Coronary heart disease – Related resources

Cochrane reviews

Drug therapy

• Fixed-dose combination therapy for cardiovascular disease prevention may not decrease all-cause mortality or cardiovascular events and may lead to more adverse events compared with placebo, single drug active component, or usual care .

Surgery

• Preoperative statin therapy in cardiac surgery patients appears to reduce post-operative atrial fibrillation.Transmyocardial laser revascularization (TMRL) compared to medical therapy may relieve angina in persons with medically refractory angina not amenable to other revascularization techniques but does not decrease mortality .
• Incentive spirometry may not be effective in reducing pulmonary complications and in decreasing the negative effects on pulmonary function in patients undergoing coronary artery bypass graft (CABG) .

Physiotherapy and rehabilitation

• Patient education of coronary heart disease patients might possibly be beneficial compared to control but the evidence is insufficient .
• Psychological interventions may produce small to moderate reductions in depression and anxiety in coronary heart disease patients .
• Interventions involving motivational communications delivered through letters, telephone calls and home visits may be effective in increasing uptake of cardiac rehabilitation .
• Home- and centre-based cardiac rehabilitation may be similar in their benefits on risk factors, health-related quality of life, death, clinical events, and costs .

Lifestyle and counselling

• Dietary advice to follow a Mediterranean-style dietary pattern might possibly be effective for the primary prevention of cardiovascular disease but the evidence is insufficient .
• Selenium supplements may not be beneficial for primary prevention of cardiovascular disease, especially in those individuals and populations with adequate-to-high selenium status .
• Modified fat intake, or modified and reduced fat intake combined (but not reduced fat intake alone) appears to reduce cardiovascular events but not total or cardiovascular mortality .
• Interventions using counselling and education aimed at behaviour change may not reduce total or coronary heart disease mortality or clinical events in general populations but may be effective in reducing mortality in high-risk hypertensive and diabetic populations.
• Dietary advice from health personnel appears to be effective in reducing blood lipid levels, blood pressure and dietary fat intake, and increasing fruit and vegetable intake.
• Low glycaemic index diets may slightly reduce total cholesterol and HbA1c, but evidence is insufficient to recommend such diets for the purpose of improving risk factors for CHD .
• Dietary or supplemental omega 3 fats may not alter total mortality, combined cardiovascular events or cancers in people with, or at high risk of, cardiovascular disease or in the general population .
• Music listening may have a beneficial effect for persons with coronary heart disease .

Other evidence summaries

Drug therapy

• Long-term use of aspirin dosages greater than 75 to 81 mg/d in the setting of cardiovascular disease prevention appear not to better prevent events but is associated with increased risks of gastrointestinal bleeding .
• Except for patients with a mechanical heart valve, the benefits of oral anticoagulant (OAC) therapy plus aspirin in reducing thromboembolic events appear to be unclear compared with OAC alone, and there may be increased risk of major bleeding .
• Intensive lipid lowering with high-dose statin therapy appears to provide a benefit over standard-dose therapy for preventing predominantly non-fatal cardiovascular events in patients with stable coronary heart disease or acute coronary syndrome .
• In patients with coronary disease, the use of short-acting nifedipine in moderate to high doses may cause an increase in total mortality .
• Beta-blockers and calcium antagonists appear to provide similar outcomes, but beta-blockers fewer adverse effects .Oestrogen plus progestin does not decrease cardiovascular events during a 4-year follow-up. During the first year there is an excess of cardiovascular events .

Surgery

• In single- or double-vessel disease, off-pump coronary artery bypass (OPCAB) reduces the need for re-intervention for ischaemia, the recurrence of angina and major coronary adverse events at 1 to 5 years compared with percutaneous coronary intervention (PCI) but is associated with an increased length of hospital stay. There appears not to be differences between OPCAB and PCI in death, myocardial infarction, and stroke .

Physiotherapy and rehabilitation

Cardiac exercise training improves exercise tolerance. Multi-factorial rehabilitation may be effective in improving psychosocial well-being, improving lipid levels, and reducing smoking. There is some evidence that exercise training, especially as a component of multi-factorial rehabilitation, reduces total and cardiovascular mortality .
• The addition of psychosocial treatments to standard cardiac rehabilitation reduces mortality and morbidity, psychological distress and some biological risk factors .

Lifestyle and counselling

• Vitamin E and vitamin C are of unknown effectiveness, and beta carotene may be harmful .Selenium supplements may not reduce the risk of coronary heart disease .
• Omega-3 fatty acids appear to reduce total mortality and the risk of death due to myocardial infarction in CHD patients, but there is no evidence of the benefit in patients taking statins .
• Fish consumption may decrease the risk of coronary death in high-risk populations, but probably not in low-risk populations .
• Current evidence does not seem to support the use of ginseng to treat cardiovascular risk factors, although the evidence is insufficient .Compliance in the treatment of cardiovascular disease can be increased with several strategies. However, the quality of studies is suboptimal and no firm recommendations can be made of different strategies .

Others

C-reactive protein may have independent value as a predictor of cardiovascular disease risk, but conclusive evidence on its role in risk assessment is lacking .
• A high concentration of serum homocysteine is probably not a risk factor for coronary events in a population free of heart disease. However, mild hyperhomocystinemia predicts secondary coronary events in men with heart disease, possibly as a consequence of atherosclerotic changes .
• Self-reported dyspnea at cardiac stress testing appears to be an independent predictor of the risk of death from cardiac or any causes .
• Low cardiorespiratory fitness may be a strong and independent predictor of CVD and all-cause mortality and comparable in importance with that of diabetes mellitus and other CVD risk factors .
• Waist-to-hip ratio appears to have a graded and highly significant association with myocardial infarction risk in most ethnic groups worldwide. The use of waist-to-hip ratio instead of BMI appears to improve the risk estimate of myocardial infarction .Among firefighters fire suppression is associated with markedly higher risk of death from coronary heart disease than the risk associated with nonemergency duties .

Clinical guidelines

• Qaseem A, Fihn SD, Williams S et al. Diagnosis of stable ischemic heart disease: summary of a clinical practice guideline from the American College of Physicians/American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med 2012;157(10):729-34.
• Qaseem A, Fihn SD, Dallas P et al. Management of stable ischemic heart disease: summary of a clinical practice guideline from the American College of Physicians/American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med 2012;157(10):735-43.
• Perk J, De Backer G, Gohlke H et al. European Guidelines on cardiovascular disease prevention in clinical practice (version 2012). The Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts). Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J 2012;33(13):1635-701.
• Fox K, Garcia MA, Ardissino D, et al; Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology, ESC Committee for Practice Guidelines (CPG). Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. Eur Heart J 2006 Jun;27(11):1341-81.
• Gibbons RJ, Chatterjee K, Daley J, et al. ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina). Circulation 1999 Jun 1;99(21):2829-48.
• Gibbons RJ, Abrams J, Chatterjee K, et al; American College of Cardiology, American Heart Association Task Force on Practice Guidelines. Committee on the Management of Patients With Chronic Stable Angina. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina). Circulation 2003 Jan 7;107(1):149-58.
• Mosca L, Benjamin EJ, Berra K, Bezanson JL, Dolor RJ et al. 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.

Literature

• Pfisterer ME, Zellweger MJ, Gersh BJ. Management of stable coronary artery disease. Lancet 2010 Feb 27;375(9716):763-72.