4.3 Chronic Coronary Disease

Fatal or nonfatal myocardial infarction (MI)*, angina pectoris

Coronary heart disease (CHD)

Fatal or nonfatal stroke and transient ischemic attack (TIA)

Cerebrovascular disease

Intermittent claudication and critical limb ischemia

Peripheral artery disease

Abdominal aortic aneurysm or descending thoracic aneurysm

Aortic atherosclerotic disease

fatal or nonfatal MI or unstable angina

acute coronary syndrome (ACS)

__________ is caused by an obstructive atherosclerotic plaque in one or more coronary arteries.

Chronic coronary disease (CCD)

_____ is the hallmark symptom of CCD

Chest pain (angina)

Acute coronary syndrome includes ____and ______

unstable angina and myocardial infarction

Chronic coronary disease includes

- Stabilized plaque

- Healed ruptured plaque

- Progressive vessel stenosis and angina

- Patient that recovered from MI

Reduction in blood flow due to atherosclerotic plaques in coronary arterial lumen

Chronic Coronary Disease (CCD)/ Stable Ischemic Heart Disease (SIHD)

Unstable Angina

- Thrombus partially occludes coronary artery

- Body's endogenous fibrinolytic system is able to halt thrombus progression

- Myocardial necrosis/cell death does NOT occur

Acute myocardial infarction (MI)

- Necrosis of myocardium

- Elevated cardiac enzymes as they are released from dying cells (troponin, CK-MB)

- Can be subdivided in STEMI or NSTEMI

NSTEMI

• Thrombus incompletely occludes vessel

• ST depression or T wave inversion on EKG

STEMI

• Thrombus completely occludes vessel resulting in abrupt cessation of blood flow

• ST elevations or new left bundle branch block on ECG

Percutaneous Coronary Intervention (PCI)

• Catheter is inserted via the femoral, brachial, or radial arteries and guided to the blockage

• Blockage is opened via balloon angioplasty and held open with a stent

Coronary Artery Bypass Graft (CABG)

• Open-heart surgery

• Vessels are harvested from other parts of the body and used to bypass affected sections of coronary artery

• Usually preferred for patients with complex and diffuse CAD

How is CCD diagnosed?

- Cardiac stress test

- Coronary angiography

- ECG

- Echocardiogram

- Labs

- Questionnaire

CCD Questionnaires typically include:

- Precipitating factors

- Palliative measures

- Quality of pain

- Region

- Radiation

- Severity

- Temporal pattern (timing)

Which are the goals of therapy for a patient diagnosed with CCD?

1. Prevent ischemic events, progression of atherosclerosis, and death

2. Alleviate acute symptoms of myocardial ischemia

3. Prevent recurrent symptoms of myocardial ischemia

4. Avoid/minimize adverse treatment effects

MACE stands for?

major adverse cardiovascular events

Estimated that 90% of MI risk is attributable to 9 risk factors

- Smoking

- Alcohol use

- Diabetes

- Hypertension

- Obesity

- Impaired psychological well-being

- Poor diet

- Lack of exercise

- Dyslipidemia

Limit salt intake to less than _________ (ideally no more than________) and minimize processed meat

2,300 mg/day, 1,500 mg/day

Patients should receive annual ______ and _____ vaccination. _____ vaccine would also be reasonable to reduce morbidity and mortality

- influenza vaccine

- COVID-19

- Pneumococcal

Medications not recommended for CCD treatment include:

- Estrogen therapy

- Vitamin C, E, or beta-carotene

- Vitamin B6 and B12

- Iron chelation therapy

- Garlic, Co-Q10, selenium, or chromium

Which statins are recommended to reduce the risk of MACE in patients with CCD?

High-intensity statin (goal of ≥ 50% LDL-C reduction)

Patients with contraindications or who cannot tolerate high intensity statin: __________ to reduce MACE risk

moderate-intensity (goal of 30-49% LDL reduction)

_________ decreases platelet aggregation via irreversible COX enzyme inhibition

Aspirin

What is the Aspirin dose that is recommended for patients with CCD, with no indication for oral anticoagulants, for reduction of MACE risk?

75 to 100 mg daily → 81mg daily

________ antagonize ADP P2Y12 receptor on platelet surface to inhibit platelet aggregation

P2Y12 Inhibitors

Oral P2Y12 Inhibitors include:

Clopidogrel, Prasugrel, Ticagrelor

Clopidogrel has _____ and is dosed ________

- Pharmacogenetic interactions

- 75mg once daily

Prasugrel is considered more potent than clopidogrel, is contraindicated in patients with_______ and is dosed _________

- history of stroke or TIA

- 10mg once daily

Ticagrelor is considered more potent than clopidogrel, is associated with _______, and is dosed ________

- dyspnea

90mg twice daily

What drug class is recommended in patients with history of diabetes, HTN, renal disease, MI, or LV dysfunction (LVEF ≤40%) for MACE reduction?

