Ischemic Heart Disease
NOUF ALOUDAH

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
ISCHEMIC HEART DISEASE
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
http://www.americanheart.org/presen
ter.jhtml?identifier=3004542

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
 70-325 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
ADDITIONAL THERAPIES
FOR CHRONIC STABLE
ANGINA

Goal:
 Reduce
symptoms of ischemia,
increase physical function, and
improve quality of life

Achieved by:
 Decrease
myocardial demand
 Increasing myocardial oxygen
supply
STABLE ANGINA
5) Beta Blockers
 Pharmacologic effects
 decrease
inotropy and heart rate
(decrease oxygen demand)
 Goal resting HR 55-60 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
STABLE ANGINA
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
STABLE ANGINA
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)
STABLE ANGINA
6) Calcium antagonists
 CI
 overt
decompenstaed HF,
 sever bradycardia,
 high degree AV block and
 sick sinus syndrome (without
pacemaker)
STABLE ANGINA
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)
STABLE ANGINA
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
