Special Considerations In addition to patients coronary anatomy, left ventricular func- tion, and history of prior revascularization, clinical features such as the existence of coexisting chronic conditions might influence decision making. However, the paucity of informa- tion about special subgroups is one of the greatest challenges in developing evidence-based guidelines applicable to large populations. As is the case for many chronic conditions, studies specifically geared toward answering clinical questions about the management of SIHD in women, older adults, and persons with chronic kidney disease are lacking. The ACCF/AHA guidelines for the management of patients with unstable angina/ non ST-elevation myocardial infarction 90,91 address special subgroups. The present section echoes those management rec- ommendations. Although this section will briefly review some special considerations for diagnosis and therapy in certain groups of patients, the general approach should be to apply the recommendations in this guideline consistently among groups. 5.12.3. Diabetes Mellitus See Online Data Supplement 6 for additional evidence table. In the FREEDOM (Future Revascularization Evaluation in Patients With Diabetes Mellitus: Optimal Management of Multivessel Disease) trial, 1900 patients with multivessel CAD were randomized to either PCI with DES or CABG.68 The primary outcome a composite of death, nonfatal MI, or nonfatal stroke occurred less frequently in the CABG group (P=0.005), with 5-year rates of 18.7% in the CABG group and 26.6% in the DES group. The benefit of CABG was related to differences in rates of both MI (P<0.001) and death from any cause (P=0.049). Stroke was more frequent in the CABG group, with 5-year rates of 5.2% in the CABG group and 2.4% in the DES group (P=0.03). Other studies have provided mixed evidence, but none has suggested a survival advantage of PCI. The 5-year update from the SYNTAX trial did not show a significant advantage in survival after CABG compared with survival after DES in patients with diabetes mellitus and multivessel CAD (12.9% A meta-analysis of 4 trials showed no significant advantage in survival after CABG compared with survival after PCI for patients with diabetes mellitus In a pooled analysis, it was found that patients with diabetes mellitus assigned to CABG had improved survival (23% versus 29%; P=0.008 for the interaction between presence of diabetes mellitus and type of revascularization procedure after adjustment).93 The strongest evidence supporting the use of CABG over PCI for patients with diabetes mellitus and multivessel CAD comes from a published meta-analysis of 8 trials (including The study of 3131 patients showed that at 5-year or longest follow-up, patients with diabetes mellitus randomized to CABG had a lower all-cause mortality rate than did those randomized to PCI with either DES or bare metal In summary, patients with SIHD and diabetes mellitus should receive GDMT. For patients whose symptoms compromise their quality of life, revascularization should be considered. CABG appears to be associated with lower risk of mortality than is PCI in most patients with diabetes mellitus and complex Fihn et al 2014 Stable Ischemic Heart Disease Focused Update 1759 multivessel disease, although the Heart Team may identify exceptions. To address the important issue of deciding between PCI and CABG in patients with diabetes mellitus and complex multivessel CAD, a Heart Team approach would be beneficial. This was an integral component of the FREEDOM, SYNTAX, and BARI trials59,68,69 and is therefore emphasized in this set- ting. The Heart Team is a multidisciplinary team composed of an interventional cardiologist and a cardiac surgeon who jointly 1) review the patient s medical condition and coronary anatomy, 2) determine that PCI and/or CABG are technically feasible and reasonable, and, 3) discusses revascularization options with the patient before a treatment strategy is selected. Future research may be facilitated by including a field in the National Cardiovascular Data PCI Registry and the STS database to identify cases turned down for the alternative revascularization strategy. Presidents and Staff American College of Cardiology Patrick T. O Gara, MD, MACC, President Shalom Jacobovitz, Chief Executive Officer William J. Oetgen, MD, MBA, FACC, Executive Vice President, Science, Education, and Quality Amelia Scholtz, PhD, Publications Manager, Clinical Policy and Pathways American College of Cardiology/American Heart Association Lisa Bradfield, CAE, Director, Clinical Policy and Guidelines Ezaldeen Ramadhan III, Project Management Team Leader, Science and Clinical Policy American Heart Association Elliott Antman, MD, FACC, FAHA, President Nancy Brown, Chief Executive Officer Rose Marie Robertson, MD, FAHA, Chief Science Officer Gayle R. Whitman, PhD, RN, FAHA, FAAN, Senior Vice President, Office of Science Operations Marco Di Buono, PhD, Vice President, Science, Research, and Professional Education, Office of Science Operations Jody Hundley, Production Manager, Scientific Publications, Office of Science Operations References 1. American College of Cardiology/American Heart Association: Methodology Manual and Policies From the ACCF/AHA Task Force on Practice Guidelines. 