© copyright annals of internal medicine, 2014 ann int med. 160 (1): itc1-1. * for best viewing:...

© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (1): ITC1-1.

* For Best Viewing:

Open in Slide Show Mode Click on icon or

From the View menu, select the Slide Show option

* To help you as you prepare a talk, we have included the relevant text from ITC in the notes pages of each slide


Terms of Use

The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets constitutes copyright infringement.


in the clinic

Stable Ischemic Heart Disease


Why is it important to differentiate SIHD from unstable angina? Stable angina

Typically brought on by exertion or emotion

Unstable angina

More random and unpredictable, occurring without trigger

Rest angina: Occurring at rest and lasting >20 minutes

New-onset severe angina: Severe onset ≤2 months of initial presentation

Increasing angina: Previously diagnosed, crescendo pattern

Manage low-risk unstable angina the same as SIHD

Manage intermediate- or high-risk unstable angina more aggressively


What other diseases might be confused with stable ischemic heart disease?

Nonischemic CV: aortic dissection, pericarditis

Pulmonary: embolus, pneumothorax, pneumonia, pleuritis

Esophageal: esophagitis, spasm, reflux

Biliary: colic, cholecystitis, choledocholithiasis, cholangitis

Peptic ulcer

Pancreatitis

Chest wall: costochondrosis, fibrositis, rib fracture, sternoclavicular arthritis, herpes zoster (before the rash)

Psychiatric: anxiety/ affective/ somatoform/ thought disorders


Why is it important to estimate the probability of disease separately from the mortality risk? If <5% probability of CAD: look for other causes of pain

Predictors of CAD Patient age, sex, and type of angina Smoking history, hyperlipidemia, diabetes

Clinical Classification of Chest Pain Typical angina (definite)

Substernal chest discomfort: characteristic quality, duration

Provoked by stress; relieved by rest or nitroglycerin

Atypical angina (probable) Meets 2 of the above characteristics

Noncardiac chest pain Meets ≤1 of typical angina characteristics


How should information from the physical exam be used to evaluate people with SIHD? May reveal related conditions (HF, valvular heart disease)

Signs suggesting CAD (only present during chest pain) S3 or S4 gallop, mitral regurgitant murmur, bibasilar rales,

paradoxically split S2, or chest wall heave

Signs of CHD Jugular venous pulsation, S3 gallop, mitral regurgitation

murmur, displaced apical impulse, pulmonary crackles, diminished breath sounds, dullness to percussion, abdomino-jugular reflux, hepatomegaly, lower extremity edema

Signs of noncoronary atherosclerotic vascular disease

Carotid bruit, diminished / absent pedal pulses, abdominal aneurysms

Xanthelasma and xanthomas: hyperlipidemias


What other preliminary tests should be used to evaluate people with suspected SIHD?

Electrocardiogram

All patients: resting ECG

Chest X-ray

If no obvious noncardiac cause of angina

Echocardiography (rest)

If patient has signs or symptoms suggesting HF or cardiac valvular lesions

If ECG findings show a pathologic Q-wave

If ECG findings show complex ventricular arrhythmias

Not recommended for most patients with SIHD


Which diagnostic test should follow the preliminary assessment?

Standard exercise ECG

If exercise ECG can’t be interpreted / performed:

If due to left bundle branch block: Pharmacologic stress test with imaging (radionuclide perfusion of myocardium / ECHO)

If due to other abnormalities: Exercise stress test with imaging (radionuclide perfusion of myocardium / ECHO)

If patient can’t exercise: Pharmacologic stress test with imaging (radionuclide perfusion of myocardium / ECHO)

Coronary artery calcium for assessment: uncertain

Low coronary artery calcium score identifies people w/o CAD

High score is less reliable in ruling in CAD


Predicts mortality risk based on ECG once the diagnosis is established

If ≥ +5: estimated cardiac mortality rate ≤ 1%/y, usually no further risk assessment required

If < +5 and ≥ -10: use stress imaging or coronary angiography to stratify into low-risk and high-risk groups

If < -10: annual mortality ≥ 3%, consider for revascularization

Duke Treadmill Score


When should clinicians refer patients with suspected ischemic heart disease to specialists?

Consult a cardiologist when…

Diagnosis uncertain after noninvasive testing

Noninvasive testing is contraindicated


When should coronary angiography be used as the initial test to evaluate people with suspected ischemic heart disease?

