cardiac Rehabilitation/Secondary Prevention Programs at (25) AHA 2011
Clinical Centers and Beyond: A Presidential Advisory From the AHA
ACCF indicates American College of Cardiology Foundation; AHA, American Heart Association; ATP III, Adult Treatment Panel 3; JNC VII, The Seventh Report of the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; NHLBI, National Heart, Lung and Blood Institute; and SCAI, Society for Cardiovascular Angiography and Interventions.

sections summarizing the approaches to diagnosis, risk the patient has an interpretable ECG and at least moderate physical
assessment, treatment, and follow-up summarized in 5 functioning or no disabling comorbidity. (Level of Evidence: C)
algorithms: diagnosis (Figure 2), risk assessment (Figure 3), 2. Exercise stress with nuclear MPI or echocardiography is reasonable
GDMT (Figure 4), and revascularization (Figures 5 and 6). for patients with an intermediate to high pretest probability of
In clinical practice, steps delineated in the algorithms often obstructive IHD who have an interpretable ECG and at least moder-
overlap. An essential principle that transcends all recommen- ate physical functioning or no disabling comorbidity (4353). (Level
dations in this guideline is that of informing and involving of Evidence: B)
patients in all decisions that affect them, directly or indirectly, 3. Pharmacological stress with CMR can be useful for patients with an
as summarized in the following recommendation: intermediate to high pretest probability of obstructive IHD who have
an uninterpretable ECG and at least moderate physical functioning
1.8. Vital Importance of Involvement by an or no disabling comorbidity (50,54,55). (Level of Evidence: B)
Informed Patient: Recommendation
CLASS IIb
CLASS I
1. CCTA might be reasonable for patients with an intermediate pretest
1. Choices about diagnostic and therapeutic options should be made
probability of IHD who have at least moderate physical functioning
through a process of shared decision making involving the patient
or no disabling comorbidity (5563). (Level of Evidence: B)
and provider, with the provider explaining information about risks,
benefits, and costs to the patient. (Level of Evidence: C) 2. For patients with a low pretest probability of obstructive IHD who do
require testing, standard exercise stress echocardiography might be
reasonable, provided the patient has an interpretable ECG and at
2. Diagnosis of SIHD: Recommendations
least moderate physical functioning or no disabling comorbidity.
(Level of Evidence: C)
2.1. Clinical Evaluation of Patients With Chest Pain
CLASS III: No Benefit
2.1.1. Clinical Evaluation in the Initial Diagnosis of 1. Pharmacological stress with nuclear MPI, echocardiography, or
SIHD in Patients With Chest Pain CMR is not recommended for patients who have an interpretable
CLASS I ECG and at least moderate physical functioning or no disabling
1. Patients with chest pain should receive a thorough history and comorbidity (52,64,65). (Level of Evidence: C)
physical examination to assess the probability of IHD before addi- 2. Exercise stress with nuclear MPI is not recommended as an initial
tional testing (34). (Level of Evidence: C) test in low-risk patients who have an interpretable ECG and at least
2. Patients who present with acute angina should be categorized as moderate physical functioning or no disabling comorbidity. (Level of
stable or unstable; patients with UA should be further categorized as Evidence: C)
being at high, moderate, or low risk (5,5a). (Level of Evidence: C)
2.1.3.2. UNABLE TO EXERCISE
2.1.2. Electrocardiography
CLASS I
2.1.2.1. RESTING ELECTROCARDIOGRAPHY TO ASSESS RISK
1. Pharmacological stress with nuclear MPI or echocardiography is
CLASS I recommended for patients with an intermediate to high pretest
1. A resting ECG is recommended in patients without an obvious, probability of IHD who are incapable of at least moderate physical
noncardiac cause of chest pain (3638). (Level of Evidence: B) functioning or have disabling comorbidity (43,46,47,4953). (Level
2.1.3. Stress Testing and Advanced Imaging for Initial of Evidence: B)
Diagnosis in Patients With Suspected SIHD Who CLASS IIa
Require Noninvasive Testing 1. Pharmacological stress echocardiography is reasonable for patients
See Table 4 for a summary of recommendations from this with a low pretest probability of IHD who require testing and are
section. incapable of at least moderate physical functioning or have dis-
abling comorbidity. (Level of Evidence: C)
2.1.3.1. ABLE TO EXERCISE 2. CCTA is reasonable for patients with a low to intermediate pretest
CLASS I probability of IHD who are incapable of at least moderate physical
1. Standard exercise ECG testing is recommended for patients with an functioning or have disabling comorbidity (5563). (Level of Evi-
intermediate pretest probability of IHD who have an interpretable dence: B)
ECG and at least moderate physical functioning or no disabling 3. Pharmacological stress CMR is reasonable for patients with an
comorbidity (3942). (Level of Evidence: A) intermediate to high pretest probability of IHD who are incapable of
2. Exercise stress with nuclear MPI or echocardiography is recom- at least moderate physical functioning or have disabling comorbid-
mended for patients with an intermediate to high pretest probability ity (50,54,55,6669). (Level of Evidence: B)
of IHD who have an uninterpretable ECG and at least moderate
physical functioning or no disabling comorbidity (4353). (Level of CLASS III: No Benefit
Evidence: B) 1. Standard exercise ECG testing is not recommended for patients who
CLASS IIa have an uninterpretable ECG or are incapable of at least moderate
1. For patients with a low pretest probability of obstructive IHD who do physical functioning or have disabling comorbidity (4353,58).
require testing, standard exercise ECG testing can be useful, provided (Level of Evidence: C)

Figure 2. Diagnosis of Patients with Suspected IHD
Colors correspond to the class of recommendations in the ACCF/AHA Table 1. The algorithms do not represent a comprehensive list of recommendations (see full guideline
text [2] for all recommendations). See Table 2 for short-term risk of death or nonfatal MI in patients with UA/NSTEMI. CCTA is reasonable only for patients with intermedi-
ate probability of IHD. CCTA indicates computed coronary tomography angiography; CMR, cardiac magnetic resonance; ECG, electrocardiogram; Echo, echocardiography; IHD,
ischemic heart disease; MI, myocardial infarction; MPI, myocardial perfusion imaging; Pharm, pharmacological; UA, unstable angina; and UA/NSTEMI, unstable angina/non
ST-elevation myocardial infarction.

Figure 3. Algorithm for Risk Assessment of Patients With SIHD*
*Colors correspond to the class of recommendations in the ACCF/AHA Table 1. The algorithms do not represent a comprehensive list of recommendations (see full guideline
text [2] for all recommendations). CCTA indicates coronary computed tomography angiography; CMR, cardiac magnetic resonance; ECG, electrocardiogram; Echo, echocardi-
ography; LBBB, left bundle-branch block; MPI, myocardial perfusion imaging; and Pharm, pharmacological.
2.1.3.3. OTHER 3. Risk Assessment: Recommendations

CLASS IIa
1. CCTA is reasonable for patients with an intermediate pretest prob-
ability of IHD who a) have continued symptoms with prior normal 3.1. Advanced Testing: Resting and
test findings, or b) have inconclusive results from prior exercise or Stress Noninvasive Testing
pharmacological stress testing, or c) are unable to undergo stress
3.1.1. Resting Imaging to Assess Cardiac
with nuclear MPI or echocardiography (70). (Level of Evidence: C)
Structure and Function
CLASS IIb
1. For patients with a low to intermediate pretest probability of ob- CLASS I
structive IHD, noncontrast cardiac computed tomography to deter- 1. Assessment of resting left ventricular (LV) systolic and diastolic
mine the coronary artery calcium score may be considered (71). ventricular function and evaluation for abnormalities of myocar-
(Level of Evidence: C) dium, heart valves, or pericardium are recommended with the use

Figure 4. Algorithm for Guideline-Directed Medical Therapy for Patients With SIHD*
text [2] for all recommendations). The use of bile acid sequestrant is relatively contraindicated when triglycerides are 200 mg/dL and is contraindicated when triglycer-
ides are 500 mg/dL. Dietary supplement niacin must not be used as a substitute for prescription niacin.ACCF indicates American College of Cardiology Foundation; ACEI,
angiotensin-converting enzyme inhibitor; AHA, American Heart Association; ARB, angiotensin-receptor blocker; ASA, aspirin, ATP III, Adult Treatment Panel 3; BP, blood pres-
sure; CCB, calcium channel blocker; CKD, chronic kidney disease; HDL-C, high-density lipoprotein cholesterol, JNC VII, Seventh Report of the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; LDL-C, low-density lipoprotein cholesterol; LV, left ventricular; MI, myocardial infarction; NHLBI,
National Heart, Lung, and Blood Institute; and NTG, nitroglycerin.
of Doppler echocardiography in patients with known or suspected 2. Routine reassessment (1 year) of LV function with technologies
IHD and a prior MI, pathological Q waves, symptoms or signs such as echocardiography radionuclide imaging, CMR, or cardiac
suggestive of heart failure, complex ventricular arrhythmias, or an computed tomography is not recommended in patients with no
undiagnosed heart murmur (17,36,37,72,73). (Level of Evidence: B) change in clinical status and for whom no change in therapy is
contemplated. (Level of Evidence: C)
CLASS IIb
1. Assessment of cardiac structure and function with resting echocar- 3.1.2. Stress Testing and Advanced Imaging in
diography may be considered in patients with hypertension or Patients With Known SIHD Who Require
diabetes mellitus and an abnormal ECG. (Level of Evidence: C) Noninvasive Testing for Risk Assessment
2. Measurement of LV function with radionuclide imaging may be
considered in patients with a prior MI or pathological Q waves,
See Table 5 for a summary of recommendations from this
provided there is no need to evaluate symptoms or signs suggestive
section.
of heart failure, complex ventricular arrhythmias, or an undiagnosed 3.1.2.1. RISK ASSESSMENT IN PATIENTS ABLE TO EXERCISE
heart murmur. (Level of Evidence: C)
CLASS I
CLASS III: No Benefit 1. Standard exercise ECG testing is recommended for risk assess-
1. Echocardiography, radionuclide imaging, CMR, and cardiac com- ment in patients with SIHD who are able to exercise to an
puted tomography are not recommended for routine assessment of adequate workload and have an interpretable ECG (41,45,7482).
LV function in patients with a normal ECG, no history of MI, no (Level of Evidence: B)
symptoms or signs suggestive of heart failure, and no complex 2. The addition of either nuclear MPI or echocardiography to stan-
ventricular arrhythmias. (Level of Evidence: C) dard exercise ECG testing is recommended for risk assessment in

