University of Pittsburgh Hybrid Physician Assistant Studies Clinical Medicine I/Lab Ischemic Heart Disease Carlos Gutiérrez, EdD, MMS, PA-C Associate Professor Instructional Objectives 1. 2. 3. 4. 5. 6. 7. 8. Discuss risk factors for ischemic heart disease to include healthcare inequity Outline screening recommendations regarding lipids, blood pressure, and family history to identify patients who may be at risk for cardiovascular disease. Compare and contrast primary versus secondary prevention of ischemic heart disease Define the pathogenesis of atherosclerosis and arteriosclerosis, outline goals for prevention and treatment of each Outline the etiology, pathophysiology, clinical manifestations, diagnostic evaluation and management of a. Stable angina b. Prinzmetal’s angina Discuss treatment of angina to include the following pharmacologic agents, as well as their indications, mechanism of action, contraindications, adverse effects a. Aspirin b. Oxygen c. Nitrates d. Beta-adrenergic blockers e. Calcium antagonists f. Morphine sulfate Differentiate angina from acute myocardial infarction. Explain the indication, interpretation, normal and abnormal results of each of the following diagnostic studies which may be used in the evaluation of suspected ischemic heart disease: a. Appropriate radiographic studies b. EKG c. Cardiac stress testing d. Cardiac catheterization / arteriography e. Appropriate laboratory studies Ischemic Heart Disease • Coronary Heart Disease (Coronary artery disease) • Definition • Blood supply to the heart is reduced or blocked • Atherosclerosis • Chronic vs Acute • Stable vs Unstable • 360,000 deaths/year • #1 cause of death. Blausen.com staff (2014). "Medical gallery of Blausen Medical 2014". WikiJournal of Medicine 1 (2). DOI:10.15347/w jm/2014.010. ISSN 2002-4436., CC BY 3.0, via Wikimedia Commons Risk Factors for Atherosclerosis Modifiable Risk Factors: Nonmodifiable Risk Factors: • Hyperlipidemia • Age • Hypertension • Male • Diabetes Mellitus • Family history of premature coronary artery disease • Health care inequity • Metabolic syndrome • Cigarette smoking • Obesity • Sedentary lifestyle • Heavy alcohol intake Screening Recommendations for Cardiovascular Disease Risk Factors • Lipid screening • AHA • NCEP ATP III • Blood Pressure screening • AHA • Family History screening • AHA Primary vs. Secondary Prevention Primary Prevention • Decrease incidence of IHD in those who not develop disease • All about modifying those risk factors and others: controlling lipids, BP, etc. • Healthy lifestyle • Healthy diet, regular exercise, avoid smoking • Medical Interventions • Statins, blood pressure medications Secondary Prevention • Decrease events and complications in individuals with established IHD • Medical Interventions • Statin, P2Y12 inhibitors, ASA • Cardiac Rehab • Same items from Primary Prevention Atherosclerosis and Arteriosclerosis • Arteriosclerosis • General term describing hardening or thickening of arterial wall • Atherosclerosis • Chronic inflammatory disease • Accumulation • Fatty substances, cholesterol, cellular waster products, calcium • Termed atherosclerotic plaque • Can rupture → MI or CVA • Prevention • Maintain healthy weight, healthy diet, exercise, quit smoking, manage comorbidities • Treatment • Medications (statins, antiplatelet), Lifestyle changes, procedures Stable Angina • Etiology • Obstructive coronary artery disease • Pathogenesis • Imbalance of myocardial oxygen supply and demand • D/t obstruction by atherosclerosis • Definition: Angina • Chest discomfort is attributable to myocardial ischemia • Clinical Manifestations • Chest pain with exertion or stress and relieved by rest or NTG • PE: +/- ↑ BP or HR Stable Angina • Diagnosis • H&P, EKG, cardiac testing • Management • Lifestyle modifications • Smoking cessation, exercise, healthy diet • Pharmacologic therapy • Antiplatelet agents (clopidogrel), BBs (carvedilol), CCBs (verapamil), nitrates (isosorbide dinitrate), statin (atorvastatin) • Revascularization (some cases) • PCI, CABG Suspected ischemic heart disease Intermediate or high-risk UA? No Recent exercise or cardiac imaging study No No Patient able to exercise? Yes Yes Previous coronary revascularization? No Pha rm s tress MPI or echo w/exercise No Resting ECG interpretable? Yes Low-to-intermediate likelihood IHD Intermediate -to-high likelihood IHD Sta ndard exercise ECG MPI or echo w/exercise or pha rm CMR Test results suggest high-risk coronary lesion(s)? No Initiate guideline-directed medical therapy Yes Initiate guideline-directed medical therapy; consider revascularization to improve survival No Successful trea tment? Yes Routine monitoring Work-up and management of suspected ischemic heart disease. CMR, cardiac magnetic resonance; IHD, ischemic heart disease; MPI, myocardial perfusion imaging; UA, unstable angina. (Reproduced with permission from Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2012;126[25]:e354–e471.) Prinzmetal Angina • Aka vasospastic angina, variant angina • Etiology • Spasm of coronary arteries • Pathophysiology • Decreased oxygen supply to myocardium d/t spasm • Clinical Manifestations • Chest pain, severe, lasts several minutes • Diagnosis • H&P, EKG, cardiac testing • The Coronary Vasomotion Disorders International Study Dx Criteria • Management • Avoiding triggers, CCBs, Nitrates • PCI (not routinely indicated) • Surgical sympathetic denervation Stable (Chronic) Angina vs. Prinzmetal Angina Management of Chronic Coronary Syndrome (Stable Angina) • Goals of Care • Relieve symptoms • Prevent future cardiac events • Antianginal Therapy • BBs, CCBs, Nitrates • Preventing Disease Progression • ASA, Clopidogrel, Statins Beta-Blockers • Indication • Treatment of stable angina (1st line) • MOA • Blocks beta-adrenergic receptor → ↓workload, ↓oxygen demand • CIs • Hypersensitivity, severe bradycardia, 2nd/3rd AV block, decom. HF • AEs • Bradycardia, hypotension, fatigue, dizziness • Examples • Metoprolol, propranolol, atenolol Calcium Channel Blockers • Indication • Treatment of stable angina, Prinzmetal • MOA • Blocks entry of calcium into smooth muscle cells→ ↓workload, vasodilation • CIs • Severe hypotension, heart block, or heart failure • AEs • Headache, dizziness, flushing, and peripheral edema • Examples • Amlodipine, diltiazem, verapamil Nitrates • Indication • Prevention and treatment of angina in patients with stable angina & Prinzmetal • MOA • Arterial vasodilation • CIs • Allergy/hypersensitivity • AEs • headache, flushing, dizziness, and hypotension • Examples • NTG, isosorbide dinitrate, isosorbide mononitrate Antianginal Therapy – Cont. • Morphine sulfate • Should not be given routinely • Oxygen • Increased myocardial oxygen supply Aspirin • Antiplatelet Agent • Indication • Established IHD: Stable angina, unstable angina, ACS • MOA • COX inhibitor → ↓platelet aggregation • CIs • Allergy/hypersensitivity, GI ulcers, Bleeding disorder • AEs • GI upset, N/V, bleeding: GI or intracranial Preventing Disease Progression – Cont. • Clopidogrel • Statins • Atorvastatin (Lipitor®), Rosuvastatin (Crestor®), Simvastatin Angina vs. Myocardial Infarction Angina • Partial blockage Myocardial Infarction • Complete blockage • Symptoms triggered by activity or stress but resolves • Similar symptoms but severe/last longer • Stable condition w/o myocardial damage • Managed effectively • Medical emergency a/w possible myocardial damage • May cause significant damage
