Ischemic Heart Disease

 Coronary artery disease CAD is a general manifestation that dose not discriminate bet the various phases that the individual may cycle between over the course of several decades. These phases includes asymptomatic disease, stable angina, progressive angina, unstable angina, non st segment elevation MI, and St segment elevation MI

 Stable angina (SA)  Acute myocardial infarction (AMI)  Unstable angina / non ST segment elevation myocardial infarction (UA/STEMI)

 Required reading  Dipiro  ischemic heart disease  Uncomplicated myocardial infarction ACC/AHA joint guidelines ter.jhtml?identifier=  2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina

 Go and read about  Definition of myocardial ischemia  Pathophysiology and etiology of ischemic heart disease  Anatomy of coronary circulation  Epidemiology  Definition and pathophysiology, clinical presentation of  stable angina pectoris,  variant angina,  silent myocardial ischemia,  syndrome X,

 Diagnosis procedures of ischemic heart disease  History and physical examination  Electrocardiogram  Exercise stress testing  Exercise electrocardiography  Radionuclide imaging  Pharmacologic stress testing  Echocardiography  Cardiac imaging  Cardiac catheterization and coronary angioplasty

 Based on the manifestation a patient is experiencing, some therapies may be added or modified however, several basic treatment rules apply to all individuals with CAD refardless of the symptoms he or she may expeience  ABCDE!

 Management!  How to use guideline…. chronic_angina_11_13_07.pdf

 A aspirin and antiplatelets  B beta-blockers and blood pressure  C cigarette smoking and cholesterol  D diet and diabetes  E education and exercise

Antiplatelets  Aspirin  Indicated in all patients with CAD unless contraindicated  mg/day  Decrease CV events by 1/3  Inhibits synthesis of thromboxane A2

Antiplatelets  Clopidogril  75 mg/day is aspirin absolutely CI  Magnitude of benefit not clear, one study suggests its benefits approximate those of aspirin  Prevents adenosine diphosphate ADP mediated platelets activation

Antiplatelets  Dipyridamole:  should be avoided in symptomatic CAD  Increase exercise induced M.ischemia  No benefit over aspirin

Lipid lowering therapy  LDL reduction to al least 100 mg/dl  Goal of less than 70 mg/dl in some patients

Angiotensin converting enzyme inhibitors  Specifically ramipril 10 mg/day greatly decrease CV events in patients with CAD (and no LV dysfunction) at high risk of subsequent CV events  An ACEI should be used in all patents with CAD  Postulated mechanisms: plaque stabilization, specifically via “ tissue ACE” inhibition

Therapies proven to not be beneficial in patients with CAD  Vitamin D  Hormone replacement therapy  Antibiotic therapy

 Goal:  Reduce symptoms of ischemia, increase physical function, and improve quality of life  Achieved by:  Decrease myocardial demand  Increasing myocardial oxygen supply

5) Beta Blockers  Pharmacologic effects  decrease inotropy and heart rate (decrease oxygen demand)  Goal resting HR BPM  Goal exercise HR of no more than 75 % HR associated with angina symptoms  CI  severe brdaycardia, high degree AV block, sick sinus syndrome (without pacemaker) and unstable systolic dysfunction

6) Calcium antagonists  Pharmacologic effects  Decrease coronary vascular resistance and increase coronary blood flow (increase oxygen supply)  Negative inotropy to varying degree nifidipine much more than amlodipine and felodipine ( decrease oxygen demand)  Decrease heart rate verapamil/diltiazem much more than non dihydropyridine

6) Calcium antagonists  Place in therapy  Added on BB therapy to achieve HR goal  Instead of BB therapy when unacceptable adverse effects emerge  Short acting CCB (nifidipine, nisoldipine) have been associated with increase CV event and should be avoided (except inn slow release formulation)

6) Calcium antagonists  CI  overt decompenstaed HF,  sever bradycardia,  high degree AV block and  sick sinus syndrome (without pacemaker)

7) Nitroglycerin  Pharmacologic effect  Via endothelium dependent VD, dilate epicardial arteries and collateral vessels (increase oxygen supply)  Decrease LV volume, due to decrease preload mediated by venodialation (decrease oxygen demand)

7) Nitroglycerin  Place in therapy  A scheduled nitrate is useful in conjunction with BB  PRN SL or spray nitrate is necessary to relieve efforts or rest angina  PRN nitrates can also be used before exercise to avoid ischemic episodes  CI  hypertrophic obstructive cardiomyopathey,  sever aorteic valve stenosis,  sildenafil within 24 hours