ISCHEMIC

HEART DISEASE
TREATMENT

RUPESH MOHANDAS
GR 3
The treatment of chronic ischemic heart disease has two major goals:

▪ (i) to prevent myocardial infarction (MI) and death, thereby improving life
expectancy.

▪ (ii) to reduce symptoms of angina and the occurrence of ischemia, which

should improve quality of life.
Medical Treatment to Prevent Recurrent Ischemic Episodes

Pharmacologic agents are the first line of defense in the prevention of anginal attacks.
The goal of these agents is to
▪ decrease cardiac workload (i.e., reduce myocardial oxygen demand) and
▪ increase myocardial perfusion.
The three classes of medications most commonly used are the
 Organic nitrates
 β-adrenergic blockers
 Calcium channel blockers.
 NITRATES

▪ Nitrates dilate epicardial coronary arteries and arterioles and reduce

cardiac preload.
▪ Nitrates relieve ischemia primarily through vascular smooth muscle
relaxation, particularly venodilatation.
▪ Results, drop in peripheral resistance and BP and decrease venous return
to the heart.
▪ This decreases myocardial workload and restores balance in supply-
demand ratio in heart.
TYPES :- Isosorbide dinitrate, isosorbid mononitrate, nitroglycerin.
▪ Short-acting nitrates, which are most often administered as sublingual
tablets or buccal mucosal spray, are commonly used to treat acute
episodes of angina (rapid onset of action).
▪ Longer-acting anginal prevention can be achieved through oral tablets of
isosorbide dinitrate (or mononitrate) or a transdermal nitro glycerin
patch.
▪ The most important aspect of long-term nitrate therapy is to ensure an
adequate nitrate-free interval (typically night time), which will prevent
nitrate tolerance.
▪ Common side effects include headache, lightheadedness, and
palpitations induced by vasodilatation and reflex sinus
tachycardia.
▪ The latter can be prevented by combining a β-blocker with the
nitrate regimen.
 β - BLOCKERS

▪ β-blockers decrease heart rate, contractility and arterial pressure,

resulting in decreased myocardial oxygen demand.
▪ In patients with chronic stable exertional angina, β-blockers decrease
heart rate and blood pressure during exercise, and the onset of angina
(ischaemic threshold) is delayed or avoided.
▪ β-blockers are first-line chronic therapy in the treatment of CAD.
▪ Contraindications are severe bradycardia, pre-existing high degree
atrioventricular block, and severe decompensated left ventricular failure (β-
blockers have now been shown to reduce total mortality in patients with
compensated heart failure).
▪ β-blockers should also be avoided in patients with pure vasospastic angina
because these agents may induce coronary vasospasm from unopposed α-
receptor activity.
▪ Most diabetic patients tolerate β-blockers, although these agents should
be used cautiously in patients who require insulin because they can mask
tachycardia and other catecholamine-mediated responses that can warn
of hypoglycemia .
▪ They may precipitate bronchospasm in patients with underlying asthma
by antagonizing β2-receptors in the bronchial tree. All β-blockers should
be used cautiously, or avoided, in patients with significant obstructive
airway disease
 CALCIUM CHANNEL BLOCKERS

▪ Calcium channel blockers block voltage-gated L-type calcium channels.

▪ These agents are commonly divided into the dihydropyridine and
nondihydropyridine classes.
▪ Calcium antagonists decrease coronary vascular resistance and increase
coronary blood flow.
▪ All of these agents cause dilatation of the epicardial coronary vessels which
is the principal mechanism that allows calcium antagonists to relieve
vasospastic angina.
 Calcium antagonists decrease myocardial oxygen demand by
i. reduction of systemic vascular resistance and
ii. reduction in arterial pressure.
▪ Nondihydropyridine calcium channel blockers (verapamil and diltiazem)
reduce myocardial oxygen demand by
i. decreasing heart rate and
ii. contractility.
▪ Short-acting dihydropyridine calcium antagonists have the potential to
enhance the risk of adverse cardiac events and should be avoided.
▪ Long-acting calcium antagonists of the dihydro-and nondihydropyridine
class relieve angina and are appropriate initial therapy in patients with
contraindications to β-blockers.
▪ They can also be substituted for β-blockers in patients who develop
unacceptable side effects or can be used in combination with β-blockers
when initial β-blockers therapy is unsuccessful.
 Ranolazine

▪ It is a fourth type of anti-ischemic therapy and is the most recent to

become available.
▪ Inhibit the late phase of the action potential’s inward sodium current in
ventricular myocytes.
▪ The decrease in intracellular sodium causes an increase in calcium
expulsion via the Na/Ca transporter and a reduction in cardiac force and
work.
▪ Ranolazine is moderately effective in angina prophylaxis.
Medical Treatment to Prevent Acute Cardiac Events

