ACCP guideline

1. ّIschemic Heart Disease
Done by :
Raniya.Khaled
@Rania199730
References:
ACC/AHA/AATS/PCNA/SCAI/STS
focused update of the guideline for the diagnosis and
management of patients with stable ischemic heart disease.
Rxprep course book 2018 edition : Ischemic Heart Disease

2. ّIschemic Heart Disease
Angina is chest pain , pressure , tightness
or discomfort, usually caused by ischemia
of the heart muscle or spasm of the
coronary arteries.
The chest pain is described as "squeezing ,
grip like, heavy, or suffocating “, and
typically does not vary with position or
respiration.
Raniya.Khaled
@Rania1997301

3. ّIschemic Heart Disease
Stable angina:
Also known as stable
ischemic heart disease
(SIHD), is associated with
predictable chest pain often
brought on by exertion or
emotional stress and
relieved within minutes by
rest or with nitroglycerin
Un stable angina :
Is a type of acute coronary
syndrome (ACS);
this is a medical emergency
where the chest pain is
increasing (in frequency,
intensity or duration) and is
not relieved with
nitroglycerin or rest
Raniya.Khaled
@Rania1997301

4. ّIschemic Heart Disease
Prinzmetal's (variant or vasospastic) angina
When chest pain is caused by vasospasm of the coronary arteries
Some patients (women, elderly and those with diabetes) may not
experience the classic symptoms of SIHD; because of this, they
may not recognize the need for medical attention
Raniya.Khaled
@Rania1997301

5. Pathophysiology
Chest pain occurs when there is an imbalance between:
2-Myocardial
oxygen supply
(blood flow).
1-Myocardial
oxygen demand
(workload)
And
often decreased due to
plaque build up
(atherosclerosis) within
the inner walls of the
coronary arteries
increases when the heart is
working harder as a result
of increased heart rate,
contractility and left
ventricular wall tension
Raniya.Khaled
@Rania1997301

6. Evaluation Of ّIschemic Heart Disease
History and physical
CBC, CK-MB, troponins (I orT), aPTT,
PT/INR, lipid panel, glucose
ECG
(At rest and during chest
pain)
Cardiac stress
test/stress imaging
Cardiac catheterization/
angiography
Raniya.Khaled
@Rania1997301

7. Treatment
Raniya.Khaled
@Rania1997301

8. Treatment
The treatment goals for SIHD are to improve functional capacity
(by eliminating anginal pain), prevent future cardiovascular
events (e.g., MI, heart failure) and reduce the risk of
cardiovascular death.
Using
Antiplatelet agent Antianginal regimenAnd
Raniya.Khaled
@Rania1997301

9. Treatment
Antiplatelet agent
2-Clopidogrel : is used in
patients with an allergy,
or other contraindication
to aspirin,
1-Aspirin is the
recommended
antiplatelet agent
3-Dual Antiplatelet Therapy
The primary benefit in IHD is
After placement of
a bare metal stent
A drug-eluting
stent
Post-CABG
DAPT for at
least one month
(DAPT for at
least 6 months)
DAPT for
12 months
DAPT : Dual Antiplatelet Therapy
Raniya.Khaled
@Rania1997301

10. Treatment
Antianginal Treatment 1
Drug Mechanism Of Clinical Benefit
Beta Blockers
Used 1st line in
IHD
Reduce myocardial oxygen demand:
HR,
Contractility
Left ventricular wall tension
Start low, go slow; titrate to
resting HR of 55-60 BPM;
Avoid abrupt withdrawal
Calcium Channel
Blockers
Reduce myocardial oxygen demand:
Non-DHPs HR and contractility;
DHPs SVR (afterload)
Increase myocardial oxygen supply:
CCBs blood flow through coronary arteries
Can be used in IHD when beta
blockers are contraindicated or as
add-on therapy to beta-blockers
for continued anginal symptoms
Raniya.Khaled
@Rania1997301

11. Treatment
Antianginal Treatment 2
Drug Mechanism Of Clinical Benefit
Nitrates
Reduce myocardial oxygen demand:
Preload (free radical nitric oxide
produces vasodilation of veins more
than arteries)
Increases myocardial oxygen supply:
Blood flow through collateral (non-
atherosclerotic) arteries
Recommended for all
patients for fast relief of
angina
Ranolazine
Selectively inhibits the late phase Na
current and intracellular
Ca; may decrease myocardial oxygen
demand by decreasing ventricular tension
and oxygen consumption
Contraindications
Liver cirrhosis, use in
combination with strong 3A4
inhibitors and inducers
Warnings
Can cause QT prolongation
Raniya.Khaled
@Rania1997301

12. Treatment
Patients
< 75 years of age with
ASCVD should be
placed on :
High-intensity statin
therapy.
Patients
> 75 years of age
with ASCVD,
a moderate-
intensity statin is
recommended
(ASCVD) : Atherosclerotic cardiovascular diseases
Raniya.Khaled
@Rania1997301