Skip to main content
  • Guideline Summary
  • NGC:009551
  • 2012 Dec 18

2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease.

Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP, Douglas PS, Foody JM, Gerber TC, Hinderliter AL, King SB 3rd, Kligfield PD, Krumholz HM, Kwong RY, Lim MJ, Linderbaum JA, Mack MJ, Munger MA, Prager RL, Sabik JF, Shaw LJ, Sikkema JD, Smith CR Jr, Smith SC Jr, Spertus JA, Williams SV. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol. 2012 Dec 18;60(24):e44-e164. [1266 references] PubMed External Web Site Policy

View the original guideline documentation External Web Site Policy

This is the current release of the guideline.

Age Group

UMLS Concepts (what is this?)

SNOMEDCT_US
Air pollution (102413006), Alcohol consumption counseling (413473000), Angina pectoris (194828000), Angina pectoris (225566008), Angiography (77343006), Antianginal therapy (308117007), Anticholinesterase drug (372765004), Anticholinesterase drug (52761007), Aspirin (387458008), Aspirin (7947003), beta-Blocking agent (33252009), beta-Blocking agent (373254001), Calcium channel blocker (373304005), Calcium channel blocker (48698004), Cardiac rehabilitation (313395003), Chronic myocardial ischemia (413838009), Chronic myocardial ischemia (413844008), Client participation (225330006), Clopidogrel (108979001), Clopidogrel (386952008), Computerized axial tomography (77477000), Coronary angiography (33367005), Coronary artery bypass graft (232717009), Coronary artery bypass graft (67166004), Coronary artery bypass graft (90205004), Counseling (129441002), Counseling (409063005), CT angiography (418272005), Depression screening (171207006), Diabetes clinical management plan (412777005), Echocardiography (40701008), Electrocardiographic procedure (29303009), Exercise tolerance test (165079009), Hemoglobin A1c less than 7% indicating good diabetic control (165679005), HMG-CoA reductase inhibitor (372912004), HMG-CoA reductase inhibitor (96302009), Hypotensive agent (1182007), Hypotensive agent (372586001), Influenza virus vaccine (396425006), Influenza virus vaccine (46233009), Life style (134436002), Life style (60134006), Magnetic resonance imaging (113091000), Magnetic resonance imaging (312250003), Magnetic resonance imaging unit (90003000), Myocardial ischemia (414545008), Myocardial ischemia (414795007), Myocardial revascularization (174911007), Myocardial revascularization (275227003), Myocardial revascularization (81266008), Neurostimulation of spinal cord tissue (231024002), Nitrate salt (89119000), Nitroglycerin (387404004), Nitroglycerin (71759000), Patient education (311401005), Percutaneous coronary intervention (415070008), Physical activity (48761009), Physical activity (68130003), Physical assessment (302199004), Physical assessment (5880005), Physical assessment (81375008), Radionuclide myocardial perfusion study (252432008), Radionuclide myocardial perfusion study (702759004), Ranolazine (420365007), Ranolazine (420624001), Rehabilitation therapy (52052004), Risk assessment (225338004), Therapeutic electrical stimulation (169430000), Therapeutic electrical stimulation (57942008), Ticlopidine (108971003), Ticlopidine (386950000), Weight maintenance regimen (388962008)

Major Recommendations

Definitions for the level of the evidence (A-C) and classes of recommendations (I-III) are provided at the end of the "Major Recommendations" field.

Introduction

Vital Importance of Involvement by an Informed Patient

Class I

  1. Choices about diagnostic and therapeutic options should be made through a process of shared decision making involving the patient and provider, with the provider explaining information about risks, benefits, and costs to the patient. (Level of Evidence: C)

Diagnosis of Stable Ischemic Heart Disease (SIHD)

Clinical Evaluation of Patients with Chest Pain

Clinical Evaluation in the Initial Diagnosis of SIHD in Patients with Chest Pain

Class I

  1. Patients with chest pain should receive a thorough history and physical examination to assess the probability of ischemic heart disease (IHD) before additional testing (Diamond & Forrester, 1979). (Level of Evidence: C)
  2. Patients who present with acute angina should be categorized as stable or unstable; patients with unstable angina (UA) should be further categorized as being at high, moderate, or low risk (Jneid et al., 2012; Wright et al., 2011). (Level of Evidence: C)

Electrocardiography

Resting Electrocardiography to Assess Risk

Class I

  1. A resting electrocardiogram (ECG) is recommended in patients without an obvious, noncardiac cause of chest pain (Daly et al., 2006; Daly et al., 2003; Hammermeister, DeRouen, & Dodge, 1979). (Level of Evidence: B)

Noninvasive Testing for Diagnosis of IHD

Stress Testing and Advanced Imaging for Initial Diagnosis in Patients with Suspected SIHD Who Require Noninvasive Testing

See Table 11 in the original guideline document for a summary of recommendations from this section.

Able to Exercise

Class I

  1. Standard exercise ECG testing is recommended for patients with an intermediate pretest probability of IHD who have an interpretable ECG and at least moderate physical functioning or no disabling comorbidity (Sabharwal et al., 2007; Gianrossi et al., 1989; Kwok et al., 1999; Shaw et al., 2011). (Level of Evidence: A)
  2. Exercise stress with nuclear myocardial perfusion imaging (MPI) or echocardiography is recommended for patients with an intermediate to high pretest probability of IHD who have an uninterpretable ECG and at least moderate physical functioning or no disabling comorbidity (Fleischmann et al., 1998; Garber & Solomon, 1999; Biagini et al., 2006; Geleijnse et al., 2007; Imran, Palinkas, & Picano, 2003; Mahajan et al., 2010; Marcassa et al., 2008; Nandalur et al., 2007; Picano, Molinaro, & Pasanisi, 2008; Underwood et al., "Myocardial perfusion scintigraphy and cost effectiveness," 2004; Underwood et al., "Myocardial perfusion scintigraphy: the evidence," 2004). (Level of Evidence: B)

Class IIa

  1. For patients with a low pretest probability of obstructive IHD who do require testing, standard exercise ECG testing can be useful, provided the patient has an interpretable ECG and at least moderate physical functioning or no disabling comorbidity. (Level of Evidence: C)
  2. Exercise stress with nuclear MPI or echocardiography is reasonable for patients with an intermediate to high pretest probability of obstructive IHD who have an interpretable ECG and at least moderate physical functioning or no disabling comorbidity (Fleischmann et al., 1998; Garber & Solomon, 1999; Biagini et al., 2006; Geleijnse et al., 2007; Imran, Palinkas, & Picano, 2003; Mahajan et al., 2010; Marcassa et al., 2008; Nandalur et al., 2007; Picano, Molinaro, & Pasanisi, 2008; Underwood et al., "Myocardial perfusion scintigraphy and cost effectiveness," 2004; Underwood et al., "Myocardial perfusion scintigraphy: the evidence," 2004). (Level of Evidence: B)
  3. Pharmacological stress with cardiac magnetic resonance (CMR) can be useful for patients with an intermediate to high pretest probability of obstructive IHD who have an uninterpretable ECG and at least moderate physical functioning or no disabling comorbidity (Nandalur et al., 2007; Hamon et al., 2010; Schuetz et al., 2010). (Level of Evidence: B)

Class IIb

  1. Coronary/cardiac computed tomography angiography (CCTA) might be reasonable for patients with an intermediate pretest probability of IHD who have at least moderate physical functioning or no disabling comorbidity (Schuetz et al., 2010; Budoff et al., 2008; Hamon et al., 2006; Janne d'Othee et al., 2008; Meijboom et al., 2008; Miller et al., 2008; Schuijf et al., 2006; Stein et al., 2006; Sun & Jiang, 2006). (Level of Evidence: B)
  2. For patients with a low pretest probability of obstructive IHD who do require testing, standard exercise stress echocardiography might be reasonable, provided the patient has an interpretable ECG and at least moderate physical functioning or no disabling comorbidity. (Level of Evidence: C)

Class III: No Benefit

  1. Pharmacological stress with nuclear MPI, echocardiography, or CMR is not recommended for patients who have an interpretable ECG and at least moderate physical functioning or no disabling comorbidity (Underwood et al., "Myocardial perfusion scintigraphy and cost effectiveness," 2004; Underwood et al., 1999; Nucifora et al., 2011). (Level of Evidence: C)
  2. Exercise stress with nuclear MPI is not recommended as an initial test in low-risk patients who have an interpretable ECG and at least moderate physical functioning or no disabling comorbidity. (Level of Evidence: C)

Unable To Exercise

Class I

  1. Pharmacological stress with nuclear MPI or echocardiography is recommended for patients with an intermediate to high pretest probability of IHD who are incapable of at least moderate physical functioning or have disabling comorbidity (Biagini et al., 2006; Geleijnse et al., 2007; Imran, Palinkas, & Picano, 2003; Marcassa et al., 2008; Nandalur et al., 2007; Picano, Molinaro, & Pasanisi, 2008; Underwood et al., "Myocardial perfusion scintigraphy and cost effectiveness," 2004; Underwood et al., "Myocardial perfusion scintigraphy: the evidence," 2004). (Level of Evidence: B)

Class IIa

  1. Pharmacological stress echocardiography is reasonable for patients with a low pretest probability of IHD who require testing and are incapable of at least moderate physical functioning or have disabling comorbidity. (Level of Evidence: C)
  2. CCTA is reasonable for patients with a low to intermediate pretest probability of IHD who are incapable of at least moderate physical functioning or have disabling comorbidity (Schuetz et al., 2010; Budoff et al., 2008; Hamon et al., 2006; Janne d'Othee et al., 2008; Meijboom et al., 2008; Miller et al., 2008; Schuijf et al., 2006; Stein et al., 2006; Sun & Jiang, 2006). (Level of Evidence: B)
  3. Pharmacological stress CMR is reasonable for patients with an intermediate to high pretest probability of IHD who are incapable of at least moderate physical functioning or have disabling comorbidity (Nandalur et al., 2007; Hamon et al., 2010; Schuetz et al., 2010; Greenwood et al., 2012; Hundley et al., 1999; Nagel et al., 1999; Schwitter et al., 2008). (Level of Evidence: B)

Class III: No Benefit

  1. Standard exercise ECG testing is not recommended for patients who have an uninterpretable ECG or are incapable of at least moderate physical functioning or have disabling comorbidity (Fleischmann et al., 1998; Garber & Solomon, 1999; Biagini et al., 2006; Geleijnse et al., 2007; Imran, Palinkas, & Picano, 2003; Mahajan et al., 2010; Marcassa et al., 2008; Nandalur et al., 2007; Picano, Molinaro, & Pasanisi, 2008; Underwood et al., "Myocardial perfusion scintigraphy and cost effectiveness," 2004; Underwood et al., "Myocardial perfusion scintigraphy: the evidence," 2004; Janne d'Othee et al., 2008). (Level of Evidence: C)

Other

Class IIa

  1. CCTA is reasonable for patients with an intermediate pretest probability of IHD who a) have continued symptoms with prior normal test findings, or b) have inconclusive results from prior exercise or pharmacological stress testing, or c) are unable to undergo stress with nuclear MPI or echocardiography (de Azevedo et al., 2011). (Level of Evidence: C)

Class IIb

  1. For patients with a low to intermediate pretest probability of obstructive IHD, noncontrast cardiac computed tomography (CT) to determine the coronary artery calcium (CAC) score may be considered (Sarwar et al., 2009). (Level of Evidence: C)

Risk Assessment

Advanced Testing: Resting and Stress Noninvasive Testing

Resting Imaging to Assess Cardiac Structure and Function

Class I

  1. Assessment of resting left ventricular (LV) systolic and diastolic ventricular function and evaluation for abnormalities of myocardium, heart valves, or pericardium are recommended with the use of Doppler echocardiography in patients with known or suspected IHD and a prior myocardial infarction (MI), pathological Q waves, symptoms or signs suggestive of heart failure, complex ventricular arrhythmias, or an undiagnosed heart murmur (Hunt et al., 2009; Daly et al., 2006; Daly et al., 2003; Mock et al., 1982; Vitarelli et al., 2003). (Level of Evidence: B)

Class IIb

  1. Assessment of cardiac structure and function with resting echocardiography may be considered in patients with hypertension or diabetes mellitus and an abnormal ECG. (Level of Evidence: C)
  2. Measurement of LV function with radionuclide imaging may be considered in patients with a prior MI or pathological Q waves, provided there is no need to evaluate symptoms or signs suggestive of heart failure, complex ventricular arrhythmias, or an undiagnosed heart murmur. (Level of Evidence: C)

Class III: No Benefit

  1. Echocardiography, radionuclide imaging, CMR, and cardiac CT are not recommended for routine assessment of LV function in patients with a normal ECG, no history of MI, no symptoms or signs suggestive of heart failure, and no complex ventricular arrhythmias. (Level of Evidence: C)
  2. Routine reassessment (<1 year) of LV function with technologies such as echocardiography radionuclide imaging, CMR, or cardiac CT is not recommended in patients with no change in clinical status and for whom no change in therapy is contemplated. (Level of Evidence: C)

Stress Testing and Advanced Imaging in Patients with Known SIHD Who Require Noninvasive Testing for Risk Assessment

See Table 12 in the original guideline document for a summary of recommendations from this section.

Risk Assessment in Patients Able to Exercise

Class I

  1. Standard exercise ECG testing is recommended for risk assessment in patients with SIHD who are able to exercise to an adequate workload and have an interpretable ECG (Christian et al., 1994; Gibbons et al., 1990; Hachamovitch et al., 2004; Ladenheim et al., 1987; Mattera et al., 1998; Mowatt et al., 2004; Nallamothu et al., 1995; Sabharwal et al., 2007; Garber & Solomon, 1999; Kuntz et al., 1999; Lorenzoni et al., 2003). (Level of Evidence: B)
  2. The addition of either nuclear MPI or echocardiography to standard exercise ECG testing is recommended for risk assessment in patients with SIHD who are able to exercise to an adequate workload but have an uninterpretable ECG not due to left bundle-branch block (LBBB) or ventricular pacing (Gibbons et al., 2003; Metz et al., 2007; Nagao et al., 2007; Leischik et al., 2007; Johansen et al., 2006; Wagdy et al., 1998; McCully et al., 2002; Shaw et al., 2003). (Level of Evidence: B)

Class IIa

  1. The addition of either nuclear MPI or echocardiography to standard exercise ECG testing is reasonable for risk assessment in patients with SIHD who are able to exercise to an adequate workload and have an interpretable ECG (Bouzas-Mosquera et al., 2009; Navare et al., 2004; Gebker et al., 2011; Peteiro et al., 2010; Yao et al., 2012; Shaw et al., 2012; Hachamovitch et al., 2011; Doesch et al., 2009; Jahnke et al., 2007). (Level of Evidence: B)
  2. CMR with pharmacological stress is reasonable for risk assessment in patients with SIHD who are able to exercise to an adequate workload but have an uninterpretable ECG (Jahnke et al., 2007; Bingham & Hachamovitch, 2011; Coelho-Filho et al., 2011; Kelle et al., 2011; Korosoglou et al., 2010; Steel et al., 2009). (Level of Evidence: B)

Class IIb

  1. CCTA may be reasonable for risk assessment in patients with SIHD who are able to exercise to an adequate workload but have an uninterpretable ECG (Chow et al., 2010; Min et al., 2011). (Level of Evidence: B)

Class III: No Benefit

  1. Pharmacological stress imaging (nuclear MPI, echocardiography, or CMR) or CCTA is not recommended for risk assessment in patients with SIHD who are able to exercise to an adequate workload and have an interpretable ECG. (Level of Evidence: C)

Risk Assessment in Patients Unable to Exercise

Class I

  1. Pharmacological stress with either nuclear MPI or echocardiography is recommended for risk assessment in patients with SIHD who are unable to exercise to an adequate workload regardless of interpretability of ECG (Gibbons et al., 2003; Nagao et al., 2007; Leischik et al., 2007; Johansen et al., 2006; America et al., 2007; Gil et al., 1998; Nallamothu et al., 1997; Nigam & Humen, 1998). (Level of Evidence: B)

Class IIa

  1. Pharmacological stress CMR is reasonable for risk assessment in patients with SIHD who are unable to exercise to an adequate workload regardless of interpretability of ECG (Bingham & Hachamovitch, 2011; Coelho-Filho et al., 2011; Kelle et al., 2011; Korosoglou et al., 2010; Steel et al., 2009; Pilz et al., 2008). (Level of Evidence: B)
  2. CCTA can be useful as a first-line test for risk assessment in patients with SIHD who are unable to exercise to an adequate workload regardless of interpretability of ECG (Min et al., 2011). (Level of Evidence: C)

Risk Assessment Regardless of Patients' Ability to Exercise

Class I

  1. Pharmacological stress with either nuclear MPI or echocardiography is recommended for risk assessment in patients with SIHD who have LBBB on ECG, regardless of ability to exercise to an adequate workload (America et al., 2007; Gil et al., 1998; Nallamothu et al., 1997; Nigam & Humen, 1998; Tandogan et al., 2001). (Level of Evidence: B)
  2. Either exercise or pharmacological stress with imaging (nuclear MPI, echocardiography, or CMR) is recommended for risk assessment in patients with SIHD who are being considered for revascularization of known coronary stenosis of unclear physiological significance (Johansen et al., 2006; Doesch et al., 2009; Hacker et al., 2007; Yao, Bangalore, & Chaudhry, 2010). (Level of Evidence: B)

Class IIa

  1. CCTA can be useful for risk assessment in patients with SIHD who have an indeterminate result from functional testing (Min et al., 2011). (Level of Evidence: C)

Class IIb

  1. CCTA might be considered for risk assessment in patients with SIHD unable to undergo stress imaging or as an alternative to invasive coronary angiography when functional testing indicates a moderate- to high-risk result and knowledge of angiographic coronary anatomy is unknown. (Level of Evidence: C)

Class III: No Benefit

  1. A request to perform either a) more than one stress imaging study or b) a stress imaging study and a CCTA at the same time is not recommended for risk assessment in patients with SIHD. (Level of Evidence: C)

Coronary Angiography

Coronary Angiography as an Initial Testing Strategy to Assess Risk

Class I

  1. Patients with SIHD who have survived sudden cardiac death or potentially life-threatening ventricular arrhythmia should undergo coronary angiography to assess cardiac risk ("Survivors," 1997; Every et al., 1992; Spaulding et al., 1997). (Level of Evidence: B)
  2. Patients with SIHD who develop symptoms and signs of heart failure should be evaluated to determine whether coronary angiography should be performed for risk assessment (Califf et al., 1989; Myers et al., 1989; Myers et al., 1987; Bonow et al., 2011). (Level of Evidence: B)

Coronary Angiography to Assess Risk After Initial Workup with Noninvasive Testing

Class I

  1. Coronary arteriography is recommended for patients with SIHD whose clinical characteristics and results of noninvasive testing indicate a high likelihood of severe IHD and when the benefits are deemed to exceed risk (Hammermeister, DeRouen, & Dodge, 1979; Mark et al., 1987; Mock et al., 1982; Hachamovitch et al., 1998; Brunelli, Cristofani, & L'Abbate, 1989; Chuah et al., 1998; Harris et al., 1979; Ladenheim et al., 1986; Marwick et al., 1997; Morrow et al., 1993; Stratmann et al., 1994). (Level of Evidence: C)

Class IIa

  1. Coronary angiography is reasonable to further assess risk in patients with SIHD who have depressed LV function (ejection fraction [EF] <50%) and moderate risk criteria on noninvasive testing with demonstrable ischemia (Miller et al., 1994; Emond et al., 1994; Alderman et al., 1983). (Level of Evidence: C)
  2. Coronary angiography is reasonable to further assess risk in patients with SIHD and inconclusive prognostic information after noninvasive testing or in patients for whom noninvasive testing is contraindicated or inadequate. (Level of Evidence: C)
  3. Coronary angiography for risk assessment is reasonable for patients with SIHD who have unsatisfactory quality of life due to angina, have preserved LV function (EF >50%), and have intermediate risk criteria on noninvasive testing (Shaw et al., 2008; Boden et al., 2007). (Level of Evidence: C)

Class III: No Benefit

  1. Coronary angiography for risk assessment is not recommended in patients with SIHD who elect not to undergo revascularization or who are not candidates for revascularization because of comorbidities or individual preferences (Shaw et al., 2008; Boden et al., 2007). (Level of Evidence: B)
  2. Coronary angiography is not recommended to further assess risk in patients with SIHD who have preserved LV function (EF >50%) and low-risk criteria on noninvasive testing (Shaw et al., 2008; Boden et al., 2007). (Level of Evidence: B)
  3. Coronary angiography is not recommended to assess risk in patients who are at low risk according to clinical criteria and who have not undergone noninvasive risk testing. (Level of Evidence: C)
  4. Coronary angiography is not recommended to assess risk in asymptomatic patients with no evidence of ischemia on noninvasive testing. (Level of Evidence: C)

Treatment

Patient Education

Class I

  1. Patients with SIHD should have an individualized education plan to optimize care and promote wellness, including:
    1. Education on the importance of medication adherence for managing symptoms and retarding disease progression (McGillion et al., 2007; Muszbek et al., 2008; Rao et al., 2004) (Level of Evidence: C)
    2. An explanation of medication management and cardiovascular risk reduction strategies in a manner that respects the patient's level of understanding, reading comprehension, and ethnicity (Smith et al., 2011; Mosca et al., 2011; Joint Commission, 2007; Miller & Taylor, 1995; DeBusk et al., 1994; Haskell et al., 1994;) (Level of Evidence: B)
    3. A comprehensive review of all therapeutic options (Smith et al., 2011; Joint Commission, 2007; Miller & Taylor, 1995; DeBusk et al., 1994; Haskell et al., 1994) (Level of Evidence: B)
    4. A description of appropriate levels of exercise, with encouragement to maintain recommended levels of daily physical activity (Smith et al., 2011; American Heart Association Nutrition Committee et al., 2006; Thompson et al., 2003; Thompson et al., 2007; Artinian et al., 2010) (Level of Evidence: C)
    5. Introduction to self-monitoring skills (American Heart Association Nutrition Committee et al., 2006; Thompson et al., 2007; Artinian et al., 2010) (Level of Evidence: C)
    6. Information on how to recognize worsening cardiovascular symptoms and take appropriate action. (Level of Evidence: C)
  2. Patients with SIHD should be educated about the following lifestyle elements that could influence prognosis: weight control, maintenance of a body mass index (BMI) of 18.5 to 24.9 kg/m2, and maintenance of a waist circumference less than 102 cm (40 inches) in men and less than 88 cm (35 inches) in women (less for certain racial groups) (Smith et al., 2011; Mosca et al., 2011; National Heart Lung and Blood Institute [NHLBI], 1998; Oka et al., 2008; Tan et al., 2004; Buse et al., 2007); lipid management ("Third Report," 2002); blood pressure (BP) control (Chobanian et al., 2003; Bosworth et al., 2007); smoking cessation and avoidance of exposure to secondhand smoke (Smith et al., 2011; "The 2004 United States Surgeon General's Report," 2004; Critchley & Capewell, "Mortality," 2003); and individualized medical, nutrition, and lifestyle changes for patients with diabetes mellitus to supplement diabetes treatment goals and education (American Diabetes Association, 2011). (Level of Evidence: C)

Class IIa

  1. It is reasonable to educate patients with SIHD about:
    1. Adherence to a diet that is low in saturated fat, cholesterol, and trans fat; high in fresh fruits, whole grains, and vegetables; and reduced in sodium intake, with cultural and ethnic preferences incorporated (Smith et al., 2011; Chobanian et al., 2003; "Third Report," 2002; Appel et al., 2003; Cholesterol Treatment Trialists' [CTT] Collaboration et al., 2010) (Level of Evidence: B)
    2. Common symptoms of stress and depression to minimize stress-related angina symptoms (Frattaroli et al., 2008) (Level of Evidence: C)
    3. Comprehensive behavioral approaches for the management of stress and depression (Berkman et al., 2003; Carney et al., 1995; Rees et al., 2004; Ziegelstein et al., 2000) (Level of Evidence: C)
    4. Evaluation and treatment of major depressive disorder when indicated (Berkman et al., 2003; Glassman et al., 2002; McGillion et al., 2007; Rees et al., 2004; Lesperance et al., 2007; McManus, Pipkin, & Whooley, 2005; Whooley, 2006; Lichtman et al., 2008). (Level of Evidence: B)

Guideline-Directed Medical Therapy (GDMT)

Risk Factor Modification

Lipid Management

Class I

  1. Lifestyle modifications, including daily physical activity and weight management, are strongly recommended for all patients with SIHD ("Third Report," 2002; Dattilo & Kris-Etherton, 1992). (Level of Evidence: B)
  2. Dietary therapy for all patients should include reduced intake of saturated fats (to <7% of total calories), trans fatty acids (to <1% of total calories), and cholesterol (to <200 mg/d) ("Third Report," 2002; Ginsberg et al., 1998; Schaefer et al., 1997; Schaefer et al., 1995; Yu-Poth et al., 1999). (Level of Evidence: B)
  3. In addition to therapeutic lifestyle changes, a moderate or high dose of a statin therapy should be prescribed, in the absence of contraindications or documented adverse effects ("Third Report," 2002; Heart Protection Study Collaborative Group, 2002; LaRosa et al., 2005; CTT Collaboration et al., 2010; Pedersen et al., 2005). (Level of Evidence: A)

Class IIa

  1. For patients who do not tolerate statins, low-density lipoprotein (LDL) cholesterol–lowering therapy with bile acid sequestrants,* niacin, or both is reasonable ("The Lipid Research Clinics," 1984; Canner et al., 1986; Brown et al., 2001). (Level of Evidence: B)

*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.

