Management for Stable Ischemic Heart Disease: Part 2

The ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) found that invasive approaches do not benefit endpoints such as cardiovascular death, myocardial infarction or hospitalisation for heart failure. There was also only a modest improvement in quality of life from invasive techniques. Furthermore, revascularisation was tested in a placebo-controlled trial. The results showed no improvement in quality of life nor angina relief in the placebo versus procedure group, bringing under questioning at least a partial placebo effect of the approach.

From this, it is clear that management with non-invasive testing, lifestyle interventions and complementary pharmacological interventions are the most effective route for optimising stable ischemic heart disease outcomes. Although achieving optimal medication for individuals is difficult, it should not justify referral to revascularisation since it does not appear to be the most effective method of management, nor adhere to newly understood causes of heart disease. Effective medical therapy must be explored through medical collaboration with patients to provide an education that allows for patient-directed care. Personal pharmacological interventions must be tailored to target specific underlying causes of ischemia, including drugs such as beta-blockers, ivabradine, ranolazine or trimetazidine (and others).

Overall, clinicians and cardiologists must re-prioritise their thinking regarding heart disease. It is essential to understand that angina may be caused by either obstructive or non-obstructive causes, especially since women are most affected by INOCA.

This review by Boden W et al. aimed to summarise the new shifts required in understanding ischemic heart disease and angina.

Key learnings

Both invasive and non-invasive methods should be used as complementary to lifestyle and pharmacological interventions. The management team must be more co-ordinated, including nurse practitioners, physician assistants and pharmacists to improve optimised medical treatment and patient care. This total evaluation of pharmacotherapy, risk factors and functional/anatomical diagnosis will help to improve our current management of ischemic heart disease.