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Chapter 8: Stable Ischemic Heart Disease

Dejan Landup; Dawn Havrda

LEARNING OBJECTIVES

LEARNING OBJECTIVES

Upon completion of the chapter, the reader will be able to:

  1. Identify risk factors for the development of ischemic heart disease (IHD).

  2. Differentiate between the pathophysiology of chronic stable angina and acute coronary syndromes (ACS).

  3. Recognize symptoms and diagnostic criteria of IHD in a specific patient.

  4. Compare and contrast the diagnostic criteria of IHD and ACS.

  5. Identify treatment goals of stable ischemic heart disease (SIHD).

  6. Identify appropriate lifestyle modifications and pharmacologic therapy to address each treatment goal.

  7. Design an appropriate treatment regimen for the management of SIHD based on patient-specific information.

  8. Formulate a monitoring plan to assess effectiveness and adverse effects of a SIHD drug regimen.

INTRODUCTION

Ischemic heart disease (IHD) is also called coronary heart disease (CHD) or coronary artery disease (CAD). The term ischemic refers to a decreased supply of oxygenated blood to the heart muscle. IHD is caused by stenosis, or narrowing, in one or more of the major coronary arteries that supply blood to the heart, most commonly by atherosclerotic plaques. Atherosclerotic plaques may impede coronary blood flow to the extent that cardiac tissue distal to the coronary artery narrowing is deprived of sufficient oxygen to meet oxygen demand. image IHD results from an imbalance between myocardial oxygen supply and oxygen demand (Figure 8–1). Common clinical manifestations of IHD include chronic stable angina and the acute coronary syndromes (ACS) of unstable angina (UA), non–ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI).

FIGURE 8–1.

This illustration depicts the balance between myocardial oxygen supply and demand and various factors that affect each. It should be noted that diastolic filling time is not an independent predictor of myocardial oxygen supply per se but rather a determinant of coronary blood flow. On the left is myocardial oxygen supply and demand under normal circumstances. On the right is the mismatch between oxygen supply and demand in patients with IHD. In patients without IHD, coronary blood flow increases in response to increases in myocardial oxygen demand. However, in patients with IHD, coronary blood flow cannot sufficiently increase (and may decrease) in response to increased oxygen demand, resulting in angina. (IHD, ischemic heart disease; Po2, partial pressure of oxygen.)

An illustration shows the difference in supply and demand of oxygen under normal circumstances and in ischemic heart disease.
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Angina pectoris, or simply angina, is the most common symptom of IHD. Angina is discomfort in the chest that occurs when the blood supply to the myocardium is compromised. Chronic stable angina is a chronic occurrence of chest discomfort due to transient myocardial ischemia with physical exertion or other conditions that increase myocardial oxygen demand. The primary focus of this chapter is management of stable ischemic heart disease (SIHD), the most common manifestation of which is chronic stable angina. However, some information is also provided related to ACS, given the overlap between the two disease states. The American College of Cardiology (ACC), ...

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