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CHAPTER SUMMARY FROM THE PHARMACOTHERAPY HANDBOOK
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For the Chapter in the Schwinghammer Handbook, please go to Chapter 11, Ischemic Heart Disease.
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KEY CONCEPTS
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.
Chest pain (angina) from exertion is the cardinal symptom of myocardial ischemia in patients with SIHD.
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).
Management of modifiable atherosclerotic risk factors is key to improving the quantity of life in patients with SIHD.
Aspirin, angiotensin-converting enzyme inhibitors, and statins play an important role in preventing adverse cardiovascular events in patients with SIHD.
β-Blockers are typically regarded as first-line therapy in the management and control of episodes of angina in patients with SIHD.
Calcium channel blockers, long-acting nitrates, and ranolazine are often used as additional therapies for angina. Calcium channel blockers and nitrates are first-line therapies in vasospastic disease.
All patients with SHID should receive sublingual nitroglycerin for acute treatment and should receive education regarding its proper use.
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. Antithrombotic therapy is necessary after revascularization for a variable duration of time.
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BEYOND THE BOX
To better understand the normal physiology of the heart and the pathophysiology of coronary artery disease (CAD), please watch the following videos. These videos are useful to enhance learner’s understanding regarding the COLLECT and ASSESS steps in the Patient Care Process.
Pathophysiology of CAD—What is Coronary Artery Disease? Khan Academy: https://tinyurl.com/y3cjyb8v (Duration: 13:38 minutes)
Myocardial oxygen supply—University of British Columbia, UBC Anesthesiology: https://tinyurl.com/yxjouoh3 (Duration: 4:59 minutes)
Myocardial oxygen demand—University of British Columbia, UBC Anesthesiology: https://tinyurl.com/y5488brm (Duration: 4:37 minutes)
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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 life and beyond. In addition to CAD, atherosclerosis also manifests in other vascular beds leading to cerebrovascular disease (Stroke, Chapter 39) and peripheral arterial disease (Chapter e35). Ischemic heart disease may present as an acute coronary syndrome (ACS) (Chapter ...