Figure 5. Algorithm for Revascularization to Improve Survival of Patients With SIHD*
text [2] for all recommendations).
patients with SIHD who are able to exercise to an adequate CLASS III: No Benefit
workload but have an uninterpretable ECG not due to left bundle- 1. Pharmacological stress imaging (nuclear MPI, echocardiography, or
branch block or ventricular pacing (8387,117119). (Level of CMR) or CCTA is not recommended for risk assessment in patients
Evidence: B) with SIHD who are able to exercise to an adequate workload and
have an interpretable ECG. (Level of Evidence: C)
CLASS IIa
1. The addition of either nuclear MPI or echocardiography to standard 3.1.2.2. RISK ASSESSMENT IN PATIENTS UNABLE TO EXERCISE
exercise ECG testing is reasonable for risk assessment in patients
with SIHD who are able to exercise to an adequate workload and CLASS I
have an interpretable ECG (8897). (Level of Evidence: B) 1. Pharmacological stress with either nuclear MPI or echocardiogra-
2. CMR with pharmacological stress is reasonable for risk assessment phy is recommended for risk assessment in patients with SIHD who
in patients with SIHD who are able to exercise to an adequate are unable to exercise to an adequate workload regardless of
workload but have an uninterpretable ECG (97102). (Level of interpretability of ECG (8386,105108). (Level of Evidence: B)
Evidence: B)
CLASS IIa
CLASS IIb 1. Pharmacological stress CMR is reasonable for risk assessment in
1. CCTA may be reasonable for risk assessment in patients with SIHD patients with SIHD who are unable to exercise to an adequate
who are able to exercise to an adequate workload but have an workload regardless of interpretability of ECG (98102,109). (Level
uninterpretable ECG (103,104). (Level of Evidence: B) of Evidence: B)

Figure 6. Algorithm for Revascularization to Improve Symptoms of Patients With SIHD*
text [2] for all recommendations). CABG indicates coronary artery bypass graft; and PCI, percutaneous coronary intervention.
2. CCTA can be useful as a first-line test for risk assessment in patients larization of known coronary stenosis of unclear physiological sig-
with SIHD who are unable to exercise to an adequate workload nificance (84,96,111,112). (Level of Evidence: B)
regardless of interpretability of ECG (104). (Level of Evidence: C) CLASS IIa
1. CCTA can be useful for risk assessment in patients with SIHD who have an
indeterminate result from functional testing (104). (Level of Evidence: C)
3.1.2.3. RISK ASSESSMENT REGARDLESS OF PATIENTS ABILITY TO EXERCISE
CLASS IIb
CLASS I 1. CCTA might be considered for risk assessment in patients with SIHD
1. Pharmacological stress with either nuclear MPI or echocardiogra- unable to undergo stress imaging or as an alternative to invasive
phy is recommended for risk assessment in patients with SIHD who coronary angiography when functional testing indicates a moderate- to
have left bundle-branch block on ECG, regardless of ability to high-risk result and knowledge of angiographic coronary anatomy is
exercise to an adequate workload (105108,110). (Level of Evi- unknown. (Level of Evidence: C)
dence: B) CLASS III: No Benefit
2. Either exercise or pharmacological stress with imaging (nuclear 1. A request to perform either a) more than 1 stress imaging study or b) a
MPI, echocardiography, or CMR) is recommended for risk assess- stress imaging study and a CCTA at the same time is not recommended
ment in patients with SIHD who are being considered for revascu- for risk assessment in patients with SIHD. (Level of Evidence: C)

Table 4. Stress Testing and Advanced Imaging for Initial Diagnosis in Patients With Suspected SIHD
Who Require Noninvasive Testing
Exercise ECG
Status Interpretable Pretest Probability of IHD
Test Able Unable Yes No Low Intermediate High COR LOE References
Patients able to exercise*
Exercise ECG X X X I A (3942)
Exercise with nuclear MPI or Echo X X X X I B (4353)
Exercise ECG X X X IIa C N/A
Exercise with nuclear MPI or Echo X X X X IIa B (4353)
Pharmacological stress CMR X X X X IIa B (50,54,55)
CCTA X Any X IIb B (5563)
Exercise Echo X X X IIb C N/A
Pharmacological stress with nuclear X X Any III: No Benefit C (52,64,65)
MPI, Echo, or CMR
Exercise stress with nuclear MPI X X X III: No Benefit C N/A
Patients unable to exercise
Pharmacological stress with nuclear X Any X X I B (43,46,47,4953)
MPI or Echo
Pharmacological stress Echo X Any X IIa C N/A
CCTA X Any X X IIa B (5563)
Pharmacological stress CMR X Any X X IIa B (50,54,55,6669)
Exercise ECG X X Any III: No Benefit C (4353,58)
Other
CCTA Any Any X IIa C (70)
If patient has any of the following:
a) Continued symptoms with prior
normal test, or
b) Inconclusive exercise or
pharmacological stress, or
c) Unable to undergo stress with MPI
or Echo
CAC score Any Any X IIb C (71)
*Patients are candidates for exercise testing if they are capable of performing at least moderate physical functioning (i.e., moderate household, yard, or recreational work and most activities of daily
living) and have no disabling comorbidity. Patients should be able to achieve 85% of age-predicted maximum heart rate.
CAC indicates coronary artery calcium; CCTA, cardiac computed tomography angiography; CMR, cardiac magnetic resonance imaging; COR, class of recommendation; ECG, electrocardiogram; Echo,
echocardiography; IHD, ischemic heart disease; LOE, level of evidence; MPI, myocardial perfusion imaging; N/A, not available, and SIHD, stable ischemic heart disease.
3.2. Coronary Angiography CLASS IIa

1. Coronary angiography is reasonable to further assess risk in pa-
3.2.1. Coronary Angiography as an Initial Testing tients with SIHD who have depressed LV function (ejection fraction
Strategy to Assess Risk 50%) and moderate risk criteria on noninvasive testing with
demonstrable ischemia (137139). (Level of Evidence: C)
CLASS I
2. Coronary angiography is reasonable to further assess risk in pa-
1. Patients with SIHD who have survived sudden cardiac death or
tients with SIHD and inconclusive prognostic information after
potentially life-threatening ventricular arrhythmia should undergo
noninvasive testing or in patients for whom noninvasive testing is
coronary angiography to assess cardiac risk (121123). (Level of
contraindicated or inadequate. (Level of Evidence: C)
Evidence: B)
3. Coronary angiography for risk assessment is reasonable for
2. Patients with SIHD who develop symptoms and signs of heart failure
patients with SIHD who have unsatisfactory quality of life due to
should be evaluated to determine whether coronary angiography
angina, have preserved LV function (ejection fraction 50%), and
should be performed for risk assessment (124127). (Level of
have intermediate risk criteria on noninvasive testing (140,141).
Evidence: B)
(Level of Evidence: C)
3.2.2. Coronary Angiography to Assess Risk After CLASS III: No Benefit
Initial Workup With Noninvasive Testing 1.
Coronary angiography for risk assessment is not recommended in
CLASS I patients with SIHD who elect not to undergo revascularization or
1. Coronary arteriography is recommended for patients with SIHD who are not candidates for revascularization because of comorbidi-
whose clinical characteristics and results of noninvasive testing ties or individual preferences (140,141). (Level of Evidence: B)
indicate a high likelihood of severe IHD and when the benefits are 2. Coronary angiography is not recommended to further assess risk in
deemed to exceed risk (38,72,128136). (Level of Evidence: C) patients with SIHD who have preserved LV function (ejection frac-

Table 5. Using Stress Testing and Advanced Imaging for Patients With Known SIHD Who Require Noninvasive Testing for Risk
Assessment
Exercise ECG
Status Interpretable
Test Able Unable Yes No COR LOE References Additional Considerations

