Algorithm for Guideline-Directed Medical Therapy for Patients with Stable Ischemic Heart Disease - Flowchart

Algorithm for Guideline-Directed Medical Therapy for Patients with Stable Ischemic Heart Disease - Flowchart

Algorithm for Guideline-Directed Medical Therapy for Patients with Stable Ischemic Heart Disease - Flowchart Coronary Artery Disease Coronary Artery Disease

«Flowchart»

Stable ischemic heart disease^**

Stable ischemic heart disease^**

Stable ischemic heart disease^**

^** ^**

Serious adverse effect or contraindication

Serious adverse effect or contraindication

Serious adverse effect or contraindication

Guideline-directed medical therapy with ongoing patient education

Guideline-directed medical therapy with ongoing patient education

Guideline-directed medical therapy with ongoing patient education

ASA 75 to 162 mg daily

ASA 75 to 162 mg daily

ASA 75 to 162 mg daily

Lifestyle modification including diet, weight loss, physical activity

Lifestyle modification including diet, weight loss, physical activity

Lifestyle modification including diet, weight loss, physical activity

Anginal symptoms?

Anginal symptoms?

Anginal symptoms?

Clopidogrel 75 mg daily or ASA desensitization

Clopidogrel 75 mg daily or ASA desensitization

Clopidogrel 75 mg daily or ASA desensitization

or or

End

End

End

Sublingual NTG

Sublingual NTG

Sublingual NTG

Yes

Yes

Yes

No

No

No

Beta-blocker if no contraindication (Espec. if prior MI, heart failure, or other indication)

Beta-blocker if no contraindication (Espec. if prior MI, heart failure, or other indication)

Beta-blocker if no contraindication (Espec. if prior MI, heart failure, or other indication)

Espec. if prior MI, heart failure, or other indication

Yes

Yes

Yes

Serious contraindication

Serious contraindication

Serious contraindication

Add/substitute ranolazine

Add/substitute ranolazine

Add/substitute ranolazine

Add/substitute
CCB and/or long-acting nitrate if no contraindication

Add/substitute
CCB and/or long-acting nitrate if no contraindication

Add/substitute
CCB and/or long-acting nitrate if no contraindication

Yes

Yes

Yes

Serious contraindication

Serious contraindication

Serious contraindication

Yes

Yes

Yes

Persistent symptoms despite adequate trial of guideline-directed medical therapy

Persistent symptoms despite adequate trial of guideline-directed medical therapy

Persistent symptoms despite adequate trial of guideline-directed medical therapy

Successful treatment?

Successful treatment?

Successful treatment?

Yes

Yes

Yes

No

No

No

Yes

Yes

Yes

Consider revascularization to improve symptoms

Consider revascularization to improve symptoms

Consider revascularization to improve symptoms

Consider revascularization to improve symptoms

Successful treatment?

Successful treatment?

Successful treatment?

Yes

Yes

Yes

No

No

No

Successful treatment?

Successful treatment?

Successful treatment?

Yes

Yes

Yes

No

No

No

See AHA/ACCF cardiovascular risk reduction guideline

See AHA/ACCF cardiovascular risk reduction guideline

See AHA/ACCF cardiovascular risk reduction guideline

Cigarette smoking?

Cigarette smoking?

Cigarette smoking?

Smoking cessation

Smoking cessation

Smoking cessation

Yes

Yes

Yes

Moderate- to high-dose statin

Moderate- to high-dose statin

Moderate- to high-dose statin

Consider adding bile-sequestrant^† or niacin^‡

Consider adding bile-sequestrant^† or niacin^‡

Consider adding bile-sequestrant^† or niacin^‡

^† ^† ^‡ ^‡

Contraindicated or adverse effect

Contraindicated or adverse effect

Contraindicated or adverse effect

Hypertension?

Hypertension?

Hypertension?

See NHLBI ATP III prevention guideline

See NHLBI ATP III prevention guideline

See NHLBI ATP III prevention guideline

BP ≥140/90 mm Hg after diet, physical activity program?

BP ≥140/90 mm Hg after diet, physical activity program?

BP ≥140/90 mm Hg after diet, physical activity program?

≥

Yes

Yes

Yes

Yes

Yes

Yes

Diabetes?

Diabetes?

Diabetes?

Yes

Yes

Yes

Drug therapy to achieve BP <140/90 mm Hg consider ACEI/ARB if LV dysfunction, diabetes, CKD

Drug therapy to achieve BP <140/90 mm Hg consider ACEI/ARB if LV dysfunction, diabetes, CKD

Drug therapy to achieve BP <140/90 mm Hg consider ACEI/ARB if LV dysfunction, diabetes, CKD

LV dysfunction, diabetes, CKD

See JNC VII guidelines

See JNC VII guidelines

See JNC VII guidelines

Appropriate glycemic control

Appropriate glycemic control

Appropriate glycemic control

^**The algorithms do not represent a comprehensive list of recommendations (see text for all recommendations).

^**The algorithms do not represent a comprehensive list of recommendations (see text for all recommendations).

^**The algorithms do not represent a comprehensive list of recommendations (see text for all recommendations).

^**

^†The use of bile acid sequestrant is relatively contraindicated when triglycerides are ≥200 mg/dl and is contraindicated when triglycerides are ≥500 mg/dl.

^†The use of bile acid sequestrant is relatively contraindicated when triglycerides are ≥200 mg/dl and is contraindicated when triglycerides are ≥500 mg/dl.

^†The use of bile acid sequestrant is relatively contraindicated when triglycerides are ≥200 mg/dl and is contraindicated when triglycerides are ≥500 mg/dl.

^† ≥ ≥

^‡Dietary supplement niacin must not be used as a substitute for prescription niacin.

^‡Dietary supplement niacin must not be used as a substitute for prescription niacin.

^‡Dietary supplement niacin must not be used as a substitute for prescription niacin.

^‡