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CHAPTER SUMMARY FROM THE PHARMACOTHERAPY HANDBOOK

For the Chapter in the Schwinghammer, Handbook (not Wells Handbook anymore) please go to Chapter 11, Ischemic Heart Disease.

UPDATE SUMMARY

  • The following updates were made October 6, 2020:

    • Recommendations from the 2018 Guideline on the Management of Blood Cholesterol were added to Lipid Management section and dipipharm11_c32_tbl005

    • Recommendations from the 2020 Standards of Medical Care in Diabetes were added to the Diabetes Management section and Table 32-5

    • Added data from the ISCHEMIA trial to the PCI vs Medical Management section

KEY CONCEPTS

KEY CONCEPTS

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

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

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

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

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

  • image 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.

PRECLASS ACTIVITY

Preclass Engaged Learning Activity

To better understand the normal physiology of the heart and the pathophysiology of coronary artery disease (CAD) please watch the following videos:

  1. Pathophysiology of CAD—What is Coronary Artery Disease? Khan Academy: https://tinyurl.com/y3cjyb8v (Duration: 13:38 minutes)

  2. Myocardial oxygen supply—University of British Columbia, UBC Anesthesiology: https://tinyurl.com/yxjouoh3 (Duration: 4:59 minutes)

  3. Myocardial oxygen demand—University of British Columbia, UBC Anesthesiology: https://tinyurl.com/y5488brm (Duration: 4:37 minutes)

INTRODUCTION

Coronary artery disease (CAD) is the leading cause of ischemic heart disease and is typically the result of atherosclerotic plaques in the epicardial vessels. The process of atherosclerosis begins early in life, with fatty steaks developing in many people in their teenage years or early twenties. These plaques grow over decades and start to become pathologic in a person’s fifth decade of ...

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