Citation:

Management of Ischemic Heart Disease. Washington, DC: VA/DoD Clinical Practice Guideline Working Group, Veterans Health Administration, Department of Veterans Affairs and Health Affairs, Department of Defense, October 2001. Update November 2003. Office of Quality and Performance publication 10Q-CPG/IHD-03

Completion Date:

May 2001

Release Date:

September 2001;  Update: November 2003

Source(s):

The Guideline for the Management of Ischemic Heart Disease was developed by and for clinicians from the Department of Veterans Affairs (VA) and the Department of Defense (DoD).

Adaptation:

The guideline draws, in part, from:

• ACC/AHA Guidelines for Unstable Angina (Braunwald et al., 2000, 2002) (Referred to throughout the guideline as ACC/AHA UA—NSTEMI, 2002)
• ACC/AHA Guidelines for the Management of Patients with Acute Myocardial Infarction (Ryan, Anderson et al., 1996 and Ryan et al., 1999) (Referred to throughout the guideline as ACC/AHA AMI, 1996 or 1999)
• ACC/AHA/ACP-ASIM Guidelines for the Management of Patients with Chronic Stable Angina (Gibbons et al., 2003) (Referred to throughout the guideline as ACC/AHA Stable Angina, 1999 or 2003)
• ACC/AHA Guidelines for Exercise Testing (Gibbons et al., 1997) (referred to throughout the guideline as ACC/AHA Exercise Testing, 1997)

Guideline Status:

This is the current version of the guideline. An update is targeted for 2004.

Developer(s):

V eterans Health Administration (VHA), Department of Veterans Affairs (VA) - Federal Government Agency [U.S.]
Department of Defense (DoD) – Federal Government Agency [US]

Funding Source:

United States Government

Committee:

The Management of Ischemic Heart Disease Working Group
 

Group Composition:

The list of contributors to the guideline. The list of contributors to this guideline includes nurses, cardiologists, endocrinologists, internal medicine and primary care physicians, pharmacists, rehabilitation specialists, dieticians and experts in the field of guideline and algorithm development.

Disease/Condition:

Ischemic Heart Disease.

Category:

Assessment, Diagnosis, Treatment, Management.

Intended Users:

Clinical Staff including Physicians; Nurses; Nurse Practitioners; Physician Assistants.

Target Population:

Any person with ischemic heart disease who is eligible for care in the VA or DoD health care delivery system.

VA:
Robert L. Jesse, MD
Chief, Cardiology
VAMC (111B)
1201 Broad Rock Road
Richmond, VA
804-675-5860
Robert.Jesse@med.va.gov

DoD:
LTC Michael D. Eisenhauer, MD, FACC, FACP, FSCAI
Chief, Cardiology
Service William Beaumont Army Medical Center
Attn:  MCHM-MED-C
5005 North Piedras Street
El Paso, TX  79920
Tel: 915-569-2573
Fax: 915-569-1610

Michael.Eisenhauer@AMEDD.ARMY.MIL

GOALS/OBJECTIVES

• To describe the critical decision points in the management of ischemic heart disease

• To provide a clear and comprehensive guideline incorporating current information and practices for practitioners throughout the DoD and Veterans Health Administration system

• To improve local management of patients with ischemic heart disease and improve patient outcomes

INTERVENTIONS AND PRACTICES

The Guideline consists of 8 modules which address distinct aspects of the management of ischemic heart disease:

• Core: Initial Evaluation/Triage
• Module A: Suspected Acute Myocardial Infarction
• Module B: Suspected Acute Coronary Syndrome (Unstable Angina or Non-ST Segment Elevation MI)
• Module C: Management of Stable Angina
• Module G: Follow-up and Secondary Prevention
• Module D: Evaluation and Management of the Asymptomatic Patient
• Module E: Outpatient Cardiac Rehabilitation
• Module F: Non-Invasive Evaluation for Diagnosis, Risk Stratification, And Medical Therapy

OUTCOMES CONSIDERED

Functional status, symptoms, and rate of progression of coronary disease, risk assessment, morbidity and mortality.

MAJOR RECOMMENDATIONS

Presentation of the algorithms is intended to assist the clinician in reviewing and identifying key points that are comprehensively discussed in the guideline document.

