Ischemic Heart Disease: Risk Factors, Medications, and Goals of Therapy

Topic XI: Ischemic Heart Disease
Introduction
ISCHEMIC HEART DISEASE
Ischemic heart disease is one of the most common cardiovascular diseases affecting ≈ 9.8 million persons in the United States. Ischemic heart disease begins early in life BUT does not present clinically until middle-aged years when atherosclerosis of the vessels that supply the myocardium with blood flow become occluded.
Angina pectoris is a classic symptom of chronic stable disease (i.e., "effort angina"), it is however important to note that atypical symptoms (indigestion – weakness – back pain - dizziness) are possible, especially in women, elderly and diabetics.
The term angina pectoris refers to a suffocating, recurring, pain (angina) of the chest (pectoris) or discomfort occurring when a part of the heart doesn’t receive enough blood (ischemia).
image explains that In the presence of a fixed atherosclerotic plaque with increased MVO2… Vessels are maximally dilated and can provide no additional ‘supply’
Other types of angina include vasospastic angina (sometimes referred to as variant angina or Prinzmetal's angina) where transient vasospasm of the coronary arteries causes significant ischemia and pain; and unstable angina (an acute coronary syndrome) when the severity (lower thresholds), duration (> 20 minutes) and frequency exceed that of stable disease and ST-T changes are often noted.
Therapeutics of ischemic heart disease can be easily remembered with the following mnemonic:
A = aspirin, ACEIs and antianginal therapy
B = β Blocker and BP
C = cigarette smoking and cholesterol
D = diet and diabetes
E = education and exercise
→ Although not all patients have diabetes or smoke, it is an easy way to remember the primary areas to be addressed
Primary prevention should include lifestyle interventions including aggressive control of modifiable risk factors and comorbid conditions as well as antiplatelet and "statin" therapy.
Treatment and secondary preventions are aimed at preventing progression to acute coronary syndromes, cardiovascular death, reducing or eliminating symptoms of angina, improving quality of life, improving exercise tolerance and minimizing ventricular remodeling.
Medications employed typically include ACEIs (angiotensin converting enzyme inhibitors), β blockers, calcium channel blockers, nitrates (short and long acting) and ranolazine. Pharmacological management involves knowing the type of angina (stable vs. variant), recommendations set forth in the current guidelines, the patient's hemodynamic status, comorbid disease states or contraindications, side effects and limitations, drug interactions, follow up and monitoring.
This image describes the therapeutic approach for the management of angina pectoris caused by both ischemic and vasospastic disease. Beta-blockers are the preferred therapy for ischemic disease (assuming no contraindications) while calcium channel blockers are preferred in vasospastic disease.
Objectives
Ischemic Heart Disease
See "Learning Objectives" outlined in chapter 7 of Pharmacotherapy: Principles and Practices; page 95
Describe the Pathophysiology of effort (exertional) and vasospastic angina and the major determinants of myocardial oxygen demand
List the strategies and drug targets for the relief of anginal pain
Contrast the therapeutic and ADEs of nitrates, β-blockers and CCB when used for angina
Describe the pharmacology of ranolazine and its potential place in therapy
Elucidate the differences in immediate release and sustained release formulations of nitrates and what is meant by nitrate free interval
Explain why the combination of a nitrate with a BB or CCB may be more beneficial than either alone
Explain why a nitrate and sildenafil can be dangerous
Provide a recommendation for evidence-based pharmacologic regimen for a patient with coronary artery disease in both the presence and absence of stable angina.
Forward
Ischemic Heart Disease
You are expected to thoroughly understand the material as presented in chapter 7 of the assigned textbook. You should understand the recommendations and set forth in the guidelines and apply them to current standards of practice to a given case or patient.
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Readings
Text
Pharmacotherapy: Principles and Practices. Chisholm-Burns et. al., eds. 5th edition. Chapter 7
Evidence-Based Medicine Resources
American College of Cardiology/American Heart Association (ACC/AHA)2007 focused update of ACC/AHA 2002 guideline on management of patients with chronic stable angina. https://www-sciencedirect-com(dot)wilkes(dot)idm(dot)oclc(dot)org/science/article/pii/S0735109707024825
2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease: Executive Summary: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2012;126:3097-3137. Originally published online November 19, 2012; doi: 10.1161/CIR.0b013e3182776f83. https://www-ahajournals-org(dot)wilkes(dot)idm(dot)oclc(dot)org/doi/full/10.1161/cir.0b013e318277d6a0
Dynamed permalinks:
Ischemic Heart Disease - https://wilkes(dot)idm(dot)oclc(dot)org/login?url=http://www(dot)dynamed(dot)com/topics/dmp~AN~T114265/
Videos
Angina Animation - https://www(dot)youtube(dot)com/watch?v=fBn9munofVs
Transcript for What is Angina? Chronic Angina Animation video
Module XI Discussions & Assignments
Discussion
Bill is a 58yo male recently diagnosed with stable angina. He has been experiencing chest pain about 2-3 times per week for the last month. His chest pain typically occurs while walking, which he does about 3 times each week. He has no other significant past medical history, takes no medications, has no drug allergies, and does not smoke. His BP is 122/74, HR 72. His labs are all normal. His fasting lipid profile is Total Cholesterol 175, HDL 45, LDL 90, TG 125. Waist circumference is 30”, and BMI is 24. His family history is unremarkable.
What risk factors are present and are they modifiable?
What are the goals of therapy?
What medication(s) do you recommend to prevent Bill from experiencing angina-related chest discomfort and to increase exercise capacity?
What do you recommend to treat acute episodes of stable-angina-related chest discomfort?
What additional medications can improve outcomes (e.g. decreased cardiovascular mortality, non-fatal MI, cardiac arrest, etc.) in a patient like Bill who has stable angina?
What is your drug therapy monitoring plan?
What patient education should you provide?
Module XI: IHD Discussion
Assignments
None
Post your initial response by Wednesday at midnight. Respond to one student by Sunday at midnight. Both responses should be a minimum of 150 words, scholarly written, APA formatted, and referenced. A minimum of 2 references are required (other than your text). Refer to the Grading Rubric for Online Discussion in the Course Resource section.
Special Guidance on APA formatting in Discussion Posts
APA formatting is required in discussion posts with the following two exceptions (due to limitations with the text editor in LIVE): double line space and indent 1/2 inch from the left margin. Discussion posts will NOT be evaluated on those two formatting requirements. All other APA formatting guidelines should be followed. For example, in-text citations must be formatted with the appropriate information and in the correct sequence (Author, year), reference list entries must include all appropriate information following guidelines for capitalization, italics, and be in the correct sequence. Refer to the APA Publication Manual 7th ed. for each source type's specific requirements. Please let your instructor know if you have any questions.