128 Ischemic Heart Disease

Question 1

Progression of Atherosclerosis (Figure)

Answer 1

1. Endothelial injury
2. Monocyte migration, cytokine formation, foam cell formation, smooth muscle proliferation, plaque and cap formation

3.Rupture of cap, thrombus
formation

(e.g., oxidized LDL)

Question 2

Stable vs Unstable atherosclerosis

Answer 2

Question 3

Ischemic Cascade

Answer 3

Question 4

Microvascular Coronary Disease

Answer 4

• Exertional angina
• Abnormal SPECT
• No obstructive CAD
• Abnormal coronary flow reserve and elevated LVEDP
• Diffuse atherosclerosis by IVUS

Question 5

Modifiable vs non-modifiable risk factors for atherothrombosis

Answer 5

Question 6

Angina-Atypical Angina-Anginal Equivalents

Answer 6

Angina

• §Pain or discomfort in the chest or adjacent areas caused by insufficient blood flow to the heart
• §Clinical types
  
  • −Chronic, stable
  • −Atypical
  • −Anginal equivalents and silent ischemia
  • −Others: Decubitus, nocturnal, refractory, unstable, microvascular, vasospastic

Atypical Angina/Eqivalents

• §Angina pectoris may be atypical in location and not strictly related to provoking factors especially in women and diabetic patients
• §Anginal “equivalents“
  
  • −Symptoms of myocardial ischemia other than angina
    
    • •Dyspnea, nausea, fatigue, and faintness
    • •More common women, the elderly, and in diabetic patients

Question 7

Canadian Classifications of Angina

Answer 7

Question 8

Exercise stress testing

Answer 8

Question 9

Myocardial Perfusion Imaging: Nuclear imaging stress test

Answer 9

Question 10

Stress Echo

Answer 10

Advantages

• §Real-time information
• §Portable
• §Provides regional and global left and right ventricular function
• §No radiation
• §Low cost
• §Evaluates other anatomic abnormalities
• §Can provide Doppler information

Question 11

Cardiac CT

Answer 11

Question 12

Nonpharmacologic Treatment
of Chronic Angina

Answer 12

Class I* and IIa… Recommendations

1. Smoking cessation
2. Regular physical activity
3. Weight management
4. Moderation of alcohol; limiting sodium intake
5. Cardiac rehabilitation
6. Influenza vaccination

Question 13

Initial Treatment of
Chronic Stable Angina

Answer 13

A = Aspirin and antianginal therapy

B = Beta-blocker and Blood pressure

C = Cigarette smoking and Cholesterol

D = Diet and Diabetes

E = Education

Question 14

Medical management of angina

Answer 14

• §Antiplatelet agents
• –Aspirin
• Clopidogrel/Prasugrel/Ticagrelor/Ticlopidine/Vorapaxar
• §Anti-ischemic agents
• –Beta blockers
• –Nitrates
• –Calcium channel antagonists
• –Ranolazine
• §Lipid lowering therapies
• §Angiotensin converting enzyme inhibitors/angiotensin receptor blockers

Approach for Chronic Angina:

• §Evaluate and treat risk factors
• §Evaluate threshold for ischemia, and when appropriate, LV function
• §Treat to prevent symptoms of ischemia
• §If LV dysfunction, congestive heart failure, significant arrhythmia, or low threshold for ischemia by stress testing or symptoms are present, refer for revascularization

Question 15

Anti-Ischemic Strategies
in Chronic Symptomatic CAD

Answer 15

Question 16

Percutaneous Coronary Intervention

Answer 16

1. §Balloon Angioplasty
2. §Stenting (bare metal stents BMS) vs. drug eluting stents (DES)

§Outcomes:

–Mortality—1 %

–Myocardial infarction 2-4%

–Procedural success rates—90-95%

–Restenosis—15-25% with bare metal stents; 2-5% with DES (drug eluting stents)

-26% of patients report recent angina after PCI

Question 17

Comparing CABG
to PCI to Medical Therapy

Answer 17

§There are emerging clinical data comparing contemporary medical treatment strategies to CABG and PCI stenting outcomes which reveal similar long term outcomes if ischemic symptoms can be controlled in patients with preserved left ventricular function

§However, in the setting of recurrent ischemic symptoms, left ventricular systolic dysfunction, recurrent arrhythmias, and/or symptomatic heart failure, revascularization with guideline directed medical therapy provides the best outcomes for the patient

Question 18

Pharmacological therapies and physiologic effects and outcomes for Chronic Angina (3)

Answer 18

Question 19

Hemodynamic Effects of
Antianginal Drugs

Answer 19

Question 20

Pharmacologic Treatment of
Chronic CAD

Answer 20

1. Aspirin, if not contraindicated
2. Beta-blockers, if not contraindicated
3. Consider ACE inhibitors or ARBs
4. Nitroglycerin (sublingual or spray) for immediate relief of angina
5. Calcium antagonists or long acting nitrates in combination with beta-blockers in initial treatment with beta-blockers not successful
6. Blood pressure control (JNC VII Guidelines: blood pressure <140/90 mm Hg)
7. Reduction of LDL cholesterol to <70 mg/dL
8. Proper management of diabetes

Question 21

Gender Differences in CHD

Answer 21

• §Women report more symptoms and their symptoms are more likely atypical
• §Significant national gender gap in CHD-MI mortality
• §Women, particularly younger women, face a more adverse
• CHD prognosis
  
  • –Not fully explained by a gender gap with regard to therapy
• §Women are twice as likely as men to have ischemia/MI
• in the absence of obstructive CAD
• §Pathophysiology includes abnormalities in endothelial and microvascular coronary function
• §Women with ischemia but normal or minimal CAD have an adverse prognosis and need treatment