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Key Words: AHA Scientific Statements cardiac catheterization cardiovascular chelation therapy coronary angiography coronary artery bypass counterpulsation diagnostic techniques focused update myocardial ischemia percutaneous coronary intervention. Appendix 1. Author Relationships With Industry and Other Entities (Relevant) 2014 Acc/Aha/Aats/Pcna/Scai/Sts Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease Committee Member Employment Consultant Speaker s Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness Voting Recusals by Section* Stephan D. Fihn (Chair) Department of Veterans Affairs Director, Office of Analytics and Business Intelligence None None None None None None None James C. Blankenship (Vice Chair) Geisinger Medical Center Staff Physician; Director, Cardiac Catheterization Laboratory None None None AstraZeneca None None 2.2.5 Boston Scientific 4.4.2 Kai Pharmaceutical 4.4.4 The Medicines Company Schering-Plough Volcano Karen P. Alexander Duke University Medical Center Associate Professor of Medicine/ Cardiology None None None Gilead Sanofi-aventis None 2.2.5 John A. Bittl Munroe Regional Medical Center Invasive Cardiologist None None None None None None None John G. Byrne Brigham and Women s Hospital Chief, Division of Cardiac Surgery None None None None None None None Barbara J. Fletcher University of North Florida Clinical Associate Professor, School of Nursing None None None None None None None Gregg C. Fonarow UCLA Cardiomyopathy Center Professor of Medicine Boston Scientific None None None None None 2.2.5 Johnson & Johnson The Medicines Company Medtronic Richard A. Lange University of Texas Health Science Center, San Antonio Professor of Medicine None None None None None None None Glenn N. Levine Baylor College of Medicine Professor of Medicine; Director, Cardiac Care Unit None None None None None None None Thomas M. Maddox VA Eastern Colorado Health Care System Cardiologist None None None None None None None Srihari S. Naidu Winthrop University Hospital Director, Cardiac Catheterization Laboratory None None None None None None None (Continued) Fihn et al 2014 Stable Ischemic Heart Disease Focused Update 1763 Appendix 1. Continued Committee Member Employment Consultant Speaker s Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness Voting Recusals by Section* E. Magnus Ohman Duke Medicine Professor of Medicine AstraZeneca Gilead Sciences None Daiichi-Sankyo None None 2.2.5 Bristol-Myers Squibb Gilead Sciences Gilead Sciences The Medicines Company Merck Sanofi-aventis Peter K. Smith Duke University Medical Center Professor of Surgery; Chief, Thoracic Surgery None None None None None None None This table represents the relationships of writing group members with industry and other entities that were determined to be relevant to this document. These relationships were reviewed and updated in conjunction with all meetings and/or conference calls of the writing group during the document development process. The table does not necessarily reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of 5% of the voting stock or share of the business entity, or ownership of $10000 of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the person s gross income for the previous year. Relationships that exist with no financial benefit are also included for the purpose of transparency. Relationships in this table are modest unless otherwise noted. According to the ACC/AHA, a person has a relevant relationship IF: a) the relationship or interest relates to the same or similar subject matter, intellectual property or asset, topic, or issue addressed in the document; or b) the company/entity (with whom the relationship exists) makes a drug, drug class, or device addressed in the document, or makes a competing drug or device addressed in the document; or c) the person or a member of the person s household has a reasonable potential for financial, professional, or other personal gain or loss as a result of the issues/content addressed in the document. *Writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply. Section numbers pertain to those in the full-text guideline. Significant relationship. No financial benefit. AATS indicates American Association for Thoracic Surgery; ACC, American College of Cardiology; AHA, American Heart Association; PCNA, Preventive Cardiovascular Nurses Association; SCAI, Society for Cardiovascular Angiography and Interventions; STS, Society of Thoracic Surgeons; and VA, Veterans Affairs. Appendix 2. Reviewer Relationships With Industry and Other Entities (Relevant) 2014 Acc/Aha/Aats/Pcna/Scai/Sts Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease Peer Reviewer Representation Employment Consultant Speaker s Bureau Personal Research Institutional, Organizational, or