Blood Pressure Management

Class I

  1. All patients should be counseled about the need for lifestyle modification: weight control; increased physical activity; alcohol moderation; sodium reduction; and emphasis on increased consumption of fresh fruits, vegetables, and low-fat dairy products (Chobanian et al., 2003; "Effects of weight loss," 1997; Stevens et al., 1993; Whelton et al., 1998; Appel et al., 1997; Sacks et al., 2001; MacGregor et al., 1989; Whelton et al., 2002; Xin et al., 2001; Appel et al., 2011). (Level of Evidence: B)
  2. In patients with SIHD with BP 140/90 mm Hg or higher, antihypertensive drug therapy should be instituted in addition to or after a trial of lifestyle modifications ("Medical Research Council," 1992; SHEP Cooperative Research Group, 1991; "MRC trial of treatment," 1985; "Effect of stepped care," 1984; "The effect of treatment," 1982; "Five-year findings," 1979). (Level of Evidence: A)
  3. The specific medications used for treatment of high BP should be based on specific patient characteristics and may include angiotensin-converting enzyme (ACE) inhibitors and/or beta blockers, with addition of other drugs, such as thiazide diuretics or calcium channel blockers, if needed to achieve a goal BP of less than 140/90 mm Hg ("Major outcomes," 2002; Turnbull, 2003). (Level of Evidence: B)

Diabetes Management

Class IIa

  1. For selected individual patients, such as those with a short duration of diabetes mellitus and a long life expectancy, a goal hemoglobin A1c (HbA1c) of 7% or less is reasonable (Diabetes Control and Complications Trial Research Group, 1993; U.K. Prospective Diabetes Study [UKPDS] Group, 1998; ADVANCE Collaborative Group et al., 2008). (Level of Evidence: B)
  2. A goal HbA1c between 7% and 9% is reasonable for certain patients according to age, history of hypoglycemia, presence of microvascular or macrovascular complications, or presence of coexisting medical conditions (Dluhy & McMahon, 2008; Duckworth et al., 2009). (Level of Evidence: C)

Class IIb

  1. Initiation of pharmacotherapy interventions to achieve target HbA1c might be reasonable (American Diabetes Association, 2011; Nathan et al., 2005; "Effect of intensive," 1998; Dormandy et al., 2005; Skyler et al., 2009; Kelly et al., 2009; Selvin et al., 2008; Turnbull et al., 2009; Ray et al., 2009; Currie et al., 2010; Holman et al., 2008). (Level of Evidence: A)

Class III: Harm

  1. Therapy with rosiglitazone should not be initiated in patients with SIHD (Loke, Kwok, & Singh, 2011; Woodcock, 2010). (Level of Evidence: C)

Physical Activity

Class I

  1. For all patients, the clinician should encourage 30 to 60 minutes of moderate-intensity aerobic activity, such as brisk walking, at least 5 days and preferably 7 days per week, supplemented by an increase in daily lifestyle activities (e.g., walking breaks at work, gardening, household work) to improve cardiorespiratory fitness and move patients out of the least-fit, least-active, high-risk cohort (bottom 20%) (Taylor et al., 2004; Haskell et al., 2007; U.S. Department of Health and Human Services, 2008). (Level of Evidence: B)
  2. For all patients, risk assessment with a physical activity history and/or an exercise test is recommended to guide prognosis and prescription (Ken-Dror et al., 2004; Cardinal, 1996; Nowak et al., 2010; Jurca et al., 2005). (Level of Evidence: B)
  3. Medically supervised programs (cardiac rehabilitation) and physician-directed, home-based programs are recommended for at-risk patients at first diagnosis (Taylor et al., 2004; Taylor et al., 2010; Clark et al., 2010). (Level of Evidence: A)

Class IIa

  1. It is reasonable for the clinician to recommend complementary resistance training at least 2 days per week (McCartney et al., 1991; Beniamini et al., 1999). (Level of Evidence: C)

Weight Management

Class I

  1. BMI and/or waist circumference should be assessed at every visit, and the clinician should consistently encourage weight maintenance or reduction through an appropriate balance of lifestyle physical activity, structured exercise, caloric intake, and formal behavioral programs when indicated to maintain or achieve a BMI between 18.5 and 24.9 kg/m2 and a waist circumference less than 102 cm (40 inches) in men and less than 88 cm (35 inches) in women (less for certain racial groups) (Grundy et al., 2005; NHLBI, 1998; Bogers et al., 2007; Klein et al., 2004; Calle et al., 1999; Jensen et al., 2008; Arnlov et al., 2010; Lavie, Milani & Ventura, 2009; Gruberg et al., 2002; Jacobs et al., 2010). (Level of Evidence: B)
  2. The initial goal of weight loss therapy should be to reduce body weight by approximately 5% to 10% from baseline. With success, further weight loss can be attempted if indicated. (Level of Evidence: C)

Smoking Cessation Counseling

Class I

  1. Smoking cessation and avoidance of exposure to environmental tobacco smoke at work and home should be encouraged for all patients with SIHD. Follow-up, referral to special programs, and pharmacotherapy are recommended, as is a stepwise strategy for smoking cessation (Ask, Advise, Assess, Assist, Arrange, Avoid) (Critchley & Capewell, "Smoking," 2003; Rigotti, 2009; Smith & Burgess, 2009). (Level of Evidence: B)

Management of Psychological Factors

Class IIa

  1. It is reasonable to consider screening SIHD patients for depression and to refer or treat when indicated (Berkman et al., 2003; Ruo et al., 2003; Yoshinaga et al., 2006; Appel et al., 2003; Lesperance et al., 2007; Honig et al., 2007; DiMatteo, Lepper, & Croghan, 2000). (Level of Evidence: B)

Class IIb

  1. Treatment of depression has not been shown to improve cardiovascular disease outcomes but might be reasonable for its other clinical benefits (Berkman et al., 2003; Glassman et al., 2002; Taylor et al., 2005). (Level of Evidence: C)

Alcohol Consumption

Class IIb

  1. In patients with SIHD who use alcohol, it might be reasonable for nonpregnant women to have 1 drink (4 ounces of wine, 12 ounces of beer, or 1 ounce of spirits) a day and for men to have 1 or 2 drinks a day, unless alcohol is contraindicated (such as in patients with a history of alcohol abuse or dependence or with liver disease) (Di Castelnuovo et al., 2002; Mukamal et al., 2001; Muntwyler et al., 1998). (Level of Evidence: C)

Avoiding Exposure to Air Pollution

Class IIa

  1. It is reasonable for patients with SIHD to avoid exposure to increased air pollution to reduce the risk of cardiovascular events (Pope et al., 2004; Pope et al., 2006; Pope, 2007; Brook et al., 2010). (Level of Evidence: C)

Additional Medical Therapy to Prevent MI and Death

Antiplatelet Therapy

Class I

  1. Treatment with aspirin 75 to 162 mg daily should be continued indefinitely in the absence of contraindications in patients with SIHD (Antithrombotic Trialists' Collaboration, 2002; Juul-Moller et al., 1992). (Level of Evidence: A)
  2. Treatment with clopidogrel is reasonable when aspirin is contraindicated in patients with SIHD (CAPRIE Steering Committee, 1996). (Level of Evidence: B)

Class IIb

  1. Treatment with aspirin 75 to 162 mg daily and clopidogrel 75 mg daily might be reasonable in certain high-risk patients with SIHD (Bhatt et al., 2007). (Level of Evidence: B)

Class III: No Benefit

  1. Dipyridamole is not recommended as antiplatelet therapy for patients with SIHD (Hirsh et al., 1995; Balsano et al., 1990; "The Persantine-aspirin reinfarction study," 1980). (Level of Evidence: B)

Beta-Blocker Therapy

Class I

  1. Beta-blocker therapy should be started and continued for 3 years in all patients with normal LV function after MI or acute coronary syndrome (ACS) (Kernis et al., 2004; de Peuter et al., 2009; Freemantle et al., 1999). (Level of Evidence: B)
  2. Beta-blocker therapy should be used in all patients with LV systolic dysfunction (EF ≤40%) with heart failure or prior MI, unless contraindicated. (Use should be limited to carvedilol, metoprolol succinate, or bisoprolol, which have been shown to reduce risk of death.) (Tepper, 1999; Packer et al., 1996; Leizorovicz et al., 2002; Poole-Wilson et al., 2003; Domanski et al., 2003) (Level of Evidence: A)

Class IIb

  1. Beta blockers may be considered as chronic therapy for all other patients with coronary or other vascular disease. (Level of Evidence: C)

Renin-Angiotensin-Aldosterone Blocker Therapy

Class I

  1. ACE inhibitors should be prescribed in all patients with SIHD who also have hypertension, diabetes mellitus, left ventricular ejection fraction (LVEF) 40% or less, or chronic kidney disease (CKD), unless contraindicated (Braunwald et al., 2004; Fox, 2003; Garg & Yusuf, 1995; Kunz et al., 2008; Yusuf et al., "Effects," 2000). (Level of Evidence: A)
  2. Angiotensin-receptor blockers (ARBs) are recommended for patients with SIHD who have hypertension, diabetes mellitus, LV systolic dysfunction, or CKD and have indications for, but are intolerant of, ACE inhibitors (McMurray et al., 2003; Nissen et al., 2004; Julius et al., 2006). (Level of Evidence: A)

Class IIa

  1. Treatment with an ACE inhibitor is reasonable in patients with both SIHD and other vascular disease (Danchin et al., 2006; Al-Mallah et al., 2006). (Level of Evidence: B)
  2. It is reasonable to use ARBs in other patients who are ACE inhibitor intolerant (Pitt et al., 2001). (Level of Evidence: C) (see Table 15 in the original guideline document.)

Influenza Vaccination

Class I

  1. An annual influenza vaccine is recommended for patients with SIHD ("H5N1 avian influenza," 2005; Davis et al., 2006; de Diego et al., 2009; Couch et al., 2007; Keitel et al., 2006). (Level of Evidence: B)

Additional Therapy to Reduce Risk of MI and Death

Class III: No Benefit

  1. Estrogen therapy is not recommended in postmenopausal women with SIHD with the intent of reducing cardiovascular risk or improving clinical outcomes (Hulley et al., 1998; Anderson et al., 2004; Manson et al., 2003; Rossouw et al., 2002). (Level of Evidence: A)
  2. Vitamin C, vitamin E, and beta-carotene supplementation are not recommended with the intent of reducing cardiovascular risk or improving clinical outcomes in patients with SIHD (Heart Protection Study Collaborative Group, 2002; "Dietary supplementation," 1999; de Gaetano, 2001; Stephens et al., 1996; Yusuf et al., "Vitamin E," 2000; Bjelakovic et al., 2007). (Level of Evidence: A)
  3. Treatment of elevated homocysteine with folate or vitamins B6 and B12 is not recommended with the intent of reducing cardiovascular risk or improving clinical outcomes in patients with SIHD (Bazzano et al., 2006; Bonaa et al., 2006; Lonn et al., 2006; Toole et al., 2004). (Level of Evidence: A)
  4. Chelation therapy is not recommended with the intent of improving symptoms or reducing cardiovascular risk in patients with SIHD (Guldager et al., 1992; van Rij et al., 1994; Sloth-Nielsen et al., 1991; Knudtson et al., 2002). (Level of Evidence: C)
  5. Treatment with garlic, coenzyme Q10, selenium, or chromium is not recommended with the intent of reducing cardiovascular risk or improving clinical outcomes in patients with SIHD. (Level of Evidence: C)

Medical Therapy for Relief of Symptoms

Use of Anti-ischemic Medications

Class I

  1. Beta blockers should be prescribed as initial therapy for relief of symptoms in patients with SIHD (Kernis et al., 2004; Frishman et al., 1991; Narahara, 1990). (Level of Evidence: B)
  2. Calcium channel blockers or long-acting nitrates should be prescribed for relief of symptoms when beta blockers are contraindicated or cause unacceptable side effects in patients with SIHD (Heidenreich et al., 1999; Ryden, 1992; Boberg, Larsen, & Pehrsson, 1992). (Level of Evidence: B)
  3. Calcium channel blockers or long-acting nitrates, in combination with beta blockers, should be prescribed for relief of symptoms when initial treatment with beta blockers is unsuccessful in patients with SIHD (Heidenreich et al., 1999). (Level of Evidence: B)
  4. Sublingual nitroglycerin or nitroglycerin spray is recommended for immediate relief of angina in patients with SIHD (Abrams, 2005; Wight et al., 1992; VandenBurg et al., 1986). (Level of Evidence: B)

Class IIa

  1. Treatment with a long-acting nondihydropyridine calcium channel blocker (verapamil or diltiazem) instead of a beta blocker as initial therapy for relief of symptoms is reasonable in patients with SIHD (Heidenreich et al., 1999). (Level of Evidence: B)
  2. Ranolazine can be useful when prescribed as a substitute for beta blockers for relief of symptoms in patients with SIHD if initial treatment with beta blockers leads to unacceptable side effects or is ineffective or if initial treatment with beta blockers is contraindicated (Rousseau et al., 2005). (Level of Evidence: B)
  3. Ranolazine in combination with beta blockers can be useful when prescribed for relief of symptoms when initial treatment with beta blockers is not successful in patients with SIHD (Chaitman et al., 2004; Stone et al., 2006). (Level of Evidence: A)

Alternative Therapies for Relief of Symptoms in Patients with Refractory Angina

Class IIb

  1. Enhanced external counterpulsation (EECP) may be considered for relief of refractory angina in patients with SIHD (Arora et al., 1999). (Level of Evidence: B)
  2. Spinal cord stimulation may be considered for relief of refractory angina in patients with SIHD (Mannheimer et al., 1998; Hautvast et al., 1998). (Level of Evidence: C)
  3. Transmyocardial revascularization (TMR) may be considered for relief of refractory angina in patients with SIHD (van der Sloot et al., 2004; Guleserian et al., 2003; Myers et al., 2002). (Level of Evidence: B)

Class III: No Benefit

  1. Acupuncture should not be used for the purpose of improving symptoms or reducing cardiovascular risk in patients with SIHD (Ballegaard et al., 1990; Ballegaard et al., 1986). (Level of Evidence: C)

Coronary Artery Disease (CAD) Revascularization

Heart Team Approach to Revascularization Decisions

Class I

  1. A Heart Team approach to revascularization is recommended in patients with unprotected left main or complex CAD (Serruys et al., 2009; Feit et al., 2000; King et al., 1997). (Level of Evidence: C)

Class IIa

  1. Calculation of the Society of Thoracic Surgeons (STS) and Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery (SYNTAX) scores is reasonable in patients with unprotected left main and complex CAD (Morice et al., 2010; Serruys et al., 2009; Chakravarty et al., 2011; Grover et al., 2001; Kim et al., 2010; Shahian et al., 2009; Shahian et al., 2010). (Level of Evidence: B)

Revascularization to Improve Survival

Left Main CAD Revascularization

Class I

  1. Coronary artery bypass graft (CABG) to improve survival is recommended for patients with significant (≥50% diameter stenosis) left main coronary artery stenosis (Chaitman et al., 1981; Caracciolo et al., 1995; Yusuf et al., 1994; Dzavik et al., 2001; Takaro et al., 1976; Takaro et al., 1982; Taylor et al., 1989). (Level of Evidence: B)

Class IIa

  1. Percutaneous coronary intervention (PCI) to improve survival is reasonable as an alternative to CABG in selected stable patients with significant (≥50% diameter stenosis) unprotected left main CAD with: 1) anatomic conditions associated with a low risk of PCI procedural complications and a high likelihood of good long-term outcome (e.g., a low SYNTAX score [≤22], ostial or trunk left main CAD); and 2) clinical characteristics that predict a significantly increased risk of adverse surgical outcomes (e.g., STS-predicted risk of operative mortality ≥5%) (Morice et al., 2010; Chakravarty et al., 2011; Kim et al., 2010; Buszman et al., 2008; Capodanno et al., 2011; Hannan et al., 2008; Ellis et al., 1997; Biondi-Zoccai et al., 2008; Boudriot et al., 2011; Brener et al., 2008; Chieffo et al., 2010; Chieffo et al., 2006; Lee et al., 2006; Makikallio et al., 2008; Naik et al., 2009; Palmerini et al., 2006; Park et al., 2010; Rodes-Cabau et al., 2008; Sanmartin et al., 2007; Seung et al., 2008; White et al., 2008). (Level of Evidence: B)
  2. PCI to improve survival is reasonable in patients with unstable angina/non–ST-elevation myocardial infarction (UA/NSTEMI) when an unprotected left main coronary artery is the culprit lesion and the patient is not a candidate for CABG (Morice et al., 2010; Brener et al., 2008; Chieffo et al., 2010; Chieffo et al., 2006; Lee et al., 2006; Rodes-Cabau et al., 2008; Sanmartin et al., 2007; Seung et al., 2008; White et al., 2008; Montalescot et al., 2009). (Level of Evidence: B)
  3. PCI to improve survival is reasonable in patients with acute ST-elevation myocardial infarction (STEMI) when an unprotected left main coronary artery is the culprit lesion, distal coronary flow is less than TIMI (Thrombolysis In Myocardial Infarction) grade 3, and PCI can be performed more rapidly and safely than CABG (Ellis et al., 1997; Lee et al., 2008; Lee et al., 2010). (Level of Evidence: C)

Class IIb

  1. PCI to improve survival may be reasonable as an alternative to CABG in selected stable patients with significant (≥50% diameter stenosis) unprotected left main CAD with: a) anatomic conditions associated with a low to intermediate risk of PCI procedural complications and an intermediate to high likelihood of good long-term outcome (e.g., low–intermediate SYNTAX score of <33, bifurcation left main CAD); and b) clinical characteristics that predict an increased risk of adverse surgical outcomes (e.g., moderate–severe chronic obstructive pulmonary disease, disability from previous stroke, or previous cardiac surgery; STS-predicted risk of operative mortality <2%) (Morice et al., 2010; Chakravarty et al., 2011; Kim et al., 2010; Buszman et al., 2008; Capodanno et al., 2011; Hannan et al., 2008; Ellis et al., 1997; Biondi-Zoccai et al., 2008; Boudriot et al., 2011; Brener et al., 2008; Chieffo et al., 2010; Chieffo et al., 2006; Lee et al., 2006; Makikallio et al., 2008; Naik et al., 2009; Palmerini et al., 2006; Park et al., 2010; Rodes-Cabau et al., 2008; Sanmartin et al., 2007; Seung et al., 2008; White et al., 2008; Park et al., 2011). (Level of Evidence: B)

Class III: Harm

  1. PCI to improve survival should not be performed in stable patients with significant (≥50% diameter stenosis) unprotected left main CAD who have unfavorable anatomy for PCI and who are good candidates for CABG (Chaitman et al., 1981; Caracciolo et al., 1995; Yusuf et al., 1994; Morice et al., 2010; Chakravarty et al., 2011; Kim et al., 2010; Dzavik et al., 2001; Takaro et al., 1976; Takaro et al., 1982; Taylor et al., 1989; Capodanno et al., 2011; Hannan et al., 2008). (Level of Evidence: B)

Non–Left Main CAD Revascularization

Class I

  1. CABG to improve survival is beneficial in patients with significant (≥70% diameter) stenoses in three major coronary arteries (with or without involvement of the proximal left anterior descending [LAD] artery) or in the proximal LAD artery plus one other major coronary artery (Myers et al., 1989; Yusuf et al., 1994; Dzavik et al., 2001; Jones et al., 1996; Varnauskas, 1988; Smith et al., 2006). (Level of Evidence: B)
  2. CABG or PCI to improve survival is beneficial in survivors of sudden cardiac death with presumed ischemia-mediated ventricular tachycardia caused by significant (≥70% diameter) stenosis in a major coronary artery. (CABG Level of Evidence: B [Every et al., 1992; Borger van der Burg et al., 2003; Kaiser et al., 1975]; PCI Level of Evidence: C [Borger van der Burg et al., 2003])

Class IIa

  1. CABG to improve survival is reasonable in patients with significant (≥70% diameter) stenoses in two major coronary arteries with severe or extensive myocardial ischemia (e.g., high-risk criteria on stress testing, abnormal intracoronary hemodynamic evaluation, or >20% perfusion defect by myocardial perfusion stress imaging) or target vessels supplying a large area of viable myocardium (Hachamovitch et al., 2003; Di Carli et al., 1998; Sorajja et al., 2005; Davies et al., 1997). (Level of Evidence: B)
  2. CABG to improve survival is reasonable in patients with mild–moderate LV systolic dysfunction (EF 35% to 50%) and significant (≥70% diameter stenosis) multivessel CAD or proximal LAD coronary artery stenosis, when viable myocardium is present in the region of intended revascularization (Alderman et al., 1983; Yusuf et al., 1994; O'Connor et al., 2002; Phillips, O'Connor, & Rogers, 2007; Tarakji et al., 2006; Tsuyuki et al., 2006). (Level of Evidence: B)
  3. CABG with a left internal mammary artery (LIMA) graft to improve survival is reasonable in patients with significant (≥70% diameter) stenosis in the proximal LAD artery and evidence of extensive ischemia (Yusuf et al., 1994; Smith et al., 2006; Cameron et al., 1996; Loop et al., 1986). (Level of Evidence: B)
  4. It is reasonable to choose CABG over PCI to improve survival in patients with complex 3-vessel CAD (e.g., SYNTAX score >22), with or without involvement of the proximal LAD artery who are good candidates for CABG (Hannan et al., 2008; Kappetein et al., 2011; Smith et al., 2006; Brener et al., 2004; Hannan et al., 2005). (Level of Evidence: B)
  5. CABG is probably recommended in preference to PCI to improve survival in patients with multivessel CAD and diabetes mellitus, particularly if a LIMA graft can be anastomosed to the LAD artery (Sorajja et al., 2005; "Influence of diabetes," 1997; Banning et al., 2010; Hoffman et al., 2003; Hueb et al., 2007; Malenka et al., 2005; Niles et al., 2001; Weintraub et al., 1998). (Level of Evidence: B)

Class IIb

  1. The usefulness of CABG to improve survival is uncertain in patients with significant (70%) diameter stenoses in two major coronary arteries not involving the proximal LAD artery and without extensive ischemia (Smith et al., 2006). (Level of Evidence: C)
  2. The usefulness of PCI to improve survival is uncertain in patients with 2- or 3-vessel CAD (with or without involvement of the proximal LAD artery) or 1-vessel proximal LAD disease (Boden et al., 2007; Dzavik et al., 2001; Jones et al., 1996; Smith et al., 2006). (Level of Evidence: B)
  3. CABG might be considered with the primary or sole intent of improving survival in patients with SIHD with severe LV systolic dysfunction (EF <35%) whether or not viable myocardium is present (Bonow et al., 2011; Alderman et al., 1983; Velazquez et al., 2011; Yusuf et al., 1994; O'Connor et al., 2002; Phillips, O'Connor, & Rogers, 2007; Tarakji et al., 2006; Tsuyuki et al., 2006). (Level of Evidence: B)
  4. The usefulness of CABG or PCI to improve survival is uncertain in patients with previous CABG and extensive anterior wall ischemia on noninvasive testing (Gurfinkel et al., 2007; Morrison et al., 2001; Subramanian et al., 2009; Pfautsch et al., 1999; Weintraub et al., 1997; Brener et al., 2006; Lytle et al., 1993; Sergeant et al., 1998; Stephan et al., 1996). (Level of Evidence: B)

Class III: Harm

  1. CABG or PCI should not be performed with the primary or sole intent to improve survival in patients with SIHD with one or more coronary stenoses that are not anatomically or functionally significant (e.g., <70% diameter non–left main coronary artery stenosis, fractional flow reserve [FFR] >0.80, no or only mild ischemia on noninvasive testing), involve only the left circumflex or right coronary artery, or subtend only a small area of viable myocardium (Shaw et al., 2008; Hachamovitch et al., 2003; Yusuf et al., 1994; Jones et al., 1996; Di Carli et al., 1998; Cashin et al., 1984; Pijls et al., 1996; Tonino et al., 2009; Sawada et al., 2003). (Level of Evidence: B)

Revascularization to Improve Symptoms

Class I

  1. CABG or PCI to improve symptoms is beneficial in patients with one or more significant (≥70% diameter) coronary artery stenoses amenable to revascularization and unacceptable angina despite GDMT (Boden et al., 2007; Weintraub et al., 2008; Benzer, Hofer, & Oldridge, 2003; Bonaros et al., 2005; Bucher et al., 2000; Favarato et al., 2007; Hueb et al., 2010; Pocock et al., 1996; Pocock et al., 2000; Wijeysundera et al., 2010; Abizaid et al., 2001). (Level of Evidence: A)

Class IIa

  1. CABG or PCI to improve symptoms is reasonable in patients with one or more significant (≥70% diameter) coronary artery stenoses and unacceptable angina for whom GDMT cannot be implemented because of medication contraindications, adverse effects, or patient preferences. (Level of Evidence: C)
  2. PCI to improve symptoms is reasonable in patients with previous CABG, one or more significant (≥70% diameter) coronary artery stenoses associated with ischemia, and unacceptable angina despite GDMT (Gurfinkel et al., 2007; Subramanian et al., 2009; Pfautsch et al., 1999). (Level of Evidence: C)
  3. It is reasonable to choose CABG over PCI to improve symptoms in patients with complex 3-vessel CAD (e.g., SYNTAX score >22), with or without involvement of the proximal LAD artery, who are good candidates for CABG (Hannan et al., 2008; Kappetein et al., 2011; Smith et al., 2006; Brener et al., 2004; Hannan et al., 2005). (Level of Evidence: B)

Class IIb

  1. CABG to improve symptoms might be reasonable for patients with previous CABG, one or more significant (≥70% diameter) coronary artery stenoses not amenable to PCI, and unacceptable angina despite GDMT (Weintraub et al., 1997). (Level of Evidence: C)
  2. TMR performed as an adjunct to CABG to improve symptoms may be reasonable in patients with viable ischemic myocardium that is perfused by arteries that are not amenable to grafting (Aaberge et al., 2000; Burkhoff et al., 1999; Schofield et al., 1999; Allen et al., 2000; Stamou et al., 2002). (Level of Evidence: B)

Class III: Harm

  1. CABG or PCI to improve symptoms should not be performed in patients who do not meet anatomic (≥50% diameter left main or ≥70% non–left main stenosis diameter) or physiological (e.g., abnormal FFR) criteria for revascularization. (Level of Evidence: C)

Clinical Factors That May Influence the Choice of Revascularization

Dual Antiplatelet Therapy (DAPT) Compliance and Stent Thrombosis

Class III: Harm

  1. PCI with coronary stenting (bare-metal stent [BMS] or drug-eluting stent [DES]) should not be performed if the patient is not likely to be able to tolerate and comply with DAPT for the appropriate duration of treatment based on the type of stent implanted (Grines et al., 2007; Leon et al., 1998; Mauri et al., 2007; McFadden et al., 2004). (Level of Evidence: B)

Hybrid Coronary Revascularization

Class IIa

  1. Hybrid coronary revascularization (defined as the planned combination of LIMA-to-LAD artery grafting and PCI of ≥1 non-LAD coronary arteries) is reasonable in patients with one or more of the following (Bonatti et al., 2008; Gilard et al., 2007; Holzhey et al., 2008; Kon et al., 2008; Reicher et al., 2008; Vassiliades et al., 2006; Zhao et al., 2009) (Level of Evidence: B):
    1. Limitations to traditional CABG, such as heavily calcified proximal aorta or poor target vessels for CABG (but amenable to PCI)
    2. Lack of suitable graft conduits
    3. Unfavorable LAD artery for PCI (i.e., excessive vessel tortuosity or chronic total occlusion)

Class IIb

  1. Hybrid coronary revascularization (defined as the planned combination of LIMA-to-LAD artery grafting and PCI of ≥1 non-LAD coronary arteries) may be reasonable as an alternative to multivessel PCI or CABG in an attempt to improve the overall risk–benefit ratio of the procedures. (Level of Evidence: C)

Patient Follow-Up: Monitoring of Symptoms and Antianginal Therapy

Clinical Evaluation, Echocardiography During Routine, Periodic Follow-Up

Class I

  1. Patients with SIHD should receive periodic follow-up, at least annually, that includes all of the following (Level of Evidence: C):
    1. Assessment of symptoms and clinical function
    2. Surveillance for complications of SIHD, including heart failure and arrhythmias
    3. Monitoring of cardiac risk factors
    4. Assessment of the adequacy of and adherence to recommended lifestyle changes and medical therapy
  2. Assessment of LVEF and segmental wall motion by echocardiography or radionuclide imaging is recommended in patients with new or worsening heart failure or evidence of intervening MI by history or ECG. (Level of Evidence: C)

Class IIb

  1. Periodic screening for important comorbidities that are prevalent in patients with SIHD, including diabetes mellitus, depression, and CKD, might be reasonable. (Level of Evidence: C)
  2. A resting 12-lead ECG at 1-year or longer intervals between studies in patients with stable symptoms might be reasonable. (Level of Evidence: C)

Class III: No Benefit

  1. Measurement of LV function with a technology such as echocardiography or radionuclide imaging is not recommended for routine periodic reassessment of patients who have not had a change in clinical status or who are at low risk of adverse cardiovascular events (Hachamovitch et al., 2002). (Level of Evidence: C)

Noninvasive Testing in Known SIHD

Follow-Up Noninvasive Testing in Patients with Known SIHD: New, Recurrent, or Worsening Symptoms Not Consistent with Unstable Angina

See Table 20 in the original guideline document for a summary of recommendations from this section.

Patients Able To Exercise

Class I

  1. Standard exercise ECG testing is recommended in patients with known SIHD who have new or worsening symptoms not consistent with UA and who have a) at least moderate physical functioning and no disabling comorbidity and b) an interpretable ECG (Sabharwal et al., 2007; Gianrossi et al., 1989; Kwok et al., 1999; Shaw et al., 2011). (Level of Evidence: B)
  2. Exercise with nuclear MPI or echocardiography is recommended in patients with known SIHD who have new or worsening symptoms not consistent with UA and who have a) at least moderate physical functioning or no disabling comorbidity but b) an uninterpretable ECG (Schwitter et al., 2008; Shaw et al., 2012; Doesch et al., 2009; Steel et al., 2009; Shaw et al., 2008; Shaw et al., 2000; Shaw et al., 2005; Hachamovitch et al., 2005; Yao et al., 2003; Hachamovitch et al., 2003; Gehi et al., 2008; Bodi et al., 2007; Sawada et al., 2007; Lauer et al., 1998; Calnon et al., 2001; Berman et al., 1995). (Level of Evidence: B)

Class IIa

  1. Exercise with nuclear MPI or echocardiography is reasonable in patients with known SIHD who have new or worsening symptoms not consistent with UA and who have a) at least moderate physical functioning and no disabling comorbidity, b) previously required imaging with exercise stress, or c) known multivessel disease or high risk for multivessel disease (Chatziioannou et al., 1999; Peteiro et al., 2006). (Level of Evidence: B)

Class III: No Benefit

  1. Pharmacological stress imaging with nuclear MPI, echocardiography, or CMR is not recommended in patients with known SIHD who have new or worsening symptoms not consistent with UA and who are capable of at least moderate physical functioning or have no disabling comorbidity (Parisi, Hartigan, & Folland, 1997). (Level of Evidence: C)

Patients Unable To Exercise

Class I

  1. Pharmacological stress imaging with nuclear MPI or echocardiography is recommended in patients with known SIHD who have new or worsening symptoms not consistent with UA and who are incapable of at least moderate physical functioning or have disabling comorbidity (Biagini et al., 2006; Geleijnse et al., 2007; Imran, Palinkas, & Picano, 2003; Marcassa et al., 2008; Nandalur et al., 2007; Picano, Molinaro, & Pasanisi, 2008; Underwood et al., "Myocardial perfusion scintigraphy and cost effectiveness," 2004; Underwood et al., "Myocardial perfusion scintigraphy: the evidence," 2004). (Level of Evidence: B)

Class IIa

  1. Pharmacological stress imaging with CMR is reasonable in patients with known SIHD who have new or worsening symptoms not consistent with UA and who are incapable of at least moderate physical functioning or have disabling comorbidity (Bingham & Hachamovitch, 2011; Coelho-Filho et al., 2011; Korosoglou et al., 2010). (Level of Evidence: B)

Class III: No Benefit

  1. Standard exercise ECG testing should not be performed in patients with known SIHD who have new or worsening symptoms not consistent with UA and who a) are incapable of at least moderate physical functioning or have disabling comorbidity or b) have an uninterpretable ECG. (Level of Evidence: C)

Irrespective of Ability to Exercise

Class IIb

  1. CCTA for assessment of patency of CABG or of coronary stents 3 mm or larger in diameter might be reasonable in patients with known SIHD who have new or worsening symptoms not consistent with UA, irrespective of ability to exercise (Mowatt et al., 2008; Jones et al., 2007; Hamon et al., 2008; Carrabba et al., 2010; Sun & Almutairi, 2010). (Level of Evidence: B)
  2. CCTA might be reasonable in patients with known SIHD who have new or worsening symptoms not consistent with UA, irrespective of ability to exercise, in the absence of known moderate or severe calcification or if the CCTA is intended to assess coronary stents less than 3 mm in diameter (Schuetz et al., 2010; Janne d'Othee et al., 2008; Mowatt et al., 2008). (Level of Evidence: B)

Class III: No Benefit

  1. CCTA should not be performed for assessment of native coronary arteries with known moderate or severe calcification or with coronary stents less than 3 mm in diameter in patients with known SIHD who have new or worsening symptoms not consistent with UA, irrespective of ability to exercise (Mowatt et al., 2008; Jones et al., 2007; Hamon et al., 2008; Carrabba et al., 2010; Sun & Almutairi, 2010). (Level of Evidence: B)

Noninvasive Testing in Known SIHD—Asymptomatic (or Stable Symptoms)

See Table 21 in the original guideline document for a summary of recommendations from this section.

