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Stable Ischaemic Heart Disease in Diabetics : 489
Medical Therapy vs Revascularization

support the benefit of beta blockers for patients with day and for men to have 1 or 2 drinks a day unless
diabetes in the chronic ambulatory setting and in the alcohol is contraindicated (such as in patients with a
post-ACS population. history of alcohol abuse or dependence or those with
liver disease).
Randomized trials of thiazide diuretics that included
substantial numbers of patients with diabetes have
consistently demonstrated CVD benefits. Pharmacologic Therapy
Antiplatelet Therapy
Diabetes Management
1. Treatment with aspirin, 75 to 162 mg daily, should
For selected individual patients, such as those with be started immediately and continued indefinitely
a short duration of diabetes mellitus and a long life in the absence of contraindications in patients with
expectancy, a goal hemoglobin A1c (HbA1c) of 7% or SIHD.
less is reasonable. A goal HbA1c between 7% and 9% 2. Treatment with clopidogrel is reasonable when as-

is reasonable for certain patients according to age, pirin is contraindicated in patients with SIHD.
history of hypoglycemia, presence of microvascular or
macrovascular complications, or presence of coexisting 3. Treatment with aspirin, 75 to 162 mg daily, and
medical conditions. Therapy with rosiglitazone should clopidogrel, 75 mg daily, might be reasonable in cer-
not be initiated in patients with SIHD. tain high-risk patients with SIHD.

Physical Activity 4. Dipyridamole is not recommended as antiplatelet
therapy for patients with SIHD.
For all patients 30 to 60 minutes of moderate-intensity
aerobic activity at least 5 days and preferably 7 days Medical Therapy for Relief of Symptoms
per week, supplemented by an increase in daily lifestyle 1. Beta-blocking agents should be prescribed as initial
activities (e.g.walking breaks at work, gardening, therapy for relief of symptoms in patients with SIHD.
household work) is necessary to improve cardio
respiratory fitness and move patients out of the least-fit, 2. Calcium channel blocking agents or long-acting
least-active, high-risk cohort (bottom 20%). nitrates should be prescribed for relief of symptoms
when beta-blocking agents are contraindicated or
Weight Management cause unacceptable side effects in patients with
SIHD.
BMI and/or waist circumference should be assessed at
every visit, and clinicians should consistently encourage 3. Calcium channel blocking agents or long-acting
weight maintenance or reduction through an appropriate nitrates, in combination with beta-blocking agents,
balance of lifestyle physical activity,structured exercise, should be prescribed for relief of symptoms when
caloric intake, and formal behavioral programs when initial treatment with beta-blocking agents is unsuc-
indicated to maintain or achieve a BMI of between 18.5 cessful in patients with SIHD.
and 24.9 kg/m2 and a waist circumference of less than 4. Sublingual nitroglycerin or nitroglycerin spray is
102 cm (40 inches) in men and less than 88 cm (35 recommended for immediate relief of angina in pa-
inches) in women (less for certain racial groups). tients with SIHD.

Smoking Cessation 5. Ranolazine , nicorandil, ivabradine and trimetazi-
dine should be considered for patients intolerant of
Smoking cessation and avoidance of exposure to , or insufficiently responsive to beta blockers and
environmental tobacco smoke at work and home nitrates.
should be encouraged for all patients with SIHD.
Patient Follow-Up
Management of Psychological Factors
Patients with SIHD should be in follow-up evalua-
It is reasonable to consider screening patients with tions at least annually for assessment of symptoms
SIHD for depression and to refer or treat when indicated. and clinical function, surveillance of complications of
SIHD, monitoring of cardiac risk factors, and assess-
Alcohol Consumption ment of the adequacy of and adherence to lifestyle
In patients with SIHD who drink alcohol, it interventions and GDMT. Assessment of the LV ejec-
might be reasonable for nonpregnant women to have tion fraction is recommended for patients with SIHD
1 drink(4 oz of wine, 12 oz of beer, or 1 oz of spirits) a and new or worsening heart failure or evidence of

Cardio Diabetes Medicine