Key priorities for implementation

The following recommendations have been identified as priorities for implementation.
Explore and address issues according to the person’s needs, which may include:
self-management skills such as pacing their activities and goal setting
concerns about the impact of stress, anxiety or depression on angina
advice about physical exertion including sexual activity.

Offer people optimal drug treatment for the initial management of stable angina. Optimal drug treatment consists of one or two anti-anginal drugs as necessary plus drugs for secondary prevention of cardiovascular disease.

Consider revascularisation (coronary artery bypass graft [CABG] or percutaneous coronary intervention [PCI]) for people with stable angina whose symptoms are not satisfactorily controlled with optimal medical treatment.

When either procedure would be appropriate, explain to the person the risks and benefits of PCI and CABG for people with anatomically less complex disease whose symptoms are not satisfactorily controlled with optimal medical treatment. If the person does not express a preference, take account of the evidence that suggests that PCI may be the more cost-effective procedure in selecting the course of treatment.

When either procedure would be appropriate, take into account the potential survival advantage of CABG over PCI for people with multivessel disease whose symptoms are not satisfactorily controlled with optimal medical treatment and who:
have diabetes or
are over 65 years or
have anatomically complex three-vessel disease, with or without involvement of the left main stem.

Consider the relative risks and benefits of CABG and PCI for people with stable angina using a systematic approach to assess the severity and complexity of the person’s coronary disease, in addition to other relevant clinical factors and comorbidities.

Ensure that there is a regular multidisciplinary team meeting to discuss the risks and benefits of continuing drug treatment or the revascularisation strategy (CABG or PCI) for people with stable angina.
The team should include cardiac surgeons and interventional cardiologists.
Treatment strategy should be discussed for the following people, including but not limited to:
people with left main stem or anatomically complex three-vessel disease
people in whom there is doubt about the best method of revascularisation because of the complexity of coronary anatomy, the extent of stenting required or other relevant clinical factors and comorbidities.

Ensure people with stable angina receive balanced information and have the opportunity to discuss the benefits, limitations and risks of continuing drug treatment, CABG and PCI to help them make an informed decision about their treatment.

When either revascularisation procedure is appropriate, explain to the person:
The main purpose of revascularisation is to improve the symptoms of stable angina.
CABG and PCI are effective in relieving symptoms.
Repeat revascularisation may be necessary after either CABG or PCI and the rate is lower after CABG.

Stroke is uncommon after either CABG or PCI, and the incidence is similar between the two procedures.
There is a potential survival advantage with CABG for some people with multivessel disease.

Discuss the following with people whose symptoms are satisfactorily controlled with optimal medical treatment:
their prognosis without further investigation
the likelihood of having left main stem disease or proximal three-vessel disease
the availability of CABG to improve the prognosis in a subgroup of people with left main stem or proximal three-vessel disease
the process and risks of investigation
the benefits and risks of CABG, including the potential survival gain.

Informed evidence based decision making by the doctors in conjunction with open discussion with the patient is the key for best prognostication.

Ischaemic Heart disease is a very highly Personal,Patient specific, context guided ,medical conundrum .
When managed well , a most rewarding ,outcome based clinical entity .

G Mohan.