Monitoring
Patients with stable ischemic heart disease should have a regular follow-up every 4-6 months during the first year of therapy, every 6-12 months after the first year if the patient is stable and earlier if there is a change in the symptoms or functional capacity. Evaluation includes: Assessment of symptoms and clinical function; surveillance for complications such as arrhythmias and heart failure; monitoring and modification of cardiac risk factors; assessment of the adequacy of and compliance with lifestyle modifications and medical therapy; and adherence to changes in lifestyle and lipid-lowering medication effects should be assessed by measuring fasting lipids 4-12 weeks after statin initiation or dose adjustment and then every 3-12 months thereafter based on response to or adherence to therapy.
Periodic screening of new or worsened comorbidities that are prevalent in patients with stable ischemic heart disease such as diabetes mellitus, depression and chronic renal disease should be done. Reinforce therapies that help control risk factors such as dyslipidemia, hypertension and diabetes mellitus. Patients at risk (eg recent acute coronary syndrome or revascularization, heart failure) should have medically supervised programs (cardiac rehabilitation) and physician-directed home-based exercise programs. Resting electrocardiogram at 1-year or longer intervals between studies in patients with stable symptoms can also be performed. An additional electrocardiogram is suggested if patient experiences arrhythmia, anginal symptoms or if therapy has been modified. Exercise electrocardiogram is recommended if there are changes in the frequency of symptoms or new symptoms occur. A repeat exercise electrocardiogram may be done after 2 years if stable. A stress test may be done for reference 1-3 months post revascularization and/or periodically for ischemia reassessment. Reassessment of prognosis via stress test every 3-5 years for low-risk/asymptomatic patients. Assessment of left ventricular ejection fraction and segmental wall motion by echocardiography or radionuclide imaging is recommended in patients with new or worsening heart failure or evidence of intervening myocardial infarction by history or electrocardiogram. For patients with debilitating angina unresponsive to optimal medical therapy and revascularization (ie refractory angina), consider using an enhanced external counterpulsation (EECP), a reducer device for coronary sinus constriction, or spinal cord stimulation to improve symptoms. For patients with refractory angina despite medical therapy who are not candidates for revascularization, coronary venous return reduction via the coronary sinus can redistribute flow to ischemic areas of the myocardium. Transmyocardial revascularization is not recommended in patients with refractory angina.