7 - Chronic Coronary Disease "Secondary Prevention"

What conditions are included in ASCVD?

Coronary artery disease

Cerebrovascular disease

Peripheral artery disease

Abdominal/descending thoracic aortic aneurysm

It can also affect renal arteries

What conditions are included in coronary heart disease (CHD)?

Stable ischemic heart disease/chronic stable angina

Unstable angina/ACS, MI (NSTEMI or STEMI)

Heart failure from ischemic cardiomyopathy

What is chronic coronary disease (SIHD)?

Fixed coronary obstruction limits oxygen supply → increased activity raises oxygen demand → myocardial ischemia and predictable exertional angina

Some patients also have vasospasm

How does coronary stenosis affect ischemia and angina?

<50–70% → rarely causes ischemia/angina

70–90% → determines degree of angina

>90% → critical stenosis

What causes myocardial ischemia?

Either increased O2 demand or decreased O2 supply

Increased O2 demand → tachycardia, HTN

Decreased O2 supply → atherosclerosis

What is the 3 criteria for symptoms of myocardial ischemia?

Typical chest pain →

Substernal discomfort

Provoked by exertion/emotional stress

Relieved by rest/nitroglycerin

How is chest pain classified in myocardial ischemia?

Typical angina → all 3 criteria

Atypical chest pain → 2 of 3 criteria

Non-cardiac chest pain → 1 or 0 criteria

What are the clinical characteristics of angina?

Heavy, crushing, or suffocating discomfort → usually lasts a few minutes, is not sharp/stabbing, and does not change with breathing or position

What can cause angina?

Most often CAD-related ischemia, but also valvular heart disease, cardiac hypertrophy, uncontrolled HTN, and vasospastic disease (Prinzmetal’s angina).

What are potential symptoms of myocardial ischemia?

Neck or jaw pain

Shoulder or arm pain

A fast heartbeat

Shortness of breath

Nausea and vomiting

Sweating

Fatigue

Some patients will not have any symptoms: “silent ischemia” → only evidence of myocardial ischemia is on ECG or other testing

Stable angina?

Increased myocardial O2 demand with a fixed O2 supply

Unstable angina?

Abrupt decrease in O2 supply from plaque rupture + thrombosis

New/worsening pain, may occur at rest and last >20 min

What tests are used to evaluate myocardial ischemia and CAD?

ECG

Stress testing

Nuclear myocardial perfusion imaging

Cardiac CT/MRI

Coronary angiography/cardiac catheterization

What are the types of chronic coronary disease?

Stable exertional angina → most common

Prinzmetal’s angina → vasospastic → occurs at rest/early morning, not with exertion

Silent ischemia → no symptoms → detected by ECG/ECHO → can coexist with angina and is treated similarly

What factors affect prognosis in chronic coronary disease?

LV function

Number/location of stenotic lesions

Recent MI or unstable angina within 6 months

Overall health and comorbidities

What is the goal of GDMT in chronic coronary disease?

Prevent MI and death

One key component is antiplatelet therapy

Class I antiplatelet therapy for chronic coronary disease?

Aspirin 81 mg daily should be continued indefinitely unless contraindicated

Clopidogrel 75 mg daily is reasonable when aspirin is contraindicated

Class IIB antiplatelet therapy for chronic coronary disease?

Aspirin 81 mg and clopidogrel 75 mg daily for up to 3 years might be reasonable in certain high-risk patients

MOA of aspirin?

Irreversibly inhibits platelet COX → decreases platelet activity and clot formation

81 mg is as effective as 325 mg with less bleeding risk

Bleeding risk increases with age >60, NSAIDs, anticoagulants, corticosteroids, or prior GI ulcer/bleed

MOA of Clopidogrel?

Irreversibly blocks ADP-P2Y12 → decreasing platelet activity

Requires CYP2C19 activation

Omeprazole has the most concern for interaction, with pantoprazole preferred

Clopidogrel is an alternative to aspirin

When are ACE inhibitors recommended in CCD?

