The patient most likely to be treated with Bivalirudin. Bivalirudin is a direct thrombin inhibitor that can be used as an alternative to heparin in patients who have developed heparin-induced thrombocytopenia. Abciximab, tirofiban, and plasminogen are not appropriate replacements for heparin in this clinical scenario.

1. Ischemic Heart Diseases
Presenters : ABDULLAH ATEEQ
AMINA TAHIR
AJLAL REHMAN
FATIMA SIKANDAR

2. Presentation Outline
• Introduction
• Epidemiology
• Pathophysiology
• Types
• Diagnosis
• Management
• Classification Of Anti-Platelets
• MOA and role of drugs in IHD
• Adverse effects
• Latest trends

3. What is Ischemic Heart Disease
Group of diseases resulting from Myocardial Ischemia
- imbalance between the supply (perfusion) and demand of the heart
for oxygenated blood.
• Coronary Arteries become narrowed
Either due to
Atheroma formation
Or
Connective tissue disorders
•Most common form of Heart Disease

4. Types/Classification
IHD
Angina Pectoris
Stable angina,
Vasospastic angina,
Unstable angina—
Acute MI
STEMI
NSTEMI
Chronic IHD
with Heart
Failure
Sudden Cardiac
Death

5. Epidemiology
Pakistan ranks 63rd in the world
Deaths due to CHD have reached 9.8% of total deaths
Risk after age 40 is 2 in 3 men & more than
1 in 2 women.
CAD as of 2010 was the
leading cause of death globally resulting in
over 7 million deaths
84% of those who die from CAD are 65 or older
In Pakistan, 33% of population above the age of 45 has hypertension
Prevalence of hypertension is 19% in people of age 15 or above
Reference: Heart Disease and Stroke Statistics 2009 Update: A Report from the American Heart Association Statistics Committee and Stroke Statistics
Subcommittee. Circulation. 2009, January 27.
WHO data , Published in May 2014

6. Risk factors

7. What are the Health Concerns/Risk
Factors
Uncontrolled Controlled
 Sex
 Hereditary
 Race
 Age
 High blood pressure
 High blood cholesterol
 Smoking
 Physical activity
 Obesity
 Diet high in saturated fat &
cholesterol
 Diabetes
 Stress and anger

8. pathophysiology

9. Pathophysiology
• Coronary atherosclerotic plaque formation
• Artery lining becomes
Hardened
Stiffened
 Swollen with Fatty Deposits
Ca²⁺ Deposits
Abnormal Inflammatory Cells

10. Pathophysiology contd.
• Stable plaque
Predictable angina
• Unstable plaque ruptures
Activating clotting system & thrombus formation
Impairs coronary blood flow causing unstable angina or MI
• MI heals with scarring
Impaired contractility & increasing stiffness
Leading to HF- acute/chronic
• Ischemic areas & scars
Prone to cause ventricular arrhythmias
Leading to sudden death

11. Diagnosis

12. Diagnostic Techniques
Stress Echocardiography
Nuclear Stress Imaging
Coronary Angiography

13. Management of Ischemic
Heart Disease

14. 1. Lifestyle Modifications
2. Pharmacological
Therapies
3. Surgical interventions

15. Lifestyle modifications
Smoking
Diet
Hypertension
Hyperlipidemia
Diabetes Mellitus
Sedentary Lifestyle
Alcohol
Exercise

16. Pharmacological therapy for Angina
• Prognostic therapies
• Aspirin
• Lipid-lowering therapy
• Hormone replacement therapy

17. Symptomatic treatment
• Glyceryl trinitrate (GTN) used sublingually
• Beta-blockers
• Long-acting nitrates (e.g. isosorbide mononitrate)
• Calcium-channel blockers
• Nicorandil
• Ivabradine
• Ranolazine

18. Pharmacological therapy for Coronary Syndrome

20. Pharmacological therapy for MI
 Aspirin
Thrombolytic treatment
Streptokinase
Sublingual Glyceryl trinitrate
Oxygen
Intravenous opiate, e.g. diamorphine (or
morphine)
Beta-blocker (if no contraindication) for ongoing
chest pain, hypertension, tachycardia

21. Contraindications to thrombolysis
Absolute contraindications
• Haemorrhagic stroke
• Ischaemic stroke
• Neoplasms
• Known bleeding disorder
Relative contraindications
• Oral anticoagulant therapy
• Pregnancy
• Advanced liver disease
• Infective endocarditis

22. Post-MI drug
therapy

23. • Aspirin
• beta-blocker
e.g. metoprolol
• ACE inhibitors
e.g. ramipril
• ACE inhibitors use ARB
e.g.valsartan
• Statins
• Clopidogrel
• Aldosterone
antagonist