Exercise ECG X X I B (41,45,7482)
Exercise with nuclear MPI or X X I B (8387,117119) Abnormalities other than LBBB or
Echo ventricular pacing
Exercise with nuclear MPI or X X IIa B (8897)
Echo
Pharmacological stress CMR X X IIa B (97102)
CCTA X X IIb B (103,104)
Pharmacological stress X X III: No Benefit C N/A
imaging (nuclear MPI, Echo,
CMR) or CCTA
Pharmacological stress with X Any I B (8386,105108)
nuclear MPI or Echo
Pharmacological stress CMR X Any IIa B (98102,109)
CCTA X Any IIa C (104) Without prior stress test
Regardless of patients ability to exercise
Pharmacological stress with Any X I B (105108,110) LBBB present
nuclear MPI or Echo
Exercise/pharmacological Any Any I B (84,96,111,112) Known coronary stenosis of unclear
stress with nuclear MPI, physiological significance being
Echo, or CMR considered for revascularization
CCTA Any Any IIa C N/A Indeterminate result from
functional testing
CCTA Any Any IIb C N/A Unable to undergo stress imaging
or as alternative to coronary
catheterization when functional
testing indicates moderate to
high risk and angiographic
coronary anatomy is unknown
Requests to perform multiple Any Any III: No Benefit C N/A
cardiac imaging or stress
studies at the same time
CCTA indicates cardiac computed tomography angiography; CMR, cardiac magnetic resonance imaging; COR, class of recommendation; ECG, electrocardiogram; Echo, echocardiography; LBBB, left
bundle-branch block; LOE, level of evidence; MPI, myocardial perfusion imaging; and N/A, not available.
tion 50%) and low-risk criteria on noninvasive testing (140,141). b. an explanation of medication management and cardiovascular
(Level of Evidence: B) risk reduction strategies in a manner that respects the patients
3. Coronary angiography is not recommended to assess risk in pa- level of understanding, reading comprehension, and ethnicity
tients who are at low risk according to clinical criteria and who have (8,145149) (Level of Evidence: B);
not undergone noninvasive risk testing. (Level of Evidence: C) c. a comprehensive review of all therapeutic options (8,146149)
4. Coronary angiography is not recommended to assess risk in asymp- (Level of Evidence: B);
tomatic patients with no evidence of ischemia on noninvasive d. a description of appropriate levels of exercise, with encourage-
testing. (Level of Evidence: C) ment to maintain recommended levels of daily physical activity
(8,150153) (Level of Evidence: C);
4. Treatment: Recommendations e. introduction to self-monitoring skills (150,152,153) (Level of
Evidence: C); and
f. information on how to recognize worsening cardiovascular symp-
4.1. Patient Education
toms and take appropriate action. (Level of Evidence: C)
CLASS I
1. Patients with SIHD should have an individualized education plan to 2. Patients with SIHD should be educated about the following lifestyle
optimize care and promote wellness, including: elements that could influence prognosis: weight control, mainte-
a. education on the importance of medication adherence for man- nance of a body mass index of 18.5 to 24.9 kg/m2, and mainte-
aging symptoms and retarding disease progression (142144) nance of a waist circumference less than 102 cm (40 inches) in
(Level of Evidence: C); men and less than 88 cm (35 inches) in women (less for certain

racial groups) (8,145,154157); lipid management (23); blood ers, with addition of other drugs, such as thiazide diuretics or
pressure control (24,158); smoking cessation and avoidance of expo- calcium channel blockers, if needed to achieve a goal blood pres-
sure to secondhand smoke (8,159,160); and individualized medical, sure of less than 140/90 mm Hg (203,204). (Level of Evidence: B)
nutrition, and lifestyle changes for patients with diabetes mellitus to
4.2.1.3. DIABETES MANAGEMENT
supplement diabetes treatment goals and education (161). (Level of
Evidence: C) CLASS IIa
1. For selected individual patients, such as those with a short duration
CLASS IIa of diabetes mellitus and a long life expectancy, a goal hemoglobin
1. It is reasonable to educate patients with SIHD about
A1c of 7% or less is reasonable (205207). (Level of Evidence: B)
a. adherence to a diet that is low in saturated fat, cholesterol, and
2. A goal hemoglobin A1c between 7% and 9% is reasonable for
trans fat; high in fresh fruits, whole grains, and vegetables; and
certain patients according to age, history of hypoglycemia, presence
reduced in sodium intake, with cultural and ethnic preferences
of microvascular or macrovascular complications, or presence of
incorporated (8,23,24,162,163) (Level of Evidence: B);
coexisting medical conditions (208,209). (Level of Evidence: C)
b. common symptoms of stress and depression to minimize stress-
related angina symptoms (164) (Level of Evidence: C); CLASS IIb
c. comprehensive behavioral approaches for the management of 1. Initiation of pharmacotherapy interventions to achieve target hemoglo-
stress and depression (165168) (Level of Evidence: C); and bin A1c might be reasonable (161,210219). (Level of Evidence: A)
d. evaluation and treatment of major depressive disorder when CLASS III: Harm
indicated (142,165,167,169,170,173175). (Level of Evi- 1. Therapy with rosiglitazone should not be initiated in patients with
dence: B) SIHD (220,221). (Level of Evidence: C)
4.2. Guideline-Directed Medical Therapy 4.2.1.4. PHYSICAL ACTIVITY
4.2.1. Risk Factor Modification CLASS I

1. For all patients, the clinician should encourage 30 to 60 minutes of
4.2.1.1. LIPID MANAGEMENT moderate-intensity aerobic activity, such as brisk walking, at least 5
days and preferably 7 days per week, supplemented by an increase
CLASS I
1. Lifestyle modifications, including daily physical activity and weight in daily lifestyle activities (e.g., walking breaks at work, gardening,
management, are strongly recommended for all patients with SIHD household work) to improve cardiorespiratory fitness and move
(23,176). (Level of Evidence: B) patients out of the least-fit, least-active, high-risk cohort (bottom
2. Dietary therapy for all patients should include reduced intake of 20%) (222224). (Level of Evidence: B)
saturated fats (to 7% of total calories), trans fatty acids (to 1% 2. For all patients, risk assessment with a physical activity history
of total calories), and cholesterol (to 200 mg/d) (23,177180). and/or an exercise test is recommended to guide prognosis and
(Level of Evidence: B) prescription (225228). (Level of Evidence: B)
3. In addition to therapeutic lifestyle changes, a moderate or high dose 3. Medically supervised programs (cardiac rehabilitation) and physician-
of a statin therapy should be prescribed, in the absence of contra- directed, home-based programs are recommended for at-risk patients
indications or documented adverse effects (23,163,181183). at first diagnosis (222,229, 230). (Level of Evidence: A)
(Level of Evidence: A) CLASS IIa
1. It is reasonable for the clinician to recommend complementary
CLASS IIa
resistance training at least 2 days per week (231,232). (Level of
1. For patients who do not tolerate statins, low-density lipoprotein-
Evidence: C)
cholesterollowering therapy with bile acid sequestrants,* niacin,
or both is reasonable (184,186,187). (Level of Evidence: B) 4.2.1.5. WEIGHT MANAGEMENT
4.2.1.2. BLOOD PRESSURE MANAGEMENT CLASS I

1. Body mass index and/or waist circumference should be assessed at
CLASS I every visit, and the clinician should consistently encourage weight
1. All patients should be counseled about the need for lifestyle modi- maintenance or reduction through an appropriate balance of life-
fication: weight control; increased physical activity; alcohol moder- style physical activity, structured exercise, caloric intake, and formal
ation; sodium reduction; and emphasis on increased consumption behavioral programs when indicated to maintain or achieve a body
of fresh fruits, vegetables, and low-fat dairy products (24,188196). mass index between 18.5 and 24.9 kg/m2 and a waist circumfer-
(Level of Evidence: B) ence less than 102 cm (40 inches) in men and less than 88 cm (35
2. In patients with SIHD with blood pressure 140/90 mm Hg or inches) in women (less for certain racial groups) (154,233241).
higher, antihypertensive drug therapy should be instituted in (Level of Evidence: B)
addition to or after a trial of lifestyle modifications (197202). 2. The initial goal of weight loss therapy should be to reduce body weight
(Level of Evidence: A) by approximately 5% to 10% from baseline. With success, further
3. The specific medications used for treatment of high blood pressure weight loss can be attempted if indicated. (Level of Evidence: C)
should be based on specific patient characteristics and may include
angiotensin-converting enzyme (ACE) inhibitors and/or beta block- 4.2.1.6. SMOKING CESSATION COUNSELING
*The use of bile acid sequestrant is relatively contraindicated when triglycerides are CLASS I
200 mg/dL and is contraindicated when triglycerides are 500 mg/dL. 1. Smoking cessation and avoidance of exposure to environmental
Dietary supplement niacin must not be used as a substitute for prescription niacin. tobacco smoke at work and home should be encouraged for all

patients with SIHD. Follow-up, referral to special programs, and CLASS IIb
pharmacotherapy are recommended, as is a stepwise strategy for 1. Beta blockers may be considered as chronic therapy for all other
smoking cessation (Ask, Advise, Assess, Assist, Arrange, Avoid) patients with coronary or other vascular disease. (Level of Evidence: C)
(242244). (Level of Evidence: B)
4.2.2.3. RENIN-ANGIOTENSIN-ALDOSTERONE BLOCKER THERAPY
4.2.1.7. MANAGEMENT OF PSYCHOLOGICAL FACTORS CLASS I

