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KEY CONCEPTS

KEY CONCEPTS

  • Image not available. Stable 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.

  • Image not available. Chest pain (angina) from exertion is the cardinal symptom of myocardial ischemia in patients with SIHD.

  • Image not available. Assessment 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).

  • Image not available. Management of modifiable atherosclerotic risk factors is key to improving the quantity of life in patients with SIHD.

  • Image not available. Aspirin, angiotensin-converting enzyme inhibitors, and statins play an important role in preventing adverse cardiovascular events in patients with SIHD.

  • Image not available. β-blockers are typically regarded as first-line therapy in the management and control of episodes of angina in patients with SIHD.

  • Image not available. Calcium 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.

  • Image not available. All patients with SHID should receive sublingual nitroglycerin for acute treatment and should receive education regarding its proper use.

  • Image not available. Revascularization 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

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 ...

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