Upon completion of the chapter, the reader will be able to:
Identify risk factors for the development of ischemic heart disease.
Differentiate between the pathophysiology of chronic stable angina and acute coronary syndromes.
Recognize symptoms and diagnostic criteria of ischemic heart disease in a specific patient.
Identify treatment goals of ischemic heart disease, appropriate lifestyle modifications, and pharmacologic therapy to address each goal.
Design an appropriate therapeutic regimen for the management of ischemic heart disease based on patient-specific information.
Formulate a monitoring plan to assess effectiveness and adverse effects of an ischemic heart disease drug regimen.
Ischemic heart disease results from an imbalance between myocardial oxygen demand and oxygen supply that is most often due to coronary atherosclerosis. Common clinical manifestations of ischemic heart disease include chronic stable angina and the acute coronary syndromes of unstable angina, non–ST-segment elevation myocardial infarction, and ST-segment elevation myocardial infarction.
Early detection and aggressive modification of risk factors are the primary strategies for delaying ischemic heart disease progression and preventing ischemic heart disease–related events including death.
Patients with chest pressure or heaviness that is provoked by activity and relieved with rest should be assessed for ischemic heart disease. Sharp pain is not a typical symptom of ischemic heart disease. Some patients may experience discomfort in the neck, jaw, shoulder, or arm rather than, or in addition to, the chest. Pain may be accompanied by nausea, vomiting, or diaphoresis.
The major goals for the treatment of ischemic heart disease are to prevent acute coronary syndrome and death, alleviate acute symptoms of myocardial ischemia, prevent recurrent symptoms of myocardial ischemia, prevent disease progression, reduce complications, and avoid or minimize adverse treatment effects.
Both 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) and angiotensin-converting enzyme inhibitors are believed to provide vasculoprotective effects, and in addition to antiplatelet agents, they have been shown to reduce the risk of acute coronary events and death in patients with ischemic heart disease. Angiotensin receptor blockers may be used in patients who cannot tolerate angiotensin-converting enzyme inhibitors because of side effects (e.g., chronic cough). β-Blockers have been shown to decrease morbidity and improve survival in patients who have suffered a myocardial infarction.
Antiplatelet therapy with aspirin should be considered for all patients without contraindications, particularly in patients with a history of myocardial infarction. Clopidogrel may be considered in patients with allergies or intolerance to aspirin. In some patients, combination antiplatelet therapy with aspirin and P2Y12 inhibitor may be used.
To control risk factors and prevent major adverse cardiac events, statin therapy should be considered in all patients with ischemic heart disease, particularly in those individuals with elevated low-density lipoprotein cholesterol. In the absence of contraindications, angiotensin-converting enzyme inhibitors are initiated in individuals with ischemic heart disease, diabetes mellitus, left ventricular dysfunction, or a history of myocardial infarction. Angiotensin receptor blockers may be used in patients who cannot tolerate angiotensin-converting enzyme inhibitors because ...
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