1. ACE inhibitors should be prescribed in all patients with SIHD who
CLASS IIa
1. It is reasonable to consider screening SIHD patients for depression also have hypertension, diabetes mellitus, LV ejection fraction 40%
and to refer or treat when indicated (162,165,169,245248). (Level or less, or chronic kidney disease, unless contraindicated (113
of Evidence: B) 116,120). (Level of Evidence: A)
2. Angiotensin-receptor blockers are recommended for patients with
CLASS IIb SIHD who have hypertension, diabetes mellitus, LV systolic dysfunc-
1. Treatment of depression has not been shown to improve cardiovas- tion, or chronic kidney disease and have indications for, but are
cular disease outcomes but might be reasonable for its other intolerant of, ACE inhibitors (272274). (Level of Evidence: A)
clinical benefits (165,173,249). (Level of Evidence: C)
CLASS IIa
4.2.1.8. ALCOHOL CONSUMPTION 1. Treatment with an ACE inhibitor is reasonable in patients with both
SIHD and other vascular disease (275,276). (Level of Evidence: B)
CLASS IIb 2. It is reasonable to use angiotensin-receptor blockers in other pa-
1. In patients with SIHD who use alcohol, it might be reasonable for
tients who are ACE inhibitor intolerant (277). (Level of Evidence: C)
nonpregnant women to have 1 drink (4 ounces of wine, 12 ounces
of beer, or 1 ounce of spirits) a day and for men to have 1 or 2 drinks 4.2.2.4. INFLUENZA VACCINATION
a day, unless alcohol is contraindicated (such as in patients with a
CLASS I
history of alcohol abuse or dependence or with liver disease)
1. An annual influenza vaccine is recommended for patients with SIHD
(250252). (Level of Evidence: C)
4.2.1.9. AVOIDING EXPOSURE TO AIR POLLUTION
4.2.2.5. ADDITIONAL THERAPY TO REDUCE RISK OF MI AND DEATH
CLASS IIa
1. It is reasonable for patients with SIHD to avoid exposure to in- 1. Estrogen therapy is not recommended in postmenopausal women
creased air pollution to reduce the risk of cardiovascular events with SIHD with the intent of reducing cardiovascular risk or improv-
(253256). (Level of Evidence: C) ing clinical outcomes (283286). (Level of Evidence: A)
4.2.2. Additional Medical Therapy to 2. Vitamin C, vitamin E, and beta-carotene supplementation are not
recommended with the intent of reducing cardiovascular risk or
Prevent MI and Death
improving clinical outcomes in patients with SIHD (181,287291).
4.2.2.1. ANTIPLATELET THERAPY (Level of Evidence: A)
3. Treatment of elevated homocysteine with folate or vitamins B6 and
CLASS I
B12 is not recommended with the intent of reducing cardiovascular
1. Treatment with aspirin 75 to 162 mg daily should be continued
risk or improving clinical outcomes in patients with SIHD (292295).
indefinitely in the absence of contraindications in patients with SIHD
(Level of Evidence: A)
(257,258). (Level of Evidence: A)
4. Chelation therapy is not recommended with the intent of improving
2. Treatment with clopidogrel is reasonable when aspirin is contrain-
symptoms or reducing cardiovascular risk in patients with SIHD
dicated in patients with SIHD (259). (Level of Evidence: B)
(296299). (Level of Evidence: C)
CLASS IIb 5. Treatment with garlic, coenzyme Q10, selenium, or chromium is not
1. Treatment with aspirin 75 to 162 mg daily and clopidogrel 75 mg recommended with the intent of reducing cardiovascular risk or
daily might be reasonable in certain high-risk patients with SIHD improving clinical outcomes in patients with SIHD. (Level of Evi-
(260). (Level of Evidence: B) dence: C)
CLASS III: No Benefit 4.2.3. Medical Therapy for Relief of Symptoms

1. Dipyridamole is not recommended as antiplatelet therapy for pa-
tients with SIHD (261263). (Level of Evidence: B) 4.2.3.1. USE OF ANTI-ISCHEMIC MEDICATIONS
CLASS I
4.2.2.2. BETA-BLOCKER THERAPY
1. Beta blockers should be prescribed as initial therapy for relief of
CLASS I symptoms in patients with SIHD (264,300,301). (Level of Evidence: B)
1. Beta-blocker therapy should be started and continued for 3 years in 2. Calcium channel blockers or long-acting nitrates should be pre-
all patients with normal LV function after MI or ACS (264266). scribed for relief of symptoms when beta blockers are contraindi-
(Level of Evidence: B) cated or cause unacceptable side effects in patients with SIHD
2. Beta-blocker therapy should be used in all patients with LV systolic (302304). (Level of Evidence: B)
dysfunction (ejection fraction 40%) with heart failure or prior MI, 3. Calcium channel blockers or long-acting nitrates, in combination
unless contraindicated. (Use should be limited to carvedilol, meto- with beta blockers, should be prescribed for relief of symptoms
prolol succinate, or bisoprolol, which have been shown to reduce when initial treatment with beta blockers is unsuccessful in patients
risk of death.) (267271) (Level of Evidence: A) with SIHD (304). (Level of Evidence: B)

4. Sublingual nitroglycerin or nitroglycerin spray is recommended for CLASS IIa

immediate relief of angina in patients with SIHD (305307). (Level 1. PCI to improve survival is reasonable as an alternative to CABG in
of Evidence: B) selected stable patients with significant (50% diameter stenosis)
unprotected left main CAD with: 1) anatomic conditions associated
CLASS IIa with a low risk of PCI procedural complications and a high likelihood
1. Treatment with a long-acting nondihydropyridine calcium channel of good long-term outcome (e.g., a low SYNTAX score [22], ostial
blocker (verapamil or diltiazem) instead of a beta blocker as initial or trunk left main CAD); and 2) clinical characteristics that predict a
therapy for relief of symptoms is reasonable in patients with SIHD significantly increased risk of adverse surgical outcomes (e.g.,
(304). (Level of Evidence: B) STS-predicted risk of operative mortality 5%) (322,324,325,335
2. Ranolazine can be useful when prescribed as a substitute for beta 353). (Level of Evidence: B)
blockers for relief of symptoms in patients with SIHD if initial 2. PCI to improve survival is reasonable in patients with unstable
treatment with beta blockers leads to unacceptable side effects or angina/nonST-elevation MI when an unprotected left main coro-
is ineffective or if initial treatment with beta blockers is contraindi- nary artery is the culprit lesion and the patient is not a candidate for
cated (308). (Level of Evidence: B) CABG (325,340,342344,349352,354). (Level of Evidence: B)
3. Ranolazine in combination with beta blockers can be useful when 3. PCI to improve survival is reasonable in patients with acute ST-
prescribed for relief of symptoms when initial treatment with beta elevation MI when an unprotected left main coronary artery is the
blockers is not successful in patients with SIHD (309,310). (Level of culprit lesion, distal coronary flow is less than TIMI (Thrombolysis In
Evidence: A) Myocardial Infarction) grade 3, and PCI can be performed more
rapidly and safely than CABG (337,355,356). (Level of Evidence: C)
4.2.4. Alternative Therapies for Relief of Symptoms in
Patients With Refractory Angina CLASS IIb
1. PCI to improve survival may be reasonable as an alternative to
CLASS IIb CABG in selected stable patients with significant (50% diameter
1. Enhanced external counterpulsation may be considered for relief of
stenosis) unprotected left main CAD with: a) anatomic conditions
refractory angina in patients with SIHD (311). (Level of Evidence: B)
associated with a low to intermediate risk of PCI procedural com-
2. Spinal cord stimulation may be considered for relief of refractory
plications and an intermediate to high likelihood of good long-term
angina in patients with SIHD (312,313). (Level of Evidence: C)
outcome (e.g., lowintermediate SYNTAX score of 33, bifurcation
3. Transmyocardial revascularization may be considered for relief of
left main CAD); and b) clinical characteristics that predict an
refractory angina in patients with SIHD (314316). (Level of Evi-
increased risk of adverse surgical outcomes (e.g., moderate
dence: B)
severe chronic obstructive pulmonary disease, disability from
previous stroke, or previous cardiac surgery; STS-predicted risk of
1. Acupuncture should not be used for the purpose of improving operative mortality 2%) (322,324,325,335353,357). (Level
symptoms or reducing cardiovascular risk in patients with SIHD of Evidence: B)
(317,318). (Level of Evidence: C)
CLASS III: Harm
1. PCI to improve survival should not be performed in stable
5. CAD Revascularization: patients with significant (50% diameter stenosis) unprotected
Recommendations left main CAD who have unfavorable anatomy for PCI and who
are good candidates for CABG (322,324,325,328336). (Level of
Evidence: B)
Table 6 and Table 7 provide summaries of recommenda-
tions from this section. NonLeft Main CAD Revascularization
CLASS I
5.1. Heart Team Approach to 1. CABG to improve survival is beneficial in patients with significant
Revascularization Decisions (70% diameter) stenoses in 3 major coronary arteries (with or
CLASS I
without involvement of the proximal LAD artery) or in the proxi-
1. A Heart Team approach to revascularization is recommended in mal LAD artery plus 1 other major coronary artery (125,330,334,
patients with unprotected left main or complex CAD (319321). 358360). (Level of Evidence: B)
(Level of Evidence: C) 2. CABG or PCI to improve survival is beneficial in survivors of sudden
cardiac death with presumed ischemia-mediated ventricular tachy-
CLASS IIa cardia caused by significant (70% diameter) stenosis in a major
1. Calculation of the STS and SYNTAX scores is reasonable in patients coronary artery. (CABG Level of Evidence: B [122,378,379]; PCI
with unprotected left main and complex CAD (321327). (Level of Level of Evidence: C [378])
Evidence: B)
CLASS IIa
5.2. Revascularization to Improve Survival 1. CABG to improve survival is reasonable in patients with signifi-
cant (70% diameter) stenoses in 2 major coronary arteries with
Left Main CAD Revascularization
severe or extensive myocardial ischemia (e.g., high-risk criteria
CLASS I on stress testing, abnormal intracoronary hemodynamic evalua-
1. CABG to improve survival is recommended for patients with signif- tion, or 20% perfusion defect by myocardial perfusion stress
icant (50% diameter stenosis) left main coronary artery stenosis imaging) or target vessels supplying a large area of viable
(328334). (Level of Evidence: B) myocardium (363366). (Level of Evidence: B)

Table 6. Revascularization to Improve Survival Compared With Medical Therapy

Anatomic Setting COR LOE References
UPLM or complex CAD
CABG and PCI IHeart Team approach recommended C (319321)
CABG and PCI IIaCalculation of STS and SYNTAX scores B (321327)
UPLM*
CABG I B (328334)
PCI IIaFor SIHD when both of the following are present: B (322,324,325,335353)
Anatomic conditions associated with a low risk of PCI procedural
complications and a high likelihood of good long-term outcome (e.g., a low

