Assignment: Ischemic Heart Disease

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Introduction

ISCHEMIC HEART DISEASE

Ischemic heart disease is one of the most common cardiovascular diseases affecting ≈ 9.8 million persons in the United States. Ischemic heart disease begins early in life BUT does not present clinically until middle-aged years when atherosclerosis of the vessels that supply the myocardium with blood flow become occluded. Assignment: Ischemic Heart Disease

Angina pectoris is a classic symptom of chronic stable disease (i.e., “effort angina”), it is however important to note that atypical symptoms (indigestion – weakness – back pain – dizziness) are possible, especially in women, elderly and diabetics.

The term angina pectoris refers to a suffocating, recurring, pain (angina) of the chest (pectoris) or discomfort occurring when a part of the heart doesn’t receive enough blood (ischemia).

Other types of angina include vasospastic angina (sometimes referred to as variant angina or Prinzmetal’s angina) where transient vasospasm of the coronary arteries causes significant ischemia and pain; and unstable angina (an acute coronary syndrome) when the severity (lower thresholds), duration (> 20 minutes) and frequency exceed that of stable disease and ST-T changes are often noted.

Therapeutics of ischemic heart disease can be easily remembered with the following mnemonic:

A = aspirin, ACEIs and antianginal therapy
B = β Blocker and BP
C = cigarette smoking and cholesterol
D = diet and diabetes
E = education and exercise

→ Although not all patients have diabetes or smoke, it is an easy way to remember the primary areas to be addressed

Primary prevention should include lifestyle interventions including aggressive control of modifiable risk factors and comorbid conditions as well as antiplatelet and “statin” therapy.

Treatment and secondary preventions are aimed at preventing progression to acute coronary syndromes, cardiovascular death, reducing or eliminating symptoms of angina, improving quality of life, improving exercise tolerance and minimizing ventricular remodeling.

Medications employed typically include ACEIs (angiotensin converting enzyme inhibitors), β blockers, calcium channel blockers, nitrates (short and long acting) and ranolazine. Pharmacological management involves knowing the type of angina (stable vs. variant), recommendations set forth in the current guidelines, the patient’s hemodynamic status, comorbid disease states or contraindications, side effects and limitations, drug interactions, follow up and monitoring.

Discussions & Assignments
Discussion	Bill is a 58yo male recently diagnosed with stable angina. He has been experiencing chest pain about 2-3 times per week for the last month. His chest pain typically occurs while walking, which he does about 3 times each week. He has no other significant past medical history, takes no medications, has no drug allergies, and does not smoke. His BP is 122/74, HR 72. His labs are all normal. His fasting lipid profile is Total Cholesterol 175, HDL 45, LDL 90, TG 125. Waist circumference is 30”, and BMI is 24. His family history is unremarkable. What risk factors are present and are they modifiable? What are the goals of therapy? What medication(s) do you recommend to prevent Bill from experiencing angina-related chest discomfort and to increase exercise capacity? What do you recommend to treat acute episodes of stable-angina-related chest discomfort? What additional medications can improve *outcomes* (e.g. decreased cardiovascular mortality, non-fatal MI, cardiac arrest, etc.) in a patient like Bill who has stable angina? What is your drug therapy monitoring plan? What patient education should you provide?
Assignments
	Responses should be a minimum of 150 words, scholarly written, APA 7^th Ed formatted, and referenced. A minimum of 2 journal article references are required (other than your text). Refer to the Grading Rubric for Online Discussion in the Course Resource section.