Evaluation and Therapy for Heart Failure in the Setting of Ischemic Heart Disease
Evaluation for CAD
Recommendations
Ongoing assessment for risk factors for CAD is recommended in all patients with chronic HF regardless of LVEF. (Strength of Evidence = A)
It is recommended that the diagnostic approach for CAD be individualized based on patient preference and comorbidities, eligibility, symptoms suggestive of angina and willingness to undergo revascularization. (Strength of Evidence = C)
It is recommended that patients with HF and symptoms suggestive of angina undergo cardiac catheterization with coronary angiography to assess for potential revascularization. (Strength of Evidence = B)
It is recommended that, at the initial diagnosis of HF and any time symptoms worsen without obvious cause, patients with HF, no angina, and known CAD should undergo risk assessment that may include noninvasive stress imaging and/or coronary angiography to assess severity of coronary disease and the presence of ischemia. (Strength of Evidence = C)
It is recommended that patients with HF, no angina, and unknown CAD status who are at high risk for CAD should undergo noninvasive stress imaging and/or coronary angiography to assess severity of coronary disease and the presence of ischemia. (Strength of Evidence = C)
In patients with HF, no angina, and unknown CAD status who are at low risk for CAD noninvasive evaluation should be considered and coronary angiography may be considered. (Strength of Evidence = C)
Any of the following imaging tests should be considered to identify inducible ischemia or viable myocardium:
- Exercise or pharmacologic stress myocardial perfusion imaging
- Exercise or pharmacologic stress echocardiography
- Cardiac magnetic resonance imaging (MRI)
- Positron emission tomography scanning (PET) (Strength of Evidence = B)
Background
Evaluation for CAD in Patents with HF. Multiple studies have evaluated the impact of nuclear viability imaging on intermediate to long-term survival in patients with CAD and LV systolic dysfunction.76-89 However, none of these studies met the criteria published by the Evidence-Based Medicine Group on therapeutic interventions and prognosis.90,91 In these studies treatment allocation to revascularization or medical therapy was often made by physicians who requested and, in some cases, interpreted the viability tests. Viability was never blindly evaluated without impacting subsequent treatment allocation. A randomized clinical trial is necessary to properly evaluate the utility of viability imaging to determine treatment allocation between revascularization and medical therapy and subsequent prognosis.
Recommendation
Any of the following imaging tests should be considered to identify inducible ischemia or viable myocardium:
- Exercise or pharmacologic stress myocardial perfusion imaging
- Exercise or pharmacologic stress echocardiography
- Cardiac magnetic resonance imaging (MRI)
- Positron emission tomography scanning (PET) (Strength of Evidence = B)
Background
For more information on lipid management, smoking cessation, weight management, and physical activity see Sections 3 and 6 in this guideline.