24. Surgical Interventions
• Angioplasty
• Stents
• Coronary Artery Bypass
Grafting (CABG)

25. Anticoagulants

26. • Drugs used to decrease
clotting or dissolve clots
already present in
patients.
Among them we have:
1. Anti clotting drugs
• Drugs used to increase
clotting in patients with
clotting deficiencies.
Among them we have:
1. Replacement factors
2. Vitamin K
3. Anti plasmins drugs

27. Classificat
ion
of Drugs
used in

28. Anti Clotting Drugs
• Heparins:
i. Unfractionated Heparins
ii. LMW Heparins
• Direct Factor X Inhibitors:
i. Rivaroxaban
ii. Apixaban
• Direct Thrombin
Inhibitors:
i. Argatroban
ii. Buvalirudin
• Coumadin Anti
coagulants:
i. Warfarin

29. Thrombolytic drugs
• Alteplase, Recombinant
Human Tissue,
Plasminogen Activator.
• Reteplase
• Streptokinase

30. Anti Platelet Drugs
• COX Inhibitors:
Aspirin
• Glycoprotein IIb/IIIa Inhibitors:
a. Abciximab
b. Triofiban
• ADP Receptor Antagonists:
a. Clopidogrel
b. Ticlopidine
• Dipyridamole:
Cilostazol

32. Fatima Sikandar
3rd year MBBS
SIDE EFFECTS OF
DRUGS USED FOR
ISCHEMIC HEART DESEASES

34. • Nitrates
• Calcium channel blockers
• Beta blockers
• Ranolazine
• ACE inhibitors
• Anti Coagulants
• Anti Platelets
PHARMACOLOGIC THERAPIES

35. Sublingual nitroglycerin
• Nervous system
 Headache
Dizziness
• Cardiovascular
 increased angina
tachycardia
• Gastrointestinal
• Psychiatric
restlessness
NITRATES

36. Calcium channel blockers
Verapamil , Nifedipine
• Gastrointestinal
Constipation
• Cardiovascular
CHF
Pulmonary edema
• Nervous system
jerky movements
• Musculoskeletal
myalgia
muscle fatigue

37. BETA BLOCKERS
Propanolol,Esmolol Atenolol
• General
Hypotension
Tiredness
• Cardiovascular
Cold extremities
Raynaud’s phenomena
• Nervous system
Fatigue
Sleep disorders
Depression

38. ACE Inhibitors
Captopril ,Enalapril
• Dermatologic
Rash
• Gastrointestinal
• Nervous Systems
Dizziness
• Respiration
Cough

39. ANTI PLATELETS
Aspirin ,Abciximab
• Gastrointestinal
Epigastric distress
• Hypersensitivity
• Dermatologic
Stevens johnson
syndrome
• Nervous system
Dizziness
Headache

40. ANTI COAGULANTS
• Heparin
• Cardiovascular
White clot
syndrome
• Dermatologic
lesions , eczema
• Musculoskeletal
osteoporosis
• Renal
 hemolytic uremic
syndrome
• General
Bleeding/
hemorrhage

41. Warfarin
• Dermatologic
Purple Toe Syndrome
• Cardiovascular
artheroemboli
• Renal
Acute renal
failure
• Genitourinary
Priapism
• Ocular
Retinal
hemorrhage

42. Factor x inhibitors
RIVAROXABAN
• General
Bleeding complications
• Hematologic
Anemia
• Gastrointestinal
• Nervous System
 Dizziness headache
• Dermatologic
 Blisters
• Psychatic
Anxiety

43. Thrombin Inhibitors
ARGATROBIN
• Cardiovascular
Hypotension
cardiac arrest
• Gastrointestinal
• Respiratory
Dyspnea
• General
Fever , Sepsis

44. WORLD WIDE
USED
ANTICOAGULANTS

45. Coumadin -Warfarin
Heparin
Pradaxa - Dabigatran
Xarelto- Rivaroxaban
Eliqus - Apixaban

47. ANTICOAGULANTS
USED IN
PAKISTAN

48. PERCENTAGE

49. HEPARIN
30%
WARFARIN
33%
STREPTOKINASE
20%
RIVAROXABAN
17%
GHURKI

51. • A patient develops severe thrombocytopenia
in response to treatment with heparin and still
requires parenteral anticoagulation. The
patient is most likely to be treated with which
of following
• A . Abciximab
• B. Tirofiban
• C. Bivalirudin
• D. Plasminogen

52. • A patient develops severe thrombocytopenia
in response to treatment with heparin and still
requires parenteral anticoagulation. The
patient is most likely to be treated with which
of following
• A . Abciximab
• B. Tirofiban
• C. Bivalirudin
• D. Plasminogen