Updating standard advice with modern therapies
If you have heart disease, you probably already know that successfully managing the condition and preventing its progression hinges on your willingness to eliminate unhealthy behaviors and treat high blood pressure, diabetes and cholesterol problems.
As well-established as this advice is, researchers continue to study heart disease therapies so they can recommend the safest and most effective strategies available. As a result, seven leading medical societies, including the American Heart Association and the American College of Physicians, have jointly published revised clinical practice guidelines (Circulation, December 2012) for treating stable ischemic heart diseasethat is, coronary heart disease (CHD) with manageable symptoms.
CHD is a narrowing of the coronary arteries caused by plaque buildup, which impairs the body's ability to pump sufficient blood to the heart. CHD can lead to serious complications such as chest pain (angina), heart attacks, heart failure and irregular heartbeats (arrhythmias).
Combining lifestyle changes and drug therapy is the best way for most patients to control symptoms and prevent a heart attack or other complications, according to the guidelines. Doctors should tailor the recommendations for each individual, since patients have different symptoms, coexisting health conditions and preferences.
Patients should be actively engaged in their care to help achieve a successful outcome, say the guidelines. This means that you should have a say in how your disease is managed with counseling from your doctor. He or she should explain all risk-reduction strategies and therapeutic options, based on strong scientific evidence.
Ask your doctor to show you how to self-monitor your condition (such as home blood pressure or glucose monitoring) and how to recognize worsening symptoms that require immediate medical attention. And be sure to see your primary care physician or cardiologist for a routine checkup at least once a year.
The first step toward keeping heart disease stable is to eliminate unhealthy lifestyle behaviors. The guidelines mostly stick with the tried and true: Eat a healthy diet, control your weight, get regular physical activity, quit smoking, avoid secondhand smoke, manage stress and depression. The new guidelines also add a warning to avoid air pollution. Plus, good lifestyle habits can help make your medicine more effective and may allow you to take a smaller dose, which can reduce side effects.
Drugs can help prevent a heart attack and reduce symptomsa fact that the new guidelines strongly emphasize. They suggest that patients with stable CHD be placed on moderate- to high-dose statins. Bile acid sequestrants, niacin or both are recommended if you can't tolerate statins. If you have coexisting health conditions, such as high blood pressure or diabetes, your doctor will recommend additional drugs.Two other therapies should also be part of your treatment:
- A daily aspirin of 75 to 162 milligrams. If you can't tolerate aspirin, your doctor can prescribe clopidogrel. In some cases, he or she may combine the two.
- An annual flu shot.
If you have angina, besides taking beta-blockers, you should:
- Use nitroglycerin for immediate relief.
- Take a calcium channel blocker or use a long-acting nitrate if beta-blockers aren't effective or have adverse effects. They may also be taken in addition to beta-blockers. If these aren't effective, ranolazine (Ranexa) may be used
When drug therapy is ineffective and you're at high risk for complications, a revascularization procedure may improve symptoms or prevent heart attack and death. The guidelines recommend using either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (angioplasty), depending on the blockage's severity and location.
But before undergoing a procedure, it's worth knowing that the 2007 COURAGE trial found that people with CHD and stable angina who underwent revascularization were unlikely to have any less risk of heart attack or death than those who used drug therapy alone. Make sure your cardiologist or other member of your heart team explicitly describes a procedure's risks, benefits and costs.
Source: Prepared by the Editors of The Johns Hopkins Medical Letter: Health After 50