Other Financial Benefit Judith S. Hochman Official Reviewer ACC/AHA Task Force on Practice Guidelines New York University School of Medicine Clinical Chief of Cardiology None None NIH (PI ISCHEMIA trial)* None Bruce W. Lytle Official Reviewer AHA Cleveland Clinic Foundation Chairman, Thoracic and Cardiovascular Surgery None None None None Margo B. Minissian Official Reviewer ACC Board of Governors Cedar-Sinai s Heart Institute Cardiology Nurse Practitioner; University of California Los Angeles Assistant Clinical Professor None None None Gilead Sciences* C. Michael Valentine Official Reviewer ACC Board of Trustees Centra Lynchburg General Hospital Director, Cardiac Progressive Care Unit; Centra Stroobants Heart Center Director of Clinical Quality None None None None Lani M. Zimmerman Official Reviewer AHA University of Nebraska Medical Center Professor, College of Nursing None None None None Robert S.D. Higgins Organizational Reviewer STS Ohio State University Director, Division of Cardiac Surgery None None None None Ajay J. Kirtane Organizational Reviewer SCAI Columbia University Medical Center Chief Academic Officer; Director, Interventional Cardiology Fellowship Program; and Assistant Professor of Clinical Medicine None Boston Scientific* Medtronic* None Joseph D. Schmoker Organizational Reviewer AATS University of Vermont Associate Professor of Surgery and Medicine; Fletcher Allen Health Care Director of the Center for Thoracic Aortic Disease None None None None Joanna D. Sikkema Organizational Reviewer PCNA University of Miami Adult Nurse Practitioner, School of Nursing and Health Studies None None None None Nancy M. Albert Content Reviewer ACC/AHA Task Force on Practice Guidelines Cleveland Clinic Foundation Senior Director of Nursing and Research None None None None Mohamed A. Sobhy Aly Content Reviewer AIG Alexandria University Professor of Cardiology, Head of Cardiology Department None None None None Jeffrey L. Anderson Content Reviewer ACC/AHA Task Force on Practice Guidelines Intermountain Medical Center Associate Chief of Cardiology Sanofi-aventis None None None (Continued) Fihn et al 2014 Stable Ischemic Heart Disease Focused Update 1765 Appendix 2. Continued Peer Reviewer Representation Employment Consultant Speaker s Bureau Personal Research Institutional, Organizational, or Other Financial Benefit Eric R. Bates Content Reviewer University of Michigan Health System Professor, Department of Internal Medicine AstraZeneca None None None Bristol-Myers Squibb Daiichi-Sankyo Merck Sanofi-aventis Ralph G. Brindis Content Reviewer ACC/AHA Task Force on Practice Guidelines University of California San Francisco Clinical Professor of Medicine, Department of Medicine and Philip R. Lee Institute for Health Policy Studies None None None None Biykem Bozkurt Content Reviewer ACC/AHA Task Force on Practice Guidelines Michael E. DeBakey VA Medical Center Chief, Cardiology Section; The Mary and Gordon Cain Chair and Professor of Medicine; Director, Winters Center for Heart Failure Research None None None None Steven M. Bradley Content Reviewer VA Eastern Colorado Health Care System Physician None None None None James A. Burke Content Reviewer ACC Interventional Scientific Council Lehigh Valley Heart Specialists Cardiovascular Disease Doctor None None None None John H. Calhoon Content Reviewer University of Texas Health Science Center Professor; Chair, CT Surgery Department None None None None Lesley Curtis Content Reviewer ACC/AHA Task Force on Practice Guidelines Duke University School of Medicine Associate Professor of Medicine None None GE Healthcare* Johnson & Johnson* None Prakash C. Deedwania Content Reviewer University of California San Francisco Chief of Cardiology Gilead Sciences None None None Gregory J. Dehmer Content Reviewer Scott & White Healthcare Director, Division of Cardiology; Texas A&M Health Science Center College of Medicine Professor of Medicine None None None None Linda D. Gillam Content Reviewer ACC Imaging Council Morristown Medical Center Professor of Cardiology; Vice Chair, Cardiovascular Medicine None None Edwards Lifesciences Edwards Lifesciences Christopher B. Granger Content Reviewer AHA Duke Clinical Research Institute Associate Professor of Medicine; Director, Cardiac Care Unit AstraZeneca Bristol-Myers Squibb Daiichi-Sankyo Eli Lilly The Medicines Company None Bristol-Myers Squibb* Medtronic* Merck* Sanofi- aventis* The Medicines Company* GE Healthcare* Medtronic* Philips Medical* (Continued) Appendix 2. Continued Peer Reviewer Representation Employment Consultant Speakers Bureau Personal Research Institutional, Organizational, or Other Financial Benefit Robert A. Guyton Content Reviewer ACC/AHA Task Force on Practice Guidelines Emory University School of Medicine Professor of Surgery and Chief, Division of Cardiothoracic Surgery Medtronic None None None Jonathan L. Halperin Content Reviewer ACC/AHA Task Force on Practice Guidelines Mt. Sinai Medical Center Professor of Medicine AstraZeneca None None None Boston Scientific Bristol-Myers Squibb Daiichi-Sankyo