Class IIa

  1. Nuclear MPI, echocardiography, or CMR with either exercise or pharmacological stress can be useful for follow-up assessment at 2-year or longer intervals in patients with SIHD with prior evidence of silent ischemia or who are at high risk for a recurrent cardiac event and a) are unable to exercise to an adequate workload, b) have an uninterpretable ECG, or c) have a history of incomplete coronary revascularization (American College of Cardiology Foundation et al., 2011; Hendel et al., 2009; American College of Cardiology Foundation Appropriate Use Criteria Task Force et al., 2011). (Level of Evidence: C)

Class IIb

  1. Standard exercise ECG testing performed at 1-year or longer intervals might be considered for follow-up assessment in patients with SIHD who have had prior evidence of silent ischemia or are at high risk for a recurrent cardiac event and are able to exercise to an adequate workload and have an interpretable ECG. (Level of Evidence: C)
  2. In patients who have no new or worsening symptoms or no prior evidence of silent ischemia and are not at high risk for a recurrent cardiac event, the usefulness of annual surveillance exercise ECG testing is not well established. (Level of Evidence: C)

Class III: No Benefit

  1. Nuclear MPI, echocardiography, or CMR, with either exercise or pharmacological stress or CCTA, is not recommended for follow-up assessment in patients with SIHD, if performed more frequently than at a) 5-year intervals after CABG or b) 2-year intervals after PCI (American College of Cardiology Foundation et al., 2011; Hendel et al., 2009; American College of Cardiology Foundation Appropriate Use Criteria Task Force et al., 2011). (Level of Evidence: C)

Definitions:

Applying Classification of Recommendations and Level of Evidence

  Size of Treatment Effect
  CLASS I

Benefit >>> Risk

Procedure/Treatment
SHOULD be performed/ administered
CLASS IIa

Benefit >> Risk
Additional studies with focused objectives needed


IT IS REASONABLE to perform procedure/administer treatment
CLASS IIb

Benefit ≥ Risk
Additional studies with broad objectives needed; additional registry data would be helpful


Procedure/Treatment
MAY BE CONSIDERED
CLASS III No Benefit
or Class III Harm
  Procedure/Test Treatment
COR III:
No Benefit
Not helpful No proven benefit
COR III:
Harm
Excess Cost without Benefit or Harmful Harmful to Patients
Estimate of Certainty (Precision) of Treatment Effect LEVEL A

Multiple populations evaluated*

Data derived from multiple randomized clinical trials or meta-analyses
  • Recommendation that procedure or treatment is useful/effective
  • Sufficient evidence from multiple randomized trials or meta-analyses
  • Recommendation in favor of treatment or procedure being useful/effective
  • Some conflicting evidence from multiple randomized trials or meta-analyses
  • Recommendation's usefulness/efficacy less well established
  • Greater conflicting evidence from multiple randomized trials or meta-analyses
  • Recommendation that procedure or treatment is not useful/effective and may be harmful
  • Sufficient evidence from multiple randomized trials or meta-analyses
LEVEL B

Limited populations evaluated*

Data derived from a single randomized clinical trials or nonrandomized studies
  • Recommendation that procedure or treatment is useful/effective
  • Evidence from single randomized trial or nonrandomized studies
  • Recommendation in favor of treatment or procedure being useful/effective
  • Some conflicting evidence from single randomized trial or nonrandomized studies
  • Recommendation's usefulness/efficacy less well established
  • Greater conflicting evidence from single randomized trial or nonrandomized studies
  • Recommendation that procedure or treatment is not useful/effective and may be harmful
  • Evidence from single randomized trial or nonrandomized studies
LEVEL C

Very limited populations evaluated*

Only consensus opinion of experts, case studies or standard of care
  • Recommendation that procedure or treatment is useful/effective
  • Only expert opinion, case studies, or standard of care
  • Recommendation in favor of treatment or procedure being useful/effective
  • Only diverging expert opinion, case studies, or standard of care
  • Recommendation's usefulness/efficacy less well established
  • Only diverging expert opinion, case studies, or standard of care
  • Recommendation that procedure or treatment is not useful/effective and may be harmful
  • Only expert opinion, case studies, or standard of care

A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Although randomized trials are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.

*Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as gender, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use.

Clinical Algorithm(s)

The following algorithms are provided in the original guideline document:

  • Diagnosis of Patients with Suspected Ischemic Heart Disease (SIHD)
  • Algorithm for Risk Assessment of Patients with Stable SIHD
  • Algorithm for Guideline-Directed Medical Therapy for Patients with SIHD
  • Algorithm for Revascularization to Improve Survival of Patients with SIHD
  • Algorithm for Revascularization to Improve Symptoms of Patients with SIHD

Disease/Condition(s)

Stable ischemic heart disease

Guideline Category

Counseling

Diagnosis

Evaluation

Management

Prevention

Risk Assessment

Screening

Treatment

Clinical Specialty

Cardiology

Family Practice

Geriatrics

Internal Medicine

Nephrology

Nursing

Nutrition

Preventive Medicine

Radiology

Thoracic Surgery

Intended Users

Advanced Practice Nurses

Nurses

Physician Assistants

Physicians

Guideline Objective(s)

To assist healthcare providers in clinical decision making by describing a range of generally acceptable approaches to the diagnosis, management, and prevention of stable ischemic heart disease

Target Population

  • Adult patients with stable known or suspected ischemic heart disease (IHD), including new-onset chest pain (i.e., low-risk unstable angina [UA])
  • Adult patients with stable pain syndromes, including patients who have "ischemic equivalents," such as dyspnea or arm pain with exertion
  • Asymptomatic patients who were previously symptomatic, including those who have undergone percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG)
  • Asymptomatic patients with stable ischemic heart disease (SIHD) that has been diagnosed solely on the basis of an abnormal screening study

Note: The following populations are beyond the scope of this guideline:

  • Patients with acute myocardial infarction (AMI) or moderate- to high-risk UA
  • Patients with IHD who develop recurrent chest pain if evaluation demonstrates that IHD is unlikely to cause the symptoms (i.e., noncardiac causes)
  • Asymptomatic patients who are at risk for IHD but who are not known to have IHD
  • Patients with chest pain symptoms early after revascularization by either percutaneous techniques or CABG (i.e., within 6 months of revascularization)
  • Patients with chest pain syndromes after cardiac transplantation
  • Pediatric patients

Interventions and Practices Considered

Diagnosis/Evaluation/Risk Assessment

  1. Shared decision-making between patient and provider in choices made on diagnostic and therapeutic options
  2. Clinical evaluation (history, physical examination, risk assessment in patients presenting with angina)
  3. Resting electrocardiography (ECG)
  4. Standard exercise ECG
  5. Exercise stress testing with nuclear myocardial perfusion imaging (MPI) or echocardiography
  6. Pharmacological stress testing with nuclear MPI, echocardiography, or cardiac magnetic resonance (CMR) imaging
  7. Cardiac/coronary computed tomography angiography (CCTA)
  8. Noncontrast cardiac computed tomography (CT)
  9. Coronary angiography

Prevention/Treatment/Management

  1. Individualized patient education and treatment plan
  2. Lipid management
    • Lifestyle modification
    • Dietary therapy
    • Statin or other cholesterol-lowering therapy
  3. Blood pressure management
    • Lifestyle modification
    • Antihypertensive drug therapy
  4. Diabetes management with a goal hemoglobin A1c (HbA1c) of 7% or less
  5. Physical activity counseling and cardiac rehabilitation
  6. Weight management
  7. Smoking cessation counseling and treatment
  8. Screening for and treatment of depression
  9. Moderation of alcohol consumption
  10. Avoidance of exposure to air pollution
  11. Antiplatelet therapy (aspirin, clopidogrel)
  12. Beta-blocker therapy
  13. Renin-angiotensin-aldosterone blocker therapy
  14. Annual influenza vaccination
  15. Anti-ischemic medications
    • Beta-blockers
    • Calcium channel blockers
    • Long-acting nitrates
    • Sublingual nitroglycerin or nitroglycerin spray
    • Ranolazine
  16. Alternative therapies for relief of symptoms
    • Enhanced external counterpulsation
    • Spinal cord stimulation
    • Transmyocardial revascularization (TMR)
  17. Revascularization using a Heart Team approach
    • Coronary artery bypass graft (CABG)
    • Percutaneous coronary intervention (PCI)
    • TMR performed as an adjunct to CABG
    • Hybrid coronary revascularization
  18. Patient follow-up with monitoring of symptoms and antianginal therapy

Note: Estrogen therapy; vitamin C, vitamin E, and beta-carotene supplementation; treatment of elevated homocysteine with folate or vitamins B6 and B12; chelation therapy; garlic; coenzyme Q10; selenium; and chromium were considered but not recommended as risk reduction therapies. Acupuncture was considered but not recommended as an alternative therapy for relief of symptoms.

Major Outcomes Considered

  • Accuracy, sensitivity, specificity, and positive and negative predictive value of diagnostic tests
  • Prognostic value of tests
  • Risk of ischemic heart disease (IHD) and other cardiovascular diseases and conditions
  • Risk of cardiac events
  • Mortality
  • Morbidity
  • Survival
  • Effectiveness of treatment
  • Changes in risk factors for heart disease
  • Health status, including severity of symptoms, functional limitations, and quality of life
  • Adverse events associated with treatment
  • Safety of treatment
  • Cost-effectiveness

Methods Used to Collect/Select the Evidence

Searches of Electronic Databases

Description of Methods Used to Collect/Select the Evidence

An extensive evidence review was conducted as the document was compiled through December 2008. Repeated literature searches were performed by the guideline development staff and writing committee members as new issues were considered. New clinical trials published in peer-reviewed journals and articles through December 2011 were also reviewed and incorporated when relevant. Furthermore, because of the extended development time period for this guideline, peer review comments indicated that the sections focused on imaging technologies required additional updating, which occurred during 2011. Therefore, the evidence review for the imaging sections includes published literature through December 2011.

Searches were limited to studies, reviews, and other evidence in human subjects and that were published in English. Searches were conducted using PubMed and the Cochrane Collaboration Database. Key search words included but were not limited to the following: accuracy, angina, asymptomatic patients, cardiac magnetic resonance (CMR), cardiac rehabilitation, chest pain, chronic angina, chronic coronary occlusions, chronic ischemic heart disease (IHD), chronic total occlusion, connective tissue disease, coronary artery bypass graft (CABG) versus medical therapy, coronary artery disease (CAD) and exercise, coronary calcium scanning, cardiac/coronary computed tomography angiography (CCTA), CMR angiography, CMR imaging, coronary stenosis, death, depression, detection of CAD in symptomatic patients, diabetes, diagnosis, dobutamine stress echocardiography, echocardiography, elderly, electrocardiogram (ECG) and chronic stable angina, emergency department, ethnic, exercise, exercise stress testing, follow-up testing, gender, glycemic control, hypertension, intravascular ultrasound, fractional flow reserve (FFR), invasive coronary angiography, kidney disease, low-density lipoprotein (LDL) lowering, magnetic resonance imaging (MRI), medication adherence, minority groups, mortality, myocardial infarction (MI), noninvasive testing and mortality, nuclear myocardial perfusion, nutrition, obesity, outcomes, patient follow-up, patient education, prognosis, proximal left anterior descending (LAD) disease, physical activity, reoperation, risk stratification, smoking, stable ischemic heart disease (SIHD), stable angina and reoperation, stable angina and revascularization, stress echocardiography, radionuclide stress testing, stenting versus CABG, unprotected left main, weight reduction, and women.

The writing committee used current and credible meta-analyses, when available, instead of conducting a systematic review of all primary literature.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Applying Classification of Recommendations and Level of Evidence

  Size of Treatment Effect
  CLASS I

Benefit >>> Risk

Procedure/Treatment
SHOULD be performed/ administered
CLASS IIa

Benefit >> Risk
Additional studies with focused objectives needed


IT IS REASONABLE to perform procedure/administer treatment
CLASS IIb

Benefit ≥ Risk
Additional studies with broad objectives needed; additional registry data would be helpful


Procedure/Treatment
MAY BE CONSIDERED
CLASS III No Benefit
or Class III Harm
  Procedure/Test Treatment
COR III:
No Benefit
Not helpful No proven benefit
COR III:
Harm
Excess Cost without Benefit or Harmful Harmful to Patients
Estimate of Certainty (Precision) of Treatment Effect LEVEL A

Multiple populations evaluated*

Data derived from multiple randomized clinical trials or meta-analyses
  • Recommendation that procedure or treatment is useful/effective
  • Sufficient evidence from multiple randomized trials or meta-analyses
  • Recommendation in favor of treatment or procedure being useful/effective
  • Some conflicting evidence from multiple randomized trials or meta-analyses
  • Recommendation's usefulness/efficacy less well established
  • Greater conflicting evidence from multiple randomized trials or meta-analyses
  • Recommendation that procedure or treatment is not useful/effective and may be harmful
  • Sufficient evidence from multiple randomized trials or meta-analyses
LEVEL B

Limited populations evaluated*

Data derived from a single randomized clinical trials or nonrandomized studies
  • Recommendation that procedure or treatment is useful/effective
  • Evidence from single randomized trial or nonrandomized studies
  • Recommendation in favor of treatment or procedure being useful/effective
  • Some conflicting evidence from single randomized trial or nonrandomized studies
  • Recommendation's usefulness/efficacy less well established
  • Greater conflicting evidence from single randomized trial or nonrandomized studies
  • Recommendation that procedure or treatment is not useful/effective and may be harmful
  • Evidence from single randomized trial or nonrandomized studies
LEVEL C

Very limited populations evaluated*

Only consensus opinion of experts, case studies or standard of care
  • Recommendation that procedure or treatment is useful/effective
  • Only expert opinion, case studies, or standard of care
  • Recommendation in favor of treatment or procedure being useful/effective
  • Only diverging expert opinion, case studies, or standard of care
  • Recommendation's usefulness/efficacy less well established
  • Only diverging expert opinion, case studies, or standard of care
  • Recommendation that procedure or treatment is not useful/effective and may be harmful
  • Only expert opinion, case studies, or standard of care

A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Although randomized trials are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.

*Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as gender, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use.

Methods Used to Analyze the Evidence

Review of Published Meta-Analyses

Systematic Review with Evidence Tables

Description of the Methods Used to Analyze the Evidence

To provide clinicians with a comprehensive set of data, the absolute risk difference and number needed to treat or harm, if they were published and their inclusion was deemed appropriate, are provided in the guideline, along with confidence intervals and data related to the relative treatment effects, such as odds ratio, relative risk, hazard ratio, or incidence rate ratio.

In analyzing the data and developing recommendations and supporting text, the writing committee uses evidence-based methodologies developed by the Task Force. The Level of Evidence (LOE) is an estimate of the certainty or precision of the treatment effect. The writing committee reviews and ranks evidence supporting each recommendation, with the weight of evidence ranked as LOE A, B, or C according to specific definitions (see the "Rating Scheme for the Strength of the Evidence" field). Studies are identified as observational, retrospective, prospective, or randomized as appropriate.

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

Experts in the subject under consideration are selected by the American College of Cardiology Foundation (ACCF) and American Heart Association (AHA) to examine subject-specific data and write guidelines in partnership with representatives from other medical organizations and specialty groups. Writing committees are asked to perform a literature review; weigh the strength of evidence for or against particular tests, treatments, or procedures; and include estimates of expected outcomes where such data exist. Patient-specific modifiers, comorbidities, and issues of patient preference that may influence the choice of tests or therapies are considered. When available, information from studies on cost is considered, but data on efficacy and outcomes constitute the primary basis for the recommendations in these guidelines.

In analyzing the data and developing recommendations and supporting text, the writing committee uses evidence-based methodologies developed by the Task Force. The Class of Recommendation (COR) is an estimate of the size of the treatment effect, with consideration given to risks versus benefits as well as evidence and/or agreement that a given treatment or procedure is or is not useful/effective or in some situations may cause harm. The Level of Evidence (LOE) is an estimate of the certainty or precision of the treatment effect. The writing committee reviews and ranks evidence supporting each recommendation, with the weight of evidence ranked as LOE A, B, or C according to specific definitions that are included in the "Rating Scheme for the Strength of the Evidence" field. Studies are identified as observational, retrospective, prospective, or randomized as appropriate. For certain conditions for which inadequate data are available, recommendations are based on expert consensus and clinical experience and are ranked as LOE C. When recommendations at LOE C are supported by historical clinical data, appropriate references (including clinical reviews) are cited if available. For issues for which sparse data are available, a survey of current practice among the clinicians on the writing committee is the basis for LOE C recommendations, and no references are cited. The schema for COR and LOE is summarized in the "Rating Scheme for the Strength of the Evidence" field. Table 1 in the original guideline document provides suggested phrases for writing recommendations within each COR. A new addition to this methodology is separation of the Class III recommendations to delineate whether the recommendation is determined to be of "no benefit" or is associated with "harm" to the patient. In addition, in view of the increasing number of comparative effectiveness studies, comparator verbs and suggested phrases for writing recommendations for the comparative effectiveness of one treatment or strategy versus another have been added for COR I and IIa, LOE A or B only.

In view of the advances in medical therapy across the spectrum of cardiovascular diseases, the Task Force has designated the term guideline-directed medical therapy (GDMT) to represent optimal medical therapy as defined by ACCF/AHA guideline (primarily Class I)–recommended therapies. This new term, GDMT, is used in this guideline and throughout all future guidelines.

The writing committee was composed of physicians, cardiovascular interventionalists, surgeons, general internists, imagers, nurses, and pharmacists. The writing committee included representatives from the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.

General Approach and Overlap with Other Guidelines or Statements

The original guideline overlaps with numerous clinical practice guidelines published by the ACCF/AHA Task Force on Practice Guidelines; the National Heart, Lung, and Blood Institute; and the American College of Physicians (see Table 3 in the original guideline document). To maintain consistency, the writing committee worked with members of other committees to harmonize recommendations and eliminate discrepancies. Some recommendations from earlier guidelines have been updated as warranted by new evidence or a better understanding of earlier evidence, whereas others that were no longer accurate or relevant or were overlapping were modified; recommendations from previous guidelines that were similar or redundant were eliminated or consolidated when possible.

Most of the topics mentioned in the present guideline were addressed in the "ACC/AHA 2002 Guideline Update for the Management of Patients with Chronic Stable Angina—Summary Article," and many of the recommendations in the present guideline are consistent with those in the 2002 document. Whereas the 2002 update dealt individually with specific drugs and interventions for reducing cardiovascular risk and medical therapy of angina pectoris, the present document recommends a combination of lifestyle modifications and medications that constitute GDMT. In addition, recommendations for risk reduction have been revised to reflect new evidence and are now consistent with the "AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients with Coronary and Other Atherosclerotic Vascular Disease: 2011 Update." Also in the present guideline, recommendations and text related to revascularization are the result of extensive collaborative discussions between the percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) writing committees, as well as key members of the stable ischemic heart disease (SIHD) and unstable angina/non-ST-segment elevation myocardial infarction (UA/NSTEMI) writing committees. In a major undertaking, the PCI and CABG guidelines were written concurrently with input from the STEMI guideline writing committee and additional collaboration with the SIHD guideline writing committee, allowing greater collaboration between these writing committees on revascularization strategies in patients with coronary artery disease (CAD) (including unprotected left main PCI, multivessel disease revascularization, and hybrid procedures). Section 5 of the original guideline document is included as published in both the PCI and CABG guidelines in its entirety.

The writing committee recognized that it would be unfeasible to produce a document that would be simultaneously practical and exhaustive and, therefore, has tried to create a resource that provides a comprehensive approach to management of stable ischemic heart disease (SIHD) for which the relevant evidence is succinctly summarized and referenced. The writing committee used current and credible meta-analyses, when available, instead of conducting a systematic review of all primary literature.

Rating Scheme for the Strength of the Recommendations

See the "Rating Scheme for the Strength of the Evidence" field, above.

Cost Analysis

See Section 2.2.1.5 in the original guideline document for a discussion of the cost-effectiveness of noninvasive testing for diagnosis of ischemic heart disease.

Method of Guideline Validation

External Peer Review

Internal Peer Review

Description of Method of Guideline Validation

This document was reviewed by two external reviewers nominated by both the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA); two reviewers nominated by the American College of Physicians (ACP), American Association for Thoracic Surgery (AATS), Preventive Cardiovascular Nurses Association (PCNA), Society for Cardiovascular Angiography and Interventions (SCAI), and Society of Thoracic Surgeons (STS); and 19 content reviewers, including members of the ACCF Imaging Council, ACCF Interventional Scientific Council, and the AHA Council on Clinical Cardiology. Reviewers' relevant relationships with industry or other entities (RWI) information was collected and distributed to the writing committee and is published in Appendix 2 of the original guideline document. Because extensive peer review comments resulted in substantial revision, the guideline was subjected to a second peer review by all official and organizational reviewers. Lastly, the imaging sections were peer reviewed separately, after an update to that evidence base.

This document was approved for publication by the governing bodies of the ACCF, AHA, ACP, AATS, PCNA, SCAI, and STS.

References Supporting the Recommendations

Aaberge L, Nordstrand K, Dragsund M, Saatvedt K, Endresen K, Golf S, Geiran O, Abdelnoor M, Forfang K. Transmyocardial revascularization with CO2 laser in patients with refractory angina pectoris. Clinical results from the Norwegian randomized trial. J Am Coll Cardiol. 2000 Apr;35(5):1170-7. PubMed External Web Site Policy

Abizaid A, Costa MA, Centemero M, Abizaid AS, Legrand VM, Limet RV, Schuler G, Mohr FW, Lindeboom W, Sousa AG, Sousa JE, van Hout B, Hugenholtz PG, Unger F, Serruys PW. Clinical and economic impact of diabetes mellitus on percutaneous and surgical treatment of multivessel coronary disease patients: insights from the Arterial Revascularization Therapy Study (ARTS) trial. Circulation. 2001 Jul 31;104(5):533-8. PubMed External Web Site Policy

Abrams J. Clinical practice. Chronic stable angina. N Engl J Med. 2005 Jun 16;352(24):2524-33. [60 references] PubMed External Web Site Policy

ADVANCE Collaborative Group, Patel A, MacMahon S, Chalmers J, Neal B, Billot L, Woodward M, Marre M, Cooper M, Glasziou P, Grobbee D, Hamet P, Harrap S, Heller S, Liu L, Mancia G, Mogensen CE, Pan C, Poulter N, Rodgers A, Williams B, Bompoint S, de Galan BE, Joshi R, Travert F. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med. 2008 Jun 12;358(24):2560-72. PubMed External Web Site Policy

Alderman EL, Fisher LD, Litwin P, Kaiser GC, Myers WO, Maynard C, Levine F, Schloss M. Results of coronary artery surgery in patients with poor left ventricular function (CASS). Circulation. 1983 Oct;68(4):785-95. PubMed External Web Site Policy

Allen KB, Dowling RD, DelRossi AJ, Realyvasques F, Lefrak EA, Pfeffer TA, Fudge TL, Mostovych M, Schuch D, Szentpetery S, Shaar CJ. Transmyocardial laser revascularization combined with coronary artery bypass grafting: a multicenter, blinded, prospective, randomized, controlled trial. J Thorac Cardiovasc Surg. 2000 Mar;119(3):540-9. PubMed External Web Site Policy

Al-Mallah MH, Tleyjeh IM, Abdel-Latif AA, Weaver WD. Angiotensin-converting enzyme inhibitors in coronary artery disease and preserved left ventricular systolic function: a systematic review and meta-analysis of randomized controlled trials. J Am Coll Cardiol. 2006 Apr 18;47(8):1576-83. [39 references] PubMed External Web Site Policy

America YG, Bax JJ, Boersma E, Stokkel M, van der Wall EE. Prognostic value of gated SPECT in patients with left bundle branch block. J Nucl Cardiol. 2007 Jan;14(1):75-81. PubMed External Web Site Policy

American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, Douglas PS, Garcia MJ, Haines DE, Lai WW, Manning WJ, Patel AR, Picard MH, Polk DM, Ragosta M, Ward RP, Weiner RB. ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 appropriate use criteria for echocardiography: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force [trunc]. J Am Coll Cardiol. 2011 Mar 1;57(9):1126-66. PubMed External Web Site Policy

American College of Cardiology Foundation, American Heart Association Task Force on Practice Guidelines, Society for Cardiovascular Angiography and Interventions, Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH. 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol. 2011 Dec 6;58(24):e44–122. [879 references] PubMed External Web Site Policy

American Diabetes Association. Standards of medical care in diabetes--2011. Diabetes Care. 2011 Jan;34(Suppl 1):S11-61. [395 references] PubMed External Web Site Policy

American Heart Association Nutrition Committee, Lichtenstein AH, Appel LJ, Brands M, Carnethon M, Daniels S, Franch HA, Franklin B, Kris-Etherton P, Harris WS, Howard B, Karanja N, Lefevre M, Rudel L, Sacks F, Van Horn L, Winston M, Wylie-Rosett J. Diet and lifestyle recommendations revision 2006: a scientific statement from the American Heart Association Nutrition Committee. Circulation. 2006 Jul 4;114(1):82-96. [97 references] PubMed External Web Site Policy

Anderson GL, Limacher M, Assaf AR, Bassford T, Beresford SA, Black H, Bonds D, Brunner R, Brzyski R, Caan B, Chlebowski R, Curb D, Gass M, Hays J, Heiss G, Hendrix S, Howard BV, Hsia J, Hubbell A, Jackson R, Johnson KC, Judd H, Kotchen JM, Kuller L, LaCroix AZ, Lane D, Langer RD, Lasser N, Lewis CE, Manson J, Margolis K, Ockene J, O'Sullivan MJ, Phillips L, Prentice RL, Ritenbaugh C, Robbins J, Rossouw JE, Sarto G, Stefanick ML, Van Horn L, Wactawski-Wende J, Wallace R, Wassertheil-Smoller S, Women's Health Initiative Steering Committee. Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: the Women's Health Initiative randomized controlled trial. JAMA. 2004 Apr 14;291(14):1701-12. PubMed External Web Site Policy

Antithrombotic Trialists' Collaboration. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ. 2002 Jan 12;324(7329):71-86. PubMed External Web Site Policy

Appel LJ, Champagne CM, Harsha DW, Cooper LS, Obarzanek E, Elmer PJ, Stevens VJ, Vollmer WM, Lin PH, Svetkey LP, Stedman SW, Young DR. Effects of comprehensive lifestyle modification on blood pressure control: main results of the PREMIER clinical trial. JAMA. 2003 Apr 23-30;289(16):2083-93. PubMed External Web Site Policy

Appel LJ, Frohlich ED, Hall JE, Pearson TA, Sacco RL, Seals DR, Sacks FM, Smith SC Jr, Vafiadis DK, Van Horn LV. The importance of population-wide sodium reduction as a means to prevent cardiovascular disease and stroke: a call to action from the American Heart Association. Circulation. 2011 Mar 15;123(10):1138-43. PubMed External Web Site Policy

Appel LJ, Moore TJ, Obarzanek E, Vollmer WM, Svetkey LP, Sacks FM, Bray GA, Vogt TM, Cutler JA, Windhauser MM, Lin PH, Karanja N. A clinical trial of the effects of dietary patterns on blood pressure. DASH Collaborative Research Group. N Engl J Med. 1997 Apr 17;336(16):1117-24. PubMed External Web Site Policy

Arnlov J, Ingelsson E, Sundstrom J, Lind L. Impact of body mass index and the metabolic syndrome on the risk of cardiovascular disease and death in middle-aged men. Circulation. 2010 Jan 19;121(2):230-6. PubMed External Web Site Policy

Arora RR, Chou TM, Jain D, Fleishman B, Crawford L, McKiernan T, Nesto RW. The multicenter study of enhanced external counterpulsation (MUST-EECP): effect of EECP on exercise-induced myocardial ischemia and anginal episodes. J Am Coll Cardiol. 1999 Jun;33(7):1833-40. PubMed External Web Site Policy

Artinian NT, Fletcher GF, Mozaffarian D, Kris-Etherton P, Van Horn L, Lichtenstein AH, Kumanyika S, Kraus WE, Fleg JL, Redeker NS, Meininger JC, Banks J, Stuart-Shor EM, Fletcher BJ, Miller TD, Hughes S, Braun LT, Kopin LA, Berra K, Hayman LL, Ewing LJ, Ades PA, Durstine JL, Houston-Miller N, Burke LE, American Heart Association Prevention Committee of the Council on Cardiovascular Nursing. Interventions to promote physical activity and dietary lifestyle changes for cardiovascular risk factor reduction in adults: a scientific statement from the American Heart Association. Circulation. 2010 Jul 27;122(4):406-41. PubMed External Web Site Policy

Ballegaard S, Jensen G, Pedersen F, Nissen VH. Acupuncture in severe, stable angina pectoris: a randomized trial. Acta Med Scand. 1986;220(4):307-13. PubMed External Web Site Policy

Ballegaard S, Pedersen F, Pietersen A, Nissen VH, Olsen NV. Effects of acupuncture in moderate, stable angina pectoris: a controlled study. J Intern Med. 1990 Jan;227(1):25-30. PubMed External Web Site Policy

Balsano F, Rizzon P, Violi F, Scrutinio D, Cimminiello C, Aguglia F, Pasotti C, Rudelli G. Antiplatelet treatment with ticlopidine in unstable angina. A controlled multicenter clinical trial. The Studio della Ticlopidina nell'Angina Instabile Group. Circulation. 1990 Jul;82(1):17-26. PubMed External Web Site Policy

