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Ischemic Heart Diseases.pptx

  1. Ischemic Heart Diseases DR. ABDI
  2. Ischemic Heart Diseases: ▪ Stable Ischemic Heart diseases: ▪ Definition & Pathophysiology ▪ Clinical Presentation & Diagnosis ▪ Treatment ▪ Evaluation Of Therapeutic Outcomes ▪ Acute Coronary Syndrome: ▪ Pathophysiology ▪ Clinical Presentation & Diagnosis ▪ Treatment ▪ Evaluation Of Therapeutic Outcomes
  3. Pre Class Activities:
  4. Definitions: ▪ Coronary artery disease (CAD) is the leading cause of ischemic heart disease. ▪ Ischemic heart disease (IHD) is defined as lack of oxygen and decreased or no blood flow to the myocardium resulting from coronary artery narrowing or obstruction. ▪ IHD present as: ▪ Acute coronary syndrome (ACS): includes unstable angina, non-ST-segment myocardial infarction (MI), or ST-segment elevation MI. ▪ Stable ischemic heart disease or Angina
  5. Stable IHD: ▪ Angina pectoris: a discomfort in the chest and/or an adjacent area resulting from myocardial ischemia (1). ▪ Stable angina: is defined as a predictable occurrence of chest discomfort with physical exertion (2) and is predictably resolved with rest or administration of sublingual nitroglycerin (3). ▪ Prinzmetal angina: Angina caused by spasm of the coronary arteries (4).
  6. Pathophysiology: myocardial oxygen demand exceeds myocardial oxygen supply (perfusion) ▪ Due to atherosclerosis: ▪ Due to Vasospasm:
  7. Risk Factors & precipitating Factors:
  8. Clinical Presentation Diagnosis depends principally upon the history: 1. Circumstances that precipitate and relieve angina: Angina occurs most commonly during activity and is relieved by resting. 2. Characteristics of the discomfort: Patients often do not refer to angina as “pain” but as a sensation of tightness, , burning, or pressing. 3. Location and radiation: In most cases, the discomfort is felt behind or slightly to the left of the mid sternum. It radiates most often to the left shoulder and upper arm, frequently moving down the arm. It may also radiate to the right shoulder or arm, the neck, or even the back. 4. Duration of attacks: Duration of attack is usually 0.5–30 minutes. Relief of pain occurring within 45 seconds to 5 minutes of taking Nitroglycerin
  9. CP & Diagnosis: ▪ Diagnosis ▪ The resting ECG is normal in about one half of patients with angina who are not experiencing an acute attack (8). ▪ Stress ECG Testing (9). ▪ Coronary angiography: Coronary angiography is regarded as the definitive test as it demonstrates the presence of occlusions, their position and their severity Annual influenza vaccinations are recommended Controllable/ treatable Hypertension Hyperlipidemia Modifiable Smoking Obesity Sedentary Life Step 1 Risk factors Modification
  10. Pharmacologic Therapy
  11. Goal of Therapy & the GDMT ▪ Goals of Treatment: A primary goal of therapy is complete (or nearly complete) elimination of anginal chest pain and return to normal activities. ▪ Long-term goals are to slow progression of atherosclerosis and prevent complications such as MI, heart failure, stroke, and death. ▪ Guideline-directed medical therapy (GDMT) reduces the rates of death and MI similar to revascularization therapy
  12. Treatment Algorithm ▪ The current national guidelines recommend that all patients be given the following unless contraindications exist : ▪ (1)-Sublingual nitroglycerin for immediate relief of angina. ▪ (2)- Antiplatelet (Aspirin or Clopidogrel in patients with aspirin hypersensitivity or intolerance. DAPT preserved for high risk specific group). ▪ (3)-β- blockers. ▪ (4)-Calcium antagonists (N-DHP) or long-acting nitrates [isosorbide dinitrate(ISDN) or isosorbide mononitrate (ISMN) ]for reduction of symptoms when β-blockers are contraindicated (or they may be used in combination with β-blockers when initial treatment with β-blockers is not successful). ▪ (5)-LDL-lowering therapy: moderate- or high-dose statin therapy Addition of ezetimibe (first) or a PCSK9 inhibitor (second) is reasonable for patients who do not tolerate statins or do not attain a 50% decrease in LDL .
  13. Algorithm for treatment of stable ischemic heart disease (guideline-directed medical therapy). (ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; BP, blood pressure; CABG, coronary artery bypass graft; CCB, calcium channel blocker; CKD, chronic kidney disease; DAPT, dual antiplatelet therapy; DHP, dihydropyridine; DM, diabetes mellitus; Hb, hemoglobin; HTN, hypertension; LA, long-acting; LVEF, left ventricular ejection fraction; PCI, percutaneous coronary intervention; SL NTG, sublingual nitroglycerin.)
  14. Pharmacological agents: ▪ Aspirin therapy: (75–162 mg daily) should be prescribed for all patients with angina. Clopidogrel, 75 mg daily is a good alternative in aspirin-intolerant patients. ▪ Dual antiplatelet therapy (DAPT) with aspirin plus a P2Y12 inhibitor (clopidogrel, prasugrel, ticagrelor) is beneficial after PCI with coronary stent placement and after treatment for ACS. Its benefits in other situations are less clear. The combination of aspirin (75–162 mg daily) and clopidogrel 75 mg daily may be reasonable in certain high-risk patients. Clinical Pharmacology of Antiplatelet Drugs for Neurointerventionalists.