Patients have survived sudden cardiac death or a life-threatening ventricular arrhythmia

Some employers require before allowing return to work

Regardless of the results from noninvasive testing

Pilots, firefighters, police force

Patients have a high likelihood of severe CAD

Coronary artery spasm strongly suspected

Some patients with HF


CLINICAL BOTTOM LINE: Diagnosis… Predictors of CAD

Age, sex, type of chest pain Smoking history, hyperlipidemia, diabetes mellitus

Physical exam Identify cardiac disease other than CAD Identify comorbid diseases exacerbating angina

Diagnostic tests Resting ECG and chest x-ray Exercise ECG: CAD probability, mortality risk Coronary angiography: specific, limited subset of patients

Consult cardiologist if: Diagnosis uncertain after noninvasive testing Noninvasive testing contraindicated


What are the goals of treatment?

Minimize likelihood of death & maximize health and function

Reduce premature CV death

Prevent complications that impair functional well-being

Strategies for achieving treatment goals

Patient education

Lifestyle modification

Medical therapy

Revascularization (coronary artery bypass grafting or PCI)

Use guideline-directed medical therapy — whether or not revascularization occurs


What is the role of patient education?

Reduce risk factors Improve medication adherence Improve patient satisfaction

Should include:

Review of individual prognosis and important risk factors

Ways to reduce these risk factors

Benefits + side effects of medications and how to administer

Address limitations on physical activity

When to seek medical help

MI signs, symptoms; when to use aspirin, nitroglycerin

What to do in an emergency


Which risk factors should be modified?

Smoking

Recommend smoking cessation and develop cessation plan

Physical activity

If angina chronic + stable: moderate aerobic activity ≥5 d/wk

If high risk of cardiac complications: medically supervised program helps establish safe exercise regimen

Dietary modification

Diet low in saturated fat, cholesterol, trans-fatty acids, and sodium and rich in fresh fruits, vegetables, whole grains

Omega-3 fatty acids, plant stanols/sterols, fiber: reduce risk

If alcohol is part of the diet, consumption should be moderate

Lipid management


Which medical therapies can prevent myocardial infarction or death?

Antiplatelet therapy

Annual influenza vaccine

ACE inhibitors

Angiotensin-receptor antagonists

Beta-blocker therapy

Vitamins and mineral supplements aren’t recommended for preventing CAD events


Which medical therapies relieve symptoms?

Short-acting nitrates

β-blocker Therapy

Calcium-channel blockers and long-acting nitrates

Ranolazine

Alternative therapies for refractory angina in SIHD

Spinal cord stimulation

Enhanced external counterpulsation

Transmyocardial revascularization


Which patients with SIHD are candidates for revascularization with either CABG or a PCI?

To improve survival if mortality risk is high

Left main or complex CAD

>50% stenosis in left main coronary artery

>70% in 3 major coronary arteries

>70% in proximal left anterior descending artery + 1 other major coronary artery

Survivors of sudden cardiac death (presumed ischemia-mediated ventricular tachycardia from >70% stenosis in major coronary artery)

To relieve symptoms if they persist despite therapy

For stenosis likely to affect survival: same recommendations

Other patients with >70% stenosis in ≥1 coronary arteries


Are there special considerations for women, older adults, or patients with diabetes mellitus, CKD, or other conditions? Women

More atypical chest pain + angina-equivalent symptoms

Tend to be treated less aggressively (bc different presentation and testing compared to men?)

Older adults Diagnosis and stress testing harder due to physiologic

changes of aging, coexisting conditions

Receive less evidence-based care (bc pharmacotherapy more difficult? bc of increased CABG morbidity, mortality?)

Diabetes mellitus

Greater risk of SIHD + magnified effects of other risk factors

Chronic kidney disease

Greater risk of SIHD + poor outcomes after AMI interventions


How should patients with treated ischemic heart disease be followed?

Each visit: obtain detailed information on angina

Decreased level of physical activity since the last visit?

Has angina increased in frequency or become more severe?

Are risk factors modified and IHD knowledge improved?

Any new comorbid illnesses?

Has severity or treatment of comorbid illnesses worsened angina?

Assess adherence to therapy and AEs

Encourage smoking cessation, exercise, balanced diet

Use lab evaluation to monitor modifiable risk factors

ECHO / radionuclide imaging / stress test: new symptoms


What do professional organizations recommend with regard to prevention, screening, diagnosis and treatment of SIHD?

Use 2012 clinical guideline for diagnosis and management of SIHD

From the ACP, ACC Foundation, AHA, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons


CLINICAL BOTTOM LINE: Treatment… Minimize likelihood of death & maximize health and function

Use guideline-directed medical therapy

Reduce risk factors with lifestyle modifications and medical Rx

Patient education ensures Understanding of underlying disease process Understanding of warning signs and symptoms of MI Informed decisions about treatment options

Consider revascularization if mortality risk is high or symptoms persist despite guideline-directed medical therapy

© copyright annals of internal medicine, 2014 ann int med. 160 (1): itc1-1. * for best viewing:...

Documents

slide slide

ann int

clinic slide sets

copyright infringement

acp copyright notice

entire slide set

emotion unstable angina

highrisk unstable angina