Johnson & Johnson Medtronic Sanofi-aventis* Mark A. Hlatky Content Reviewer Stanford University School of Medicine Professor of Health Research and Policy Blue Cross/Blue Shield None None None Gilead Sciences HeartFlow* Lloyd W. Klein Content Reviewer Rush University Medical Center Professor, Internal Medicine None None None None Richard J. Kovacs Content Reviewer ACC/AHA Task Force on Practice Guidelines Krannert Institute of Cardiology Professor of Clinical Medicine None None None Cook Medical* Eli Lilly Stephen J. Lahey Content Reviewer University of Connecticut Health Center Professor; Chief of Cardiothoracic Surgery None None None None Michael J. Mack Content Reviewer Baylor Health Care System Director None None Edwards Lifesciences None Daniel B. Mark Content Reviewer Duke Clinical Research Institute Professor of Medicine None None AstraZeneca Eli Lilly* Eli Lilly* Medtronic* Gilead Sciences Medtronic* David J. Maron Content Reviewer Vanderbilt University Medical Center Director, Vanderbilt Chest Pain Center None None AstraZeneca* None Gilead Sciences* Merck* Hani K. Najm Content Reviewer ACC Surgeons Scientific Council National Guard Health Affairs President, Saudi Heart Association None None None None L. Kristin Newby Content Reviewer Duke University Medical Center Associate Professor, Clinical Medicine AstraZeneca Daiichi-Sankyo Johnson & Johnson Philips Medical WebMD None Amylin Eli Lilly Bristol-Myers Squibb* Merck* Patrick T. O Gara Content Reviewer Brigham and Women s Hospital Director, Clinical Cardiology; Harvard Medical School Professor of Medicine None None None Lantheus Medical (Continued) Fihn et al 2014 Stable Ischemic Heart Disease Focused Update 1767 Appendix 2. Continued Peer Reviewer Representation Employment Consultant Speakers Bureau Personal Research Institutional, Organizational, or Other Financial Benefit Joseph F. Sabik Content Reviewer ACC Surgeons Scientific Council Cleveland Clinic Department Chair, Thoracic and Cardiovascular Surgery Edwards Lifesciences None Abbott Laboratories None Medtronic Edwards Lifesciences Vikas Saini Content Reviewer The Lown Institute President None None None None Frank W. Sellke Content Reviewer ACC/AHA Task Force on Practice Guidelines Brown Medical School and Lifespan Chief of Cardiothoracic Surgery None None The Medicines Company None William S. Weintraub Content Reviewer Christiana Care Health System Section Chief, Cardiology Bristol-Myers Squibb None None None Daiichi-Sankyo Eli Lilly Christopher J. White Content Reviewer Ochsner Health System Director, John Ochsner Heart and Vascular Institute None None None St. Jude Medical (DSMB) Sankey V. Williams Content Reviewer ACP University of Pennsylvania Health System Professor of General Medicine None None None None Poh Shuan Daniel Yeo Content Reviewer AIG Tan Tock Seng Hospital, Department of Cardiology Cardiologist None None None Boston Scientific Merck Schering-Plough No reviewer had a relevant ownership, partnership, or principal position to report. No reviewer reported acting as an expert witness in a relevant matter. This table represents the relationships of reviewers with industry and other entities that were disclosed at the time of peer review and determined to be relevant to this document. It does not necessarily reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of 5% of the voting stock or share of the business entity, or ownership of $10000 of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the person s gross income for the previous year. A relationship is considered to be modest if it is less than significant under the preceding definition. Relationships that exist with no financial benefit are also included for the purpose of transparency. Relationships in this table are modest unless otherwise noted. Names are listed in alphabetical order within each category of review. According to the ACC/AHA, a person has a relevant relationship IF: a) the relationship or interest relates to the same or similar subject matter, intellectual property or asset, topic, or issue addressed in the document; or b) the company/entity (with whom the relationship exists) makes a drug, drug class, or device addressed in the document, or makes a competing drug or device addressed in the document; or c) the person or a member of the person s household has a reasonable potential for financial, professional, or other personal gain or loss as a result of the issues/content addressed in the document. *Significant relationship. No financial benefit. AATS indicates American Association for Thoracic Surgery; ACC, American College of Cardiology; ACP, American College of Physicians; AHA, American Heart Association; AIG, Association of International Governors; DSMB, Data Safety Monitoring Board; ISCHEMIA trial, International Study of Comparative Health Effectiveness With Medical and Invasive Approaches trial; PCNA, Preventive Cardiovascular Nurses Association; PI, principle investigator; SCAI, Society for Cardiovascular Angiography and Interventions; and STS, Society of Thoracic Surgeons.