SYNTAX score of 22, ostial or trunk left main CAD)
Clinical characteristics that predict a significantly increased risk of adverse
surgical outcomes (e.g., STS-predicted risk of operative mortality 5%)

IIaFor UA/NSTEMI if not a CABG candidate B (325,340,342344,349352,354)
IIaFor STEMI when distal coronary flow is TIMI flow grade 3 and PCI can be C (337,355,356)
performed more rapidly and safely than CABG
IIbFor SIHD when both of the following are present: B (322,324,325,335353,357)
Anatomic conditions associated with a low to intermediate risk of PCI
procedural complications and an intermediate to high likelihood of good long-

term outcome (e.g., low-intermediate SYNTAX score of 33, bifurcation left
main CAD)
Clinical characteristics that predict an increased risk of adverse surgical
outcomes (e.g., moderatesevere COPD, disability from prior stroke, or prior

cardiac surgery; STS-predicted operative mortality 2%)
III: HarmFor SIHD in patients (versus performing CABG) with unfavorable B (322,324,325,328336)
anatomy for PCI and who are good candidates for CABG
3-vessel disease with or without proximal LAD artery disease*
CABG I B (125,330,334,358360)
IIaIt is reasonable to choose CABG over PCI in patients with complex 3-vessel B (336,353,360362)
CAD (e.g., SYNTAX score 22) who are good candidates for CABG.
PCI IIbOf uncertain benefit B (140,330,353,358,360)
2-vessel disease with proximal LAD artery disease*
CABG I B (125,330,334,358360)
PCI IIbOf uncertain benefit B (140,330,358,360)
2-vessel disease without proximal LAD artery disease*
CABG IIaWith extensive ischemia B (363366)
IIbOf uncertain benefit without extensive ischemia C (360)
1-vessel proximal LAD artery disease
CABG IIaWith LIMA for long-term benefit B (334,360,367,368)
1-vessel disease without proximal LAD artery involvement
CABG III: Harm B (141,334,358,363, 364,369372)
PCI III: Harm B (141,334,358,363,364, 369372)
LV dysfunction
CABG IIaEF 35% to 50% B (139,334,373376)
CABG IIbEF 35% without significant left main CAD B (127,139,334,373377)
PCI Insufficient data N/A
Survivors of sudden cardiac death with presumed ischemia-mediated VT
CABG I B (122,378,379)
PCI I C (378)
No anatomic or physiological criteria for revascularization
CABG III: Harm B (141,334,358,363, 364,369372)
PCI III: Harm B (141,334,358,363,364,369372)
*In patients with multivessel disease who also have diabetes mellitus, it is reasonable to choose CABG (with LIMA) over PCI (365,380,381,381386) (Class IIa; LOE: B).
CABG indicates coronary artery bypass graft; CAD, coronary artery disease; COPD, chronic obstructive pulmonary disease; COR, class of recommendation; EF, ejection fraction; LAD, left anterior
descending; LIMA, left internal mammary artery; LOE, level of evidence; LV, left ventricular; N/A, not available; PCI, percutaneous coronary intervention; SIHD, stable ischemic heart disease; STEMI,
ST-elevation myocardial infarction; STS, Society of Thoracic Surgeons; SYNTAX, Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery; TIMI, Thrombolysis In Myocardial
Infarction; UA/NSTEMI, unstable angina/nonST-elevation myocardial infarction; UPLM, unprotected left main disease; and VT, ventricular tachycardia.

Table 7. Revascularization to Improve Symptoms With Significant Anatomic (>50% Left Main or >70% NonLeft Main CAD) or
Physiological (FFR <0.80) Coronary Artery Stenoses
Clinical Setting COR LOE References
1 significant stenoses amenable to revascularization and 1CABG A (140,387396)
unacceptable angina despite GDMT 1PCI
1 significant stenoses and unacceptable angina in whom GDMT IIaCABG C N/A
cannot be implemented because of medication contraindications, IIaPCI C N/A
adverse effects, or patient preferences
Previous CABG with 1 significant stenoses associated with IIaPCI C (397400)
ischemia and unacceptable angina despite GDMT IIbCABG C (401)
Complex 3-vessel CAD (e.g., SYNTAX score >22) with or without IIaCABG preferred over PCI B (353,360362)
involvement of the proximal LAD artery and a good candidate for
CABG
Viable ischemic myocardium that is perfused by coronary arteries that IIbTMR as an adjunct to CABG B (402406)
are not amenable to grafting
No anatomic or physiological criteria for revascularization III: HarmCABG C N/A
III: HarmPCI C N/A
CABG indicates coronary artery bypass graft; CAD, coronary artery disease; COR, class of recommendation; FFR, fractional flow reserve; GDMT, guideline-directed medical therapy; LOE, level of evidence;
N/A, not available; PCI, percutaneous coronary intervention; SYNTAX, Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery; and TMR, transmyocardial revascularization.
2. CABG to improve survival is reasonable in patients with mildmoderate stenosis, fractional flow reserve 0.80, no or only mild ischemia
LV systolic dysfunction (ejection fraction 35% to 50%) and significant on noninvasive testing), involve only the left circumflex or right
(70% diameter stenosis) multivessel CAD or proximal LAD coronary coronary artery, or subtend only a small area of viable myocar-
artery stenosis, when viable myocardium is present in the region of dium (141,334,358,363,364,369372). (Level of Evidence: B)
intended revascularization (139,334,373376). (Level of Evidence: B)
3. CABG with a left internal mammary artery graft to improve survival
5.3. Revascularization to Improve Symptoms
is reasonable in patients with significant (70% diameter) stenosis CLASS I
in the proximal LAD artery and evidence of extensive ischemia 1. CABG or PCI to improve symptoms is beneficial in patients with 1 or
(334,360,367,368). (Level of Evidence: B) more significant (70% diameter) coronary artery stenoses ame-
4. It is reasonable to choose CABG over PCI to improve survival in nable to revascularization and unacceptable angina despite GDMT
patients with complex 3-vessel CAD (e.g., SYNTAX score 22), with (140,387393,395,396,412). (Level of Evidence: A)
or without involvement of the proximal LAD artery who are good
CLASS IIa
candidates for CABG (336,353,360362). (Level of Evidence: B) 1. CABG or PCI to improve symptoms is reasonable in patients with 1
5. CABG is probably recommended in preference to PCI to improve or more significant (70% diameter) coronary artery stenoses and
survival in patients with multivessel CAD and diabetes mellitus, unacceptable angina for whom GDMT cannot be implemented
particularly if a left internal mammary artery graft can be anasto- because of medication contraindications, adverse effects, or patient
mosed to the LAD artery (365,380,381386). (Level of Evidence: B) preferences. (Level of Evidence: C)
2. PCI to improve symptoms is reasonable in patients with previous
CLASS IIb
1. The usefulness of CABG to improve survival is uncertain in patients CABG, 1 or more significant (70% diameter) coronary artery
with significant (70%) diameter stenoses in 2 major coronary stenoses associated with ischemia, and unacceptable angina de-
arteries not involving the proximal LAD artery and without extensive spite GDMT (397,399,400). (Level of Evidence: C)
ischemia (360). (Level of Evidence: C) 3. It is reasonable to choose CABG over PCI to improve symptoms in
2. The usefulness of PCI to improve survival is uncertain in patients patients with complex 3-vessel CAD (e.g., SYNTAX score 22), with or
with 2- or 3-vessel CAD (with or without involvement of the proximal without involvement of the proximal LAD artery, who are good candi-
LAD artery) or 1-vessel proximal LAD disease (140,330,358,360). dates for CABG (325,336,353,360362). (Level of Evidence: B)
(Level of Evidence: B) CLASS IIb
3. CABG might be considered with the primary or sole intent of 1. CABG to improve symptoms might be reasonable for patients with
improving survival in patients with SIHD with severe LV systolic previous CABG, 1 or more significant (70% diameter) coronary
dysfunction (ejection fraction 35%) whether or not viable myocar- artery stenoses not amenable to PCI, and unacceptable angina
dium is present (127,139,334,373377). (Level of Evidence: B) despite GDMT (401). (Level of Evidence: C)
4. The usefulness of CABG or PCI to improve survival is uncertain in 2. Transmyocardial revascularization performed as an adjunct to
patients with previous CABG and extensive anterior wall ischemia CABG to improve symptoms may be reasonable in patients with
on noninvasive testing (397401,408411). (Level of Evidence: B) viable ischemic myocardium that is perfused by arteries that are not
amenable to grafting (402406). (Level of Evidence: B)
CLASS III: Harm
1. CABG or PCI should not be performed with the primary or sole CLASS III: Harm
intent to improve survival in patients with SIHD with 1 or more 1. CABG or PCI to improve symptoms should not be performed in
coronary stenoses that are not anatomically or functionally patients who do not meet anatomic (50% diameter left main or
significant (e.g., 70% diameter nonleft main coronary artery 70% nonleft main stenosis diameter) or physiological (e.g.,

