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KEY CONCEPTS

KEY CONCEPTS

  • imageStable ischemic heart disease (SIHD) is caused by an obstructive atherosclerotic plaque in one or more epicardial coronary arteries. Increases in myocardial oxygen demand in the setting of a fixed decrease in myocardial oxygen supply result in myocardial ischemia. Some patients with SIHD may have a component of vasospasm that requires a slightly different pharmacologic approach.

  • imageChest pain (angina) from exertion is the cardinal symptom of myocardial ischemia in patients with SIHD.

  • imageAssessment of successful treatment of angina includes reducing the number of episodes, enabling patients to participate in activities that provide a high-level quality of life, and decreasing mortality by using guideline-directed medical therapy (GDMT).

  • imageManagement of modifiable atherosclerotic risk factors is key to improving the quantity of life in patients with SIHD.

  • imageAspirin, angiotensin-converting enzyme inhibitors, and statins play an important role in preventing adverse cardiovascular events in patients with SIHD.

  • imageβ-blockers are typically regarded as first-line therapy in the management and control of episodes of angina in patients with SIHD.

  • imageCalcium channel blockers, long-acting nitrates, and ranolazine are often used as additional therapy for angina. Calcium channel blockers and nitrates are first-line therapies in vasospastic disease.

  • imageAll patients with SHID should receive sublingual nitroglycerin for acute treatment and should receive education regarding its proper use.

  • imageRevascularization procedures may provide a survival advantage over GDMT in SIHD patients with more extensive atherosclerotic disease but have not demonstrated a clear advantage over GDMT in those with less extensive disease.

Patient Care Process for Stable Ischemic Heart Disease (SIHD)

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Collect

  • Patient characteristics (eg, age, sex, pregnant)

  • Description of chest discomfort and/or related symptoms (eg, precipitating factors, palliative measures, quality, location, radiation, and severity)

  • Patient medical (personal and family) and social histories (eg, tobacco/ethanol use), dietary habits (eg, intake of foods high in sodium, cholesterol, and/or saturated fat), physical activity (eg, frequency and duration of moderate-intensity aerobic activity)

  • Current medications including over-the-counter (OTC) medications (eg, aspirin-containing medications), herbals/dietary supplements

  • History of allergy or intolerance to previous medications

  • Objective data

  • Blood pressure (BP), heart rate (HR), respiratory rate (RR), height, weight, O2-saturation

    • Labs: serum creatinine (SCr), potassium (K+), hemoglobin (Hgb), platelets, liver function tests (LFTs), lipid profile, blood glucose, A1c

    • Diagnostic testing results

Assess

  • Description of chest discomfort to determine differential diagnosis and classification of angina symptoms

  • Presence of provoking factors (eg, exertion, mental/emotional stress, tachyarrhythmia, high adrenergic state including the use of stimulant medications, exposure to cold)

  • Presence/control of risk factors for SIHD (eg, hypertension, dyslipidemia, diabetes, smoking, obesity)

  • Presence/control of SIHD-related complications (eg, myocardial infarction [MI], heart failure [HF], stroke)

  • Adverse effects from current/previous medications used to treat/prevent angina symptoms or major adverse cardiac events (MACE)

  • Previous/recent revascularization procedures (eg, percutaneous coronary intervention [PCI] with/without stenting, coronary artery bypass graft [CABG] surgery)

  • Contraindications to medications to treat/prevent angina symptoms and/or prevent MACE

  • Barriers that may impair adherence to the care plan

Plan*

  • Initiate/modify drug therapy to treat and prevent angina symptoms, ...

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