Banning AP, Westaby S, Morice MC, Kappetein AP, Mohr FW, Berti S, Glauber M, Kellett MA, Kramer RS, Leadley K, Dawkins KD, Serruys PW. Diabetic and nondiabetic patients with left main and/or 3-vessel coronary artery disease: comparison of outcomes with cardiac surgery and paclitaxel-eluting stents. J Am Coll Cardiol. 2010 Mar 16;55(11):1067-75. PubMed External Web Site Policy

Bazzano LA, Reynolds K, Holder KN, He J. Effect of folic acid supplementation on risk of cardiovascular diseases: a meta-analysis of randomized controlled trials. JAMA. 2006 Dec 13;296(22):2720-6. PubMed External Web Site Policy

Beniamini Y, Rubenstein JJ, Faigenbaum AD, Lichtenstein AH, Crim MC. High-intensity strength training of patients enrolled in an outpatient cardiac rehabilitation program. J Cardiopulm Rehabil. 1999 Jan-Feb;19(1):8-17. PubMed External Web Site Policy

Benzer W, Hofer S, Oldridge NB. Health-related quality of life in patients with coronary artery disease after different treatments for angina in routine clinical practice. Herz. 2003 Aug;28(5):421-8. PubMed External Web Site Policy

Berkman LF, Blumenthal J, Burg M, Carney RM, Catellier D, Cowan MJ, Czajkowski SM, DeBusk R, Hosking J, Jaffe A, Kaufmann PG, Mitchell P, Norman J, Powell LH, Raczynski JM, Schneiderman N. Effects of treating depression and low perceived social support on clinical events after myocardial infarction: the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) Randomized Trial. JAMA. 2003 Jun 18;289(23):3106-16. PubMed External Web Site Policy

Berman DS, Hachamovitch R, Kiat H, Cohen I, Cabico JA, Wang FP, Friedman JD, Germano G, Van Train K, Diamond GA. Incremental value of prognostic testing in patients with known or suspected ischemic heart disease: a basis for optimal utilization of exercise technetium-99m sestamibi myocardial perfusion single-photon emission computed tomography. J Am Coll Cardiol. 1995 Sep;26(3):639-47. PubMed External Web Site Policy

Bhatt DL, Flather MD, Hacke W, Berger PB, Black HR, Boden WE, Cacoub P, Cohen EA, Creager MA, Easton JD, Hamm CW, Hankey GJ, Johnston SC, Mak KH, Mas JL, Montalescot G, Pearson TA, Steg PG, Steinhubl SR, Weber MA, Fabry-Ribaudo L, Hu T, Topol EJ, Fox KA, CHARISMA Investigators. Patients with prior myocardial infarction, stroke, or symptomatic peripheral arterial disease in the CHARISMA trial. J Am Coll Cardiol. 2007 May 15;49(19):1982-8. PubMed External Web Site Policy

Biagini E, Shaw LJ, Poldermans D, Schinkel AF, Rizzello V, Elhendy A, Rapezzi C, Bax JJ. Accuracy of non-invasive techniques for diagnosis of coronary artery disease and prediction of cardiac events in patients with left bundle branch block: a meta-analysis. Eur J Nucl Med Mol Imaging. 2006 Dec;33(12):1442-51. PubMed External Web Site Policy

Bingham SE, Hachamovitch R. Incremental prognostic significance of combined cardiac magnetic resonance imaging, adenosine stress perfusion, delayed enhancement, and left ventricular function over preimaging information for the prediction of adverse events. Circulation. 2011 Apr 12;123(14):1509-18. PubMed External Web Site Policy

Biondi-Zoccai GG, Lotrionte M, Moretti C, Meliga E, Agostoni P, Valgimigli M, Migliorini A, Antoniucci D, Carrie D, Sangiorgi G, Chieffo A, Colombo A, Price MJ, Teirstein PS, Christiansen EH, Abbate A, Testa L, Gunn JP, Burzotta F, Laudito A, Trevi GP, Sheiban I. A collaborative systematic review and meta-analysis on 1278 patients undergoing percutaneous drug-eluting stenting for unprotected left main coronary artery disease. Am Heart J. 2008 Feb;155(2):274-83. [31 references] PubMed External Web Site Policy

Bjelakovic G, Nikolova D, Gluud LL, Simonetti RG, Gluud C. Mortality in randomized trials of antioxidant supplements for primary and secondary prevention: systematic review and meta-analysis. JAMA. 2007 Feb 28;297(8):842-57. [138 references] PubMed External Web Site Policy

Boberg J, Larsen FF, Pehrsson SK. The effects of beta blockade with (epanolol) and without (atenolol) intrinsic sympathomimetic activity in stable angina pectoris. The Visacor Study Group. Clin Cardiol. 1992 Aug;15(8):591-5. PubMed External Web Site Policy

Boden WE, O'Rourke RA, Teo KK, Hartigan PM, Maron DJ, Kostuk WJ, Knudtson M, Dada M, Casperson P, Harris CL, Chaitman BR, Shaw L, Gosselin G, Nawaz S, Title LM, Gau G, Blaustein AS, Booth DC, Bates ER, Spertus JA, Berman DS, Mancini GB, Weintraub WS. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 2007 Apr 12;356(15):1503-16. [46 references] PubMed External Web Site Policy

Bodi V, Sanchis J, Lopez-Lereu MP, Nunez J, Mainar L, Monmeneu JV, Husser O, Dominguez E, Chorro FJ, Llacer A. Prognostic value of dipyridamole stress cardiovascular magnetic resonance imaging in patients with known or suspected coronary artery disease. J Am Coll Cardiol. 2007 Sep 18;50(12):1174-9. PubMed External Web Site Policy

Bogers RP, Bemelmans WJ, Hoogenveen RT, Boshuizen HC, Woodward M, Knekt P, van Dam RM, Hu FB, Visscher TL, Menotti A, Thorpe RJ Jr, Jamrozik K, Calling S, Strand BH, Shipley MJ, BMI-CHD Collaboration Investigators. Association of overweight with increased risk of coronary heart disease partly independent of blood pressure and cholesterol levels: a meta-analysis of 21 cohort studies including more than 300 000 persons. Arch Intern Med. 2007 Sep 10;167(16):1720-8. [47 references] PubMed External Web Site Policy

Bonaa KH, Njolstad I, Ueland PM, Schirmer H, Tverdal A, Steigen T, Wang H, Nordrehaug JE, Arnesen E, Rasmussen K, NORVIT Trial Investigators. Homocysteine lowering and cardiovascular events after acute myocardial infarction. N Engl J Med. 2006 Apr 13;354(15):1578-88. PubMed External Web Site Policy

Bonaros N, Schachner T, Ohlinger A, Friedrich G, Laufer G, Bonatti J. Assessment of health-related quality of life after coronary revascularization. Heart Surg Forum. 2005;8(5):E380-5. [50 references] PubMed External Web Site Policy

Bonatti J, Schachner T, Bonaros N, Jonetzko P, Ohlinger A, Ruetzler E, Kolbitsch C, Feuchtner G, Laufer G, Pachinger O, Friedrich G. Simultaneous hybrid coronary revascularization using totally endoscopic left internal mammary artery bypass grafting and placement of rapamycin eluting stents in the same interventional session. The COMBINATION pilot study. Cardiology. 2008;110(2):92-5. PubMed External Web Site Policy

Bonow RO, Maurer G, Lee KL, Holly TA, Binkley PF, Desvigne-Nickens P, Drozdz J, Farsky PS, Feldman AM, Doenst T, Michler RE, Berman DS, Nicolau JC, Pellikka PA, Wrobel K, Alotti N, Asch FM, Favaloro LE, She L, Velazquez EJ, Jones RH, Panza JA, STICH Trial Investigators. Myocardial viability and survival in ischemic left ventricular dysfunction. N Engl J Med. 2011 Apr 28;364(17):1617-25. PubMed External Web Site Policy

Borger van der Burg AE, Bax JJ, Boersma E, Bootsma M, van Erven L, van der Wall EE, Schalij MJ. Impact of percutaneous coronary intervention or coronary artery bypass grafting on outcome after nonfatal cardiac arrest outside the hospital. Am J Cardiol. 2003 Apr 1;91(7):785-9. PubMed External Web Site Policy

Bosworth HB, Olsen MK, Dudley T, Orr M, Neary A, Harrelson M, Adams M, Svetkey LP, Dolor RJ, Oddone EZ. The Take Control of Your Blood pressure (TCYB) study: study design and methodology. Contemp Clin Trials. 2007 Jan;28(1):33-47. PubMed External Web Site Policy

Boudriot E, Thiele H, Walther T, Liebetrau C, Boeckstegers P, Pohl T, Reichart B, Mudra H, Beier F, Gansera B, Neumann FJ, Gick M, Zietak T, Desch S, Schuler G, Mohr FW. Randomized comparison of percutaneous coronary intervention with sirolimus-eluting stents versus coronary artery bypass grafting in unprotected left main stem stenosis. J Am Coll Cardiol. 2011 Feb 1;57(5):538-45. PubMed External Web Site Policy

Bouzas-Mosquera A, Peteiro J, Alvarez-Garcia N, Broullon FJ, Mosquera VX, Garcia-Bueno L, Ferro L, Castro-Beiras A. Prediction of mortality and major cardiac events by exercise echocardiography in patients with normal exercise electrocardiographic testing. J Am Coll Cardiol. 2009 May 26;53(21):1981-90. PubMed External Web Site Policy

Braunwald E, Domanski MJ, Fowler SE, Geller NL, Gersh BJ, Hsia J, Pfeffer MA, Rice MM, Rosenberg YD, Rouleau JL, PEACE Trial Investigators. Angiotensin-converting-enzyme inhibition in stable coronary artery disease. N Engl J Med. 2004 Nov 11;351(20):2058-68. PubMed External Web Site Policy

Brener SJ, Galla JM, Bryant R 3rd, Sabik JF 3rd, Ellis SG. Comparison of percutaneous versus surgical revascularization of severe unprotected left main coronary stenosis in matched patients. Am J Cardiol. 2008 Jan 15;101(2):169-72. PubMed External Web Site Policy

Brener SJ, Lytle BW, Casserly IP, Ellis SG, Topol EJ, Lauer MS. Predictors of revascularization method and long-term outcome of percutaneous coronary intervention or repeat coronary bypass surgery in patients with multivessel coronary disease and previous coronary bypass surgery. Eur Heart J. 2006 Feb;27(4):413-8. PubMed External Web Site Policy

Brener SJ, Lytle BW, Casserly IP, Schneider JP, Topol EJ, Lauer MS. Propensity analysis of long-term survival after surgical or percutaneous revascularization in patients with multivessel coronary artery disease and high-risk features. Circulation. 2004 May 18;109(19):2290-5. PubMed External Web Site Policy

Brook RD, Rajagopalan S, Pope CA 3rd, Brook JR, Bhatnagar A, Diez-Roux AV, Holguin F, Hong Y, Luepker RV, Mittleman MA, Peters A, Siscovick D, Smith SC Jr, Whitsel L, Kaufman JD, American Heart Association Council on Epidemiology and Prevention, Council on the Kidney in Cardiovascular Disease, Council on Nutrition, Physical Activity and Metabolism. Particulate matter air pollution and cardiovascular disease: An update to the scientific statement from the American Heart Association. Circulation. 2010 Jun 1;121(21):2331-78. [426 references] PubMed External Web Site Policy

Brown BG, Zhao XQ, Chait A, Fisher LD, Cheung MC, Morse JS, Dowdy AA, Marino EK, Bolson EL, Alaupovic P, Frohlich J, Albers JJ. Simvastatin and niacin, antioxidant vitamins, or the combination for the prevention of coronary disease. N Engl J Med. 2001 Nov 29;345(22):1583-92. PubMed External Web Site Policy

Brunelli C, Cristofani R, L'Abbate A. Long-term survival in medically treated patients with ischaemic heart disease and prognostic importance of clinical and electrocardiographic data (the Italian CNR Multicentre Prospective Study OD1). Eur Heart J. 1989 Apr;10(4):292-303. PubMed External Web Site Policy

Bucher HC, Hengstler P, Schindler C, Guyatt GH. Percutaneous transluminal coronary angioplasty versus medical treatment for non-acute coronary heart disease: meta-analysis of randomised controlled trials. BMJ. 2000 Jul 8;321(7253):73-7. PubMed External Web Site Policy

Budoff MJ, Dowe D, Jollis JG, Gitter M, Sutherland J, Halamert E, Scherer M, Bellinger R, Martin A, Benton R, Delago A, Min JK. Diagnostic performance of 64-multidetector row coronary computed tomographic angiography for evaluation of coronary artery stenosis in individuals without known coronary artery disease: results from the prospective multicenter ACCURACY [trunc]. J Am Coll Cardiol. 2008 Nov 18;52(21):1724-32. PubMed External Web Site Policy

Burkhoff D, Schmidt S, Schulman SP, Myers J, Resar J, Becker LC, Weiss J, Jones JW. Transmyocardial laser revascularisation compared with continued medical therapy for treatment of refractory angina pectoris: a prospective randomised trial. ATLANTIC Investigators. Angina Treatments-Lasers and Normal Therapies in Comparison. Lancet. 1999 Sep 11;354(9182):885-90. PubMed External Web Site Policy

Buse JB, Ginsberg HN, Bakris GL, Clark NG, Costa F, Eckel R, Fonseca V, Gerstein HC, Grundy S, Nesto RW, Pignone MP, Plutzky J, Porte D, Redberg R, Stitzel KF, Stone NJ, American Heart Association, American Diabetes Association. Primary prevention of cardiovascular diseases in people with diabetes mellitus: a scientific statement from the American Heart Association and the American Diabetes Association. Circulation. 2007 Jan 2;115(1):114-26. PubMed External Web Site Policy

Buszman PE, Kiesz SR, Bochenek A, Peszek-Przybyla E, Szkrobka I, Debinski M, Bialkowska B, Dudek D, Gruszka A, Zurakowski A, Milewski K, Wilczynski M, Rzeszutko L, Buszman P, Szymszal J, Martin JL, Tendera M. Acute and late outcomes of unprotected left main stenting in comparison with surgical revascularization. J Am Coll Cardiol. 2008 Feb 5;51(5):538-45. PubMed External Web Site Policy

Califf RM, Harrell FE Jr, Lee KL, Rankin JS, Hlatky MA, Mark DB, Jones RH, Muhlbaier LH, Oldham HN Jr, Pryor DB. The evolution of medical and surgical therapy for coronary artery disease. A 15-year perspective. JAMA. 1989 Apr 14;261(14):2077-86. PubMed External Web Site Policy

Calle EE, Thun MJ, Petrelli JM, Rodriguez C, Heath CW Jr. Body-mass index and mortality in a prospective cohort of U.S. adults. N Engl J Med. 1999 Oct 7;341(15):1097-105. PubMed External Web Site Policy

Calnon DA, McGrath PD, Doss AL, Harrell FE Jr, Watson DD, Beller GA. Prognostic value of dobutamine stress technetium-99m-sestamibi single-photon emission computed tomography myocardial perfusion imaging: stratification of a high-risk population. J Am Coll Cardiol. 2001 Nov 1;38(5):1511-7. PubMed External Web Site Policy

Cameron A, Davis KB, Green G, Schaff HV. Coronary bypass surgery with internal-thoracic-artery grafts--effects on survival over a 15-year period. N Engl J Med. 1996 Jan 25;334(4):216-9. PubMed External Web Site Policy

Canner PL, Berge KG, Wenger NK, Stamler J, Friedman L, Prineas RJ, Friedewald W. Fifteen year mortality in Coronary Drug Project patients: long-term benefit with niacin. J Am Coll Cardiol. 1986 Dec;8(6):1245-55. PubMed External Web Site Policy

Capodanno D, Caggegi A, Miano M, Cincotta G, Dipasqua F, Giacchi G, Capranzano P, Ussia G, Di Salvo ME, La Manna A, Tamburino C. Global risk classification and clinical SYNTAX (synergy between percutaneous coronary intervention with TAXUS and cardiac surgery) score in patients undergoing percutaneous or surgical left main revascularization. JACC Cardiovasc Interv. 2011 Mar;4(3):287-97. PubMed External Web Site Policy

CAPRIE Steering Committee. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). Lancet. 1996 Nov 16;348(9038):1329-39. PubMed External Web Site Policy

Caracciolo EA, Davis KB, Sopko G, Kaiser GC, Corley SD, Schaff H, Taylor HA, Chaitman BR. Comparison of surgical and medical group survival in patients with left main coronary artery disease. Long-term CASS experience. Circulation. 1995 May 1;91(9):2325-34. PubMed External Web Site Policy

Cardinal BJ. Predicting cardiorespiratory fitness without exercise testing in epidemiologic studies: a concurrent validity study. J Epidemiol. 1996 Mar;6(1):31-5. PubMed External Web Site Policy

Carney RM, Freedland KE, Eisen SA, Rich MW, Jaffe AS. Major depression and medication adherence in elderly patients with coronary artery disease. Health Psychol. 1995 Jan;14(1):88-90. PubMed External Web Site Policy

Carrabba N, Schuijf JD, de Graaf FR, Parodi G, Maffei E, Valenti R, Palumbo A, Weustink AC, Mollet NR, Accetta G, Cademartiri F, Antoniucci D, Bax JJ. Diagnostic accuracy of 64-slice computed tomography coronary angiography for the detection of in-stent restenosis: a meta-analysis. J Nucl Cardiol. 2010 Jun;17(3):470-8. PubMed External Web Site Policy

Cashin WL, Sanmarco ME, Nessim SA, Blankenhorn DH. Accelerated progression of atherosclerosis in coronary vessels with minimal lesions that are bypassed. N Engl J Med. 1984 Sep 27;311(13):824-8. PubMed External Web Site Policy

Center for Drug Evaluation and Research. Woodcock J. Decision on continued marketing of rosiglitazone (Avandia, Avandamet, Avandaryl) [Report NDA 021071]. 2010.

Chaitman BR, Bourassa MG, Davis K, Rogers WJ, Tyras DH, Berger R, Kennedy JW, Fisher L, Judkins MP, Mock MB, Killip T. Angiographic prevalence of high-risk coronary artery disease in patient subsets (CASS). Circulation. 1981 Aug;64(2):360-7. PubMed External Web Site Policy

Chaitman BR, Pepine CJ, Parker JO, Skopal J, Chumakova G, Kuch J, Wang W, Skettino SL, Wolff AA, Combination Assessment of Ranolazine In Stable Angina (CARISA) Investigators. Effects of ranolazine with atenolol, amlodipine, or diltiazem on exercise tolerance and angina frequency in patients with severe chronic angina: a randomized controlled trial. JAMA. 2004 Jan 21;291(3):309-16. PubMed External Web Site Policy

Chakravarty T, Buch MH, Naik H, White AJ, Doctor N, Schapira J, Mirocha JM, Fontana G, Forrester JS, Makkar R. Predictive accuracy of SYNTAX score for predicting long-term outcomes of unprotected left main coronary artery revascularization. Am J Cardiol. 2011 Feb 1;107(3):360-6. PubMed External Web Site Policy

Chatziioannou SN, Moore WH, Ford PV, Fisher RE, Lee VV, Alfaro-Franco C, Dhekne RD. Prognostic value of myocardial perfusion imaging in patients with high exercise tolerance. Circulation. 1999 Feb 23;99(7):867-72. PubMed External Web Site Policy

Chieffo A, Magni V, Latib A, Maisano F, Ielasi A, Montorfano M, Carlino M, Godino C, Ferraro M, Calori G, Alfieri O, Colombo A. 5-year outcomes following percutaneous coronary intervention with drug-eluting stent implantation versus coronary artery bypass graft for unprotected left main coronary artery lesions the Milan experience. JACC Cardiovasc Interv. 2010 Jun;3(6):595-601. PubMed External Web Site Policy

Chieffo A, Morici N, Maisano F, Bonizzoni E, Cosgrave J, Montorfano M, Airoldi F, Carlino M, Michev I, Melzi G, Sangiorgi G, Alfieri O, Colombo A. Percutaneous treatment with drug-eluting stent implantation versus bypass surgery for unprotected left main stenosis: a single-center experience. Circulation. 2006;113(21):2542-7. PubMed External Web Site Policy

Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, Jones DW, Materson BJ, Oparil S, Wright JT Jr, Roccella EJ. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003 Dec;42(6):1206-52. [386 references] PubMed External Web Site Policy

Cholesterol Treatment Trialists' (CTT) Collaboration, Baigent C, Blackwell L, Emberson J, Holland LE, Reith C, Bhala N, Peto R, Barnes EH, Keech A, Simes J, Collins R. Efficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of data from 170,000 participants in 26 randomised trials. Lancet. 2010 Nov 13;376(9753):1670-81. PubMed External Web Site Policy

Chow BJ, Wells GA, Chen L, Yam Y, Galiwango P, Abraham A, Sheth T, Dennie C, Beanlands RS, Ruddy TD. Prognostic value of 64-slice cardiac computed tomography severity of coronary artery disease, coronary atherosclerosis, and left ventricular ejection fraction. J Am Coll Cardiol. 2010 Mar 9;55(10):1017-28. PubMed External Web Site Policy

Christian TF, Miller TD, Bailey KR, Gibbons RJ. Exercise tomographic thallium-201 imaging in patients with severe coronary artery disease and normal electrocardiograms. Ann Intern Med. 1994 Dec 1;121(11):825-32. PubMed External Web Site Policy

Chuah SC, Pellikka PA, Roger VL, McCully RB, Seward JB. Role of dobutamine stress echocardiography in predicting outcome in 860 patients with known or suspected coronary artery disease. Circulation. 1998 Apr 21;97(15):1474-80. PubMed External Web Site Policy

Clark AM, Haykowsky M, Kryworuchko J, MacClure T, Scott J, DesMeules M, Luo W, Liang Y, McAlister FA. A meta-analysis of randomized control trials of home-based secondary prevention programs for coronary artery disease. Eur J Cardiovasc Prev Rehabil. 2010 Jun;17(3):261-70. [64 references] PubMed External Web Site Policy

Coelho-Filho OR, Seabra LF, Mongeon FP, Abdullah SM, Francis SA, Blankstein R, Di Carli MF, Jerosch-Herold M, Kwong RY. Stress myocardial perfusion imaging by CMR provides strong prognostic value to cardiac events regardless of patient's sex. JACC Cardiovasc Imaging. 2011 Aug;4(8):850-61. PubMed External Web Site Policy

Couch RB, Winokur P, Brady R, Belshe R, Chen WH, Cate TR, Sigurdardottir B, Hoeper A, Graham IL, Edelman R, He F, Nino D, Capellan J, Ruben FL. Safety and immunogenicity of a high dosage trivalent influenza vaccine among elderly subjects. Vaccine. 2007 Nov 1;25(44):7656-63. PubMed External Web Site Policy

Critchley J, Capewell S. Smoking cessation for the secondary prevention of coronary heart disease. Cochrane Database Syst Rev. 2003;(4):CD003041. [115 references] PubMed External Web Site Policy

Critchley JA, Capewell S. Mortality risk reduction associated with smoking cessation in patients with coronary heart disease: a systematic review. JAMA. 2003 Jul 2;290(1):86-97. [63 references] PubMed External Web Site Policy

Currie CJ, Peters JR, Tynan A, Evans M, Heine RJ, Bracco OL, Zagar T, Poole CD. Survival as a function of HbA(1c) in people with type 2 diabetes: a retrospective cohort study. Lancet. 2010 Feb 6;375(9713):481-9. PubMed External Web Site Policy

Daly C, Norrie J, Murdoch DL, Ford I, Dargie HJ, Fox K, TIBET (Total Ischaemic Burden European Trial) study group. The value of routine non-invasive tests to predict clinical outcome in stable angina. Eur Heart J. 2003 Mar;24(6):532-40. PubMed External Web Site Policy

Daly CA, De Stavola B, Sendon JL, Tavazzi L, Boersma E, Clemens F, Danchin N, Delahaye F, Gitt A, Julian D, Mulcahy D, Ruzyllo W, Thygesen K, Verheugt F, Fox KM, Euro Heart Survey Investigators. Predicting prognosis in stable angina--results from the Euro heart survey of stable angina: prospective observational study. BMJ. 2006 Feb 4;332(7536):262-7. PubMed External Web Site Policy

Danchin N, Cucherat M, Thuillez C, Durand E, Kadri Z, Steg PG. Angiotensin-converting enzyme inhibitors in patients with coronary artery disease and absence of heart failure or left ventricular systolic dysfunction: an overview of long-term randomized controlled trials. Arch Intern Med. 2006 Apr 10;166(7):787-96. PubMed External Web Site Policy

Dattilo AM, Kris-Etherton PM. Effects of weight reduction on blood lipids and lipoproteins: a meta-analysis. Am J Clin Nutr. 1992 Aug;56(2):320-8. [83 references] PubMed External Web Site Policy

Davies RF, Goldberg AD, Forman S, Pepine CJ, Knatterud GL, Geller N, Sopko G, Pratt C, Deanfield J, Conti CR. Asymptomatic Cardiac Ischemia Pilot (ACIP) study two-year follow-up: outcomes of patients randomized to initial strategies of medical therapy versus revascularization. Circulation. 1997 Apr 15;95(8):2037-43. PubMed External Web Site Policy

Davis MM, Taubert K, Benin AL, Brown DW, Mensah GA, Baddour LM, Dunbar S, Krumholz HM, American Heart Association, American College of Cardiology, American Association of Cardiovascular and Pulmonary Rehabilitation, American Association of Critical Care Nurses, American Association of Heart Failure Nurses, American Diabetes Association, Association of Black Cardiologists, Inc, Heart Failure Society of America, Preventive Cardiovascular Nurses Association, American Academy of Nurse Practitioners, Centers for Disease Control and Prevention and the Advisory Committee on Immunization. Influenza vaccination as secondary prevention for cardiovascular disease: a science advisory from the American Heart Association/American College of Cardiology. J Am Coll Cardiol. 2006 Oct 3;48(7):1498-502. [33 references] PubMed External Web Site Policy

de Azevedo CF, Hadlich MS, Bezerra SG, Petriz JL, Alves RR, de Souza O, Rati M, Albuquerque DC, Moll J. Prognostic value of CT angiography in patients with inconclusive functional stress tests. JACC Cardiovasc Imaging. 2011 Jul;4(7):740-51. PubMed External Web Site Policy

de Diego C, Vila-Corcoles A, Ochoa O, Rodriguez-Blanco T, Salsench E, Hospital I, Bejarano F, Del Puy Muniain M, Fortin M, Canals M, EPIVAC Study Group. Effects of annual influenza vaccination on winter mortality in elderly people with chronic heart disease. Eur Heart J. 2009 Jan;30(2):209-16. PubMed External Web Site Policy

de Gaetano G. Low-dose aspirin and vitamin E in people at cardiovascular risk: a randomised trial in general practice. Collaborative Group of the Primary Prevention Project. Lancet. 2001 Jan 13;357(9250):89-95. PubMed External Web Site Policy

de Peuter OR, Lussana F, Peters RJ, Buller HR, Kamphuisen PW. A systematic review of selective and non-selective beta blockers for prevention of vascular events in patients with acute coronary syndrome or heart failure. Neth J Med. 2009 Oct;67(9):284-94. [66 references] PubMed External Web Site Policy

DeBusk RF, Miller NH, Superko HR, Dennis CA, Thomas RJ, Lew HT, Berger WE 3rd, Heller RS, Rompf J, Gee D, Kraemer HC, Bandura A, Ghandour G, Clark M, Shah RV, Fisher L, Taylor CB. A case-management system for coronary risk factor modification after acute myocardial infarction. Ann Intern Med. 1994 May 1;120(9):721-9. PubMed External Web Site Policy

Di Carli MF, Maddahi J, Rokhsar S, Schelbert HR, Bianco-Batlles D, Brunken RC, Fromm B. Long-term survival of patients with coronary artery disease and left ventricular dysfunction: implications for the role of myocardial viability assessment in management decisions. J Thorac Cardiovasc Surg. 1998 Dec;116(6):997-1004. PubMed External Web Site Policy

Di Castelnuovo A, Rotondo S, Iacoviello L, Donati MB, De Gaetano G. Meta-analysis of wine and beer consumption in relation to vascular risk. Circulation. 2002 Jun 18;105(24):2836-44. PubMed External Web Site Policy

Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993 Sep 30;329(14):977-86. PubMed External Web Site Policy

Diamond GA, Forrester JS. Analysis of probability as an aid in the clinical diagnosis of coronary-artery disease. N Engl J Med. 1979 Jun 14;300(24):1350-8. PubMed External Web Site Policy

Dietary supplementation with n-3 polyunsaturated fatty acids and vitamin E after myocardial infarction: results of the GISSI-Prevenzione trial. Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto miocardico. Lancet. 1999 Aug 7;354(9177):447-55. PubMed External Web Site Policy

DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med. 2000 Jul 24;160(14):2101-7. PubMed External Web Site Policy

Dluhy RG, McMahon GT. Intensive glycemic control in the ACCORD and ADVANCE trials. N Engl J Med. 2008 Jun 12;358(24):2630-3. PubMed External Web Site Policy

Doesch C, Seeger A, Doering J, Herdeg C, Burgstahler C, Claussen CD, Gawaz M, Miller S, May AE. Risk stratification by adenosine stress cardiac magnetic resonance in patients with coronary artery stenoses of intermediate angiographic severity. JACC Cardiovasc Imaging. 2009 Apr;2(4):424-33. PubMed External Web Site Policy

