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B. Obtain Focused History, Physical Exam, And Review Medication And Reversible Risk Factors

OBJECTIVE

Assess clinical predictors for progression of IHD and identify areas for which there are effective interventions.

ANNOTATION

A focused history should include assessment of risk factors for which interventions can improve outcome. All patients should be on appropriate medical therapy. Patients with IHD have a predictable prognosis, and efficacious treatment may be needed, depending on the stage and progression of the disease. Life-saving therapies, such as beta-blockers after MI, aspirin (ASA), angiotensin-converting enzyme (ACE) inhibitors and lipid-lowering therapy, are under-prescribed in patients with known IHD. It is important to review whether such medications are prescribed, dosed appropriately, and actually taken. Medication compliance and adverse drug reactions should be addressed. When feasible, attempt to simplify medication regimens to improve compliance.

EVIDENCE

Table 1. Medical Therapies
  Recommended Medications Sources of Evidence QE   R
1 Aspirin reduces cardiovascular (CV) events in patients with acute MI, previous MI, and unstable angina Antiplatelet Trialists
Collaboration, 1994 		I   A
2 Aspirin reduces risk of MI in patients with chronic stable angina SAPAT, 1992
Physicians' Health Study
Research Group, 1989
Antiplatelet Trialists
Collaboration, 1994 		I   A
3 Beta-blockers improve symptoms in patients with IHD Heidenreich et al., 1999 I   A
4 Beta-blockers improve morbidity and mortality in patients with IHD and previous MI NMS, 1981
BHAT, 1982 		I   A
5 Beta-blockers reduce CV events in patients with silent ischemia ASIST, 1994 I   A
6 ACE inhibitors improve CV outcomes in patients with IHD, and are especially recommended in patients with diabetes or low LV ejection fraction Garg & Yusuf, 1995 I   A
8 Lipid-lowering therapy improves CV outcomes in patients with IHD and elevated lipids 4S, 1994
LIPID, 1998 		I   A
9 Lipid-lowering therapy improves CV outcomes in patients with IHD and average cholesterol CARE, 1996
LIPID, 1998 		I   A
10 Gemfibrozil improves outcomes in patients with IHD and low high-density lipoproteins - cholesterol (HDL-C) VA-HIT, 1999 I   B
QE = Quality of Evidence; R = Recommendation (See Introduction)