abnormal fractional flow reserve) criteria for revascularization. c. Unfavorable LAD artery for PCI (i.e., excessive vessel tortuosity or
(Level of Evidence: C) chronic total occlusion).
CLASS IIb
5.4. Dual Antiplatelet Therapy Compliance and 1. Hybrid coronary revascularization (defined as the planned com-
Stent Thrombosis bination of left internal mammary arterytoLAD artery grafting
and PCI of 1 non-LAD coronary arteries) may be reasonable as
CLASS III: Harm an alternative to multivessel PCI or CABG in an attempt to
1. PCI with coronary stenting (bare-metal stent or drug-eluting stent) improve the overall riskbenefit ratio of the procedures. (Level of
should not be performed if the patient is not likely to be able to Evidence: C)
tolerate and comply with dual antiplatelet therapy for the appropri-
ate duration of treatment based on the type of stent implanted 6. Patient Follow-Up: Monitoring of
Symptoms and Antianginal Therapy:
Recommendations
5.5. Hybrid Coronary Revascularization
CLASS IIa
6.1. Clinical Evaluation, Echocardiography During
1. Hybrid coronary revascularization (defined as the planned combina- Routine, Periodic Follow-Up
tion of left internal mammary arterytoLAD artery grafting and PCI CLASS I
of 1 non-LAD coronary arteries) is reasonable in patients with 1 or 1. Patients with SIHD should receive periodic follow-up, at least annu-
more of the following (418424) (Level of Evidence: B): ally, that includes all of the following (Level of Evidence: C):
a. Limitations to traditional CABG, such as heavily calcified proxi- a. Assessment of symptoms and clinical function;
mal aorta or poor target vessels for CABG (but amenable to PCI); b. Surveillance for complications of SIHD, including heart failure
b. Lack of suitable graft conduits; and arrhythmias;
Table 8. Follow-Up Noninvasive Testing in Patients With Known SIHD: New, Recurrent, or Worsening Symptoms
Not Consistent With UA
Exercise ECG
Status Interpretable
Test Able Unable Yes No COR LOE References Additional Considerations

Exercise ECG X X I B (3942)
Exercise with nuclear MPI or X X I B (69,95,96,102,
Echo 141,364,
426435)
Exercise with nuclear MPI or X Any IIa B (436,437) Prior requirement for imaging with
Echo exercise
Known or at high risk for multivessel
disease
Pharmacological stress X X III: No Benefit C (438)
nuclear MPI/Echo/CMR
Pharmacological stress X Any I B (43,46,47,4953)
nuclear MPI or Echo
Pharmacological stress CMR X Any IIa B (98,99,101)
Exercise ECG X X III: No Benefit C N/A
Irrespective of ability to exercise
CCTA Any Any IIb B (439443) Patency of CABG or coronary stent 3 mm
diameter
CCTA Any Any IIb B (55,58,439) In the absence of known moderate or
severe calcification and intent to assess
coronary stent 3 mm in diameter
CCTA Any Any III: No Benefit B (439443) Known moderate or severe native coronary
calcification or assessment of coronary
stent 3 mm in diameter in patients
who have new or worsening symptoms
not consistent with UA
CABG indicates coronary artery bypass graft surgery; CCTA, cardiac computed tomography angiography; CMR, cardiac magnetic resonance; COR, class of recommendation; ECG, electrocardiogram;
Echo, echocardiography; LOE, level of evidence; MPI, myocardial perfusion imaging; N/A, not available; SIHD, stable ischemic heart disease; and UA, unstable angina.

c. Monitoring of cardiac risk factors; and 6.2.1.1. PATIENTS ABLE TO EXERCISE

d. Assessment of the adequacy of and adherence to recommended
CLASS I
lifestyle changes and medical therapy. 1. Standard exercise ECG testing is recommended in patients with
known SIHD who have new or worsening symptoms not consistent
2. Assessment of LV ejection fraction and segmental wall motion by
with UA and who have a) at least moderate physical functioning and
echocardiography or radionuclide imaging is recommended in pa-
no disabling comorbidity and b) an interpretable ECG (3942).
tients with new or worsening heart failure or evidence of intervening
(Level of Evidence: B)
MI by history or ECG. (Level of Evidence: C)
2. Exercise with nuclear MPI or echocardiography is recommended in
CLASS IIb patients with known SIHD who have new or worsening symptoms
1. Periodic screening for important comorbidities that are prevalent in not consistent with UA and who have a) at least moderate physical
patients with SIHD, including diabetes mellitus, depression, and functioning or no disabling comorbidity but b) an uninterpretable
chronic kidney disease might be reasonable. (Level of Evidence: C) ECG (69,95,96,102,141,364,426435). (Level of Evidence: B)
2. A resting 12-lead ECG at 1-year or longer intervals between studies CLASS IIa
in patients with stable symptoms might be reasonable. (Level of 1. Exercise with nuclear MPI or echocardiography is reasonable in
Evidence: C) patients with known SIHD who have new or worsening symptoms
not consistent with UA and who have a) at least moderate physical
functioning and no disabling comorbidity, b) previously required
1. Measurement of LV function with a technology such as echocardi-
imaging with exercise stress, or c) known multivessel disease or
ography or radionuclide imaging is not recommended for routine
high risk for multivessel disease (436,437). (Level of Evidence: B)
periodic reassessment of patients who have not had a change in
clinical status or who are at low risk of adverse cardiovascular CLASS III: No Benefit
events (425). (Level of Evidence: C) 1. Pharmacological stress imaging with nuclear MPI, echocardiogra-
phy, or CMR is not recommended in patients with known SIHD who
have new or worsening symptoms not consistent with UA and who
6.2. Noninvasive Testing in Known SIHD
are capable of at least moderate physical functioning or have no
6.2.1. Follow-Up Noninvasive Testing in Patients disabling comorbidity (438). (Level of Evidence: C)
With Known SIHD: New, Recurrent, or Worsening
6.2.1.2. PATIENTS UNABLE TO EXERCISE
Symptoms Not Consistent With Unstable Angina
CLASS I
See Table 8 for a summary of recommendations from this 1. Pharmacological stress imaging with nuclear MPI or echocardiog-
section. raphy is recommended in patients with known SIHD who have new
Table 9. Noninvasive Testing in Known SIHD: Asymptomatic (or Stable Symptoms)

ECG
Exercise Status Interpretable
Pretest Probability of Additional
Test Able* Unable Yes No Ischemia COR LOE References Considerations
Exercise or pharmacological X X Prior evidence of silent IIa C (10,13,20) a) Unable to exercise to
stress with nuclear MPI, ischemia or high risk adequate workload
Echo, or CMR at 2-y for recurrent cardiac or
intervals event. Meets criteria b) Uninterpretable ECG
listed in additional or
considerations. c) History of incomplete
coronary
revascularization
Exercise ECG at 1-y X X Any IIb C N/A a) Prior evidence of
intervals silent ischemia OR
b) At high risk for
recurrent cardiac
event
Exercise ECG X X No prior evidence of silent IIb C N/A For annual surveillance
ischemia and not at
high risk of recurrent
cardiac event.
Exercise or pharmacological Any Any Any III: No C (10,13,20) a) 5-y intervals after
stress with nuclear MPI, Benefit CABG, or
Echo, or CMR or CCTA b) 2-y intervals after
PCI
CABG indicates coronary artery bypass graft surgery; CCTA, cardiac computed tomography angiography; CMR, coronary magnetic resonance; COR, class of recommendation; CCTA, computed
tomography angiography; CMR, cardiac magnetic resonance; ECG, electrocardiogram; Echo, echocardiography; LOE, level of evidence; MPI, myocardial perfusion imaging; N/A, not available; PCI,
percutaneous coronary intervention; and SIHD, stable ischemic heart disease.