An Executive Summary that summarizes the key points of the module precedes each module.

CLINICAL ALGORITHM(s) ARE PROVIDED FOR:

Seven modules include an algorithm:

• Core: Initial Evaluation/Triage
• Module A: Suspected Acute Myocardial Infarction
• Module B: Suspected Acute Coronary Syndrome (Unstable Angina or Non-ST Segment Elevation MI)
• Module C: Management of Stable Angina
• Module G: Follow-up and Secondary Prevention
• Module D: Evaluation and Management of the Asymptomatic Patient        
• Module E: Outpatient Cardiac Rehabilitation
• Module F: Non-invasive Evaluation for Diagnosis, Risk Stratification, and Guidance of Medical Therapy

TYPE OF EVIDENCE

The guideline is supported by the literature in a majority of areas, with evidence-based tables and references throughout the document. The evidence consists of key clinical randomized controlled trials and loMsoNormalngitudinal studies in the area of heart disease. Where existing literature is ambiguous or conflicting, or where scientific data are lacking on an issue, recommendations are based on the expert panel's opinion and clinical experience. The guideline contains a bibliography and discussion of the evidence supporting each recommendation.

DESCRIPTION OF METHODS TO COLLECT EVIDENCE

The literature supporting the decision points and directives in this guideline is referenced in Evidence Tables and Discussions. The working group leaders were solicited for input on focal issues prior to a review of the literature. A search was carried out using the National Library of Medicine's (NLM) MEDLINE database. Electronic searches of the Cochrane Controlled Trials Register ( www.update-software.com ) were undertaken. Papers selected for further review were those published in English-languet peer-reviewed journals between 1994 and 1999. Preference was given to papers based on randomized, controlled clinical trials, or nonrandomized case-control studies. Studies involving meta-analyses were also reviewed.

Selected articles were identified for inclusion in a table of information that was provided to each expert participant. The table of information contained: Title, Author(s), Publication type, Abstract and Source. Copies of these tables were made available to all participants. In addition, the assembled experts suggested numerous additional references. Copies of specific articles were provided to participants on an as-needed basis. This document includes references through the year 2003. More recent information will be included in the next guideline update.

(Note: The research on treatment for IHD is very intensive. During the final editing stages of this guideline, important relevant findings from early 2003 were incorporated into the modules and added to the reference list.)

METHODS TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Evidence-based practice involves integrating clinical expertise with the best available clinical evidence derived from systematic research. The working group reviewed the articles for relevance and graded the evidence using the rating scheme published in the U.S. Preventive Services Task Force (U.S. PSTF) Guide to Clinical Preventive Services, Second Edition (1996), displayed in Table 1. The experts themselves formulated Quality of Evidence (QE) ratings after an orientation and tutorial on the evidence grading process. Each reference was appraised for scientific merit, clinical relevance, and applicability to the populations served by the Federal health care system. The QE rating is based on experimental design and overall quality. Randomized controlled trials (RCT) received the highest ratings (QE=I), while other well-designed studies received a lower score (QE=II-1, II-2, or II-3). The QE ratings are based on the quality, consistency, reproducibility, and relevance of the studies.

The U.S. PSTF grading process suggests assigning a second grade that reflects the strength of the recommendation (SR) for each appraised study. The evidence grade score (i.e., the SR) reflects the significance of the evidence as drawn from the scientific studies, but does not always reflect the importance of the recommendation to individual patient care. Often, the most basic patient management questions and well-accepted care strategies are the most difficult to test through RCTs (i.e., QE=I), especially when experimental design puts patients at risk. For example, no RCTs have been conducted to quantify the value of administering supplemental oxygen to a patient who presents with an AMI.

In lieu of the SR rating, the working group formulated a recommendation rating (R, using a rating scale from A to E. The specific language used to formulate each recommendation conveys panel opinion of both the clinical importance attributed to the topic and the strength of evidence available. When appropriate and necessary, expert opinion was formally derived from the working group panel to supplement or balance the conclusions reached after reviewing the scientific evidence.

Table 2: Recommendation Rating (adapted from Gibbons et al., 1999)