128 Ischemic Heart Disease Flashcards
Progression of Atherosclerosis (Figure)
- Endothelial injury
- Monocyte migration, cytokine formation, foam cell formation, smooth muscle proliferation, plaque and cap formation
3.Rupture of cap, thrombus
formation
(e.g., oxidized LDL)
Stable vs Unstable atherosclerosis
Ischemic Cascade
Microvascular Coronary Disease
- Exertional angina
- Abnormal SPECT
- No obstructive CAD
- Abnormal coronary flow reserve and elevated LVEDP
- Diffuse atherosclerosis by IVUS
Modifiable vs non-modifiable risk factors for atherothrombosis
Angina-Atypical Angina-Anginal Equivalents
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
- −Symptoms of myocardial ischemia other than angina
Canadian Classifications of Angina
Exercise stress testing
Myocardial Perfusion Imaging: Nuclear imaging stress test
Stress Echo
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
Cardiac CT
Nonpharmacologic Treatment
of Chronic Angina
Class I* and IIa Recommendations
- Smoking cessation
- Regular physical activity
- Weight management
- Moderation of alcohol; limiting sodium intake
- Cardiac rehabilitation
- Influenza vaccination
Initial Treatment of
Chronic Stable Angina
A = Aspirin and antianginal therapy
B = Beta-blocker and Blood pressure
C = Cigarette smoking and Cholesterol
D = Diet and Diabetes
E = Education
Medical management of angina
- §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
Anti-Ischemic Strategies
in Chronic Symptomatic CAD
Percutaneous Coronary Intervention
- §Balloon Angioplasty
- §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
Comparing CABG
to PCI to Medical Therapy
§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
Pharmacological therapies and physiologic effects and outcomes for Chronic Angina (3)
Hemodynamic Effects of
Antianginal Drugs
Pharmacologic Treatment of
Chronic CAD
- Aspirin, if not contraindicated
- Beta-blockers, if not contraindicated
- Consider ACE inhibitors or ARBs
- Nitroglycerin (sublingual or spray) for immediate relief of angina
- Calcium antagonists or long acting nitrates in combination with beta-blockers in initial treatment with beta-blockers not successful
- Blood pressure control (JNC VII Guidelines: blood pressure <140/90 mm Hg)
- Reduction of LDL cholesterol to <70 mg/dL
- Proper management of diabetes
Gender Differences in CHD
- §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