or worsening symptoms not consistent with UA and who are inca- cardiac event, the usefulness of annual surveillance exercise ECG
pable of at least moderate physical functioning or have disabling testing is not well established. (Level of Evidence: C)
comorbidity (43,46,47,4953). (Level of Evidence: B)
1. Nuclear MPI, echocardiography, or CMR, with either exercise or
CLASS IIa
1. Pharmacological stress imaging with CMR is reasonable in patients pharmacological stress or CCTA, is not recommended for follow-up
with known SIHD who have new or worsening symptoms not con- assessment in patients with SIHD, if performed more frequently
sistent with UA and who are incapable of at least moderate physical than at a) 5-year intervals after CABG or b) 2-year intervals after PCI
functioning or have disabling comorbidity (98,99,101). (Level of (10,13,20). (Level of Evidence: C)
Evidence: B)
Presidents and Staff
1. Standard exercise ECG testing should not be performed in patients
with known SIHD who have new or worsening symptoms not con- American College of Cardiology Foundation
sistent with UA and who a) are incapable of at least moderate William A. Zoghbi, MD, FACC, President
physical functioning or have disabling comorbidity or b) have an Thomas E. Arend, Jr, Esq, CAE, Interim Chief Staff Officer
uninterpretable ECG. (Level of Evidence: C) William J. Oetgen, MD, MBA, FACC, Senior Vice
President, Science and Quality
6.2.1.3. IRRESPECTIVE OF ABILITY TO EXERCISE
Charlene L. May, Senior Director, Science and Clinical Policy
CLASS IIb Erin A. Barrett, MPS, Senior Specialist, Science and Clinical
1. CCTA for assessment of patency of CABG or of coronary stents 3 Policy
mm or larger in diameter might be reasonable in patients with
known SIHD who have new or worsening symptoms not consistent American College of Cardiology Foundation/
with UA, irrespective of ability to exercise (439443). (Level of American Heart Association
Evidence: B) Lisa Bradfield, CAE, Director, Science and Clinical Policy
2. CCTA might be reasonable in patients with known SIHD who have Maria Koinis, Specialist, Science and Clinical Policy
new or worsening symptoms not consistent with UA, irrespective of Sue Keller, BSN, MPH, Senior Specialist, Evidence-Based
ability to exercise, in the absence of known moderate or severe Medicine
calcification or if the CCTA is intended to assess coronary stents less
than 3 mm in diameter (55,58,439). (Level of Evidence: B) American Heart Association
Gordon F. Tomaselli, MD, FAHA, President
CLASS III: No Benefit Nancy Brown, Chief Executive Officer
1. CCTA should not be performed for assessment of native coronary
Rose Marie Robertson, MD, FAHA, Chief Science Officer
arteries with known moderate or severe calcification or with coro-
nary stents less than 3 mm in diameter in patients with known SIHD
Gayle R. Whitman, PhD, RN, FAHA, FAAN, Senior Vice
who have new or worsening symptoms not consistent with UA,
President, Office of Science Operations
irrespective of ability to exercise (439443). (Level of Evidence: B) Judy L. Bezanson, DSN, RN, CNS-MS, FAHA, Science
and Medicine Advisor, Office of Science Operations
6.2.2. Noninvasive Testing in Known SIHD
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433. Calnon DA, McGrath PD, Doss AL, et al. Prognostic value of and double-vessel disease. Findings from the Angioplasty Compared
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patients with known or suspected coronary artery disease. J Am Coll 440. Jones CM, Athanasiou T, Dunne N, et al. Multi-detector computed
Cardiol. 2007;50:1174 9. tomography in coronary artery bypass graft assessment: a meta-
435. Berman DS, Hachamovitch R, Kiat H, et al. Incremental value of analysis. Ann Thorac Surg. 2007;83:341 8.
prognostic testing in patients with known or suspected ischemic heart 441. Hamon M, Lepage O, Malagutti P, et al. Diagnostic performance of
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assessment: meta-analysis. Radiology. 2008;247:679 86.
sestamibi myocardial perfusion single-photon emission computed
442. Carrabba N, Schuijf JD, de Graaf FR, et al. Diagnostic accuracy of
tomography. J Am Coll Cardiol. 1995;26:639 47.
64-slice computed tomography coronary angiography for the detec-
436. Chatziioannou SN, Moore WH, Ford PV, et al. Prognostic value of tion of in-stent restenosis: a meta-analysis. J Nucl Cardiol. 2010;17:
myocardial perfusion imaging in patients with high exercise tolerance. 470 8.
Circulation. 1999;99:86772. 443. Sun Z, Almutairi AM. Diagnostic accuracy of 64 multislice CT
437. Peteiro J, Monserrrat L, Pineiro M, et al. Comparison of exercise angiography in the assessment of coronary in-stent restenosis: a
echocardiography and the Duke treadmill score for risk stratification meta-analysis. Eur J Radiol. 2010;73:266 73.
in patients with known or suspected coronary artery disease and
normal resting electrocardiogram. Am Heart J. 2006;151:1324 10. Key Words: ACCF/AHA Practice Guidelines y cardiovascular
438. Parisi AF, Hartigan PM, Folland ED. Evaluation of exercise thal- diagnostic techniques y coronary artery disease y coronary stenosis y
lium scintigraphy versus exercise electrocardiography in predicting minimally invasive surgical procedures y myocardial ischemia y
survival outcomes and morbid cardiac events in patients with single- myocardial revascularization y prognosis y risk factors y stable angina.
APPENDIX 1. AUTHOR RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT):

2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS GUIDELINES FOR THE DIAGNOSIS AND MANAGEMENT OF
PATIENTS WITH STABLE ISCHEMIC HEART DISEASE
Institutional,
Ownership/ Organizational, or Voting
Committee Partnership/ Other Financial Expert Recusals by
Member Employment Consultant Speakers Bureau Principal Personal Research Benefit Witness Section*
Stephan D. Veterans Health None None None None None None None
Fihn (Chair) Administration
Director, Office of
Analytics and
Business Intelligence;
University of Washington
Professor of Medicine
and of Health Services;
Head,
Division of General
Internal Medicine
Julius M. Hackensack University Arena Bristol-Myers Squibb None Merck (Expired Dec. None None 4.4.1.1
Gardin (Vice Medical Center Pharmaceuticals (Expired Dec. 2009) 2009) 4.4.1.2
Chair) Professor and (Expired Dec. 2008) CV Therapeutics 4.4.1.3
Chairman, AstraZeneca (Expired Dec. 2007) 4.4.1.5
Department of (Expired Dec. 2009) Pfizer (Expired Dec. 4.4.2.1
Internal Medicine Bristol-Myers Squibb 2009) 4.4.2.2
(Expired Dec. 2009) Takeda (Expired 4.4.2.3
CV Therapeutics Dec. 2007) 4.4.3.1
(Expired Dec. 2007) 4.4.4
Pfizer (Expired Dec.
2009)
Sanofi-aventis
(Expired 2009)
Takeda (Expired
Dec. 2007)
Jonathan University of New None None None None None None None
Abrams Mexico, Office of
CMEProfessor of
Medicine (Cardiology)
Kathleen Berra Stanford Prevention Boehringer Sanofi-aventis None Kai Pharmaceuticals PCNABoard None 4.4.1.1
Research Center Ingelheim Member 4.4.1.2
Clinical Trial Director CV Therapeutics 4.4.2.1
Gilead Sciences 4.4.2.2
Novartis 4.4.2.3
Pfizer 4.4.3.1
James C. Geisinger Medical None Sanofi-aventis None Abiomed None None 4.4.2.1
Blankenship CenterDirector AstraZeneca
Cardiology; Director Boston Scientific
Cardiac Conor Medsystems
Catheterization Kai Pharmaceutical
Laboratory Novartis
Schering-Plough
The Medicines
Company

Institutional,
Apostolos P. Carilion Roanoke None None GlaxoSmithKline None None None 4.4.1.2
Dallas Memorial Hospital Johnson & 4.4.1.2
Director of Johnson 4.4.1.3
Continuing Medical Novartis 4.4.1.6
Education Sanofi-aventis 4.4.2.1
4.4.2.2
4.4.2.3
4.4.3.1
Pamela S. Duke University Medical None None None Novartis None None 4.4.1.1
Douglas CenterUrsula Geller 4.4.1.2
Professor of 4.4.1.3
Research in 4.4.2.3
Cardiovascular
Diseases
JoAnne M. Harvard Medical School Abbott None None None None None 2.2.2.2
Foody Associate Professor; Amarin 2.2.3.3
Brigham and Gilead 3.2.2.6
Womens/Faulkner Merck 4.4.1.1
Hospitals Novartis 4.4.1.2
Pfizer 4.4.1.3
Sanofi-aventis 4.4.3.1.4
Thomas C. Mayo ClinicRadiology, None None None None None None None
Gerber Professor of
Medicine
Alan L. University of North None None None None None None None
Hinderliter Carolina: Division of
CardiologyAssociate
Professor
Spencer B. Saint Josephs Heart Medtronic (Expired None None None Merck (DSMB) None 4.4.2.1
King III and Vascular June 2007) Wyeth 4.4.2.2
InstitutePresident; Pharmaceuticals 4.4.2.3
Saint Josephs (DSMB) 4.4.3.1
Health
SystemExecutive
Director Academic
Affairs
Paul D. Cornell Medical Cardiac Science None None None None None 2.2.1
Kligfield CenterProfessor of GE Healthcare 2.2.4.2
Medicine MDS Pharma 2.2.4.3
Services 3.2.2
Mortara Instrument 6.1
Philips Medical
Systems
Harlan M. Yale University School None None None None None None None
Krumholz of MedicineHarold
H. Hines, Jr.
Professor of
Medicine and
Epidemiology and
Public Health
Raymond Y.K. Brigham & Womens None None None None None None None
Kwong Hospital Medicine,
Cardiovascular
DivisionInstructor
of Medicine
Michael J. Lim St. Louis University Bristol-Myers Squibb None None None None None 4.4.1.1
Associate Professor Cordis 4.4.1.2
of Medicine; Division Sanofi-aventis 4.4.1.3
of Cardiology, Interim Schering-Plough 4.4.2.1.1
Director; J. Gerard 4.4.2.3
Mudd Cardiac
Catheterization
Laboratory, Director
Jane A. Mayo ClinicAssistant None None None None None None None
Linderbaum Professor of
Medicine
Michael J. The Heart Hospital None None None None None None None
Mack Baylor
PlanoDirector
Mark A. University of Utah None Gilead None Novartis None None 4.4.3.1
Munger College of
Pharmacy
Professor
Pharmacotherapy
and Internal
Medicine; Associate
Dean, Academic
Affairs
Richard L. University of Michigan None None None None None None None
Prager Hospitals and Health
CentersProfessor
of Surgery, Section of
Cardiac Surgery

Institutional,
Joseph F. Cleveland Clinic Medtronic None None None None None 4.4.1.3
Sabik Foundation Novo Nordisk
Professor of Surgery
Leslee J. Shaw Emory University School None None None Bracco Diagnostics None None 3.2.2.6
of Medicine
Professor of
Medicine
Joanna D. University of Miami None AstraZeneca None None None None 4.4.1.1
Sikkema School of Nursing 4.4.1.2
Craig R. Smith, Columbia University None None None None None None None
Jr Chairman,
Department of
Surgery
Sidney C. Center for Eli Lilly (Expired July AstraZeneca None GlaxoSmithKline None None 4.4.2.1
Smith, Jr Cardiovascular 2007) (Expired Nov. 2009) (DSMB) (Expired March
Science and Sanofi-aventis Bayer (Expired Oct. 2009)
MedicineProfessor (Expired Sept. 2009)
of Medicine; Director 2009) Fornier (Expired May
2009)
Sanofi-aventis
(Expired Nov. 2009)