ACE inhibitors

_______ are going to help to prevent MACE in patients who have CKD and Type 2 Diabetes (DM)

ACE inhibitors

ACE inhibitors are associated with REDUCED:

- vascular hypertrophy

- atherosclerotic progression

- plaque rupture

- thrombosis

All patients should have _________

short-acting NTG (SL or spray)

What is the MOA of Nitrates?

Relax vascular smooth muscle in arteries and veins. Increases blood flow and decreases ventricular diastolic pressure, thus allowing increased flow to ischemic areas.

For Short-acting nitrates the onset of effect is usually __________, while the duration is ___________

5-10 minutes; 30-60 minutes

What are some patient counseling points for Nitrates?

1. If you have chest pain, sit down

2. Take one SL NTG tablet (or spray) under the tongue

3. Wait five minutes; if you still have chest pain, take a second dose.

4. If you do not feel any better (or if you feel worse) after the first dose, call 911

5. You can take up to three doses of SL NTG.

6. If your chest pain is not relieved after 3 doses, call 911 and chew aspirin.

Vasospastic Angina is when ________________, and patients tend to be younger with less coronary risk factors (but more commonly smoke)

Coronary blood flow decreased due to vasospasm

_________ should be used for acute episodes of Vasospastic Angina

Nitrates

______ are the first line for chronic treatment of vasospastic angina

CCBs

______ are the first line therapy to prevent anginal symptoms, they are more effective when combined with nitrates

Beta-blockers

What are some side effects of Beta-blockers?

bradycardia, fatigue, lethargy, sexual dysfunction, sleep disturbances

______ are preferred in patients with cardiac conduction problems or if taking beta-blockers, while ______ are options for patients who cannot tolerate beta blockers

- DHPs (amlodipine, felodipine)

- Non-DHPs (verapamil, diltiazem)

_______ can also be considered first line for Vasospastic Angina, may be best when added to either beta-blocker or CCB

Long-Acting Nitrates

Long-Acting Nitrates _________ to relieve angina symptoms, available in _____& ________, allow for a _____ to avoid nitrate tolerance.

- titrate dose

- oral and transdermal formulations

- nitrate free interval of 10-14 hours

What is CONTRAINDICATED with Long Acting Nitrates?

1. Hypertrophic obstructive cardiomyopathy

2. severe aortic valve stenosis

3. PDE-5 inhibitors

Do not take PDE-5 inhibitor ______ of taking nitrate due to profound hypotension (~25mmHg drop in SBP)

within at least 24hrs

________ reduces O2 demand by decreasing LV wall tension, and is an inhibitor of late inward sodium current (INA)

Ranolazine

Guidelines recommend using ______ as second line if beta-blockers cannot be used, and can be combined with BBs, nitrates, or DHP CCBs

Ranolazine

__________ is used more on the setting of frequent anginal episodes, ______ is recommended for episodic/rare anginal episodes

Ranolazine

Nitroglycerin

Ranolazine has minimal effect on ____, so attractive for patients with ________. Decreased risk of arrythmias in clinical trials.

- HR

- bradycardia

What is the dosed used for Ranolazine?

500-1000 mg BID

Where is Ranolazine contraindicated (HINT: Metabolized by CYP3A4)?

- Patients with significant hepatic dysfunction

- Patients taking potent CYP3A4 inhibitor

What are the main factors that increase oxygen demand?

↑ Heart rate, ↑ Contractility, ↑ Myocardial wall tension.

What are the main factors that decrease oxygen supply?

↓ Arterial pO₂, ↓ Diastolic filling time, ↓ Coronary blood flow

What happens when oxygen demand exceeds supply?

Myocardial ischemia occurs, leading to chest pain or angina.

How do we know if a patient is improving with the new therapy?

• Improvement of angina symptoms

• Increased exercise duration on treadmill stress test

• Improvement of ischemic changes on ECG or echocardiogram

• Visual improvement on coronary angiography

________ should be avoided due to increased risk of CV and bleeding complications

NSAIDs

_____ can be considered for secondary prevention to reduce ASCVD events in high risk patients

Colchicine

In patients with CCD and diabetes, either ____ or _____ is recommended to reduce risk of MACE

SGLT2I or GLP-1 RA

In patients with HF (regardless of LVEF) and CCD, _______ can be beneficial

SGLT2Is

SGLT2Is and GLP-1 RAs are recommended in __________ o prevent mortality and hospitalizations, and can consider in ____ to reduce hospitalizations

- HFrEF

- HFpEF