The 2012 clinical-practice guidelines for patients with stable CAD from the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons has been updated. The focused update discourages PCI prematurely after coronary angiography in patients with diabetes, and recommends CABG as the optimum treatment strategy in stable complex CAD patients with diabetes.

The update provides "a clearer recommendation that bypass surgery may be the optimal strategy in many patients who are diabetic with complex coronary disease." In this regard, the update considers a published meta-analysis of 8 trials including the Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM) trial). The FREEDOM trial showed a significant drop in risk of death from any cause, nonfatal myocardial infarction, or nonfatal stroke with CABG vs. PCI in diabetic patients with multivessel CAD.

Patients with stable IHD and type 2 diabetes should receive guideline-recommended medical therapy, and for those with symptoms that are still not adequately controlled, revascularization should be considered. The guideline also stresses that doing ad hoc PCI because it is convenient to do so, may not be the best strategy for that patient, and before a revascularization strategy is implemented, it should be considered from all points of view.

The guideline update has stressed on the importance of noninvasive testing for the diagnosis of CAD. It states that, in most patients with suspected stable CAD, "noninvasive stress testing for diagnosis and risk stratification is the appropriate initial study", and "makes the point that a catheterization in a stable patient in the absence of a noninvasive study should be a rare event". Furthermore, invasive "coronary angiography is appropriate only when the information derived from the procedure will significantly influence patient management and if the risks and benefits of the procedure [are] understood by the patient."

Fihn SD, Blankenship JC, Alexander KP, et al. 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2014; DOI:10.1161/CIR.0000000000000095. Article