John A. MidAmerica Heart Gilead None None BMS/sanofi-aventis None None 4.4.1.1
Spertus Institute of St. Lukes Cordis 4.4.1.2
HospitalDirector, Eli Lilly 4.4.1.3
Outcomes Research; Johnson & Johnson 4.4.3.1
University of Roche Diagnostics 6.3.1
MissouriKansas
City
Sankey V. Hospital of the None None Johnson & None None None 4.4.1.1
Williams University of Johnson 4.4.1.2
Pennsylvania Merck 4.4.1.3
Solomon Katz 4.4.1.5
Professor of General 4.4.1.6
Medicine, Division of 4.4.2.1
General Internal 4.4.2.2
Medicine 4.4.2.3
This table represents the relationships of committee members with industry and other entities that were reported by authors to be relevant to this document. These relationships were reviewed and
updated in conjunction with all meetings and conference calls of the writing committee during the document development process. The table does not necessarily reflect relationships with industry at
the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of 5% of the voting stock or share of the business entity, or ownership
of $10,000 of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the persons gross income for the previous year. A relationship
is considered to be modest if it is less than significant under the preceding definition. Relationships in this table are modest unless otherwise noted.
The current guideline was developed during the transition in RWI policy and occurred over an extended period of time. In the interest of transparency, we provide full information on RWI existing over the
entire period of guideline development, including delineation of relationships that expired 24 months before the guideline was finalized.
*Writing committee members are required to recuse from voting on sections to which their specific relationships with industry and other entities could apply. Section numbers apply to the full-text
guideline. Significant relationship. No financial benefit.
CV indicates cardiovascular; DSMB, data safety and monitoring board; and SAQ, Seattle Angina Questionnaire.
APPENDIX 2. REVIEWER RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT):

2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS GUIDELINES FOR THE DIAGNOSIS AND MANAGEMENT OF
PATIENTS WITH STABLE ISCHEMIC HEART DISEASE
Institutional,
Ownership/ Organizational, or
Partnership/ Other Financial
Reviewer Representation Consultant Speaker Principal Research Benefit Expert Witness
Ralph G. Brindis Official ReviewerACCF None None None None None None
Board of Trustees
Timothy D. Official ReviewerAHA CV Therapeutics None None Baxter* None None
Henry Sanofi-aventis CV Therapeutics*
Judith S. Official Reviewer Eli Lilly None None Johnson & Johnson
Hochman ACCF/AHA Task GlaxoSmithKline Merck
Force on Practice
Guidelines
Robert H. Jones Official ReviewerSTS None None None None None None
Janet B. Long Official ReviewerPCNA None AstraZeneca None None None None
Bruce W. Lytle Official ReviewerAATS None None None None None None
Douglass A. Official ReviewerSCAI None None None None None None
Morrison

Institutional,
E. Magnus Official ReviewerAHA Abiomed CV Therapeutics* Inovise* Bristol-Myers None None
Ohman Datascope The Medicines Squibb*
Inovise* Company* Daiichi-Sankyo*
Liposcience Eli Lilly*
The Medicines The Medicines
Company Company*
Response Millennium
Biomedical Pharmaceuticals*
Sanofi-aventis*
Schering-Plough*
Douglas K. Official ReviewerACP GE Healthcare* None None None None None

Owens
Paul Poirier Official ReviewerACCF None None None None None None
Board of Governors
Amir Qaseem Official ReviewerACP None None None None None None
Joyce L. Ross Official ReviewerPCNA Kaneka America Abbott None None None None
AstraZeneca*
Bristol-Myers
Squibb
Oscient
Pfizer
Sanofi-aventis
Timothy A. Official ReviewerSCAI None The Medicines None St. Jude Medical None None
Sanborn Company (DSMB)
Merck
Jeffrey L. Content Reviewer BMS/sanofi-aventis None None None None None

Anderson ACCF/AHA Task Daiichi-Sankyo
Force on Practice Eli Lilly
Guidelines
William E. Content Reviewer Abbott Medicure Pharma None None None None
Boden CV Therapeutics/
Gilead*
Sanofi-aventis
Schering-Plough
Matthew Budoff Content Reviewer None None None None None None
ACCF Imaging
Council
Kim A. Eagle Content Reviewer None None None None None None
Gordon A. Ewy Content Reviewer None None None None None None
Victor Ferrari Content Reviewer None None None None None None
ACCF Imaging
Council
Raymond J. Content Reviewer Cardiovascular None None Velomedix* None None
Gibbons Clinical Studies
Lantheus Medical
Imaging
Medscape
Molecular Insight
TherOx
Linda Gillam Content Reviewer Abbott Vascular None None None Core Lab None
ACCF Imaging Edwards Services
Council Lifesciences
Robert A. Content Reviewer None None None Edwards None None
Guyton ACCF/AHA Task Lifesciences
Force on Practice
Guidelines
L. David Hillis Content Reviewer None None None None None None
David R. Content Reviewer None None None None None None
Holmes ACCF Interventional
Scientific Council
Hani Jneid Content Reviewer None None None None None None
AHA Council on
Clinical Cardiology
Sanjay Kaul Content Reviewer None None None None None None
Howard C. Content Reviewer None None Positron None None None
Lewin ACCF Imaging Imaging
Council Partners
Todd D. Miller Content Reviewer The Medicines None None Kai Pharmaceuticals None None
AHA Council on Company King
Clinical Cardiology TherOx Pharmaceuticals
Lantheus Medical
Imaging
Molecular Insight
Pharmaceuticals
L. Kristin Newby Content Reviewer Adolor Daiichi-Sankyo None AstraZeneca None None
AHA Council on Biovascular BG Medicine
Clinical Cardiology CV Therapeutics Carvio Dx*
Inverness Medical GlaxoSmithKline*
Johnson & Johnson Medicare*
Novartis Millennium
Roche Diagnostics Pharmaceuticals
Schering-Plough*

Institutional,
Elizabeth Ross Content Reviewer None None None None None None
William S. Content Reviewer AstraZeneca* None None Abbott* None 2004; Defendant;
Weintraub Bayer* AstraZeneca* Aprotinin

Bristol-Myers Bristol-Myers 2008; Defendant;
Squibb Squibb* Quetiapine

Cardionet Otsuka* 2008; Defendant;
Eli Lilly Sanofi-aventis* Celebrex

Pfizer*
Sanofi-aventis
Shionogi
This table represents the relationships of reviewers with industry and other entities that were disclosed at the time of peer review. It does not necessarily reflect relationships with industry at the time
of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of 5% of the voting stock or share of the business entity, or ownership of >$10,000
of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the persons gross income for the previous year. A relationship is considered
to be modest if it is less than significant under the preceding definition. Relationships noted in this table are modest unless otherwise noted.
*Significant relationship.
AATS indicates American Association for Thoracic Surgery; ACCF, American College of Cardiology Foundation; ACP, American College of Physicans; AHA, American Heart Association; NIH, National
Institutes of Health; PCNA, Preventive Cardiovascular Nurses Association; SCAI, Society for Cardiovascular Interventions and Angiography; and STS, Society of Thoracic Surgeons.

Guidelines For Management of Stable Ischemic Heart Disease

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Guidelines For Management of Stable Ischemic Heart Disease

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Journal of the American College of Cardiology Vol. 60, No.

2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline

Writing Stephan D. Fihn, MD, MPH, Chair Michael J. Mack, MD*#

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3.1.1. Resting Imaging to Assess Cardiac Structure

1.2. Organization of the Writing Committee . . . . . . . . . .2569 EXERCISE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2576

4.1. Patient Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2579

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Table 1. Applying Classification of Recommendations and Level of Evidence

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Figure 1. Spectrum of IHD

Guidelines relevant to the spectrum of IHD are in parentheses.

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Table 2. Short-Term Risk of Death or Nonfatal MI in Patients With UA/NSTEMI

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Table 3. Associated Guidelines and Statements

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Figure 2. Diagnosis of Patients with Suspected IHD

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Figure 3. Algorithm for Risk Assessment of Patients With SIHD*

2.1.3.3. OTHER 3. Risk Assessment: Recommendations

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Figure 5. Algorithm for Revascularization to Improve Survival of Patients With SIHD*

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Figure 6. Algorithm for Revascularization to Improve Symptoms of Patients With SIHD*

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3.2. Coronary Angiography CLASS IIa

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Test Able Unable Yes No COR LOE References Additional Considerations

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4.2. Guideline-Directed Medical Therapy 4.2.1.4. PHYSICAL ACTIVITY

4.2.1. Risk Factor Modification CLASS I

4.2.1.2. BLOOD PRESSURE MANAGEMENT CLASS I

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4.2.1.7. MANAGEMENT OF PSYCHOLOGICAL FACTORS CLASS I

CLASS III: No Benefit 4.2.3. Medical Therapy for Relief of Symptoms

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4. Sublingual nitroglycerin or nitroglycerin spray is recommended for CLASS IIa

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Table 6. Revascularization to Improve Survival Compared With Medical Therapy

complications and a high likelihood of good long-term outcome (e.g., a low

surgical outcomes (e.g., STS-predicted risk of operative mortality 5%)

procedural complications and an intermediate to high likelihood of good long-

outcomes (e.g., moderatesevere COPD, disability from prior stroke, or prior

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Test Able Unable Yes No COR LOE References Additional Considerations

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c. Monitoring of cardiac risk factors; and 6.2.1.1. PATIENTS ABLE TO EXERCISE

Table 9. Noninvasive Testing in Known SIHD: Asymptomatic (or Stable Symptoms)

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http://www.nhlbi.nih.gov/resources/docs/06_ip_chtbk.pdf. Accessed detection of coronary artery disease: a meta-analysis. J Am Coll

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