Canadian Cardiovascular Society Guidelines for the Diagnosis and Management of Stable Ischemic Heart Disease

Mancini, G.B. John; Gosselin, Gilbert; Chow, Benjamin J.W.; Kostuk, William J.; Stone, James A.; Yvorchuk, Kenneth J.; Abramson, Beth L.; Cartier, Raymond; Huckell, Victor F.; Tardif, Jean‐Claude; Connelly, Kim A.; Ducas, John; Farkouh, Michael E.; Gupta, Milan; Juneau, Martin; O’Neill, Blair J.; Raggi, Paolo; Teo, Koon; Verma, Subodh; Zimmermann, R.

doi:10.1016/j.cjca.2014.05.013

Cited by 130 publications

(119 citation statements)

References 133 publications

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“…Despite these guidelines for management of stable obstructive CAD, previous work from our group and others has demonstrated that OMT is underused in this patient population 1, 2, 14, 16. In contrast, there are no definitive guidelines for medical management of nonobstructive CAD, and there is substantial uncertainty as to what constitutes OMT in a population of patients with nonobstructive CAD.…”

Section: Discussionmentioning

confidence: 96%

Variations in Use of Optimal Medical Therapy in Patients With Nonobstructive Coronary Artery Disease: A Population‐Based Study

Oxner

Elbaz‐Greener

Qui

et al. 2017

JAHA

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BackgroundThere is a paucity of data on the need for optimal medical therapy (OMT) in nonobstructive coronary artery disease . We sought to understand if there was variation in the use of OMT between hospitals for patients with nonobstructive coronary artery disease, the factors associated with such variation, and its clinical consequences.Methods and ResultsUsing a population‐level clinical registry in Ontario, Canada, we identified all patients >66 years undergoing coronary angiography for the indication of stable angina, who had nonobstructive coronary artery disease between November 1, 2010, and October 31, 2013. Hierarchical multivariable logistic models were developed to identify the factors associated with OMT use, with median odds ratio used to quantify the degree of variation between hospitals not explained by the modeled risk factors. Clinical outcomes of interest were all‐cause mortality and rehospitalization, with follow‐up until March 31, 2015. Our cohort consisted of 5413 patients, of whom 2554 (47.2%) were receiving OMT within 1 year. There was a 2‐fold variation in OMT across hospitals (30.4%–61.8%). The variation between hospitals was fully explained by preangiography medication use (median odds ratio of 1.21 in the null model and 1.03 in the full model). There was no difference in risk‐adjusted mortality (hazard ratio, 0.94; 95% confidence interval, 0.76–1.16); however, patients receiving OMT had a lower risk of all‐cause hospital readmission (hazard ratio, 0.89; 95% confidence interval, 0.84–0.95).ConclusionsThere is wide variation in the use of OMT in patients with nonobstructive coronary artery disease, the major driver of which is differences in baseline medication use.

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Section: Discussionmentioning

confidence: 96%

Variations in Use of Optimal Medical Therapy in Patients With Nonobstructive Coronary Artery Disease: A Population‐Based Study

Oxner

Elbaz‐Greener

Qui

et al. 2017

JAHA

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“…The management of chronic stable angina encompasses lifestyle modification, control of risk factors for coronary artery disease, and both invasive and noninvasive treatment [1][2][3][4] . Pharmacological therapy has two main goals: firstly to alleviate symptoms, increase angina-free walking time, and improve quality of life; and secondly to prevent cardiovascular events, mainly myocardial infarction and death.…”

Section: Drug Therapymentioning

confidence: 99%

“…Current clinical guidelines recommend antianginal therapy to control symptoms, before considering coronary artery revasculariza tion [1][2][3][4] . However, revascularization by either percutaneous coronary angioplasty or CABG surgery is indicated in patients who have significant artery steno sis (50% left main narrowing or proximal three-vessel disease) to reduce myocardial ischaemia and its adverse clinical manifestation.…”

mentioning

confidence: 99%

A 'diamond' approach to personalized treatment of angina

et al. 2017

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Chronic stable angina pectoris is the most prevalent symptomatic manifestation of ischaemic heart disease, and its management is a priority (BOX 1). Current clinical guidelines recommend antianginal therapy to control symptoms, before considering coronary artery revasculariza tion [1][2][3][4] . However, revascularization by either percutaneous coronary angioplasty or CABG surgery is indicated in patients who have significant artery steno sis (50% left main narrowing or proximal three-vessel disease) to reduce myocardial ischaemia and its adverse clinical manifestation. Antianginal agents are approved by documenting that they improve total exercise duration, together with a reduction in daily frequency of chronic stable angina compared with placebo and/or equivalence to an active comparator. Cardiovascular outcomes, although highly advocated, are not a pre requisite for regulatory approval. None of the antianginal drugs has been proved to reduce cardiovascular mortality or the rate of myocardial infarction. When patients are optimally treated, mortality for chronic stable angina is low, which might explain why all trials designed to improve prognosis have been negative. Guidelines recom mend a first-choice and a second-choice approach, based more on tradition and expert opinion, rather than evidence. This categorical approach has been questioned in the past couple of years 5-8 . Newer antianginal drugs, which are classified as second choice, have more evidence-based clinical data that are more contemporary to support their use than is available for the traditional first-choice drugs. Equally, the often-needed combin ation of double or triple therapy is based on expert opinion and not related to the underlying pathophysio logy. What constitutes optimal antianginal treatment, therefore, varies considerably between countries, and the majority of doctors treat their patients according to their own preconceptions.A group of experts with experience and interest in chronic stable angina met at the University of Ferrara, Italy, to discuss an individualized approach to medical treatment of chronic stable angina, on the basis E X P E RT C O N S E N S U S D O C U M E N TA 'diamond' approach to personalized treatment of angina Abstract | In clinical guidelines, drugs for symptomatic angina are classified as being first choice (β-blockers, calcium-channel blockers, short-acting nitrates) or second choice (ivabradine, nicorandil, ranolazine, trimetazidine), with the recommendation to reserve second-choice medications for patients who have contraindications to first-choice agents, do not tolerate them, or remain symptomatic. No direct comparisons between first-choice and second-choice treatments have demonstrated the superiority of one group of drugs over the other. Meta-analyses show that all antianginal drugs have similar efficacy in reducing symptoms, but provide no evidence for improvement in survival. The newer, second-choice drugs have more evidence-based clinical data that are more contemporary than is available for tr...

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“…The sample recommendations are from the 2014 Canadian Cardiovascular Society guidelines for the diagnosis and management of stable ischemic heart disease. 53 In terms of language, one recommendation suggests the addition of a nitrate…”

mentioning

confidence: 99%