Domanski MJ, Krause-Steinrauf H, Massie BM, Deedwania P, Follmann D, Kovar D, Murray D, Oren R, Rosenberg Y, Young J, Zile M, Eichhorn E, BEST Investigators. A comparative analysis of the results from 4 trials of beta-blocker therapy for heart failure: BEST, CIBIS-II, MERIT-HF, and COPERNICUS. J Card Fail. 2003 Oct;9(5):354-63. [37 references] PubMed External Web Site Policy

Dormandy JA, Charbonnel B, Eckland DJ, Erdmann E, Massi-Benedetti M, Moules IK, Skene AM, Tan MH, Lefebvre PJ, Murray GD, Standl E, Wilcox RG, Wilhelmsen L, Betteridge J, Birkeland K, Golay A, Heine RJ, Koranyi L, Laakso M, Mokan M, Norkus A, Pirags V, Podar T, Scheen A, Scherbaum W, Schernthaner G, Schmitz O, Skrha J, Smith U, Taton J, PROactive investigators. Secondary prevention of macrovascular events in patients with type 2 diabetes in the PROactive Study (PROspective pioglitAzone Clinical Trial In macroVascular Events): a randomised controlled trial. Lancet. 2005 Oct 8;366(9493):1279-89. PubMed External Web Site Policy

Duckworth W, Abraira C, Moritz T, Reda D, Emanuele N, Reaven PD, Zieve FJ, Marks J, Davis SN, Hayward R, Warren SR, Goldman S, McCarren M, Vitek ME, Henderson WG, Huang GD, VADT Investigators. Glucose control and vascular complications in veterans with type 2 diabetes. N Engl J Med. 2009 Jan 8;360(2):129-39. PubMed External Web Site Policy

Dzavik V, Ghali WA, Norris C, Mitchell LB, Koshal A, Saunders LD, Galbraith PD, Hui W, Faris P, Knudtson ML, Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease. Long-term survival in 11,661 patients with multivessel coronary artery disease in the era of stenting: a report from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) Investigators. Am Heart J. 2001 Jul;142(1):119-26. PubMed External Web Site Policy

Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). UK Prospective Diabetes Study (UKPDS) Group. Lancet. 1998 Sep 12;352(9131):854-65. PubMed External Web Site Policy

Effect of stepped care treatment on the incidence of myocardial infarction and angina pectoris. 5-Year findings of the hypertension detection and follow-up program. Hypertension. 1984 Mar-Apr;6(2 Pt 2):I198-206. PubMed External Web Site Policy

Effects of weight loss and sodium reduction intervention on blood pressure and hypertension incidence in overweight people with high-normal blood pressure. The Trials of Hypertension Prevention, phase II. The Trials of Hypertension Prevention Collaborati. Arch Intern Med. 1997 Mar 24;157(6):657-67. PubMed External Web Site Policy

Ellis SG, Tamai H, Nobuyoshi M, Kosuga K, Colombo A, Holmes DR, Macaya C, Grines CL, Whitlow PL, White HJ, Moses J, Teirstein PS, Serruys PW, Bittl JA, Mooney MR, Shimshak TM, Block PC, Erbel R. Contemporary percutaneous treatment of unprotected left main coronary stenoses: initial results from a multicenter registry analysis 1994-1996. Circulation. 1997 Dec 2;96(11):3867-72. [11 references] PubMed External Web Site Policy

Emond M, Mock MB, Davis KB, Fisher LD, Holmes DR Jr, Chaitman BR, Kaiser GC, Alderman E, Killip T 3rd. Long-term survival of medically treated patients in the Coronary Artery Surgery Study (CASS) Registry. Circulation. 1994 Dec;90(6):2645-57. PubMed External Web Site Policy

Every NR, Fahrenbruch CE, Hallstrom AP, Weaver WD, Cobb LA. Influence of coronary bypass surgery on subsequent outcome of patients resuscitated from out of hospital cardiac arrest. J Am Coll Cardiol. 1992 Jun;19(7):1435-9. PubMed External Web Site Policy

Favarato ME, Hueb W, Boden WE, Lopes N, Nogueira CR, Takiuti M, Gois AF, Borges JC, Favarato D, Aldrighi JM, Oliveira SA, Ramires JA. Quality of life in patients with symptomatic multivessel coronary artery disease: a comparative post hoc analyses of medical, angioplasty or surgical strategies-MASS II trial. Int J Cardiol. 2007 Apr 4;116(3):364-70. PubMed External Web Site Policy

Feit F, Brooks MM, Sopko G, Keller NM, Rosen A, Krone R, Berger PB, Shemin R, Attubato MJ, Williams DO, Frye R, Detre KM. Long-term clinical outcome in the Bypass Angioplasty Revascularization Investigation Registry: comparison with the randomized trial. BARI Investigators. Circulation. 2000 Jun 20;101(24):2795-802. PubMed External Web Site Policy

Five-year findings of the hypertension detection and follow-up program. I. Reduction in mortality of persons with high blood pressure, including mild hypertension. Hypertension Detection and Follow-up Program Cooperative Group. JAMA. 1979 Dec 7;242(23):2562-71. PubMed External Web Site Policy

Fleischmann KE, Hunink MG, Kuntz KM, Douglas PS. Exercise echocardiography or exercise SPECT imaging? A meta-analysis of diagnostic test performance. JAMA. 1998 Sep 9;280(10):913-20. PubMed External Web Site Policy

Fox KM. Efficacy of perindopril in reduction of cardiovascular events among patients with stable coronary artery disease: randomised, double-blind, placebo-controlled, multicentre trial (the EUROPA study). Lancet. 2003 Sep 6;362(9386):782-8. PubMed External Web Site Policy

Frattaroli J, Weidner G, Merritt-Worden TA, Frenda S, Ornish D. Angina pectoris and atherosclerotic risk factors in the multisite cardiac lifestyle intervention program. Am J Cardiol. 2008 Apr 1;101(7):911-8. PubMed External Web Site Policy

Freemantle N, Cleland J, Young P, Mason J, Harrison J. Beta blockade after myocardial infarction: systematic review and meta regression analysis. BMJ. 1999 Jun 26;318(7200):1730-7. PubMed External Web Site Policy

Frishman WH, Heiman M, Soberman J, Greenberg S, Eff J. Comparison of celiprolol and propranolol in stable angina pectoris. Celiprolol International Angina Study Group. Am J Cardiol. 1991 Apr 1;67(8):665-70. PubMed External Web Site Policy

Garber AM, Solomon NA. Cost-effectiveness of alternative test strategies for the diagnosis of coronary artery disease. Ann Intern Med. 1999 May 4;130(9):719-28. PubMed External Web Site Policy

Garg R, Yusuf S. Overview of randomized trials of angiotensin-converting enzyme inhibitors on mortality and morbidity in patients with heart failure. Collaborative Group on ACE Inhibitor Trials. JAMA. 1995 May 10;273(18):1450-6. PubMed External Web Site Policy

Gebker R, Jahnke C, Manka R, Hucko T, Schnackenburg B, Kelle S, Klein C, Fleck E, Paetsch I. The role of dobutamine stress cardiovascular magnetic resonance in the clinical management of patients with suspected and known coronary artery disease. J Cardiovasc Magn Reson. 2011;13:46. PubMed External Web Site Policy

Gehi AK, Ali S, Na B, Schiller NB, Whooley MA. Inducible ischemia and the risk of recurrent cardiovascular events in outpatients with stable coronary heart disease: the heart and soul study. Arch Intern Med. 2008 Jul 14;168(13):1423-8. PubMed External Web Site Policy

Geleijnse ML, Krenning BJ, Soliman OI, Nemes A, Galema TW, ten Cate FJ. Dobutamine stress echocardiography for the detection of coronary artery disease in women. Am J Cardiol. 2007 Mar 1;99(5):714-7. PubMed External Web Site Policy

Gianrossi R, Detrano R, Mulvihill D, Lehmann K, Dubach P, Colombo A, McArthur D, Froelicher V. Exercise-induced ST depression in the diagnosis of coronary artery disease. A meta-analysis. Circulation. 1989 Jul;80(1):87-98. PubMed External Web Site Policy

Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, Ferguson TB Jr, Fihn SD, Fraker TD Jr, Gardin JM, O'Rourke RA, Pasternak RC, Williams SV. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina. Summary article. J Am Coll Cardiol. 2003 Jan 1;41(1):159-68. PubMed External Web Site Policy

Gibbons RJ, Zinsmeister AR, Miller TD, Clements IP. Supine exercise electrocardiography compared with exercise radionuclide angiography in noninvasive identification of severe coronary artery disease. Ann Intern Med. 1990 May 15;112(10):743-9. PubMed External Web Site Policy

Gil VM, Almeida M, Ventosa A, Ferreira J, Aguiar C, Calqueiro J, Seabra-Gomes R. Prognosis in patients with left bundle branch block and normal dipyridamole thallium-201 scintigraphy. J Nucl Cardiol. 1998 Jul-Aug;5(4):414-7. PubMed External Web Site Policy

Gilard M, Bezon E, Cornily JC, Mansourati J, Mondine P, Barra JA, Boschat J. Same-day combined percutaneous coronary intervention and coronary artery surgery. Cardiology. 2007;108(4):363-7. PubMed External Web Site Policy

Ginsberg HN, Kris-Etherton P, Dennis B, Elmer PJ, Ershow A, Lefevre M, Pearson T, Roheim P, Ramakrishnan R, Reed R, Stewart K, Stewart P, Phillips K, Anderson N. Effects of reducing dietary saturated fatty acids on plasma lipids and lipoproteins in healthy subjects: the DELTA Study, protocol 1. Arterioscler Thromb Vasc Biol. 1998 Mar;18(3):441-9. PubMed External Web Site Policy

Glassman AH, O'Connor CM, Califf RM, Swedberg K, Schwartz P, Bigger JT Jr, Krishnan KR, van Zyl LT, Swenson JR, Finkel MS, Landau C, Shapiro PA, Pepine CJ, Mardekian J, Harrison WM, Barton D, Mclvor M. Sertraline treatment of major depression in patients with acute MI or unstable angina. JAMA. 2002 Aug 14;288(6):701-9. PubMed External Web Site Policy

Greenwood JP, Maredia N, Younger JF, Brown JM, Nixon J, Everett CC, Bijsterveld P, Ridgway JP, Radjenovic A, Dickinson CJ, Ball SG, Plein S. Cardiovascular magnetic resonance and single-photon emission computed tomography for diagnosis of coronary heart disease (CE-MARC): a prospective trial. Lancet. 2012 Feb 4;379(9814):453-60. PubMed External Web Site Policy

Grines CL, Bonow RO, Casey DE Jr, Gardner TJ, Lockhart PB, Moliterno DJ, O'Gara P, Whitlow P, American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, American Dental Association, American College of Physicians. Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents: a science advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography [trunc]. Circulation. 2007 Feb 13;115(6):813-8. [36 references] PubMed External Web Site Policy

Grover FL, Shroyer AL, Hammermeister K, Edwards FH, Ferguson TB Jr, Dziuban SW Jr, Cleveland JC Jr, Clark RE, McDonald G. A decade's experience with quality improvement in cardiac surgery using the Veterans Affairs and Society of Thoracic Surgeons national databases. Ann Surg. 2001 Oct;234(4):464-72; discussion 472-4. PubMed External Web Site Policy

Gruberg L, Weissman NJ, Waksman R, Fuchs S, Deible R, Pinnow EE, Ahmed LM, Kent KM, Pichard AD, Suddath WO, Satler LF, Lindsay J Jr. The impact of obesity on the short-term and long-term outcomes after percutaneous coronary intervention: the obesity paradox. J Am Coll Cardiol. 2002 Feb 20;39(4):578-84. PubMed External Web Site Policy

Grundy SM, Cleeman JI, Daniels SR, Donato KA, Eckel RH, Franklin BA, Gordon DJ, Krauss RM, Savage PJ, Smith SC Jr, Spertus JA, Costa F. Diagnosis and management of the metabolic syndrome: an American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement. Circulation. 2005 Oct 25;112(17):2735-52. [188 references] PubMed External Web Site Policy

Guldager B, Jelnes R, Jorgensen SJ, Nielsen JS, Klaerke A, Mogensen K, Larsen KE, Reimer E, Holm J, Ottesen S. EDTA treatment of intermittent claudication--a double-blind, placebo-controlled study. J Intern Med. 1992 Mar;231(3):261-7. PubMed External Web Site Policy

Guleserian KJ, Maniar HS, Camillo CJ, Bailey MS, Damiano RJ Jr, Moon MR. Quality of life and survival after transmyocardial laser revascularization with the holmium:YAG laser. Ann Thorac Surg. 2003 Jun;75(6):1842-7; discussion 1847-8. PubMed External Web Site Policy

Gurfinkel EP, Perez de la Hoz R, Brito VM, Duronto E, Dabbous OH, Gore JM, Anderson FA Jr, GRACE Investigators. Invasive vs non-invasive treatment in acute coronary syndromes and prior bypass surgery. Int J Cardiol. 2007 Jun 25;119(1):65-72. PubMed External Web Site Policy

H5N1 avian influenza: first steps towards development of a human vaccine. Wkly Epidemiol Rec. 2005 Aug 19;80(33):277-8. PubMed External Web Site Policy

Hachamovitch R, Berman DS, Kiat H, Cohen I, Friedman JD, Shaw LJ. Value of stress myocardial perfusion single photon emission computed tomography in patients with normal resting electrocardiograms: an evaluation of incremental prognostic value and cost-effectiveness. Circulation. 2002 Feb 19;105(7):823-9. PubMed External Web Site Policy

Hachamovitch R, Berman DS, Shaw LJ, Kiat H, Cohen I, Cabico JA, Friedman J, Diamond GA. Incremental prognosti. Circulation. 1998 Feb 17;97(6):535-43. PubMed External Web Site Policy

Hachamovitch R, Hayes SW, Friedman JD, Cohen I, Berman DS. A prognostic score for prediction of cardiac mortality risk after adenosine stress myocardial perfusion scintigraphy. J Am Coll Cardiol. 2005 Mar 1;45(5):722-9. PubMed External Web Site Policy

Hachamovitch R, Hayes SW, Friedman JD, Cohen I, Berman DS. Comparison of the short-term survival benefit associated with revascularization compared with medical therapy in patients with no prior coronary artery disease undergoing stress myocardial perfusion single photon emission computed tomography. Circulation. 2003 Jun 17;107(23):2900-7. PubMed External Web Site Policy

Hachamovitch R, Hayes SW, Friedman JD, Cohen I, Berman DS. Stress myocardial perfusion single-photon emission computed tomography is clinically effective and cost effective in risk stratification of patients with a high likelihood of coronary artery disease (CAD) but no known CAD. J Am Coll Cardiol. 2004 Jan 21;43(2):200-8. PubMed External Web Site Policy

Hachamovitch R, Rozanski A, Shaw LJ, Stone GW, Thomson LE, Friedman JD, Hayes SW, Cohen I, Germano G, Berman DS. Impact of ischaemia and scar on the therapeutic benefit derived from myocardial revascularization vs. medical therapy among patients undergoing stress-rest myocardial perfusion scintigraphy. Eur Heart J. 2011 Apr;32(8):1012-24. PubMed External Web Site Policy

Hacker M, Jakobs T, Hack N, Nikolaou K, Becker C, Von Ziegler F, Knez A, Konig A, Klauss V, Tiling R. Combined use of 64-slice computed tomography angiography and gated myocardial perfusion SPECT for the detection of functionally relevant coronary artery stenoses: First results in a clinical setting concerning patients with stable angina. Nucl Med (Stuttg). 2007;46(1):29-35. [35 references] PubMed External Web Site Policy

Hammermeister KE, DeRouen TA, Dodge HT. Variables predictive of survival in patients with coronary disease. Selection by univariate and multivariate analyses from the clinical, electrocardiographic, exercise, arteriographic, and quantitative angiographic evaluations. Circulation. 1979 Mar;59(3):421-30. PubMed External Web Site Policy

Hamon M, Biondi-Zoccai GG, Malagutti P, Agostoni P, Morello R, Valgimigli M, Hamon M. Diagnostic performance of multislice spiral computed tomography of coronary arteries as compared with conventional invasive coronary angiography: a meta-analysis. J Am Coll Cardiol. 2006 Nov 7;48(9):1896-910. [45 references] PubMed External Web Site Policy

Hamon M, Fau G, Nee G, Ehtisham J, Morello R, Hamon M. Meta-analysis of the diagnostic performance of stress perfusion cardiovascular magnetic resonance for detection of coronary artery disease. J Cardiovasc Magn Reson. 2010;12(1):29. [51 references] PubMed External Web Site Policy

Hamon M, Lepage O, Malagutti P, Riddell JW, Morello R, Agostini D, Hamon M. Diagnostic performance of 16- and 64-section spiral CT for coronary artery bypass graft assessment: meta-analysis. Radiology. 2008 Jun;247(3):679-86. PubMed External Web Site Policy

Hannan EL, Racz MJ, Walford G, Jones RH, Ryan TJ, Bennett E, Culliford AT, Isom OW, Gold JP, Rose EA. Long-term outcomes of coronary-artery bypass grafting versus stent implantation. N Engl J Med. 2005 May 26;352(21):2174-83. PubMed External Web Site Policy

Hannan EL, Wu C, Walford G, Culliford AT, Gold JP, Smith CR, Higgins RS, Carlson RE, Jones RH. Drug-eluting stents vs. coronary-artery bypass grafting in multivessel coronary disease. N Engl J Med. 2008 Jan 24;358(4):331-41. [29 references] PubMed External Web Site Policy

Harris PJ, Harrell FE Jr, Lee KL, Behar VS, Rosati RA. Survival in medically treated coronary artery disease. Circulation. 1979 Dec;60(6):1259-69. PubMed External Web Site Policy

Haskell WL, Alderman EL, Fair JM, Maron DJ, Mackey SF, Superko HR, Williams PT, Johnstone IM, Champagne MA, Krauss RM, et al.. Effects of intensive multiple risk factor reduction on coronary atherosclerosis and clinical cardiac events in men and women with coronary artery disease. The Stanford Coronary Risk Intervention Project (SCRIP). Circulation. 1994 Mar;89(3):975-90. PubMed External Web Site Policy

Haskell WL, Lee IM, Pate RR, Powell KE, Blair SN, Franklin BA, Macera CA, Heath GW, Thompson PD, Bauman A, American College of Sports Medicine, American Heart Association. Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Circulation. 2007 Aug 28;116(9):1081-93. [109 references] PubMed External Web Site Policy

Hautvast RW, DeJongste MJ, Staal MJ, van Gilst WH, Lie KI. Spinal cord stimulation in chronic intractable angina pectoris: a randomized, controlled efficacy study. Am Heart J. 1998 Dec;136(6):1114-20. PubMed External Web Site Policy

Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo-controlled trial. Lancet. 2002 Jul 6;360(9326):7-22. PubMed External Web Site Policy

Heidenreich PA, McDonald KM, Hastie T, Fadel B, Hagan V, Lee BK, Hlatky MA. Meta-analysis of trials comparing beta-blockers, calcium antagonists, and nitrates for stable angina. JAMA. 1999 May 26;281(20):1927-36. PubMed External Web Site Policy

Hendel RC, Berman DS, Di Carli MF, Heidenreich PA, Henkin RE, Pellikka PA, Pohost GM, Williams KA, American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Nuclear Cardiology, American College of Radiology, American Heart Association, American Society of Echocardiology, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, Society of Nuclear Medicine. ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 appropriate use criteria for cardiac radionuclide imaging: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology [trunc]. J Am Coll Cardiol. 2009 Jun 9;53(23):2201-29. PubMed External Web Site Policy

Hirsh J, Dalen JE, Fuster V, Harker LB, Patrono C, Roth G. Aspirin and other platelet-active drugs. The relationship among dose, effectiveness, and side effects. Chest. 1995 Oct;108(4 Suppl):247S-257S. [148 references] PubMed External Web Site Policy

Hoffman SN, TenBrook JA, Wolf MP, Pauker SG, Salem DN, Wong JB. A meta-analysis of randomized controlled trials comparing coronary artery bypass graft with percutaneous transluminal coronary angioplasty: one- to eight-year outcomes. J Am Coll Cardiol. 2003 Apr 16;41(8):1293-304. PubMed External Web Site Policy

Holman RR, Paul SK, Bethel MA, Matthews DR, Neil HA. 10-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med. 2008 Oct 9;359(15):1577-89. PubMed External Web Site Policy

Holzhey DM, Jacobs S, Mochalski M, Merk D, Walther T, Mohr FW, Falk V. Minimally invasive hybrid coronary artery revascularization. Ann Thorac Surg. 2008 Dec;86(6):1856-60. PubMed External Web Site Policy

Honig A, Kuyper AM, Schene AH, van Melle JP, de Jonge P, Tulner DM, Schins A, Crijns HJ, Kuijpers PM, Vossen H, Lousberg R, Ormel J, MIND-IT investigators. Treatment of post-myocardial infarction depressive disorder: a randomized, placebo-controlled trial with mirtazapine. Psychosom Med. 2007 Sep-Oct;69(7):606-13. PubMed External Web Site Policy

Hueb W, Lopes N, Gersh BJ, Soares PR, Ribeiro EE, Pereira AC, Favarato D, Rocha AS, Hueb AC, Ramires JA. Ten-year follow-up survival of the Medicine, Angioplasty, or Surgery Study (MASS II): a randomized controlled clinical trial of 3 therapeutic strategies for multivessel coronary artery disease. Circulation. 2010 Sep 7;122(10):949-57. PubMed External Web Site Policy

Hueb W, Lopes NH, Gersh BJ, Soares P, Machado LA, Jatene FB, Oliveira SA, Ramires JA. Five-year follow-up of the Medicine, Angioplasty, or Surgery Study (MASS II): a randomized controlled clinical trial of 3 therapeutic strategies for multivessel coronary artery disease. Circulation. 2007 Mar 6;115(9):1082-9. PubMed External Web Site Policy

Hulley S, Grady D, Bush T, Furberg C, Herrington D, Riggs B, Vittinghoff E. Randomized trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal women. Heart and Estrogen/progestin Replacement Study (HERS) Research Group. JAMA. 1998 Aug 19;280(7):605-13. PubMed External Web Site Policy

Hundley WG, Hamilton CA, Thomas MS, Herrington DM, Salido TB, Kitzman DW, Little WC, Link KM. Utility of fast cine magnetic resonance imaging and display for the detection of myocardial ischemia in patients not well suited for second harmonic stress echocardiography. Circulation. 1999 Oct 19;100(16):1697-702. PubMed External Web Site Policy

Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW, American College of Cardiology Foundation, American Heart Association. 2009 focused update incorporated into the ACC/AHA 2005 guidelines for the diagnosis and management of heart failure in adults [trunc]. J Am Coll Cardiol. 2009 Apr 14;53(15):e1-e90. [810 references] PubMed External Web Site Policy

Imran MB, Palinkas A, Picano E. Head-to-head comparison of dipyridamole echocardiography and stress perfusion scintigraphy for the detection of coronary artery disease: a meta-analysis. Comparison between stress echo and scintigraphy. Int J Cardiovasc Imaging. 2003 Feb;19(1):23-8. PubMed External Web Site Policy

Influence of diabetes on 5-year mortality and morbidity in a randomized trial comparing CABG and PTCA in patients with multivessel disease: the Bypass Angioplasty Revascularization Investigation (BARI). Circulation. 1997 Sep 16;96(6):1761-9. PubMed External Web Site Policy

Jacobs EJ, Newton CC, Wang Y, Patel AV, McCullough ML, Campbell PT, Thun MJ, Gapstur SM. Waist circumference and all-cause mortality in a large US cohort. Arch Intern Med. 2010 Aug 9;170(15):1293-301. PubMed External Web Site Policy

Jahnke C, Nagel E, Gebker R, Kokocinski T, Kelle S, Manka R, Fleck E, Paetsch I. Prognostic value of cardiac magnetic resonance stress tests: adenosine stress perfusion and dobutamine stress wall motion imaging. Circulation. 2007 Apr 3;115(13):1769-76. PubMed External Web Site Policy

Janne d'Othee B, Siebert U, Cury R, Jadvar H, Dunn EJ, Hoffmann U. A systematic review on diagnostic accuracy of CT-based detection of significant coronary artery disease. Eur J Radiol. 2008 Mar;65(3):449-61. [60 references] PubMed External Web Site Policy

Jensen MK, Chiuve SE, Rimm EB, Dethlefsen C, Tjonneland A, Joensen AM, Overvad K. Obesity, behavioral lifestyle factors, and risk of acute coronary events. Circulation. 2008 Jun 17;117(24):3062-9. PubMed External Web Site Policy

Jneid H, Anderson JL, Wright RS, Adams CD, Bridges CR, Casey DE, Ettinger SM, Fesmire FM, Ganiats TG, Lincoff AM, Peterson ED, Philippides GJ, Theroux P, Wenger NK, Zidar JP. 2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/non-ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2012 Aug 14;60(7):645-81. PubMed External Web Site Policy

Johansen A, Hoilund-Carlsen PF, Vach W, Christensen HW, Moldrup M, Haghfelt T. Prognostic value of myocardial perfusion imaging in patients with known or suspected stable angina pectoris: evaluation in a setting in which myocardial perfusion imaging did not influence the choice of treatment. Clin Physiol Funct Imaging. 2006 Sep;26(5):288-95. PubMed External Web Site Policy

Joint Commission. The Joint Commission announces the 2008 National Patient Safety Goals and Requirements. Jt Comm Perspect. 2007 Jul;27(7):1, 9-22. PubMed External Web Site Policy

Jones CM, Athanasiou T, Dunne N, Kirby J, Aziz O, Haq A, Rao C, Constantinides V, Purkayastha S, Darzi A. Multi-detector computed tomography in coronary artery bypass graft assessment: a meta-analysis. Ann Thorac Surg. 2007 Jan;83(1):341-8. PubMed External Web Site Policy

Jones RH, Kesler K, Phillips HR 3rd, Mark DB, Smith PK, Nelson CL, Newman MF, Reves JG, Anderson RW, Califf RM. Long-term survival benefits of coronary artery bypass grafting and percutaneous transluminal angioplasty in patients with coronary artery disease. J Thorac Cardiovasc Surg. 1996 May;111(5):1013-25. PubMed External Web Site Policy

Julius S, Weber MA, Kjeldsen SE, McInnes GT, Zanchetti A, Brunner HR, Laragh J, Schork MA, Hua TA, Amerena J, Balazovjech I, Cassel G, Herczeg B, Koylan N, Magometschnigg D, Majahalme S, Martinez F, Oigman W, Seabra Gomes R, Zhu JR. The Valsartan Antihypertensive Long-Term Use Evaluation (VALUE) trial: outcomes in patients receiving monotherapy. Hypertension. 2006 Sep;48(3):385-91. PubMed External Web Site Policy

Jurca R, Jackson AS, LaMonte MJ, Morrow JR Jr, Blair SN, Wareham NJ, Haskell WL, van Mechelen W, Church TS, Jakicic JM, Laukkanen R. Assessing cardiorespiratory fitness without performing exercise testing. Am J Prev Med. 2005 Oct;29(3):185-93. PubMed External Web Site Policy

Juul-Moller S, Edvardsson N, Jahnmatz B, Rosen A, Sorensen S, Omblus R. Double-blind trial of aspirin in primary prevention of myocardial infarction in patients with stable chronic angina pectoris. The Swedish Angina Pectoris Aspirin Trial (SAPAT) Group. Lancet. 1992 Dec 12;340(8833):1421-5. PubMed External Web Site Policy

Kaiser GA, Ghahramani A, Bolooki H, Vargas A, Thurer RJ, Williams WH, Myerburg RJ. Role of coronary artery surgery in patients surviving unexpected cardiac arrest. Surgery. 1975 Dec;78(6):749-54. PubMed External Web Site Policy

Kappetein AP, Feldman TE, Mack MJ, Morice MC, Holmes DR, Stahle E, Dawkins KD, Mohr FW, Serruys PW, Colombo A. Comparison of coronary bypass surgery with drug-eluting stenting for the treatment of left main and/or three-vessel disease: 3-year follow-up of the SYNTAX trial. Eur Heart J. 2011 Sep;32(17):2125-34. PubMed External Web Site Policy

Keitel WA, Atmar RL, Cate TR, Petersen NJ, Greenberg SB, Ruben F, Couch RB. Safety of high doses of influenza vaccine and effect on antibody responses in elderly persons. Arch Intern Med. 2006 May 22;166(10):1121-7. PubMed External Web Site Policy

Kelle S, Chiribiri A, Vierecke J, Egnell C, Hamdan A, Jahnke C, Paetsch I, Wellnhofer E, Fleck E, Klein C, Gebker R. Long-term prognostic value of dobutamine stress CMR. JACC Cardiovasc Imaging. 2011 Feb;4(2):161-72. PubMed External Web Site Policy

Kelly TN, Bazzano LA, Fonseca VA, Thethi TK, Reynolds K, He J. Systematic review: glucose control and cardiovascular disease in type 2 diabetes. Ann Intern Med. 2009 Sep 15;151(6):394-403. [34 references] PubMed External Web Site Policy

Ken-Dror G, Lerman Y, Segev S, Dankner R. [Development of a Hebrew questionnaire to be used in epidemiological studies to assess physical fitness--validation against sub maximal stress test and predicted VO2max]. Harefuah. 2004 Aug;143(8):566-72, 623. PubMed External Web Site Policy

Kernis SJ, Harjai KJ, Stone GW, Grines LL, Boura JA, O'Neill WW, Grines CL. Does beta-blocker therapy improve clinical outcomes of acute myocardial infarction after successful primary angioplasty. J Am Coll Cardiol. 2004 May 19;43(10):1773-9. PubMed External Web Site Policy

