Ischemic Heart Disease

1. Given a specific clinical scenario in the office or emergency setting, diagnose presentations of ischemic heart disease (IHD) that are:
   • classic
   • atypical (e.g., in women, those with diabetes, the young, those at no risk).
2. In a patient with modifiable risk factors for ischemic heart disease (e.g., smoking, diabetes control, obesity), develop a plan in collaboration with the patient to reduce her or his risk of developing the disease.
3. In a patient presenting with symptoms suggestive of ischemic heart disease but in whom the diagnosis may not be obvious, do not eliminate the diagnosis solely because of tests with limited specificity and sensitivity (e.g., electrocardiography, exercise stress testing, normal enzyme results).
4. In a patient with stable ischemic heart disease manage changes in symptoms with self-initiated adjustment of medication (e.g., nitroglycerin) and appropriate physician contact (e.g., office visits, phone calls, emergency department visits), depending on the nature and severity of symptoms.
5. In the regular follow-up care of patients with established ischemic heart disease, specifically verify the following to detect complications and suboptimal control:
   • symptom control.
   • medication adherence.
   • impact on daily activities
   • lifestyle modification.
   • clinical screening (i.e., symptoms and signs of complications).
6. In a person with diagnosed acute coronary syndrome (e.g., cardiogenic shock, arrhythmia, pulmonary edema, acute myocardial infarction, unstable angina), manage the condition in an appropriate and timely manner.

Diagnosis

• Ischemic heart disease diagnosis is based on pretest probability (symptoms, risk, noninvasive testing)
  • CAD diagnosis is established if history of ACS or presence of obstructive lesions on angiography

Anginal Symptoms

• Classical chest pain
  1. Dull RSCP (discomfort, heaviness, aching, pressure; not changing in intensity with inspiration, cough or position change; with or without radiation into jaw, neck, shoulders, arms)
  2. Provoked by exertion or emotional stress (lying down, post-prandially)
  3. Relieved within <5 min by rest or Nitroglycerin.
  • Non-classical symptoms might include: SOB(OE), N/V, diaphoresis, fatigue, dizziness
• Atypical chest pain in DM, women, patients without risk factors (eg. young)
  • New CP
  • Duration >20 min
  • Occurrence at rest

Risk Factors

Modifiable

• Smoking
• DLP
• DM2
• CKD
• HTN
• Obesity or Metabolic syndrome
• Physical Inactivity
• Diet
• Depression

Non-Modifiable

• Age
• Sex (male)
• Ethnicity (Hispanic, Native American, African American, Asian)
• Family history of premature CVD (1st degree relative, <55yo men, <65yo women)

CV Co-morbidities

• Valvular disease
• Cerebrovascular disease
• Peripheral vascular disease
• Renal disease

Investigations

• 12-Lead ECG
  • Findings consistent with CAD include
    • Evidence of left ventricular hypertrophy
    • ST-T wave changes consistent with ischemia
    • Previous Q-wave myocardial infarction (MI)
    • Bundle branch block
    • Conduction/rhythm disturbances
• Hemoglobin
• Full lipid panel (Total cholesterol, LDL, HDL)
• Fasting blood glucose or HbA1c
• Creatinine
• AST, ALT, Total Bilirubin
• TSH

Invasive testing (coronary angiography)

• Indicated if
  • High pretest probability of stable ischemic heart disease
  • High-risk features on non-invasive testing
  • Persistent symptoms or inadequate QOL despite optimal medical treatment
  • History of ACS
  • Life-threatening arrhythmias

Management of Stable Disease

• Counselling
  • Review treatment options
    • Medication adherence for symptom relief and prevent disease progression
  • Explanation of CV risk
    • Treat any concurrent DM2 or DLP or HTN
    • Lifestyle
      • Smoking cessation
      • Weight loss
      • Diet (high intake of vegetables, whole grains, fresh fruit; reduce salt, saturated/trans fat)
      • Physical activity (150 min/week of moderate or vigorous activity)
  • Assess and manage stress/depression
  • Red flags when to seek medical care
• Non-invasive testing as above within 2w
  • Then referral to cardiologist/specialist within further 6w

Improving prognosis

• ASA 81mg (or Clopidogrel 75mg if ASA intolerance)
• High-intensity Statin (eg. Rosuvastin 20-40mg daily, Atorvastatin 80mg daily)
• ACEI (or ARB) if HTN, DM2, CKD, LVEF ≤ 40%
• Revascularization therapy (PCI or CABG) in patients who underwent coronary angiography

Symptomatic relief

• Nitroglycerin (short-acting) 0.4mg SL tab or spray q5 mins PRN, seek prompt medical attention if pain persists after 3 doses
• Beta-blockers especially if prior MI, HF, LVEF ≤ 40%, eg. Bisoprolol, target HR 55-60 bpm
  • If cannot tolerate BB or symptomatic on monotherapy, start/combine
    • Long-acting CCB (eg. Amlodipine or Diltiazem)
      • Avoid non-dihydropyridine CCB in combination with BB if risk of AV block and excessive bradycardia
    • Nitroglycerin transdermal patch 0.2mg/hour titrate up to 0.8mg/hour (remember to remove patch 12-14h, eg. apply 8AM-8PM)

Follow-up

• HPI
  • Severity and progression of symptoms
    • Impact on daily function and QOL
      • NYHA Class I-IV
  • Complications of CAD (arrhythmia, heart failure, ACS)
  • Medication compliance
    • Appropriate use of medication (Nitro SL prn)
• Physical exam
  • Cardio exam (BP, HR, S4, murmur, bruit)
  • Resp exam (crackles)
• Investigations
  • ECG if symptom change or annually
  • Routine CBC, creat, FBG/HbA1c, lipids
• Management
  • Counselling as above
  • Optimize medication
  • Cardiac rehab program, especially s/p revascularization