In patients with HTN, diabetes, CKD, or LVEF <40%

ARBs may be used if ACE inhibitors are not tolerated

What are the goals and options of anti-anginal therapy in CCD?

Goal: reduce/eliminate ischemic symptoms and improve quality of life

Options → beta blockers, CCBs, nitrates, and ranolazine

Beta blockers in CCD?

Decrease myocardial O2 demand by reducing HR, contractility, and BP

Target HR 55–60 BPM

ADRs → fatigue, lethargy, sexual dysfunction

Avoid in severe PAD or Prinzmetal’s angina

Inhibits the late Na⁺ current → decreases myocardial O2 demand without significantly lowering HR or BP

Can be combined with BBs, CCBs, or nitrates

Prolongs QTc

Avoid strong CYP3A4 inhibitors

ADRs → constipation, nausea, headache

When to use aspirin/clopidogrel vs BB/nitrates/ranolazine in CCD?

Aspirin/clopidogrel = prevent the clot → prevent MI/death

BB/nitrates/ranolazine = treat the ischemia → prevent or relieve chest pain

What should be monitored during follow-up for SIHD?

Monitor:

Changes in physical activity or symptoms

Response to therapy, adverse effects, and adherence

Comorbidities → HTN, lipids, diabetes, obesity, smoking

New chronic conditions or changes in existing conditions

What is peripheral artery disease (PAD)?

Atherosclerotic narrowing of peripheral arteries, most often femoropopliteal-tibial

What are common clinical presentations of PAD?

Often asymptomatic, especially early

Common symptoms include intermittent claudication/leg muscle pain and rest pain

What is assessed during a physical exam for PAD?

Pulses, femoral bruits, and legs/feet for cool shiny skin, thick toenails, hair loss, elevation pallor, dependent rubor, nonhealing wounds, or gangrene

Pulses → 0 = absent, 1 = diminished, 2 = normal

What are the serious complications of PAD?

Acute limb ischemia → <2 weeks; pain, pallor, pulselessness, cold, paresthesias, paralysis.

Critical limb ischemia → >2 weeks; ischemic rest pain, nonhealing wounds/ulcers, or gangrene.

How is PAD diagnosed?

Exclude similar conditions (neuropathy, arthritis, DVT, venous congestion)

Use the ankle-brachial index (ABI) → a noninvasive test that is >90% sensitive and specific

What are the ABI values used to assess PAD?

Normal: 1.0–1.4

PAD: <0.9

Mild: 0.7–0.9

Moderate: 0.4–0.7

Severe: <0.4

What is the antiplatelet therapy for symptomatic PAD?

Aspirin 81 mg or clopidogrel 75 mg daily to reduce MI, stroke, and vascular death

DAPT benefit for CV events is uncertain but may be reasonable after lower-extremity revascularization

What is rivaroxaban + aspirin used for in PAD?

Rivaroxaban 2.5 mg BID + aspirin reduces MACE by 28% vs aspirin alone, but → increases major bleeding

FDA-approved for CAD or PAD to reduce MI, stroke, or CV death

What therapies improve symptoms and walking distance in PAD?

Cilostazol and structured exercise are recommended for claudication

Pentoxifylline is not effective

Cilostazol for PAD?

Inhibits PDE → increasing cAMP and causing antiplatelet effects + vasodilation

Improves claudication symptoms but not CV death or QoL

Contraindicated in heart failure

Common ADRs → headache, diarrhea, dizziness, palpitations, edema, tachycardia

What is structured exercise therapy for PAD?

Supervised exercise → intermittent walking/exercise >30–45 min, ≥3 times/week with rest periods

Community/home-based programs are also reasonable

What general care is recommended for patients with PAD?

Annual flu vaccine
Regular foot exams and foot care

Prompt treatment of foot infections to prevent amputation

What should be monitored during PAD follow-up?

Changes in symptoms/activity, therapy response and adherence, adverse effects, ASCVD risk factors, and new or worsening conditions