Kim YH, Park DW, Kim WJ, Lee JY, Yun SC, Kang SJ, Lee SW, Lee CW, Park SW, Park SJ. Validation of SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) score for prediction of outcomes after unprotected left main coronary revascularization. JACC Cardiovasc Interv. 2010 Jun;3(6):612-23. PubMed External Web Site Policy

King SB 3rd, Barnhart HX, Kosinski AS, Weintraub WS, Lembo NJ, Petersen JY, Douglas JS Jr, Jones EL, Craver JM, Guyton RA, Morris DC, Liberman HA. Angioplasty or surgery for multivessel coronary artery disease: comparison of eligible registry and randomized patients in the EAST trial and influence of treatment selection on outcomes. Emory Angioplasty versus Surgery Trial Investigators. Am J Cardiol. 1997 Jun 1;79(11):1453-9. PubMed External Web Site Policy

Klein S, Burke LE, Bray GA, Blair S, Allison DB, Pi-Sunyer X, Hong Y, Eckel RH. Clinical implications of obesity with specific focus on cardiovascular disease: a statement for professionals from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology. Circulation. 2004 Nov 2;110(18):2952-67. [213 references] PubMed External Web Site Policy

Knudtson ML, Wyse DG, Galbraith PD, Brant R, Hildebrand K, Paterson D, Richardson D, Burkart C, Burgess E, Program to Assess Alternative Treatment Strategies to Achieve Cardiac Health. Chelation therapy for ischemic heart disease: a randomized controlled trial. JAMA. 2002 Jan 23-30;287(4):481-6. PubMed External Web Site Policy

Kon ZN, Brown EN, Tran R, Joshi A, Reicher B, Grant MC, Kallam S, Burris N, Connerney I, Zimrin D, Poston RS. Simultaneous hybrid coronary revascularization reduces postoperative morbidity compared with results from conventional off-pump coronary artery bypass. J Thorac Cardiovasc Surg. 2008 Feb;135(2):367-75. PubMed External Web Site Policy

Korosoglou G, Elhmidi Y, Steen H, Schellberg D, Riedle N, Ahrens J, Lehrke S, Merten C, Lossnitzer D, Radeleff J, Zugck C, Giannitsis E, Katus HA. Prognostic value of high-dose dobutamine stress magnetic resonance imaging in 1,493 consecutive patients: assessment of myocardial wall motion and perfusion. J Am Coll Cardiol. 2010 Oct 5;56(15):1225-34. PubMed External Web Site Policy

Kuntz KM, Fleischmann KE, Hunink MG, Douglas PS. Cost-effectiveness of diagnostic strategies for patients with chest pain. Ann Intern Med. 1999 May 4;130(9):709-18. PubMed External Web Site Policy

Kunz R, Friedrich C, Wolbers M, Mann JF. Meta-analysis: effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease. Ann Intern Med. 2008 Jan 1;148(1):30-48. PubMed External Web Site Policy

Kwok Y, Kim C, Grady D, Segal M, Redberg R. Meta-analysis of exercise testing to detect coronary artery disease in women. Am J Cardiol. 1999 Mar 1;83(5):660-6. PubMed External Web Site Policy

Ladenheim ML, Kotler TS, Pollock BH, Berman DS, Diamond GA. Incremental prognostic power of clinical history, exercise electrocardiography and myocardial perfusion scintigraphy in suspected coronary artery disease. Am J Cardiol. 1987 Feb 1;59(4):270-7. PubMed External Web Site Policy

Ladenheim ML, Pollock BH, Rozanski A, Berman DS, Staniloff HM, Forrester JS, Diamond GA. Extent and severity of myocardial hypoperfusion as predictors of prognosis in patients with suspected coronary artery disease. J Am Coll Cardiol. 1986 Mar;7(3):464-71. PubMed External Web Site Policy

LaRosa JC, Grundy SM, Waters DD, Shear C, Barter P, Fruchart JC, Gotto AM, Greten H, Kastelein JJ, Shepherd J, Wenger NK, Treating to New Targets (TNT) Investigators. Intensive lipid lowering with atorvastatin in patients with stable coronary disease. N Engl J Med. 2005 Apr 7;352(14):1425-35. PubMed External Web Site Policy

Lauer MS, Lytle B, Pashkow F, Snader CE, Marwick TH. Prediction of death and myocardial infarction by screening with exercise-thallium testing after coronary-artery-bypass grafting. Lancet. 1998 Feb 28;351(9103):615-22. PubMed External Web Site Policy

Lavie CJ, Milani RV, Ventura HO. Obesity and cardiovascular disease: risk factor, paradox, and impact of weight loss. J Am Coll Cardiol. 2009 May 26;53(21):1925-32. [87 references] PubMed External Web Site Policy

Lee MS, Bokhoor P, Park SJ, Kim YH, Stone GW, Sheiban I, Biondi-Zoccai G, Sillano D, Tobis J, Kandzari DE. Unprotected left main coronary disease and ST-segment elevation myocardial infarction: a contemporary review and argument for percutaneous coronary intervention. JACC Cardiovasc Interv. 2010 Aug;3(8):791-5. PubMed External Web Site Policy

Lee MS, Kapoor N, Jamal F, Czer L, Aragon J, Forrester J, Kar S, Dohad S, Kass R, Eigler N, Trento A, Shah PK, Makkar RR. Comparison of coronary artery bypass surgery with percutaneous coronary intervention with drug-eluting stents for unprotected left main coronary artery disease. J Am Coll Cardiol. 2006 Feb 21;47(4):864-70. PubMed External Web Site Policy

Lee MS, Tseng CH, Barker CM, Menon V, Steckman D, Shemin R, Hochman JS. Outcome after surgery and percutaneous intervention for cardiogenic shock and left main disease. Ann Thorac Surg. 2008 Jul;86(1):29-34. PubMed External Web Site Policy

Leischik R, Dworrak B, Littwitz H, Gulker H. Prognostic significance of exercise stress echocardiography in 3329 outpatients (5-year longitudinal study). Int J Cardiol. 2007 Jul 31;119(3):297-305. PubMed External Web Site Policy

Leizorovicz A, Lechat P, Cucherat M, Bugnard F. Bisoprolol for the treatment of chronic heart failure: a meta-analysis on individual data of two placebo-controlled studies--CIBIS and CIBIS II. Cardiac Insufficiency Bisoprolol Study. Am Heart J. 2002 Feb;143(2):301-7. PubMed External Web Site Policy

Leon MB, Baim DS, Popma JJ, Gordon PC, Cutlip DE, Ho KK, Giambartolomei A, Diver DJ, Lasorda DM, Williams DO, Pocock SJ, Kuntz RE. A clinical trial comparing three antithrombotic-drug regimens after coronary-artery stenting. Stent Anticoagulation Restenosis Study Investigators. N Engl J Med. 1998 Dec 3;339(23):1665-71. PubMed External Web Site Policy

Lesperance F, Frasure-Smith N, Koszycki D, Laliberte MA, van Zyl LT, Baker B, Swenson JR, Ghatavi K, Abramson BL, Dorian P, Guertin MC, CREATE Investigators. Effects of citalopram and interpersonal psychotherapy on depression in patients with coronary artery disease: the Canadian Cardiac Randomized Evaluation of Antidepressant and Psychotherapy Efficacy (CREATE) trial. JAMA. 2007 Jan 24;297(4):367-79. PubMed External Web Site Policy

Lichtman JH, Bigger JT Jr, Blumenthal JA, Frasure-Smith N, Kaufmann PG, Lespérance F, Mark DB, Sheps DS, Taylor CB, Froelicher ES, AHA Prevention Committee of the Council on Cardiovascular Nursing, AHA Council on Clinical Cardiology, AHA Council on Epidemiology and Prevention, [trunc]. Depression and coronary heart disease: recommendations for screening, referral, and treatment: a science advisory from the American Heart Association. Circulation. 2008 Oct 21;118(17):1768-75. PubMed External Web Site Policy

Lipid Research Clinics Program. The Lipid Research Clinics Coronary Primary Prevention Trial results. I. Reduction in incidence of coronary heart disease. JAMA. 1984 Jan 20;251(3):351-64. PubMed External Web Site Policy

Loke YK, Kwok CS, Singh S. Comparative cardiovascular effects of thiazolidinediones: systematic review and meta-analysis of observational studies. BMJ. 2011;342:d1309. PubMed External Web Site Policy

Lonn E, Yusuf S, Arnold MJ, Sheridan P, Pogue J, Micks M, McQueen MJ, Probstfield J, Fodor G, Held C, Genest J Jr, Heart Outcomes Prevention Evaluation (HOPE) 2 Investigators. Homocysteine lowering with folic acid and B vitamins in vascular disease. N Engl J Med. 2006 Apr 13;354(15):1567-77. PubMed External Web Site Policy

Loop FD, Lytle BW, Cosgrove DM, Stewart RW, Goormastic M, Williams GW, Golding LA, Gill CC, Taylor PC, Sheldon WC, et al. Influence of the internal-mammary-artery graft on 10-year survival and other cardiac events. N Engl J Med. 1986 Jan 2;314(1):1-6. PubMed External Web Site Policy

Lorenzoni R, Cortigiani L, Magnani M, Desideri A, Bigi R, Manes C, Picano E. Cost-effectiveness analysis of noninvasive strategies to evaluate patients with chest pain. J Am Soc Echocardiogr. 2003 Dec;16(12):1287-91. PubMed External Web Site Policy

Lytle BW, Loop FD, Taylor PC, Goormastic M, Stewart RW, Novoa R, McCarthy P, Cosgrove DM. The effect of coronary reoperation on the survival of patients with stenoses in saphenous vein bypass grafts to coronary arteries. J Thorac Cardiovasc Surg. 1993 Apr;105(4):605-12; discussion 612-4. PubMed External Web Site Policy

MacGregor GA, Markandu ND, Sagnella GA, Singer DR, Cappuccio FP. Double-blind study of three sodium intakes and long-term effects of sodium restriction in essential hypertension. Lancet. 1989 Nov 25;2(8674):1244-7. PubMed External Web Site Policy

Mahajan N, Polavaram L, Vankayala H, Ference B, Wang Y, Ager J, Kovach J, Afonso L. Diagnostic accuracy of myocardial perfusion imaging and stress echocardiography for the diagnosis of left main and triple vessel coronary artery disease: a comparative meta-analysis. Heart. 2010 Jun;96(12):956-66. [95 references] PubMed External Web Site Policy

Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA. 2002 Dec 18;288(23):2981-97. PubMed External Web Site Policy

Makikallio TH, Niemela M, Kervinen K, Jokinen V, Laukkanen J, Ylitalo I, Tulppo MP, Juvonen J, Huikuri HV. Coronary angioplasty in drug eluting stent era for the treatment of unprotected left main stenosis compared to coronary artery bypass grafting. Ann Med. 2008;40(6):437-43. PubMed External Web Site Policy

Malenka DJ, Leavitt BJ, Hearne MJ, Robb JF, Baribeau YR, Ryan TJ, Helm RE, Kellett MA, Dauerman HL, Dacey LJ, Silver MT, VerLee PN, Weldner PW, Hettleman BD, Olmstead EM, Piper WD, O'Connor GT, Northern New England Cardiovascular Disease Study Group. Comparing long-term survival of patients with multivessel coronary disease after CABG or PCI: analysis of BARI-like patients in northern New England. Circulation. 2005 Aug 30;112(9 Suppl):I371-6. PubMed External Web Site Policy

Mannheimer C, Eliasson T, Augustinsson LE, Blomstrand C, Emanuelsson H, Larsson S, Norrsell H, Hjalmarsson A. Electrical stimulation versus coronary artery bypass surgery in severe angina pectoris: the ESBY study. Circulation. 1998 Mar 31;97(12):1157-63. PubMed External Web Site Policy

Manson JE, Hsia J, Johnson KC, Rossouw JE, Assaf AR, Lasser NL, Trevisan M, Black HR, Heckbert SR, Detrano R, Strickland OL, Wong ND, Crouse JR, Stein E, Cushman M. Estrogen plus progestin and the risk of coronary heart disease. N Engl J Med. 2003 Aug 7;349(6):523-34. [32 references] PubMed External Web Site Policy

Marcassa C, Bax JJ, Bengel F, Hesse B, Petersen CL, Reyes E, Underwood R, European Council of Nuclear Cardiology (ECNC), European Society of Cardiology Working Group 5 (Nuclear Cardiology and Cardiac, European Association of Nuclear Medicine Cardiovascular Committee. Clinical value, cost-effectiveness, and safety of myocardial perfusion scintigraphy: a position statement. Eur Heart J. 2008 Feb;29(4):557-63. [55 references] PubMed External Web Site Policy

Mark DB, Hlatky MA, Harrell FE Jr, Lee KL, Califf RM, Pryor DB. Exercise treadmill score for predicting prognosis in coronary artery disease. Ann Intern Med. 1987 Jun;106(6):793-800. PubMed External Web Site Policy

Marwick TH, Mehta R, Arheart K, Lauer MS. Use of exercise echocardiography for prognostic evaluation of patients with known or suspected coronary artery disease. J Am Coll Cardiol. 1997 Jul;30(1):83-90. PubMed External Web Site Policy

Mattera JA, Arain SA, Sinusas AJ, Finta L, Wackers FJ. Exercise testing with myocardial perfusion imaging in patients with normal baseline electrocardiograms: cost savings with a stepwise diagnostic strategy. J Nucl Cardiol. 1998 Sep-Oct;5(5):498-506. PubMed External Web Site Policy

Mauri L, Hsieh WH, Massaro JM, Ho KK, D'Agostino R, Cutlip DE. Stent thrombosis in randomized clinical trials of drug-eluting stents. N Engl J Med. 2007 Feb 12;356(10):1020-9. [30 references] PubMed External Web Site Policy

McCartney N, McKelvie RS, Haslam DR, Jones NL. Usefulness of weightlifting training in improving strength and maximal power output in coronary artery disease. Am J Cardiol. 1991 May 1;67(11):939-45. PubMed External Web Site Policy

McCully RB, Roger VL, Mahoney DW, Burger KN, Click RL, Seward JB, Pellikka PA. Outcome after abnormal exercise echocardiography for patients with good exercise capacity: prognostic importance of the extent and severity of exercise-related left ventricular dysfunction. J Am Coll Cardiol. 2002 Apr 17;39(8):1345-52. PubMed External Web Site Policy

McFadden EP, Stabile E, Regar E, Cheneau E, Ong AT, Kinnaird T, Suddath WO, Weissman NJ, Torguson R, Kent KM, Pichard AD, Satler LF, Waksman R, Serruys PW. Late thrombosis in drug-eluting coronary stents after discontinuation of antiplatelet therapy. Lancet. 2004 Oct 23;364(9444):1519-21. [7 references] PubMed External Web Site Policy

McGillion M, Watt-Watson J, LeFort S, Stevens B. Positive shifts in the perceived meaning of cardiac pain following a psychoeducation program for chronic stable angina. Can J Nurs Res. 2007 Jun;39(2):48-65. PubMed External Web Site Policy

McManus D, Pipkin SS, Whooley MA. Screening for depression in patients with coronary heart disease (data from the heart and soul study). Am J Cardiol. 2005 Oct 15;96(8):1076-81. PubMed External Web Site Policy

McMurray JJ, Ostergren J, Swedberg K, Granger CB, Held P, Michelson EL, Olofsson B, Yusuf S, Pfeffer MA. Effects of candesartan in patients with chronic heart failure and reduced left-ventricular systolic function taking angiotensin-converting-enzyme inhibitors: the CHARM-Added trial. Lancet. 2003 Sep 6;362(9386):767-71. PubMed External Web Site Policy

Medical Research Council trial of treatment of hypertension in older adults: principal results. MRC Working Party. BMJ. 1992 Feb 15;304(6824):405-12. PubMed External Web Site Policy

Meijboom WB, Meijs MF, Schuijf JD, Cramer MJ, Mollet NR, van Mieghem CA, Nieman K, van Werkhoven JM, Pundziute G, Weustink AC, de Vos AM, Pugliese F, Rensing B, Jukema JW, Bax JJ, Prokop M, Doevendans PA, Hunink MG, Krestin GP, de Feyter PJ. Diagnostic accuracy of 64-slice computed tomography coronary angiography: a prospective, multicenter, multivendor study. J Am Coll Cardiol. 2008 Dec 16;52(25):2135-44. PubMed External Web Site Policy

Metz LD, Beattie M, Hom R, Redberg RF, Grady D, Fleischmann KE. The prognostic value of normal exercise myocardial perfusion imaging and exercise echocardiography: a meta-analysis. J Am Coll Cardiol. 2007 Jan 16;49(2):227-37. [169 references] PubMed External Web Site Policy

Miller JM, Rochitte CE, Dewey M, Arbab-Zadeh A, Niinuma H, Gottlieb I, Paul N, Clouse ME, Shapiro EP, Hoe J, Lardo AC, Bush DE, de Roos A, Cox C, Brinker J, Lima JA. Diagnostic performance of coronary angiography by 64-row CT. N Engl J Med. 2008 Nov 27;359(22):2324-36. PubMed External Web Site Policy

Miller NH, Taylor C. Lifestyle management for patients with coronary heart disease. Current issues in cardiac rehabilitation, monograph no. 2. 1st ed. Champaign (IL): Human Kinetics; 1995.

Miller TD, Christian TF, Taliercio CP, Zinsmeister AR, Orszulak TA, Schaff HV, Gibbons RJ. Impaired left ventricular function, one- or two-vessel coronary artery disease, and severe ischemia: outcome with medical therapy versus revascularization. Mayo Clin Proc. 1994 Jul;69(7):626-31. PubMed External Web Site Policy

Min JK, Dunning A, Lin FY, Achenbach S, Al-Mallah M, Budoff MJ, Cademartiri F, Callister TQ, Chang HJ, Cheng V, Chinnaiyan K, Chow BJ, Delago A, Hadamitzky M, Hausleiter J, Kaufmann P, Maffei E, Raff G, Shaw LJ, Villines T, Berman DS, CONFIRM Investigators. Age- and sex-related differences in all-cause mortality risk based on coronary computed tomography angiography findings results from the International Multicenter CONFIRM [trunc]. J Am Coll Cardiol. 2011 Aug 16;58(8):849-60. PubMed External Web Site Policy

Mock MB, Ringqvist I, Fisher LD, Davis KB, Chaitman BR, Kouchoukos NT, Kaiser GC, Alderman E, Ryan TJ, Russell RO Jr, Mullin S, Fray D, Killip T 3rd. Survival of medically treated patients in the coronary artery surgery study (CASS) registry. Circulation. 1982 Sep;66(3):562-8. PubMed External Web Site Policy

Montalescot G, Brieger D, Eagle KA, Anderson FA Jr, FitzGerald G, Lee MS, Steg PG, Avezum A, Goodman SG, Gore JM, GRACE Investigators. Unprotected left main revascularization in patients with acute coronary syndromes. Eur Heart J. 2009 Oct;30(19):2308-17. PubMed External Web Site Policy

Morice MC, Serruys PW, Kappetein AP, Feldman TE, Stahle E, Colombo A, Mack MJ, Holmes DR, Torracca L, van Es GA, Leadley K, Dawkins KD, Mohr F. Outcomes in patients with de novo left main disease treated with either percutaneous coronary intervention using paclitaxel-eluting stents or coronary artery bypass graft treatment in the Synergy Between Percutaneous Coronary Intervention [trunc]. Circulation. 2010 Jun 22;121(24):2645-53. PubMed External Web Site Policy

Morrison DA, Sethi G, Sacks J, Henderson W, Grover F, Sedlis S, Esposito R, Ramanathan K, Weiman D, Saucedo J, Antakli T, Paramesh V, Pett S, Vernon S, Birjiniuk V, Welt F, Krucoff M, Wolfe W, Lucke JC, Mediratta S, Booth D, Barbiere C, Lewis D, Angina With Extremely Serious Operative Mortality Evaluation (AWESOME). Percutaneous coronary intervention versus coronary artery bypass graft surgery for patients with medically refractory myocardial ischemia and risk factors for adverse outcomes with bypass: a multicenter, randomized trial [trunc]. J Am Coll Cardiol. 2001 Jul;38(1):143-9. PubMed External Web Site Policy

Morrow K, Morris CK, Froelicher VF, Hideg A, Hunter D, Johnson E, Kawaguchi T, Lehmann K, Ribisl PM, Thomas R, Ueshima K, Froelicher E, Wallis J. Prediction of cardiovascular death in men undergoing noninvasive evaluation for coronary artery disease. Ann Intern Med. 1993 May 1;118(9):689-95. PubMed External Web Site Policy

Mosca L, Benjamin EJ, Berra K, Bezanson JL, Dolor RJ, Lloyd-Jones DM, Newby LK, Pina IL, Roger VL, Shaw LJ, Zhao D, Beckie TM, Bushnell C, D'Armiento J, Kris-Etherton PM, Fang J, Ganiats TG, Gomes AS, Gracia CR, Haan CK, Jackson EA, Judelson DR, Kelepouris E, Lavie CJ, Moore A, Nussmeier NA, Ofili E, Oparil S, Ouyang P, Pinn VW, Sherif K, Smith SC Jr, Sopko G, Chandra-Strobos N, Urbina EM, Vaccarino V, Wenger NK. Effectiveness-based guidelines for the prevention of cardiovascular disease in women--2011 update: a guideline from the American Heart Association. Circulation. 2011 Mar 22;123(11):1243-62. [142 references] PubMed External Web Site Policy

Mowatt G, Cook JA, Hillis GS, Walker S, Fraser C, Jia X, Waugh N. 64-Slice computed tomography angiography in the diagnosis and assessment of coronary artery disease: Systematic review and meta-analysis. Heart. 2008 Nov;94(11):1386-93. [63 references] PubMed External Web Site Policy

Mowatt G, Vale L, Brazzelli M, Hernandez R, Murray A, Scott N, Fraser C, McKenzie L, Gemmell H, Hillis G, Metcalfe M. Systematic review of the effectiveness and cost-effectiveness, and economic evaluation, of myocardial perfusion scintigraphy for the diagnosis and management of angina and myocardial infarction. Health Technol Assess. 2004 Jul;8(30):iii-iv, 1-207. [138 references] PubMed External Web Site Policy

MRC trial of treatment of mild hypertension: principal results. Medical Research Council Working Party. Br Med J (Clin Res Ed). 1985 Jul 13;291(6488):97-104. PubMed External Web Site Policy

Mukamal KJ, Maclure M, Muller JE, Sherwood JB, Mittleman MA. Prior alcohol consumption and mortality following acute myocardial infarction. JAMA. 2001 Apr 18;285(15):1965-70. PubMed External Web Site Policy

Muntwyler J, Hennekens CH, Buring JE, Gaziano JM. Mortality and light to moderate alcohol consumption after myocardial infarction. Lancet. 1998 Dec 12;352(9144):1882-5. PubMed External Web Site Policy

Muszbek N, Brixner D, Benedict A, Keskinaslan A, Khan ZM. The economic consequences of noncompliance in cardiovascular disease and related conditions: a literature review. Int J Clin Pract. 2008 Feb;62(2):338-51. [53 references] PubMed External Web Site Policy

Myers J, Oesterle SN, Jones J, Burkhoff D. Do transmyocardial and percutaneous laser revascularization induce silent ischemia? An assessment by exercise testing. Am Heart J. 2002 Jun;143(6):1052-7. PubMed External Web Site Policy

Myers WO, Gersh BJ, Fisher LD, Mock MB, Holmes DR, Schaff HV, Gillispie S, Ryan TJ, Kaiser GC. Medical versus early surgical therapy in patients with triple-vessel disease and mild angina pectoris: a CASS registry study of survival. Ann Thorac Surg. 1987 Nov;44(5):471-86. PubMed External Web Site Policy

Myers WO, Schaff HV, Gersh BJ, Fisher LD, Kosinski AS, Mock MB, Holmes DR, Ryan TJ, Kaiser GC. Improved survival of surgically treated patients with triple vessel coronary artery disease and severe angina pectoris. A report from the Coronary Artery Surgery Study (CASS) registry. J Thorac Cardiovasc Surg. 1989 Apr;97(4):487-95. PubMed External Web Site Policy

Nagao T, Chikamori T, Hida S, Igarashi Y, Kuwabara Y, Nishimura S, Yamazaki J, Yamashina A, Q-PROVE Study Group. Quantitative gated single-photon emission computed tomography with (99m)Tc sestamibi predicts major cardiac events in elderly patients with known or suspected coronary artery disease: the QGS-Prognostic Value in the Elderly (Q-PROVE) Study. Circ J. 2007 Jul;71(7):1029-34. PubMed External Web Site Policy

Nagel E, Lehmkuhl HB, Bocksch W, Klein C, Vogel U, Frantz E, Ellmer A, Dreysse S, Fleck E. Noninvasive diagnosis of ischemia-induced wall motion abnormalities with the use of high-dose dobutamine stress MRI: comparison with dobutamine stress echocardiography. Circulation. 1999 Feb 16;99(6):763-70. PubMed External Web Site Policy

Naik H, White AJ, Chakravarty T, Forrester J, Fontana G, Kar S, Shah PK, Weiss RE, Makkar R. A meta-analysis of 3,773 patients treated with percutaneous coronary intervention or surgery for unprotected left main coronary artery stenosis. JACC Cardiovasc Interv. 2009 Aug;2(8):739-47. [38 references] PubMed External Web Site Policy

Nallamothu N, Bagheri B, Acio ER, Heo J, Iskandrian AE. Prognostic value of stress myocardial perfusion single photon emission computed tomography imaging in patients with left ventricular bundle branch block. J Nucl Cardiol. 1997 Nov-Dec;4(6):487-93. PubMed External Web Site Policy

Nallamothu N, Ghods M, Heo J, Iskandrian AS. Comparison of thallium-201 single-photon emission computed tomography and electrocardiographic response during exercise in patients with normal rest electrocardiographic results. J Am Coll Cardiol. 1995 Mar 15;25(4):830-6. PubMed External Web Site Policy

Nandalur KR, Dwamena BA, Choudhri AF, Nandalur MR, Carlos RC. Diagnostic performance of stress cardiac magnetic resonance imaging in the detection of coronary artery disease: a meta-analysis. J Am Coll Cardiol. 2007 Oct 2;50(14):1343-53. [44 references] PubMed External Web Site Policy

Narahara KA. Double-blind comparison of once daily betaxolol versus propranolol four times daily in stable angina pectoris. Betaxolol Investigators Group. Am J Cardiol. 1990 Mar 1;65(9):577-82. PubMed External Web Site Policy

Nathan DM, Cleary PA, Backlund JY, Genuth SM, Lachin JM, Orchard TJ, Raskin P, Zinman B, Diabetes Control and Complications Trial/Epidemiology of Diabetes. Intensive diabetes treatment and cardiovascular disease in patients with type 1 diabetes. N Engl J Med. 2005 Dec 22;353(25):2643-53. PubMed External Web Site Policy

National Cholesterol Education Program. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation. 2002 Dec 17;106(25):3143-421. PubMed External Web Site Policy

National Heart Lung and Blood Institute (NHLBI), Obesity Education Initiative, Expert Panel on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. Rockville (MD): U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health (NIH), National Heart Lung and Blood Institute (NHLBI); 1998 Sep. 228 p. [763 references]

Navare SM, Mather JF, Shaw LJ, Fowler MS, Heller GV. Comparison of risk stratification with pharmacologic and exercise stress myocardial perfusion imaging: a meta-analysis. J Nucl Cardiol. 2004 Sep-Oct;11(5):551-61. PubMed External Web Site Policy

Nigam A, Humen DP. Prognostic value of myocardial perfusion imaging with exercise and/or dipyridamole hyperemia in patients with preexisting left bundle branch block. J Nucl Med. 1998 Apr;39(4):579-81. PubMed External Web Site Policy

Niles NW, McGrath PD, Malenka D, Quinton H, Wennberg D, Shubrooks SJ, Tryzelaar JF, Clough R, Hearne MJ, Hernandez F Jr, Watkins MW, O'Connor GT, Northern New England Cardiovascular Disease Study Group. Survival of patients with diabetes and multivessel coronary artery disease after surgical or percutaneous coronary revascularization: results of a large regional prospective study. Northern New England Cardiovascular Disease Study Group. J Am Coll Cardiol. 2001 Mar 15;37(4):1008-15. PubMed External Web Site Policy

Nissen SE, Tuzcu EM, Libby P, Thompson PD, Ghali M, Garza D, Berman L, Shi H, Buebendorf E, Topol EJ, CAMELOT Investigators. Effect of antihypertensive agents on cardiovascular events in patients with coronary disease and normal blood pressure: the CAMELOT study: a randomized controlled trial. JAMA. 2004 Nov 10;292(18):2217-25. PubMed External Web Site Policy

Nowak Z, Plewa M, Skowron M, Markiewicz A, Kucio C, Osiadlo G. Paffenbarger Physical Activity Questionnaire as an additional tool in clinical assessment of patients with coronary artery disease treated with angioplasty. Kardiol Pol. 2010 Jan;68(1):32-9. PubMed External Web Site Policy

Nucifora G, Schuijf JD, van Werkhoven JM, Trines SA, Kajander S, Tops LF, Turta O, Jukema JW, Schreur JH, Heijenbrok MW, Gaemperli O, Kaufmann PA, Knuuti J, van der Wall EE, Schalij MJ, Bax JJ. Relationship between obstructive coronary artery disease and abnormal stress testing in patients with paroxysmal or persistent atrial fibrillation. Int J Cardiovasc Imaging. 2011 Jul;27(6):777-85. PubMed External Web Site Policy

