Stable Ischemic Heart Disease (IHD)

Question 1

Goals of therapy for Stable Ischemic Heart Disease

Answer 1

reduce or eliminate anginal symptoms
prevent premature cardiovascular death and complications
slow progression of coronary atherosclerosis
stabilize existing atherosclerotic plaques

Question 2

Non-Pharm therapies

Answer 2

smoking cessation
weight loss (if applicable)
dietary modifications
increase physical activity
interventions (angiography, coronary artery bypass graft [CABG])

Question 3

if patient has HTN and stable ischemic heart disease

Answer 3

treat appropriately and give an ACE-I 1st line therapy

Question 4

if patient has HLD and stable ischemic heart disease

Answer 4

treat appropriately and give a high intensity statin 1st line therapy if less than or equal to 75

Question 5

if patient has diabetes and stable ischemic heart disease

Answer 5

treat appropriately

Question 6

if patient has physical inactivity/sedentary lifestyle

Answer 6

encourage regular aerobic physical activity

Question 7

if patient uses tobacco/ or cigarette smoking

Answer 7

encourage smoking cessation

Question 8

if patient on medications that may adversely affect FLP (see patient history)

Answer 8

facilitate therapeutic substitution if appropriate

Question 9

if patient has excessive alcohol intake

Answer 9

1 daily drink for women and 2 daily drinks for men

Question 10

if patient has poor nutrition

Answer 10

TLC diet, Mediterranean diet

Question 11

if patient is obese/overweight

Answer 11

encourage safe and healthy weight loss

Question 12

if patient is stressed

Answer 12

encourage stress relieving activities

Question 13

which therapies prevent patients from feeling chest pain?

Answer 13

anti-anginal agents
beta-blockers
nitrates
calcium channel blockers
ranolazine

Question 14

which therapies prevent platelet aggregation?

Answer 14

antiplatelet agents

aspirin

Question 15

what additional therapies can patient be put on for mortality reduction?

Answer 15

ACE-I (or ARB)

Statins

Question 16

Beta-blockers

Answer 16

Efficacy: reduces ischemic events, infarction, and death. reduces angina symptoms. decreases mortality and morbidity
Indication: all patients w/stable IHD. titrate dosing to goal of no chest pain. heart rate often prevents reaching target dose

Question 17

Nitrates

Answer 17

Efficacy: improves exercise tolerance, increases time to angina onset, and reduces angina symptoms. provides no reduction in death. no change in mortality, but decrease morbidity
Indication: (short acting NTG) all patients PRN use OR exercise induced angina. (long acting NTG) ongoing ischemia despite optimal use of beta-blockers OR patients with contraindications to beta-blockers.

Question 18

Patient Education of Short acting Nitrates

Answer 18

SL dosage forms for acute angina attacks or prevention of exercise-induced angina
Relax and sit when taking tablets
Take 1 tablet SL q5 mins prn chest pain x3 doses
- after 1 dose, if pain still present, call 911
Keep in original container and in close proximity
Remove cotton plug from bottle immediately after purchased
Explain potential SE of flushing and headache
SL tablets expire after 6 months, spray expires after 3 years

Question 19

Calcium Channel Blockers (CCB)

Answer 19

Efficacy: improves exercise tolerance and increases time to onset of angina. provides NO reduction in death. no change in mortality, but decreases morbidity.
Indication: patients with ongoing ischemia despite optimal use of beta-blockers OR patients with contraindications to beta-blockers.

Question 20

Ranolazine

Answer 20

Efficacy: prevents or reduces recurrent ischemia. provides NO reduction in death. No change in mortality, but decreases morbidity
Indications: ongoing ischemia despite optimal use of beta-blockers, CCB, and long-acting nitrates. hypotention, bradycardia, or if other agents contraindicated

Question 21

Aspirin

Answer 21

Efficacy: decreases MI and prevents CV death. decreases mortality
Indication: all patients (81 mg PO daily)
doses > 162 mg daily increases the risk of bleeding, but provide no additional efficacy benefit.

Question 22

Angiotensin Converting Enzyme Inhibitors (ACE-I)

Answer 22

Efficacy: reduces CV death, myocardial infarction, and stroke. decreases mortality
Indication: HTN, diabetes, LVD [EF

Question 23

Angiotensin Receptor Blockers (ARB)

Answer 23

Efficacy: reduces CV death, myocardial infarction, and stroke. decreases mortality
Indication: HTN, diabetes, LVD, or CKD unable to take and ACE-I

Question 24

Statins

Answer 24

Efficacy: prevents death, MI, and stroke.
- decreases all cause mortality, nonfatal MI, unstable angina requiring hospitalization, and revascularization
- reduces nonfatal MI and combined nonfatal and fatal stroke with high intensity statin
- decreases mortality
Indication: all patients. high intensity statin recommended in patients less than or equal to 75 yo. moderate intensity statin recommended in patients greater than or equal to 75 yo.

Question 25

Refactory Ischemia

Answer 25

combination drug therapies
consider angiography plus or minus stent implantation or CABG
- reserved for medication refractory stable angina

Question 26

what is the 1st line therapy for stable IHD?

Answer 26

beta-blocker and short acting nitrate

aspirin and statin are also required!

Question 27

what is the 2nd line therapy for stable IHD?

Answer 27

long acting nitrate or CCB

Question 28

what is the 3rd line therapy for stable IHD?

Answer 28

ranolazine (has no mortality benefit and has major SE)

Question 29

R
B
A
N
A
N
A
S

Answer 29

Ranolazine
Beta-blocker
Aspirin
NTG short
ACE-I
NTG long
ARB
Statin