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Cardiology - Ischemic Heart Disease

Cardiology - Ischemic Heart Disease

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 Primary PreventionUse the ASCVD risk calculator to assess 10-year risk. If it’s ≥7.5%, start a statin.Patients with LDL ≥190 mg/dL should be started on a high-intensity statin regardless of other factors.Diabetics aged 40–75 with LDL between 70–189 mg/dL should receive moderate- or high-intensity statins.Always address lifestyle: smoking cessation, regular exercise, weight control, and blood pressure optimization.Secondary Prevention (Established CAD)All patients with a history of MI or documented coronary disease should be on a statin and aspirin unless contraindicated.Control hypertension and diabetes aggressively.Statins are protective even in patients with average cholesterol due to plaque stabilization.Stable AnginaStart beta-blockers—they lower heart rate and myocardial oxygen demand.If symptoms persist, add nitrates.Use calcium channel blockers if beta-blockers are contraindicated (e.g., asthma, bradycardia). Prefer diltiazem or verapamil.Avoid short-acting nifedipine; amlodipine is safe in patients with low EF.Diagnostic StrategyTreadmill ECG stress testing is appropriate for intermediate-risk patients with a readable resting ECG.Use stress echo or nuclear testing if the ECG is uninterpretable or the patient cannot exercise.Findings like early ST changes, hypotension, or prolonged recovery on stress test suggest high risk and warrant angiography.Revascularization: PCI vs CABGPCI is preferred in single-vessel disease, younger patients, or those not fit for surgery.CABG improves survival in left main disease, 3-vessel disease with low EF, and in diabetics with diffuse multivessel disease.Internal mammary artery grafts are more durable than saphenous vein grafts.NSTEMI / Unstable AnginaImmediately obtain ECG, troponins, and place on telemetry.Initiate aspirin, beta-blocker, and anticoagulation (e.g., heparin).Add clopidogrel unless surgery is expected within 5 days.If troponin is elevated, ST changes are present, or symptoms are recurrent, arrange for angiography within 48 hours.STEMIFor chest pain with ST elevation or new LBBB, activate the cath lab if PCI can be done within 90–120 minutes.If PCI is delayed and no contraindications exist, give fibrinolytics (e.g., tenecteplase).Administer aspirin + clopidogrel, heparin, and oxygen if hypoxic.Avoid nitrates in hypotension, right ventricular infarct, or recent PDE5 inhibitor use.Start beta-blockers and ACE inhibitors within 24 hours unless contraindicated.Post-MI CareContinue aspirin and statin for life.Use beta-blockers long-term unless contraindicated.Add ACE inhibitors in anterior MI, reduced EF (<40%), or heart failure.Consider spironolactone or eplerenone in those with EF <40% plus diabetes or HF—avoid if potassium >5 or creatinine >2.5.Check LVEF before discharge. If ≤35% at 40 days, consider ICD.Complications to Watch ForSudden shock or PEA after MI? Suspect free wall rupture.New murmur + shock = think VSD or papillary rupture. Call surgery urgently.JVD with clear lungs after inferior MI? Think right ventricular infarct—give fluids, not nitrates=================Ischemic Heart DiseaseIf myocardial blood supply is diminished, then ischemic heart disease may result, ranging from silent ischemia to sudden death.If primary prevention and novel treatments are used, then death rates from acute MI decrease substantially (as seen since the 1970s).Risk Assessment and PreventionIf calculating 10-year ASCVD risk, then use the ASCVD risk calculator (age, sex, race, cholesterol, BP, diabetes, smoking).If patient smokes, has high LDL-C, low HDL-C, or hypertension, then these are modifiable and should be addressed.If patient has diabetes, obesity, metabolic syndrome, high triglycerides, or sedentary lifestyle, then intervention reduces risk.If a patient quits smoking, then their risk rapidly approaches that of nonsmokers within 2–3 years.If total cholesterol is reduced by 1%, then ischemic heart disease risk drops by 2–3%.If LDL-C is reduced, then it slows atherosclerosis progression and prevents events.If SBP is reduced by 10–12 mmHg (or DBP by 5–6 mmHg), then strokes drop 35–40%, CAD 20–25%, CHF 45–55%, and CV death 20–25%.If a patient maintains an active lifestyle, then MI risk falls 35–55%.If diabetes mellitus is present, then adjusted mortality is 2–7× higher.If moderate alcohol intake is present, then risk may decrease; if heavy, then risk increases.If metabolic syndrome is present, then CV mortality risk is increased 2–3×.If intermediate ischemic risk and low bleeding risk, then consider aspirin.If a woman has CV disease, then estrogen therapy is contraindicated.Secondary PreventionIf known ischemic heart disease is present, then initiate statins, control BP, diabetes, and encourage smoking cessation.If statins are used post-MI, then events decrease beyond plaque regression due to plaque stabilization.If cholesterol >220 mg/dL post-MI, then statins reduce all-cause mortality by 30% and coronary mortality ...
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