O'Connor CM, Velazquez EJ, Gardner LH, Smith PK, Newman MF, Landolfo KP, Lee KL, Califf RM, Jones RH. Comparison of coronary artery bypass grafting versus medical therapy on long-term outcome in patients with ischemic cardiomyopathy (a 25-year experience from the Duke Cardiovascular Disease Databank). Am J Cardiol. 2002 Jul 15;90(2):101-7. PubMed External Web Site Policy

Oka R, Kobayashi J, Yagi K, Tanii H, Miyamoto S, Asano A, Hagishita T, Mori M, Moriuchi T, Kobayashi M, Katsuda S, Kawashiri MA, Nohara A, Takeda Y, Mabuchi H, Yamagishi M. Reassessment of the cutoff values of waist circumference and visceral fat area for identifying Japanese subjects at risk for the metabolic syndrome. Diabetes Res Clin Pract. 2008 Mar;79(3):474-81. PubMed External Web Site Policy

Packer M, Bristow MR, Cohn JN, Colucci WS, Fowler MB, Gilbert EM, Shusterman NH. The effect of carvedilol on morbidity and mortality in patients with chronic heart failure. U.S. Carvedilol Heart Failure Study Group. N Engl J Med. 1996 May 23;334(21):1349-55. PubMed External Web Site Policy

Palmerini T, Marzocchi A, Marrozzini C, Ortolani P, Saia F, Savini C, Bacchi-Reggiani L, Gianstefani S, Virzi S, Manara F, Kiros Weldeab M, Marinelli G, Di Bartolomeo R, Branzi A. Comparison between coronary angioplasty and coronary artery bypass surgery for the treatment of unprotected left main coronary artery stenosis (the Bologna Registry). Am J Cardiol. 2006 Jul 1;98(1):54-9. PubMed External Web Site Policy

Parisi AF, Hartigan PM, Folland ED. Evaluation of exercise thallium scintigraphy versus exercise electrocardiography in predicting survival outcomes and morbid cardiac events in patients with single- and double-vessel disease. J Am Coll Cardiol. 1997 Nov 1;30(5):1256-63. PubMed External Web Site Policy

Park DW, Seung KB, Kim YH, Lee JY, Kim WJ, Kang SJ, Lee SW, Lee CW, Park SW, Yun SC, Gwon HC, Jeong MH, Jang YS, Kim HS, Kim PJ, Seong IW, Park HS, Ahn T, Chae IH, Tahk SJ, Chung WS, Park SJ. Long-term safety and efficacy of stenting versus coronary artery bypass grafting for unprotected left main coronary artery disease: 5-year results from the MAIN-COMPARE (Revascularization for Unprotected Left Main Coronary Artery Stenosis [trunc]. J Am Coll Cardiol. 2010 Jul 6;56(2):117-24. PubMed External Web Site Policy

Park SJ, Kim YH, Park DW, Yun SC, Ahn JM, Song HG, Lee JY, Kim WJ, Kang SJ, Lee SW, Lee CW, Park SW, Chung CH, Lee JW, Lim DS, Rha SW, Lee SG, Gwon HC, Kim HS, Chae IH, Jang Y, Jeong MH, Tahk SJ, Seung KB. Randomized trial of stents versus bypass surgery for left main coronary artery disease. N Engl J Med. 2011 May 5;364(18):1718-27. PubMed External Web Site Policy

Pedersen TR, Faergeman O, Kastelein JJ, Olsson AG, Tikkanen MJ, Holme I, Larsen ML, Bendiksen FS, Lindahl C, Szarek M, Tsai J, Incremental Decrease in End Points Through Aggressive Lipid Lowering (IDEAL). High-dose atorvastatin vs usual-dose simvastatin for secondary prevention after myocardial infarction: the IDEAL study: a randomized controlled trial. JAMA. 2005 Nov 16;294(19):2437-45. PubMed External Web Site Policy

Peteiro J, Bouzas-Mosquera A, Broullon FJ, Garcia-Campos A, Pazos P, Castro-Beiras A. Prognostic value of peak and post-exercise treadmill exercise echocardiography in patients with known or suspected coronary artery disease. Eur Heart J. 2010 Jan;31(2):187-95. PubMed External Web Site Policy

Peteiro J, Monserrrat L, Pineiro M, Calvino R, Vazquez JM, Marinas J, Castro-Beiras A. Comparison of exercise echocardiography and the Duke treadmill score for risk stratification in patients with known or suspected coronary artery disease and normal resting electrocardiogram. Am Heart J. 2006 Jun;151(6):1324.e1-10. PubMed External Web Site Policy

Pfautsch P, Frantz E, Ellmer A, Sauer HU, Fleck E. [Long-term outcome of therapy of recurrent myocardial ischemia after surgical revascularization]. Z Kardiol. 1999 Jul;88(7):489-97. PubMed External Web Site Policy

Phillips HR, O'Connor CM, Rogers J. Revascularization for heart failure. Am Heart J. 2007 Apr;153(4 Suppl):65-73. [40 references] PubMed External Web Site Policy

Picano E, Molinaro S, Pasanisi E. The diagnostic accuracy of pharmacological stress echocardiography for the assessment of coronary artery disease: a meta-analysis. Cardiovasc Ultrasound. 2008;6:30. [61 references] PubMed External Web Site Policy

Pijls NH, De Bruyne B, Peels K, Van Der Voort PH, Bonnier HJ, Bartunek J Koolen JJ, Koolen JJ. Measurement of fractional flow reserve to assess the functional severity of coronary-artery stenoses. N Engl J Med. 1996 Jun 27;334(26):1703-8. PubMed External Web Site Policy

Pilz G, Jeske A, Klos M, Ali E, Hoefling B, Scheck R, Bernhardt P. Prognostic value of normal adenosine-stress cardiac magnetic resonance imaging. Am J Cardiol. 2008 May 15;101(10):1408-12. PubMed External Web Site Policy

Pitt B, O'Neill B, Feldman R, Ferrari R, Schwartz L, Mudra H, Bass T, Pepine C, Texter M, Haber H, Uprichard A, Cashin-Hemphill L, Lees RS, QUIET Study Group. The QUinapril Ischemic Event Trial (QUIET): evaluation of chronic ACE inhibitor therapy in patients with ischemic heart disease and preserved left ventricular function. Am J Cardiol. 2001 May 1;87(9):1058-63. PubMed External Web Site Policy

Pocock SJ, Henderson RA, Clayton T, Lyman GH, Chamberlain DA. Quality of life after coronary angioplasty or continued medical treatment for angina: three-year follow-up in the RITA-2 trial. Randomized Intervention Treatment of Angina. J Am Coll Cardiol. 2000 Mar 15;35(4):907-14. PubMed External Web Site Policy

Pocock SJ, Henderson RA, Seed P, Treasure T, Hampton JR. Quality of life, employment status, and anginal symptoms after coronary angioplasty or bypass surgery. 3-year follow-up in the Randomized Intervention Treatment of Angina (RITA) Trial. Circulation. 1996 Jul 15;94(2):135-42. PubMed External Web Site Policy

Poole-Wilson PA, Swedberg K, Cleland JG, Di Lenarda A, Hanrath P, Komajda M, Lubsen J, Lutiger B, Metra M, Remme WJ, Torp-Pedersen C, Scherhag A, Skene A. Comparison of carvedilol and metoprolol on clinical outcomes in patients with chronic heart failure in the Carvedilol Or Metoprolol European Trial (COMET): randomised controlled trial. Lancet. 2003 Jul 5;362(9377):7-13. PubMed External Web Site Policy

Pope CA 3rd, Burnett RT, Thurston GD, Thun MJ, Calle EE, Krewski D, Godleski JJ. Cardiovascular mortality and long-term exposure to particulate air pollution: epidemiological evidence of general pathophysiological pathways of disease. Circulation. 2004 Jan 6;109(1):71-7. PubMed External Web Site Policy

Pope CA 3rd, Muhlestein JB, May HT, Renlund DG, Anderson JL, Horne BD. Ischemic heart disease events triggered by short-term exposure to fine particulate air pollution. Circulation. 2006 Dec 5;114(23):2443-8. PubMed External Web Site Policy

Pope CA 3rd. Mortality effects of longer term exposures to fine particulate air pollution: review of recent epidemiological evidence. Inhal Toxicol. 2007;19(Suppl 1):33-8. [43 references] PubMed External Web Site Policy

Rao SV, Schulman KA, Curtis LH, Gersh BJ, Jollis JG. Socioeconomic status and outcome following acute myocardial infarction in elderly patients. Arch Intern Med. 2004 May 24;164(10):1128-33. PubMed External Web Site Policy

Ray KK, Seshasai SR, Wijesuriya S, Sivakumaran R, Nethercott S, Preiss D, Erqou S, Sattar N. Effect of intensive control of glucose on cardiovascular outcomes and death in patients with diabetes mellitus: a meta-analysis of randomised controlled trials. Lancet. 2009 May 23;373(9677):1765-72. PubMed External Web Site Policy

Rees K, Bennett P, West R, Davey SG, Ebrahim S. Psychological interventions for coronary heart disease. Cochrane Database Syst Rev. 2004;(2):CD002902. [111 references] PubMed External Web Site Policy

Reicher B, Poston RS, Mehra MR, Joshi A, Odonkor P, Kon Z, Reyes PA, Zimrin DA. Simultaneous "hybrid" percutaneous coronary intervention and minimally invasive surgical bypass grafting: feasibility, safety, and clinical outcomes. Am Heart J. 2008 Apr;155(4):661-7. PubMed External Web Site Policy

Rigotti NA. Helping smokers with cardiac disease to abstain from tobacco after a stay in hospital. CMAJ. 2009 Jun 23;180(13):1283-4. PubMed External Web Site Policy

Rodes-Cabau J, Deblois J, Bertrand OF, Mohammadi S, Courtis J, Larose E, Dagenais F, Dery JP, Mathieu P, Rousseau M, Barbeau G, Baillot R, Gleeton O, Perron J, Nguyen CM, Roy L, Doyle D, De Larochelliere R, Bogaty P, Voisine P. Nonrandomized comparison of coronary artery bypass surgery and percutaneous coronary intervention for the treatment of unprotected left main coronary artery disease in octogenarians. Circulation. 2008 Dec 2;118(23):2374-81. PubMed External Web Site Policy

Rossouw JE, Writing Group for the Women's Health Initiative Investigators, Anderson GL, Prentice RL, LaCroix AZ, Kooperberg C, Stefanick ML, Jackson RD, Beresford SA, Howard BV, Johnson KC, Kotchen JM, Ockene J. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women's Health Initiative randomized controlled trial. JAMA. 2002 Jul 17;288(3):321-33. PubMed External Web Site Policy

Rousseau MF, Pouleur H, Cocco G, Wolff AA. Comparative efficacy of ranolazine versus atenolol for chronic angina pectoris. Am J Cardiol. 2005 Feb 1;95(3):311-6. PubMed External Web Site Policy

Ruo B, Rumsfeld JS, Hlatky MA, Liu H, Browner WS, Whooley MA. Depressive symptoms and health-related quality of life: the Heart and Soul Study. JAMA. 2003 Jul 9;290(2):215-21. PubMed External Web Site Policy

Ryden L. Efficacy of epanolol versus metoprolol in angina pectoris: report from a Swedish multicentre study of exercise tolerance. J Intern Med. 1992 Jan;231(1):7-11. PubMed External Web Site Policy

Sabharwal NK, Stoykova B, Taneja AK, Lahiri A. A randomized trial of exercise treadmill ECG versus stress SPECT myocardial perfusion imaging as an initial diagnostic strategy in stable patients with chest pain and suspected CAD: cost analysis. J Nucl Cardiol. 2007 Apr;14(2):174-86. PubMed External Web Site Policy

Sacks FM, Svetkey LP, Vollmer WM, Appel LJ, Bray GA, Harsha D, Obarzanek E, Conlin PR, Miller ER 3rd, Simons-Morton DG, Karanja N, Lin PH. Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. DASH-Sodium Collaborative Research Group. N Engl J Med. 2001 Jan 4;344(1):3-10. PubMed External Web Site Policy

Sanmartin M, Baz JA, Claro R, Asorey V, Duran D, Pradas G, Iniguez A. Comparison of drug-eluting stents versus surgery for unprotected left main coronary artery disease. Am J Cardiol. 2007 Sep 15;100(6):970-3. PubMed External Web Site Policy

Sarwar A, Shaw LJ, Shapiro MD, Blankstein R, Hoffmann U, Cury RC, Abbara S, Brady TJ, Budoff MJ, Blumenthal RS, Nasir K. Diagnostic and prognostic value of absence of coronary artery calcification. JACC Cardiovasc Imaging. 2009 Jun;2(6):675-88. [67 references] PubMed External Web Site Policy

Sawada S, Bapat A, Vaz D, Weksler J, Fineberg N, Greene A, Gradus-Pizlo I, Feigenbaum H. Incremental value of myocardial viability for prediction of long-term prognosis in surgically revascularized patients with left ventricular dysfunction. J Am Coll Cardiol. 2003 Dec 17;42(12):2099-105. PubMed External Web Site Policy

Sawada SG, Safadi A, Gaitonde RS, Tung N, Mahenthiran J, Gill W, Ghumman W, Gradus-Pizlo I, Kamalesh M, Fineberg N, Feigenbaum H. Stress-induced wall motion abnormalities with low-dose dobutamine infusion indicate the presence of severe disease and vulnerable myocardium. Echocardiography. 2007 Aug;24(7):739-44. PubMed External Web Site Policy

Schaefer EJ, Lamon-Fava S, Ausman LM, Ordovas JM, Clevidence BA, Judd JT, Goldin BR, Woods M, Gorbach S, Lichtenstein AH. Individual variability in lipoprotein cholesterol response to National Cholesterol Education Program Step 2 diets. Am J Clin Nutr. 1997 Mar;65(3):823-30. PubMed External Web Site Policy

Schaefer EJ, Lichtenstein AH, Lamon-Fava S, Contois JH, Li Z, Rasmussen H, McNamara JR, Ordovas JM. Efficacy of a National Cholesterol Education Program Step 2 diet in normolipidemic and hypercholesterolemic middle-aged and elderly men and women. Arterioscler Thromb Vasc Biol. 1995 Aug;15(8):1079-85. PubMed External Web Site Policy

Schofield PM, Sharples LD, Caine N, Burns S, Tait S, Wistow T, Buxton M, Wallwork J. Transmyocardial laser revascularisation in patients with refractory angina: a randomised controlled trial. Lancet. 1999 Feb 13;353(9152):519-24. PubMed External Web Site Policy

Schuetz GM, Zacharopoulou NM, Schlattmann P, Dewey M. Meta-analysis: noninvasive coronary angiography using computed tomography versus magnetic resonance imaging. Ann Intern Med. 2010 Feb 2;152(3):167-77. [160 references] PubMed External Web Site Policy

Schuijf JD, Bax JJ, Shaw LJ, de Roos A, Lamb HJ, van der Wall EE, Wijns W. Meta-analysis of comparative diagnostic performance of magnetic resonance imaging and multislice computed tomography for noninvasive coronary angiography. Am Heart J. 2006 Feb;151(2):404-11. [57 references] PubMed External Web Site Policy

Schwitter J, Wacker CM, van Rossum AC, Lombardi M, Al-Saadi N, Ahlstrom H, Dill T, Larsson HB, Flamm SD, Marquardt M, Johansson L. MR-IMPACT: comparison of perfusion-cardiac magnetic resonance with single-photon emission computed tomography for the detection of coronary artery disease in a multicentre, multivendor, randomized trial. Eur Heart J. 2008 Feb;29(4):480-9. PubMed External Web Site Policy

Selvin E, Bolen S, Yeh HC, Wiley C, Wilson LM, Marinopoulos SS, Feldman L, Vassy J, Wilson R, Bass EB, Brancati FL. Cardiovascular outcomes in trials of oral diabetes medications: a systematic review. Arch Intern Med. 2008 Oct 27;168(19):2070-80. [67 references] PubMed External Web Site Policy

Sergeant P, Blackstone E, Meyns B, Stockman B, Jashari R. First cardiological or cardiosurgical reintervention for ischemic heart disease after primary coronary artery bypass grafting. Eur J Cardiothorac Surg. 1998 Nov;14(5):480-7. PubMed External Web Site Policy

Serruys PW, Morice MC, Kappetein AP, Colombo A, Holmes DR, Mack MJ, Stahle E, Feldman TE, van den Brand M, Bass EJ, Van Dyck N, Leadley K, Dawkins KD, Mohr FW, SYNTAX Investigators. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med. 2009 Mar 5;360(10):961-72. PubMed External Web Site Policy

Seung KB, Park DW, Kim YH, Lee SW, Lee CW, Hong MK, Park SW, Yun SC, Gwon HC, Jeong MH, Jang Y, Kim HS, Kim PJ, Seong IW, Park HS, Ahn T, Chae IH, Tahk SJ, Chung WS, Park SJ. Stents versus coronary-artery bypass grafting for left main coronary artery disease. N Engl J Med. 2008 Apr 24;358(17):1781-92. PubMed External Web Site Policy

Shahian DM, O'Brien SM, Filardo G, Ferraris VA, Haan CK, Rich JB, Normand SL, DeLong ER, Shewan CM, Dokholyan RS, Peterson ED, Edwards FH, Anderson RP, Society of Thoracic Surgeons Quality Measurement Task Force. The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 1--coronary artery bypass grafting surgery. Ann Thorac Surg. 2009 Jul;88(1 Suppl):S2-22. PubMed External Web Site Policy

Shahian DM, O'Brien SM, Normand SL, Peterson ED, Edwards FH. Association of hospital coronary artery bypass volume with processes of care, mortality, morbidity, and the Society of Thoracic Surgeons composite quality score. J Thorac Cardiovasc Surg. 2010 Feb;139(2):273-82. PubMed External Web Site Policy

Shaw LJ, Berman DS, Maron DJ, Mancini GB, Hayes SW, Hartigan PM, Weintraub WS, O'Rourke RA, Dada M, Spertus JA, Chaitman BR, Friedman J, Slomka P, Heller GV, Germano G, Gosselin G, Berger P, Kostuk WJ, Schwartz RG, Knudtson M, Veledar E, Bates ER, McCallister B, Teo KK, Boden WE, COURAGE Investigators. Optimal medical therapy with or without percutaneous coronary intervention to reduce ischemic burden: results from the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial nuclear substudy. Circulation. 2008 Mar 11;117(10):1283-91. PubMed External Web Site Policy

Shaw LJ, Cerqueira MD, Brooks MM, Althouse AD, Sansing VV, Beller GA, Pop-Busui R, Taillefer R, Chaitman BR, Gibbons RJ, Heo J, Iskandrian AE. Impact of left ventricular function and the extent of ischemia and scar by stress myocardial perfusion imaging on prognosis and therapeutic risk reduction in diabetic patients with coronary artery disease [trunc]. J Nucl Cardiol. 2012 Aug;19(4):658-69. PubMed External Web Site Policy

Shaw LJ, Hachamovitch R, Heller GV, Marwick TH, Travin MI, Iskandrian AE, Kesler K, Lauer MS, Hendel R, Borges-Neto S, Lewin HC, Berman DS, Miller D. Noninvasive strategies for the estimation of cardiac risk in stable chest pain patients. The Economics of Noninvasive Diagnosis (END) Study Group. Am J Cardiol. 2000 Jul 1;86(1):1-7. PubMed External Web Site Policy

Shaw LJ, Hendel R, Borges-Neto S, Lauer MS, Alazraki N, Burnette J, Krawczynska E, Cerqueira M, Maddahi J, Myoview Multicenter Registry. Prognostic value of normal exercise and adenosine (99m)Tc-tetrofosmin SPECT imaging: results from the multicenter registry of 4,728 patients. J Nucl Med. 2003 Feb;44(2):134-9. PubMed External Web Site Policy

Shaw LJ, Hendel RC, Cerquiera M, Mieres JH, Alazraki N, Krawczynska E, Borges-Neto S, Maddahi J, Bairey Merz CN. Ethnic differences in the prognostic value of stress technetium-99m tetrofosmin gated single-photon emission computed tomography myocardial perfusion imaging. J Am Coll Cardiol. 2005 May 3;45(9):1494-504. PubMed External Web Site Policy

Shaw LJ, Mieres JH, Hendel RH, Boden WE, Gulati M, Veledar E, Hachamovitch R, Arrighi JA, Merz CN, Gibbons RJ, Wenger NK, Heller GV, WOMEN Trial Investigators. Comparative effective. Circulation. 2011 Sep 13;124(11):1239-49. PubMed External Web Site Policy

SHEP Cooperative Research Group. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. Final results of the Systolic Hypertension in the Elderly Program (SHEP). JAMA. 1991 Jun 26;265(24):3255-64. PubMed External Web Site Policy

Skyler JS, Bergenstal R, Bonow RO, Buse J, Deedwania P, Gale EA, Howard BV, Kirkman MS, Kosiborod M, Reaven P, Sherwin RS, American Diabetes Association, American College of Cardiology Foundation, American Heart Association. Intensive glycemic control and the preventio. Circulation. 2009 Jan 20;119(2):351-7. [16 references] PubMed External Web Site Policy

Sloth-Nielsen J, Guldager B, Mouritzen C, Lund EB, Egeblad M, Norregaard O, Jorgensen SJ, Jelnes R. Arteriographic findings in EDTA chelation therapy on peripheral arteriosclerosis. Am J Surg. 1991 Aug;162(2):122-5. PubMed External Web Site Policy

Smith PK, Califf RM, Tuttle RH, Shaw LK, Lee KL, Delong ER, Lilly RE, Sketch MH Jr, Peterson ED, Jones RH. Selection of surgical or percutaneous coronary intervention provides differential longevity benefit. Ann Thorac Surg. 2006 Oct;82(4):1420-8; discussion 1428-9. PubMed External Web Site Policy

Smith PM, Burgess E. Smoking cessation initiated during hospital stay for patients with coronary artery disease: a randomized controlled trial. CMAJ. 2009 Jun 23;180(13):1297-303. PubMed External Web Site Policy

Smith SC Jr, Benjamin EJ, Bonow RO, Braun LT, Creager MA, Franklin BA, Gibbons RJ, Grundy SM, Hiratzka LF, Jones DW, Lloyd-Jones DM, Minissian M, Mosca L, Peterson ED, Sacco RL, Spertus J, Stein JH, Taubert KA. AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation [trunc]. J Am Coll Cardiol. 2011 Nov 29;58(23):2432-46. PubMed External Web Site Policy

Sorajja P, Chareonthaitawee P, Rajagopalan N, Miller TD, Frye RL, Hodge DO, Gibbons RJ. Improved survival in asymptomatic diabetic patients with high-risk SPECT imaging treated with coronary artery bypass grafting. Circulation. 2005 Aug 30;112(9 Suppl):I311-6. PubMed External Web Site Policy

Spaulding CM, Joly LM, Rosenberg A, Monchi M, Weber SN, Dhainaut JF, Carli P. Immediate coronary angiography in survivors of out-of-hospital cardiac arrest. N Engl J Med. 1997 Jun 5;336(23):1629-33. PubMed External Web Site Policy

Stamou SC, Boyce SW, Cooke RH, Carlos BD, Sweet LC, Corso PJ. One-year outcome after combined coronary artery bypass grafting and transmyocardial laser revascularization for refractory angina pectoris. Am J Cardiol. 2002 Jun 15;89(12):1365-8. PubMed External Web Site Policy

Steel K, Broderick R, Gandla V, Larose E, Resnic F, Jerosch-Herold M, Brown KA, Kwong RY. Complementary prognostic values of stress myocardial perfusion and late gadolinium enhancement imaging by cardiac magnetic resonance in patients with known or suspected coronary artery disease. Circulation. 2009 Oct 6;120(14):1390-400. PubMed External Web Site Policy

Stein PD, Beemath A, Kayali F, Skaf E, Sanchez J, Olson RE. Multidetector computed tomography for the diagnosis of coronary artery disease: a systematic review. Am J Med. 2006 Mar;119(3):203-16. [73 references] PubMed External Web Site Policy

Stephan WJ, O'Keefe JH Jr, Piehler JM, McCallister BD, Dahiya RS, Shimshak TM, Ligon RW, Hartzler GO. Coronary angioplasty versus repeat coronary artery bypass grafting for patients with previous bypass surgery. J Am Coll Cardiol. 1996 Nov 1;28(5):1140-6. PubMed External Web Site Policy

Stephens NG, Parsons A, Schofield PM, Kelly F, Cheeseman K, Mitchinson MJ. Randomised controlled trial of vitamin E in patients with coronary disease: Cambridge Heart Antioxidant Study (CHAOS). Lancet. 1996 Mar 23;347(9004):781-6. PubMed External Web Site Policy

Stevens VJ, Corrigan SA, Obarzanek E, Bernauer E, Cook NR, Hebert P, Mattfeldt-Beman M, Oberman A, Sugars C, Dalcin AT, et al. Weight loss intervention in phase 1 of the Trials of Hypertension Prevention. The TOHP Collaborative Research Group. Arch Intern Med. 1993 Apr 12;153(7):849-58. PubMed External Web Site Policy

Stone PH, Gratsiansky NA, Blokhin A, Huang IZ, Meng L, ERICA Investigators. Antianginal efficacy of ranolazine when added to treatment with amlodipine: the ERICA (Efficacy of Ranolazine in Chronic Angina) trial. J Am Coll Cardiol. 2006 Aug 1;48(3):566-75. PubMed External Web Site Policy

Stratmann HG, Williams GA, Wittry MD, Chaitman BR, Miller DD. Exercise technetium-99m sestamibi tomography for cardiac risk stratification of patients with stable chest pain. Circulation. 1994 Feb;89(2):615-22. [58 references] PubMed External Web Site Policy

Subramanian S, Sabik JF 3rd, Houghtaling PL, Nowicki ER, Blackstone EH, Lytle BW. Decision-making for patients with patent left internal thoracic artery grafts to left anterior descending. Ann Thorac Surg. 2009 May;87(5):1392-8; discussion 1400. PubMed External Web Site Policy

Sun Z, Almutairi AM. Diagnostic accuracy of 64 multislice CT angiography in the assessment of coronary in-stent restenosis: a meta-analysis. Eur J Radiol. 2010 Feb;73(2):266-73. [37 references] PubMed External Web Site Policy

Sun Z, Jiang W. Diagnostic value of multislice computed tomography angiography in coronary artery disease: a meta-analysis. Eur J Radiol. 2006 Nov;60(2):279-86. PubMed External Web Site Policy

Survivors of out-of-hospital cardiac arrest with apparently normal heart. Need for definition and standardized clinical evaluation. Consensus Statement of the Joint Steering Committees of the Unexplained Cardiac Arrest Registry of Europe [trunc]. Circulation. 1997 Jan 7;95(1):265-72. [100 references] PubMed External Web Site Policy

Takaro T, Hultgren HN, Lipton MJ, Detre KM. The VA cooperative randomized study of surgery for coronary arterial occlusive disease II. Subgroup with significant left main lesions. Circulation. 1976 Dec;54(6 Suppl):III107-17. PubMed External Web Site Policy

Takaro T, Peduzzi P, Detre KM, Hultgren HN, Murphy ML, van der Bel-Kahn J, Thomsen J, Meadows WR. Survival in subgroups of patients with left main coronary artery disease. Veterans Administration Cooperative Study of Surgery for Coronary Arterial Occlusive Disease. Circulation. 1982 Jul;66(1):14-22. PubMed External Web Site Policy

Tan CE, Ma S, Wai D, Chew SK, Tai ES. Can we apply the National Cholesterol Education Program Adult Treatment Panel definition of the metabolic syndrome to Asians. Diabetes Care. 2004 May;27(5):1182-6. PubMed External Web Site Policy

Tandogan I, Yetkin E, Yanik A, Ulusoy FV, Temizhan A, Cehreli S, Sasmaz A. Comparison of thallium-201 exercise SPECT and dobutamine stress echocardiography for diagnosis of coronary artery disease in patients with left bundle branch block. Int J Cardiovasc Imaging. 2001 Oct;17(5):339-45. PubMed External Web Site Policy

Tarakji KG, Brunken R, McCarthy PM, Al-Chekakie MO, Abdel-Latif A, Pothier CE, Blackstone EH, Lauer MS. Myocardial viability testing and the effect of early intervention in patients with advanced left ventricular systolic dysfunction. Circulation. 2006 Jan 17;113(2):230-7. PubMed External Web Site Policy

Taylor CB, Youngblood ME, Catellier D, Veith RC, Carney RM, Burg MM, Kaufmann PG, Shuster J, Mellman T, Blumenthal JA, Krishnan R, Jaffe AS, ENRICHD Investigators. Effects of antidepressant medication on morbidity and mortality in depressed patients after myocardial infarction. Arch Gen Psychiatry. 2005 Jul;62(7):792-8. PubMed External Web Site Policy

Taylor HA, Deumite NJ, Chaitman BR, Davis KB, Killip T, Rogers WJ. Asymptomatic left main coronary artery disease in the Coronary Artery Surgery Study (CASS) registry. Circulation. 1989 Jun;79(6):1171-9. PubMed External Web Site Policy

Taylor RS, Brown A, Ebrahim S, Jolliffe J, Noorani H, Rees K, Skidmore B, Stone JA, Thompson DR, Oldridge N. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med. 2004 May 15;116(10):682-92. [75 references] PubMed External Web Site Policy

Taylor RS, Dalal H, Jolly K, Moxham T, Zawada A. Home-based versus centre-based cardiac rehabilitation. Cochrane Database Syst Rev. 2010;(1):CD007130. [40 references] PubMed External Web Site Policy

Tepper D. Frontiers in congestive heart failure: Effect of Metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF). Congest Heart Fail. 1999 Jul-Aug;5(4):184-185. PubMed External Web Site Policy

The 2004 United States Surgeon General's report: the health consequences of smoking. N S W Public Health Bull. 2004 May-Jun;15(5-6):107. PubMed External Web Site Policy

The effect of treatment on mortality in "mild" hypertension: results of the hypertension detection and follow-up program. N Engl J Med. 1982 Oct 14;307(16):976-80. PubMed External Web Site Policy

The Persantine-aspirin reinfarction study. The Persantine-aspirin Reinfarction Study (PARIS) research group. Circulation. 1980 Dec;62(6 Pt 2):V85-8. PubMed External Web Site Policy

Thompson PD, Buchner D, Pina IL, Balady GJ, Williams MA, Marcus BH, Berra K, Blair SN, Costa F, Franklin B, Fletcher GF, Gordon NF, Pate RR, Rodriguez BL, Yancey AK, Wenger NK. Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease: a statement from the Council on Clinical Cardiology [trunc]. Circulation. 2003 Jun 24;107(24):3109-16. [71 references] PubMed External Web Site Policy

Thompson PD, Franklin BA, Balady GJ, Blair SN, Corrado D, Estes NA 3rd, Fulton JE, Gordon NF, Haskell WL, Link MS, Maron BJ, Mittleman MA, Pelliccia A, Wenger NK, Willich SN, Costa F, American Heart Association Council on Nutrition, Physical Activity, and, American Heart Association Council on Clinical Cardiology, American College of Sports Medicine. Exercise and acute cardiovascular events placing the risks into perspective: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism and the Council on Clinical Cardiology. Circulation. 2007 May 1;115(17):2358-68. [70 references] PubMed External Web Site Policy

Tonino PA, De Bruyne B, Pijls NH, Siebert U, Ikeno F, van' t Veer M, Klauss V, Manoharan G, Engstrom T, Oldroyd KG, Ver Lee PN, MacCarthy PA, Fearon WF, FAME Study Investigators. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention. N Engl J Med. 2009 Jan 15;360(3):213-24. PubMed External Web Site Policy

Toole JF, Malinow MR, Chambless LE, Spence JD, Pettigrew LC, Howard VJ, Sides EG, Wang CH, Stampfer M. Lowering homocysteine in patients with ischemic stroke to prevent recurrent stroke, myocardial infarction, and death: the Vitamin Intervention for Stroke Prevention (VISP) randomized controlled trial. JAMA. 2004 Feb 4;291(5):565-75. PubMed External Web Site Policy

Tsuyuki RT, Shrive FM, Galbraith PD, Knudtson ML, Graham MM, APPROACH Investigators. Revascularization in patients with heart failure. CMAJ. 2006 Aug 15;175(4):361-5. PubMed External Web Site Policy

Turnbull F. Effects of different blood-pressure-lowering regimens on major cardiovascular events: results of prospectively-designed overviews of randomised trials. Lancet. 2003 Nov 8;362(9395):1527-35. PubMed External Web Site Policy

Turnbull FM, Abraira C, Anderson RJ, Byington RP, Chalmers JP, Duckworth WC, Evans GW, Gerstein HC, Holman RR, Moritz TE, Neal BC, Ninomiya T, Patel AA, Paul SK, Travert F, Woodward M, Control Group. Intensive glucose control and macrovascular outcomes in type 2 diabetes. Diabetologia. 2009 Nov;52(11):2288-98. PubMed External Web Site Policy

U.K. Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group. Lancet. 1998 Sep 12;352(9131):837-53. PubMed External Web Site Policy

U.S. Department of Health and Human Services. 2008 physical activity guidelines for Americans. Washington (DC): U.S. Department of Health and Human Services; 2008.

