Related Experiment Videos
The reasonable workup before recommending medical or surgical therapy: an overall strategy
Insights
Evaluating chronic ischemic heart disease (IHD) requires considering symptoms, disease extent, and heart function. Objective tests guide treatment decisions, but some patients need serial evaluations due to management uncertainties.
Area of Science:
- Cardiology
- Internal Medicine
- Diagnostic Imaging
Background:
- Chronic ischemic heart disease (IHD) management involves complex decision-making.
- Treatment selection (medical-surgical vs. medical) hinges on various patient-specific factors.
Purpose of the Study:
- To outline an objective approach for evaluating patients with chronic IHD.
- To determine the most effective diagnostic strategies for guiding therapy selection.
Main Methods:
- Analysis of clinical presentation, anatomical disease extent, and objective ischemia evidence.
- Utilizing exercise electrocardiography and radioventriculography for functional assessment.
- Selective and sequential use of laboratory and noninvasive tests.
Main Results:
- A single overwhelming factor can dictate treatment in a minority of IHD patients.
- Most patients require consideration of multiple factors for optimal management.
- Objective assessments like exercise tests are superior to routine clinical exams for evaluating symptoms and function.
Conclusions:
- A systematic, multi-factorial approach is crucial for IHD patient workup.
- Noninvasive evaluations should directly address clinical questions to avoid unnecessary testing.
- Coronary arteriography may be appropriate without extensive prior screening in select IHD cases.
Abstract:
The workup of a patient with chronic ischemic heart disease (IHD) before the selection of medical-surgical or medical therapy depends on multiple objective and subjective factors. These include symptoms, extent of anatomic disease (degree of coronary arteriosclerosis and left ventricular abnormalities), objective evidence of ischemia, extent of left ventricular dysfunction, and recent intercurrent ischemic events. In a minority of patients, a single factor is of overwhelming importance; e.g., the presence of severe left main coronary artery narrowing in a symptomatic patient indicates surgery is a better choice, whereas evidence of advanced left ventricular dysfunction suggests that surgery is likely to be risky and of limited help to the patient. In most instances, multiple factors should be considered before making a recommendation. The patient should be placed in the appropriate clinical subset and the objective factors that are most important in determining survival should be evaluated. Hence, an exercise electrocardiographic study to evaluate symptoms and exercise tolerance in a patient with angina pectoris and radioventriculographic studies with exercise to estimate left ventricular performance in a patient who complains of fatigue and breathlessness are superior to the subjective interpretations of routine clinical examinations. Asymptomatic patients and those with excellent exercise tolerance pose the most difficult decisions. Perhaps serial (even annual) noninvasive evaluation is appropriate in such patients in light of the current uncertainty about how to manage them. Laboratory tests should be used selectively, systematically and sequentially. The high cost of many of the examinations is reason to avoid duplication. When noninvasive evaluation can answer the question being posed and the cost of hospitalization avoided, this should be done. However, there is little reason to perform noninvasive examinations that do not answer the clinical question being asked; hence, in many patients it is appropriate to proceed directly to coronary arteriography rather than to perform a variety of "screening" examinations before this procedure.