ANTIPLATELET AGENTS
▪ Aspirin acts by inhibiting cyclooxygenase and synthesis of platelet
thromboxane A2.
▪ It is effective in preventing first heart attacks, improving mortality in acute
coronary syndromes, and reducing adverse cardiovascular events in
patients with stable angina pectoris.
▪ Aspirin should therefore be considered as first line therapy in all patients
with chronic ischaemic heart disease.
LIPID LOWERING THERAPY

▪ The HMG-CoA reductase inhibitors or statins are the most potent agents
available in lowering total and low density lipoprotein (LDL).
▪ Lower MI and death rates in patients with established coronary disease
and in those at high risk of developing CAD.
▪ Benefits of statin therapy is that they decrease vascular inflammation
and improve endothelial cell dysfunction which may help to stabilize
atherosclerotic plaques.
▪ All patients with CAD should have their LDL cholesterol maintained at
<100 mg/dL.
 REVASCULARIZATION

Coronary revascularization is done if

▪ (1) the patient’s symptoms of angina do not respond adequately to antianginal
drug therapy,
▪ (2) unacceptable side effects of medications occur, or
▪ (3) the patient is found to have high-risk coronary disease for which
revascularization is known to improve survival
The two techniques used to accomplish mechanical revascularization are
▪ Percutaneous Coronary Intervention (PCI) and
▪ Coronary Artery Bypass Graft (CABG) surgery
Percutaneous Coronary Intervention (PCI)

▪ PCI (formerly known as angioplasty with stent) is a non-surgical procedure.

▪ A catheter (a thin flexible tube) is used to place a small structure called a
stent to open up blood vessels in the heart, that have been narrowed by
plaque build-up.
▪ This improves blood flow, thus decreasing heart-related chest pain (angina),
making you feel better and increasing your ability to be active.
▪ Because stents are thrombogenic, a combination of oral antiplatelet agents
(commonly, aspirin plus clopidogrel) is crucial after stent implantation.
▪ A catheter is inserted through a
peripheral artery (usually, femoral,
brachial, or radial).
▪ Using a special type of X-ray called
fluoroscopy, the catheter is threaded
through the blood vessels into the
heart where the coronary artery is
narrowed.
▪ When the tip is in place, a balloon tip
covered with a stent is inflated.
▪ The balloon tip compresses the plaque
and expands the stent.
▪ Once the plaque is compressed and
the stent is in place, the balloon is
deflated and withdrawn.
▪ The stent stays in the artery, holding it
open.
Coronary Artery Bypass Graft (CABG) Surgery

▪ A coronary artery bypass graft (CABG) is a surgical procedure used to

treat coronary heart disease.
▪ It diverts blood around narrowed or clogged parts of the major arteries
to improve blood flow and oxygen supply to the heart.
▪ A coronary artery bypass graft involves taking a blood vessel from
another part of the body (usually the chest, leg or arm)
▪ Then attaching it to the coronary artery above and below the narrowed
area or blockage. This new blood vessel is known as a graft.
▪ The number of grafts needed will depend on how severe your coronary heart
disease is and how many of the coronary blood vessels are narrowed.
▪ A coronary artery bypass graft is carried out under general anaesthetic, which
means you'll be unconscious during the operation.
▪ It usually takes between 3 and 6 hours.
▪ As with all types of surgery, a coronary artery bypass graft carries a risk of
complications.
▪ These are usually relatively minor and treatable, such as an irregular heartbeat
or a wound infection, but there's also a risk of serious complications, such as
a stroke or heart attack.
▪ Two types of surgical grafts are used.
▪ The first employs native veins—typically, a
section of the saphenous vein that is sutured
from the base of the aorta to a coronary
segment downstream from the region of
stenosis.
▪ The second method uses arterial grafts—most
commonly, an internal mammary artery (branch
of subclavian artery)—that can be directly
anastomosed distal to a stenotic coronary site.
▪ Vein grafts have a patency rate of up to 80% at 12 months but are
vulnerable to accelerated atherosclerosis; 10 years after surgery, more
than 50% have occluded.
▪ In contrast, IMA grafts are more resistant to atherosclerosis with a
patency rate of 90% at 10 years.
▪ Therefore, IMA grafts are often used to perfuse sites of critical flow such
as the left anterior descending artery.
▪ Clinical trial evidence supports the use of aggressive lipid-lowering drug
therapy after CABG to improve the longterm patency rates of bypass
grafts.
REFRENCES

▪ nhs.uk/conditions/coronary-artery-bypass-graft-cabg/
▪ heartandstroke.ca/heart/treatments/surgery-and-other-
procedures/percutaneous-coronary-intervention
▪ mih.govmu.org
THANKYOU