Underwood SR, Anagnostopoulos C, Cerqueira M, Ell PJ, Flint EJ, Harbinson M, Kelion AD, Al-Mohammad A, Prvulovich EM, Shaw LJ, Tweddel AC, British Cardiac Society, British Nuclear Cardiology Society, British Nuclear Medicine Society, Royal College of Physicians of London, Royal College of Radiologists. Myocardial perfusion scintigraphy: the evidence. Eur J Nucl Med Mol Imaging. 2004 Feb;31(2):261-91. [290 references] PubMed External Web Site Policy

Underwood SR, Godman B, Salyani S, Ogle JR, Ell PJ. Economics of myocardial perfusion imaging in Europe--the EMPIRE Study. Eur Heart J. 1999 Jan;20(2):157-66. PubMed External Web Site Policy

Underwood SR, Shaw LJ, Anagnostopoulos C, Cerqueira M, Ell PJ, Flint J, Harbinson M, Kelion A, Al Mohammad A, Prvulovich EM. Myocardial perfusion scintigraphy and cost effectiveness of diagnosis and management of coronary heart disease. Heart. 2004 Aug;90 Suppl 5:v34-6. [19 references] PubMed External Web Site Policy

van der Sloot JA, Huikeshoven M, Tukkie R, Verberne HJ, van der Meulen J, van Eck-Smit BL, van Gemert MJ, Tijssen JG, Beek JF. Transmyocardial revascularization using an XeCl excimer laser: results of a randomized trial. Ann Thorac Surg. 2004 Sep;78(3):875-81; discussion 881-2. PubMed External Web Site Policy

van Rij AM, Solomon C, Packer SG, Hopkins WG. Chelation therapy for intermittent claudication. A double-blind, randomized, controlled trial. Circulation. 1994 Sep;90(3):1194-9. PubMed External Web Site Policy

Vandenburg MJ, Wight LJ, Griffiths GK, Brandmann S. Sublingual nitroglycerin or spray in the treatment of angina. Br J Clin Pract. 1986 Dec;40(12):524-7. PubMed External Web Site Policy

Varnauskas E. Twelve-year follow-up of survival in the randomized European Coronary Surgery Study. N Engl J Med. 1988 Aug 11;319(6):332-7. PubMed External Web Site Policy

Vassiliades TA Jr, Douglas JS, Morris DC, Block PC, Ghazzal Z, Rab ST, Cates CU. Integrated coronary revascularization with drug-eluting stents: immediate and seven-month outcome. J Thorac Cardiovasc Surg. 2006 May;131(5):956-62. PubMed External Web Site Policy

Velazquez EJ, Lee KL, Deja MA, Jain A, Sopko G, Marchenko A, Ali IS, Pohost G, Gradinac S, Abraham WT, Yii M, Prabhakaran D, Szwed H, Ferrazzi P, Petrie MC, O'Connor CM, Panchavinnin P, She L, Bonow RO, Rankin GR, Jones RH, Rouleau JL, STICH Investigators. Coronary-artery bypass surgery in patients with left ventricular dysfunction. N Engl J Med. 2011 Apr 28;364(17):1607-16. PubMed External Web Site Policy

Vitarelli A, Tiukinhoy S, Di Luzio S, Zampino M, Gheorghiade M. The role of echocardiography in the diagnosis and management of heart failure. Heart Fail Rev. 2003 Apr;8(2):181-9. [54 references] PubMed External Web Site Policy

Wagdy HM, Hodge D, Christian TF, Miller TD, Gibbons RJ. Prognostic value of vasodilator myocardial perfusion imaging in patients with left bundle-branch block. Circulation. 1998 Apr 28;97(16):1563-70. PubMed External Web Site Policy

Weintraub WS, Jones EL, Morris DC, King SB 3rd, Guyton RA, Craver JM. Outcome of reoperative coronary bypass surgery versus coronary angioplasty after previous bypass surgery. Circulation. 1997 Feb 18;95(4):868-77. PubMed External Web Site Policy

Weintraub WS, Spertus JA, Kolm P, Maron DJ, Zhang Z, Jurkovitz C, Zhang W, Hartigan PM, Lewis C, Veledar E, Bowen J, Dunbar SB, Deaton C, Kaufman S, O'Rourke RA, Goeree R, Barnett PG, Teo KK, Boden WE, COURAGE Trial Research Group, Mancini GB. Effect of PCI on quality of life in patients with stable coronary disease. N Engl J Med. 2008 Aug 14;359(7):677-87. PubMed External Web Site Policy

Weintraub WS, Stein B, Kosinski A, Douglas JS Jr, Ghazzal ZM, Jones EL, Morris DC, Guyton RA, Craver JM, King SB 3rd. Outcome of coronary bypass surgery versus coronary angioplasty in diabetic patients with multivessel coronary artery disease. J Am Coll Cardiol. 1998 Jan;31(1):10-9. PubMed External Web Site Policy

Whelton PK, Appel LJ, Espeland MA, Applegate WB, Ettinger WH Jr, Kostis JB, Kumanyika S, Lacy CR, Johnson KC, Folmar S, Cutler JA. Sodium reduction and weight loss in the treatment of hypertension in older persons: a randomized controlled trial of nonpharmacologic interventions in the elderly (TONE). TONE Collaborative Research Group. JAMA. 1998 Mar 18;279(11):839-46. PubMed External Web Site Policy

Whelton SP, Chin A, Xin X, He J. Effect of aerobic exercise on blood pressure: a meta-analysis of randomized, controlled trials. Ann Intern Med. 2002 Apr 2;136(7):493-503. PubMed External Web Site Policy

White AJ, Kedia G, Mirocha JM, Lee MS, Forrester JS, Morales WC, Dohad S, Kar S, Czer LS, Fontana GP, Trento A, Shah PK, Makkar RR. Comparison of coronary artery bypass surgery and percutaneous drug-eluting stent implantation for treatment of left main coronary artery stenosis. JACC Cardiovasc Interv. 2008 Jun;1(3):236-45. PubMed External Web Site Policy

Whooley MA. Depression and cardiovascular disease: healing the broken-hearted. JAMA. 2006 Jun 28;295(24):2874-81. PubMed External Web Site Policy

Wight LJ, VandenBurg MJ, Potter CE, Freeth CJ. A large scale comparative study in general practice with nitroglycerin spray and tablet formulations in elderly patients with angina pectoris. Eur J Clin Pharmacol. 1992;42(3):341-2. PubMed External Web Site Policy

Wijeysundera HC, Nallamothu BK, Krumholz HM, Tu JV, Ko DT. Meta-analysis: effects of percutaneous coronary intervention versus medical therapy on angina relief. Ann Intern Med. 2010 Mar 16;152(6):370-9. PubMed External Web Site Policy

Wright RS, Anderson JL, Adams CD, Bridges CR, Casey DE Jr, Ettinger SM, Fesmire FM, Ganiats TG, Jneid H, Lincoff AM, Peterson ED, Philippides GJ, Theroux P, Wenger NK, Zidar JP, Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE 2nd, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Zidar JP, American College of Cardiology Foundation/American Heart Association Task Force. 2011 ACCF/AHA focused update incorporated into the ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction [trunc]. J Am Coll Cardiol. 2011 May 10;57(19):e215-367. PubMed External Web Site Policy

Xin X, He J, Frontini MG, Ogden LG, Motsamai OI, Whelton PK. Effects of alcohol reduction on blood pressure: a meta-analysis of randomized controlled trials. Hypertension. 2001 Nov;38(5):1112-7. PubMed External Web Site Policy

Yao SS, Bangalore S, Chaudhry FA. Prognostic implications of stress echocardiography and impact on patient outcomes: an effective gatekeeper for coronary angiography and revascularization. J Am Soc Echocardiogr. 2010 Aug;23(8):832-9. PubMed External Web Site Policy

Yao SS, Qureshi E, Sherrid MV, Chaudhry FA. Practical applications in stress echocardiography: risk stratification and prognosis in patients with known or suspected ischemic heart disease. J Am Coll Cardiol. 2003 Sep 17;42(6):1084-90. PubMed External Web Site Policy

Yao SS, Wever-Pinzon O, Zhang X, Bangalore S, Chaudhry FA. Prognostic value of stress echocardiogram in patients with angiographically significant coronary artery disease. Am J Cardiol. 2012 Jan 15;109(2):153-8. PubMed External Web Site Policy

Yoshinaga K, Chow BJ, Williams K, Chen L, deKemp RA, Garrard L, Lok-Tin Szeto A, Aung M, Davies RA, Ruddy TD, Beanlands RS. What is the prognostic value of myocardial perfusion imaging using rubidium-82 positron emission tomography. J Am Coll Cardiol. 2006 Sep 5;48(5):1029-39. PubMed External Web Site Policy

Yu-Poth S, Zhao G, Etherton T, Naglak M, Jonnalagadda S, Kris-Etherton PM. Effects of the National Cholesterol Education Program's Step I and Step II dietary intervention programs on cardiovascular disease risk factors: a meta-analysis. Am J Clin Nutr. 1999 Apr;69(4):632-46. PubMed External Web Site Policy

Yusuf S, Dagenais G, Pogue J, Bosch J, Sleight P. Vitamin E supplementation and cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators. N Engl J Med. 2000 Jan 20;342(3):154-60. PubMed External Web Site Policy

Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators. N Engl J Med. 2000 Jan 20;342(3):145-53. PubMed External Web Site Policy

Yusuf S, Zucker D, Peduzzi P, Fisher LD, Takaro T, Kennedy JW, Davis K, Killip T, Passamani E, Norris R, et al.. Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomised trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration. Lancet. 1994 Aug 27;344(8922):563-70. PubMed External Web Site Policy

Zhao DX, Leacche M, Balaguer JM, Boudoulas KD, Damp JA, Greelish JP, Byrne JG, Writing Group of the Cardiac Surgery, Cardiac Anesthesiology, and Interventional , Ahmad RM, Ball SK, Cleator JH, Deegan RJ, Eagle SS, Fong PP, Fredi JL, Hoff SJ, Jennings HS 3rd, McPherson JA, Piana RN, Pretorius M, Robbins MA, Slosky DA, Thompson A. Routine intraoperative completion angiography after coronary artery bypass grafting and 1-stop hybrid revascularization results from a fully integrated hybrid catheterization laboratory/operating room. J Am Coll Cardiol. 2009 Jan 20;53(3):232-41. PubMed External Web Site Policy

Ziegelstein RC, Fauerbach JA, Stevens SS, Romanelli J, Richter DP, Bush DE. Patients with depression are less likely to follow recommendations to reduce cardiac risk during recovery from a myocardial infarction. Arch Intern Med. 2000 Jun 26;160(12):1818-23. PubMed External Web Site Policy

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Potential Benefits

Appropriate and effective diagnosis and management of patients with stable ischemic heart disease

Potential Harms

  • All forms of noninvasive stress testing carry some risk. Maximal exercise testing is associated with a low but finite incidence of cardiac arrest, acute myocardial infarction (AMI), and even death. Refer to Section 2.2.1.2 in the original guideline document, "Safety and Other Consideration Potentially Affecting Test Selection," for a detailed discussion of safety issues associated with testing.
  • All medical therapy used to prevent myocardial infarction or to relieve symptoms can cause adverse effects. Refer to the original guideline document for discussions of specific benefits and risks of antiplatelet therapy, beta-blockers, renin-angiotensin-aldosterone blocker therapy, nitrates, calcium channel blockers, and other antianginal therapy.
  • Percutaneous coronary intervention (PCI) may increase the short-term risk of myocardial infarction (MI).
  • Procedural stroke occurred more commonly with coronary artery bypass graft (CABG) than with PCI.
  • The risk of stent thrombosis is increased dramatically in patients who prematurely discontinue dual antiplatelet therapy (DAPT), and stent thrombosis is associated with a mortality rate of 20% to 45%.
  • Pharmacotherapy is more difficult in older adults because of changes in drug bioavailability and elimination. Drug–drug interactions are more common because of polypharmacy. A more conservative approach to coronary angiography is often appropriate given the higher risk of contrast-induced nephropathy in older adults. Moreover, the risks of morbidity and mortality associated with CABG are increased in older adults.
  • The incidence of periprocedural complications (e.g., death, MI, stroke, infection, renal failure) is higher in patients with chronic kidney disease than in those without renal dysfunction.

Contraindications

  • Contrast agents can affect renal function and therefore should be avoided in patients with chronic kidney disease.
  • Cardiac magnetic resonance (CMR) might be contraindicated in patients with claustrophobia or implanted devices, and use of gadolinium contrast agents is associated rarely with nephrogenic systemic fibrosis. For this reason, gadolinium is contraindicated in patients with severe renal dysfunction (estimated glomerular filtration rates <30 mL/min per 1.73 m2), and the dose should be adjusted for patients with mild to moderate dysfunction (estimated glomerular filtration rates 30 to 60 mL/min per 1.73 m2).
  • The use of bile acid sequestrant is relatively contraindicated when triglycerides are ≥200 mg/dL and is contraindicated when triglycerides are ≥500 mg/dL
  • Aspirin is relatively contraindicated in patients with known allergies to nonsteroidal antiinflammatory drugs and in patients with the syndrome of asthma, rhinitis, and nasal polyps.
  • Absolute contraindications to beta blockers are severe bradycardia, preexisting high-degree atrioventricular (AV) block, sick sinus syndrome (without a pacemaker in place), and refractory heart failure. Relative contraindications include bronchospastic disease or active peripheral artery disease (PAD) (beta blockers without vasodilating properties or selective agents at low doses may be used).
  • Because of their effects on contractility, none of the calcium channel blockers are recommended for routine treatment of patients with current or prior symptoms of heart failure and a reduced left ventricular ejection fraction (LVEF).
  • Combining verapamil or diltiazem with beta blockers generally should be avoided because of potentially profound adverse effects on AV nodal conduction, heart rate, or cardiac contractility.
  • Nitrates are relatively contraindicated in hypertrophic obstructive cardiomyopathy because of the potential to increase the outflow tract obstruction and mitral regurgitant flow. They should be avoided in patients with severe aortic valvular stenosis.
  • Coadministration of the phosphodiesterase inhibitors sildenafil, tadalafil, or vardenafil with long-acting nitrates should be strictly avoided within 24 hours of nitrate administration because of the risk of profound hypotension (e.g., 25–mm Hg drop in systolic blood pressure). Patients should be advised not to take phosphodiesterase inhibitors within 24 hours of long-acting nitrates, and nitrates should not be taken for 24 hours after use of sildenafil or 48 hours after tadalafil; a suitable time interval after vardenafil has not been determined.
  • Ranolazine is contraindicated in patients with clinically significant hepatic impairment because of increased plasma concentrations and QT prolongation.
  • Ranolazine is contraindicated in combination with potent inhibitors of the CYP3A4 pathway, including ketoconazole (3.2-fold increase in ranolazine plasma levels) and other azole antifungals, macrolide antibiotics, human immunodeficiency virus (HIV) protease inhibitors, grapefruit products or juice, diltiazem (1.8- to 2.3-fold increase in ranolazine plasma levels), itraconazole, clarithromycin, and certain HIV protease inhibitors.
  • Contraindications to enhanced external counterpulsation include decompensated heart failure, severe PAD, and severe aortic regurgitation.

Qualifying Statements

  • The American College of Cardiology Foundation (ACCF)/American Heart Association (AHA) practice guidelines are intended to assist healthcare providers in clinical decision making by describing a range of generally acceptable approaches to the diagnosis, management, and prevention of specific diseases or conditions. The guidelines attempt to define practices that meet the needs of most patients in most circumstances. The ultimate judgment about care of a particular patient must be made by the healthcare provider and patient in light of all the circumstances presented by that patient. As a result, situations may arise in which deviations from these guidelines might be appropriate. Clinical decision making should involve consideration of the quality and availability of expertise in the area where care is provided. When these guidelines are used as the basis for regulatory or payer decisions, the goal should be improvement in quality of care. The Task Force recognizes that situations arise in which additional data are needed to inform patient care more effectively; these areas will be identified within each respective guideline when appropriate.
  • Prescribed courses of treatment in accordance with these recommendations are effective only if followed. Because lack of patient understanding and adherence may adversely affect outcomes, physicians and other healthcare providers should make every effort to engage the patient's active participation in prescribed medical regimens and lifestyles.
  • A key premise of this guideline is that once a diagnosis of ischemic heart disease (IHD) is established, it is necessary in most patients to assess their risk of subsequent complications, such as acute myocardial infarction (AMI) or death. Because the approach to diagnosis of suspected IHD and the assessment of risk in a patient with known IHD are conceptually different and are based on different literature, the writing committee constructed this guideline to address these issues separately. It is recognized, however, that a clinician might select a procedure for a patient with a moderate to high pretest likelihood of IHD to provide information for both diagnosis and risk assessment, whereas in a patient with a low likelihood of IHD, it could be sensible to select a test simply for diagnostic purposes without regard to risk assessment. By separating the conceptual approaches to ascertaining diagnosis and prognosis, the goal of the writing committee is to promote the sensible application of appropriate testing rather than routine use of the most expensive or complex tests whether warranted or not. It is not the intent of the writing committee to promote unnecessary or duplicate testing, although in some patients this could be unavoidable.
  • Additionally, this guideline addresses the approach to asymptomatic patients with stable ischemic heart disease (SIHD) that has been diagnosed solely on the basis of an abnormal screening study, rather than on the basis of clinical symptoms or events such as anginal symptoms or acute coronary syndrome (ACS). The inclusion of such asymptomatic patients does not constitute an endorsement of such tests for the purposes of screening but is simply an acknowledgment of the clinical reality that asymptomatic patients often present for evaluation after such tests have been performed. Multiple ACCF/AHA guidelines and scientific statements have discouraged the use of ambulatory monitoring, treadmill testing, stress echocardiography, stress myocardial perfusion imaging (MPI), and computed tomography (CT) scoring of coronary calcium or coronary angiography as routine screening tests in asymptomatic individuals. The reader is referred to these documents for a detailed discussion of screening, which is beyond the scope of this guideline (see Table 3 in the original guideline document).
  • The writing committee readily acknowledges that in actual clinical practice, the elements comprising the four sections of the original guideline document and the steps delineated in the algorithms often overlap and are not always separable.

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools

Clinical Algorithm

Quick Reference Guides/Physician Guides

Resources

Slide Presentation

For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

IOM Care Need

Getting Better

Living with Illness

IOM Domain

Effectiveness

Patient-centeredness

Bibliographic Source(s)

Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP, Douglas PS, Foody JM, Gerber TC, Hinderliter AL, King SB 3rd, Kligfield PD, Krumholz HM, Kwong RY, Lim MJ, Linderbaum JA, Mack MJ, Munger MA, Prager RL, Sabik JF, Shaw LJ, Sikkema JD, Smith CR Jr, Smith SC Jr, Spertus JA, Williams SV. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol. 2012 Dec 18;60(24):e44-e164. [1266 references] PubMed External Web Site Policy

Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released

2012 Dec 18

Guideline Developer(s)

American Association for Thoracic Surgery - Medical Specialty Society

American College of Cardiology Foundation - Medical Specialty Society

American College of Physicians - Medical Specialty Society

American Heart Association - Professional Association

Preventive Cardiovascular Nurses Association - Medical Specialty Society

Society for Cardiovascular Angiography and Interventions - Medical Specialty Society

Society of Thoracic Surgeons - Medical Specialty Society

Source(s) of Funding

The work of the writing committee is supported exclusively by the American College of Cardiology Foundation (ACCF), American Heart Association (AHA), American College of Physicians (ACP), American Association for Thoracic Surgery (AATS), Preventive Cardiovascular Nurses Association (PCNA), Society for Cardiovascular Angiography and Interventions (SCAI), and Society of Thoracic Surgeons (STS), without commercial support.

Guideline Committee

American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines

Composition of Group That Authored the Guideline

Writing Committee Members: Stephan D. Fihn, MD, MPH (Chair); Julius M. Gardin, MD (Vice Chair); Jonathan Abrams, MD; Kathleen Berra, MSN, ANP; James C. Blankenship, MD; Apostolos P. Dallas, MD; Pamela S. Douglas, MD; JoAnne M. Foody, MD; Thomas C. Gerber, MD, PHD; Alan L. Hinderliter, MD; Spencer B. King III, MD; Paul D. Kligfield, MD; Harlan M. Krumholz, MD; Raymond Y. K. Kwong, MD; Michael J. Lim, MD; Jane A. Linderbaum, MS, CNP-BC; Michael J. Mack, MD; Mark A. Munger, PharmD; Richard L. Prager, MD; Joseph F. Sabik, MD; Leslee J. Shaw, PhD; Joanna D. Sikkema, MSN, ANP-BC; Craig R. Smith, Jr, MD; Sidney C. Smith, Jr, MD; John A. Spertus, MD, MPH; Sankey V. Williams, MD

Task Force Members: Jeffrey L. Anderson, MD, FACC, FAHA (Chair); Jonathan L. Halperin, MD, FACC, FAHA, Chair-Elect; Alice K. Jacobs, MD, FACC, FAHA (Immediate Past Chair 2009–2011*); Sidney C. Smith, Jr, MD, FACC, FAHA (Past Chair 2006–2008*); Cynthia D. Adams, MSN, APRN-BC, FAHA*; Nancy M. Albert, PhD, CCNS, CCRN, FAHA; Ralph G. Brindis, MD, MPH, MACC; Christopher E. Buller, MD, FACC*; Mark A. Creager, MD, FACC, FAHA; David DeMets, PhD; Steven M. Ettinger, MD, FACC*; Robert A. Guyton, MD, FACC; Judith S. Hochman, MD, FACC, FAHA; Sharon Ann Hunt, MD, FACC, FAHA*; Richard J. Kovacs, MD, FACC, FAHA; Frederick G. Kushner, MD, FACC, FAHA*; Bruce W. Lytle, MD, FACC, FAHA*; Rick A. Nishimura, MD, FACC, FAHA*; E. Magnus Ohman, MD, FACC; Richard L. Page, MD, FACC, FAHA*; Barbara Riegel, DNSC, RN, FAHA*; William G. Stevenson, MD, FACC, FAHA; Lynn G. Tarkington, RN*; Clyde W. Yancy, MD, FACC, FAHA

*Former Task Force member during this writing effort.

Financial Disclosures/Conflicts of Interest

The Task Force makes every effort to avoid actual, potential, or perceived conflicts of interest that may arise as a result of industry relationships or personal interests among the members of the writing committee. All writing committee members and peer reviewers of this guideline were required to disclose all such current health care-related relationships, including those existing 24 months (from 2005) before initiation of the writing effort. The writing committee chair may not have any relevant relationships with industry or other entities (RWI); however, RWI are permitted for the vice chair position. In December 2009, the American College of Cardiology Foundation (ACCF) and American Heart Association (AHA) implemented a new policy that requires a minimum of 50% of the writing committee to have no relevant RWI; in addition, the disclosure term was changed to 12 months before writing committee initiation. The present guideline was developed during the transition in RWI policy and occurred over an extended period of time. In the interest of transparency, the writing committee provides full information on RWI existing over the entire period of guideline development, including delineation of relationships that expired more than 24 months before the guideline was finalized. This information is included in Appendix 1 of the original guideline document. These statements are reviewed by the Task Force and all members during each conference call and meeting of the writing committee and are updated as changes occur. All guideline recommendations require a confidential vote by the writing committee and must be approved by a consensus of the voting members. Members who recused themselves from voting are indicated in the list of writing committee members, and specific section recusals are noted in Appendix 1 of the original guideline document. Authors' and peer reviewers' RWI pertinent to this guideline are disclosed in Appendixes 1 and 2 of the original guideline document, respectively. Comprehensive disclosure information for the Task Force is also available from the American College of Cardiology Web site External Web Site Policy.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the Journal of the American College of Cardiology (JACC) Web site External Web Site Policy and from the Circulation Web site External Web Site Policy.

Print copies: Available from the ACC, 2400 N Street NW, Washington DC, 20037; (800) 253-4636 (US only).

Availability of Companion Documents

The following are available:

  • Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP, Douglas PS, Foody JM, Gerber TC, Hinderliter AL, King SB 3rd, Kligfield PD, Krumholz HM, Kwong RY, Lim MJ, Linderbaum JA, Mack MJ, Munger MA, Prager RL, Sabik JF, Shaw LJ, Sikkema JD, Smith CR Jr, Smith SC Jr, Spertus JA, Williams SV. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary. J Am Coll Cardiol 2012 Dec 18;60(24):2564-2603. Electronic copies: Available in Portable Document Format (PDF) from the Journal of the American College of Cardiology (JACC) Web site External Web Site Policy.
  • 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: Slide set. 2012. 164 p. Electronic copies: Available from the American College of Cardiology (ACC) Web site External Web Site Policy.
  • Top ten things to know. Guideline for the diagnosis and management of patients with stable ischemic heart disease: 2012. 1 p. Electronic copies: Available from the American Heart Association (AHA) Web site External Web Site Policy.
  • 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: Ten Points to Remember. Electronic copies: Available from the ACC Web site External Web Site Policy with a subscription to CardioSource.
  • Methodology manual and policies from the ACCF/AHA Task Force on Practice Guidelines. 2010 Jun. 88 p. Electronic copies: Available in Portable Document Format (PDF) from the AHA Web site External Web Site Policy.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on March 26, 2013. The information was verified by the guideline developer on May 15, 2013.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions as follows:

Copyright to the original guideline is owned by the American College of Cardiology Foundation (ACCF) and the American Heart Association, Inc. (AHA). NGC users are free to download a single copy for personal use. Reproduction without permission of the ACC/AHA guidelines is prohibited. Permissions requests should be directed to copyright_permissions@acc.org.

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies, relevant professional associations, public or private organizations, other government agencies, health care organizations or plans, and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline developers, and are screened solely to determine that they meet the NGC Inclusion Criteria which may be found at http://www.guideline.gov/about/inclusion-criteria.aspx.

NGC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover, the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.

Readers with questions regarding guideline content are directed to contact the guideline developer.