  15. β-Adrenergic Blocking Agents: ▪ They reduce heart rate and force of contraction, allowing greater time for perfusion and decreased demand for oxygen. ▪ Cardioselective beta-blockers, such as atenolol and metoprolol, are preferred. Only the β-blockers carvedilol, metoprolol succinate, and bisoprolol should be used in patients with HFrEF, starting with low doses and titrating upward slowly. ▪ Note: β-Blockers have little or no role in the management of variant angina as they may induce coronary vasoconstriction and prolong ischemia
  16. Nitrates : ▪ Nitrate therapy may be used to terminate an acute anginal attack, to prevent effort- or stress- induced attacks, or for long-term prophylaxis. ▪ Sublingual, buccal, or spray nitroglycerin products are preferred for alleviation of anginal attacks because of rapid absorption. ▪ If the pain persists or is unimproved in 5 minutes after the first dose of NTG, contact physician & take a maximum of two more tablets each 5 minutes apart (3 tablet in 15 min totally). The patient should contact their physician or be transported to an emergency room as they may be experiencing an MI. ▪ Chewable, buccal, oral, and transdermal products are acceptable for long-term prophylaxis of angina. ▪ The main limitation to long-term nitrate therapy is tolerance, which can be limited by using a regimen that includes a minimum 8- to 10-hour period per day without nitrates (nitrate-free interval) (**Balance with B blockers if used in combination)
  17. Calcium Channel Blockers ▪ Good candidates for calcium channel antagonists include patients with contraindications or intolerance to β-blockers, Prinzmetal's angina, and peripheral vascular disease. ▪ Because calcium channel antagonists may be more effective, some authorities consider them the agents of choice for variant angina. A patient unresponsive to calcium channel antagonists alone may have nitrates added. ▪ CCBs modulate calcium entry into the myocardium, vascular smooth muscle, and other tissues, which reduces the cytosolic concentration of calcium responsible for activation of the actin–myosin complex and contraction of vascular smooth muscle and myocardium. ▪ All CCBs reduce MVO2 by reducing wall tension via lowering arterial BP and (to a minor extent) depressing contractility. ▪ CCBs also provide some increase in supply by inducing coronary vasodilation and preventing vasospasm
  18. Others antianginal agents: add-on therapy mostly ▪ Ranolazine reduces ischemic episodes by selective inhibition of late sodium current (INa), which reduces intracellular sodium concentration and improves myocardial function and perfusion ▪ Monotherapy used only if patients cannot tolerate traditional agents due to hemodynamic or other adverse effects. ▪ Adverse effects include: constipation, nausea, dizziness, and headache. Ranolazine can prolong the QTc interval and should be used with caution in patients receiving concomitant QTc-prolonging agents. ▪ It can be combined with a β- blocker when initial treatment with β-blockers alone is unsuccessful.
  19. EVALUATION OF THERAPEUTIC OUTCOMES ▪ Assess for symptom improvement by number of angina episodes, weekly SL NTG use, and increased exercise capacity or duration of exertion needed to induce angina. ▪ Use statins for dyslipidemia, strive to achieve BP and A1C goals, and implement the lifestyle modifications of dietary modification, smoking cessation, weight loss, and regular exercise. ▪ Once patients have been optimized on medical therapy, symptoms should improve over 2–4 weeks and remain stable until the disease progresses. Patients may require evaluation every 1–2 months until target endpoints are achieved; follow-up every 6–12 months thereafter is appropriate. ▪ The Seattle Angina Questionnaire, Specific Activity Scale, and Canadian Cardiovascular Society classification system can be used to improve reproducibility of symptom assessment. ▪ If the patient is doing well, no other assessment may be necessary. Although follow-up exercise tolerance testing with or without cardiac imaging can be performed to objectively assess control of ischemic episodes, this is rarely done if patients are doing well because of the expense involved. ▪ Monitor for adverse drug effects such as headache and dizziness with nitrates; fatigue and lassitude with β-blockers; and peripheral edema, constipation, and dizziness with CCBs.

Hinweis der Redaktion

  1. Psychological interventions (eg, screening and treatment for depression if appropriate), limitation of alcohol intake, and avoiding exposure to air pollution.
  2. Statin therapy has also antithrombotic and anti-inflammatory properties