- Ischemic heart disease (IHD) is primarily caused by coronary atherosclerotic plaque formation that leads to an imbalance between oxygen supply and demand resulting in myocardial ischemia.
- Chest pain is the cardinal symptom of myocardial ischemia due to coronary artery disease (CAD).
- Risk factor identification and modification are important interventions for individual patients with known or suspected IHD and as a population-based policy to reduce the impact of this disease.
- Major risk factors that can be altered include dyslipidemia (high total and low-density lipoprotein [LDL] cholesterol, low HDL cholesterol, and high triglycerides), smoking, glycemic control in diabetes mellitus, hypertension, and adoption of therapeutic lifestyle changes (exercise, weight reduction, and reduced cholesterol and fat in the diet). Reduction in inflammation may also play an important role.
- Most patients with CAD should receive antiplatelet therapy. Chronic stable angina should be managed initially with β-blockers because they provide better symptomatic control at least as well as nitrates or calcium channel blockers and decrease the risk of recurrent myocardial infarction (MI) and CAD mortality.
- Nitroglycerin and other nitrate products are useful for prophylaxis of angina when patients are undertaking activities known to provoke angina; however, when angina is occurring on a regular, routine basis, chronic prophylactic therapy should be instituted.
- Although calcium channel blockers are effective as monotherapy, they are generally used in combination with β-blockers or as monotherapy if patients are intolerant of β-blockers; most patients with moderate-to-severe angina will require two drugs to control their symptoms. Ranolazine is a second-line drug to be used with β-blockers and certain calcium channel blockers.
- Pharmacologic management is as effective as revascularization (percutaneous transluminal coronary angioplasty [PTCA], coronary artery bypass grafting [CABG], etc.) if one or two vessels are involved and there are no differences in survival, recurrent MI, or other measures of effectiveness.
- Multivessel involvement, especially if the patient has left main CAD or left main equivalent disease, or two- to three-vessel involvement with significant left ventricular dysfunction is best managed with revascularization. With improvements in stent technology, more patients are eligible for this approach compared with CABG.
- PTCA and CABG produce similar results overall, but certain patient subsets (e.g., diabetics) should have CABG done.
- The clinical performance measures for chronic stable CAD recommended by the American College of Cardiology and the American Heart Association include blood pressure measurement, lipid profile, symptom and activity assessment, smoking cessation, antiplatelet therapy, drug therapy for lowering LDL cholesterol, β-blocker therapy for prior MI, ACE inhibitor therapy, and screening for diabetes.
On completion of the chapter, the reader will be able to:
Outline the epidemiology of coronary and ischemic heart disease (IHD) and discuss trends in disease development from the perspective of gender and age.
List the major determinants of myocardial oxygen demand and factors that control coronary blood flow.
Describe the clinical presentation of IHD including symptoms, signs, abnormal laboratory tests, and principal tests that are done for diagnosis.
List the major risk factors ...