Download Pharmacotherapy of Coronary Artery Disease

Pharmacotherapy of Coronary Artery Disease
Molly Roberts, PharmD Candidate 2007
Epidemiology Coronary artery disease is the number one killer or males and females in America. People who
Disease State
Definition
survive a heart attack have a 1.5-15 times higher chance of illness and death than the rest of the
population. Both men and women have a substantial risk of another heart attack, sudden death, angina
pectoris, heart failure and stroke. Successful treatment of chronic stable angina may prevent
myocardial infarction and death as well as reduce symptoms of angina and occurrence of
ischemia thereby improving the quality of life.
Coronary artery disease (CAD), also called coronary heart disease (CHD), ischaemic heart disease, and
atherosclerotic heart disease, is the end result of the accumulation of atheromatous plaques within
the walls of the arteries that supply the myocardium. While the symptoms and signs of coronary
heart disease are noted in the advanced state of disease, most individuals with coronary heart disease
show no evidence of disease for decades as the disease progresses before the first onset of symptoms,
often a "sudden" heart attack, finally arise. After decades of progression, some of these atheromatous
plaques may rupture and (along with the activation of the blood clotting system) start limiting blood
flow to the heart muscle.
Pathophysiology
Limitation of blood flow to the heart causes ischemia of the myocardial cells. When myocardial cells
die from lack of oxygen MI. This leads to heart muscle damage, heart muscle death and later
scarring without heart muscle regrowth.
Myocardial infarction usually results from the sudden occlusion of a coronary artery when a plaque
ruptures, activating the clotting system and atheroma-clot interaction fills the lumen of the artery to the
point of sudden closure. The typical narrowing of the lumen of the heart artery before sudden closure is
typically 20%, according to clinical research completed in the late 1990s and using IVUS examinations
within 6 months prior to a heart attack. High grade stenoses as such exceeding 75% blockage, such as
detected by stress testing, were found to be responsible for only 14% of acute heart attacks the rest
being due to plaque rupture/ spasm. The events leading up to plaque rupture are only partially
understood. Myocardial infarction is also caused, far less commonly, by spasm of the artery wall
occluding the lumen, a condition also associated with atheromatous plaque and CHD.
Clinical
Presentation
Many episodes of ischemia do not cause symptoms of angina (silent ischemia).
STABLE ANGINA
 Chest pain or complaining of “heaviness, pressure, squeezing, discomfort, tightness, or
constriction”
 Chest discomfort usually begins and ends gradually, is diffuse, and radiates
 Precipitated by exertion, emotional upset, cold weather, or heavy meals.
 Pain brought on by exertion usually abates 5-10 min after cessation of activity.
 Some pts (elderly, diabetics) with stable angina may not present with pain, but with “anginal
equivalent’ symptoms such as shortness of breath, fatigue, dizziness, light-headedness, nausea,
or diaphoresis
 Patients commonly have a normal PE (unless currently in chest pain: S4, paradoxically split S2,
or mitral regurgitation murmur may be noted)
UNSTABLE ANGINA
 New-onset angina
 Angina at rest
 Increased frequency of angina
 Increased severity of angina
 Increased duration of angina
Molly Roberts, PharmD Candidate 2007
University of Maryland School of Pharmacy
Pharmacotherapy Presentation – Pharmaceutical Care Rotation
Happy Harry’s Pharmacy Patient Care Center, Perryville, MD



Risk Factors
Diagnosis
Pain occurring with decreasing levels of exertion
Pain less promptly relieved with nitroglycerin
Patients commonly have a normal PE (unless currently in chest pain: S4, paradoxically split S2,
or mitral regurgitation murmur may be noted)
Risk factors that can be modified:
 Smoking: complete cessation; no exposure to environmental tobacco smoke
 Blood Pressure: less than 140/90mmHg or less than 130/80mmHg if the patient has diabetes or
CKD
 Lipid Management: LDL-C should be less than 100mg/dL, and it is reasonable to aim for a
level less than 70mg/dL. If triglycerides are equal to or greater than 200mg/dL, non-HDL-C
should be less than 130mg/dL, and it is reasonable to aim for a level less than 100mg/dL
 Physical Activity: 30-60 minutes seven days a week (minimum five days per week)
 Weight Management: BMI - 18.5 to 24.9 kg/m2; waist circumference – men less than 40
inches, women less than 35 inches
 Diabetes Management: HbA1c levels less than 7 percent
Risk factors that cannot be modified:
 Age: men older than 45 years old and women older than 55 years old are at a higher risk
 Family History: heart disease diagnosed before age 55 in father or brother; diagnosed before
age 65 in mother or sister.
Potential risk factors:
 High blood levels of C-reactive protein (CRP), which shows in the presence of inflammation.
No single test to diagnose CAD.
EKG for any chest pain thought to be ischemic in etiology. Most pts with unstable angina have EKG
changes (most commonly ST segment depression and T-wave inversion).
In patients presenting with chest pain, a detailed symptom history, focused physical examination,
and directed risk-factor assessment should be performed. With this information, the clinician should
estimate the probability of significant CAD (i.e., low, intermediate, or high).
The following tests may be necessary:
 Echocardiogram
 Exercise Stress Test: useful in establishing diagnosis and provides prognostic info
 Chest x-ray
 Cardiac catheterization: gold standard of diagnosing CAD; however, very invasive
 Coronary angiography
 Nuclear heart scan
 Fasting glucose test
 Fasting lipoprotein profile
 Hemoglobin
Desired
Therapeutic
Outcomes*
*Reference of
Guidelines Used
Stable Angina:
 Reduce risk of MI and death and thereby increase the “quantity” of life
 Reduce symptoms of angina and the occurrence of ischemia, which should improve the quality
of life
Unstable Angina:
 Reduce risk of death or MI/(re)infarction
 Immediate relief of pain/ischemia
ACC/AHA 2002 guideline update for the management of patients with chronic stable angina: a
report of the American College of Cardiology/American Heart Association Task Force on Practice
Guidelines
Molly Roberts, PharmD Candidate 2007
University of Maryland School of Pharmacy
Pharmacotherapy Presentation – Pharmaceutical Care Rotation
Happy Harry’s Pharmacy Patient Care Center, Perryville, MD
Treatment
Options**
(Non-drug and
Drug Therapy
– include all
therapeutic
classes/agents
available and
preferences
per treatment
guidelines)
**See Treatment
Options Table
Non-Drug Therapy:
 Eat a healthy diet to prevent or reduce high blood pressure and high cholesterol and to maintain
a healthy weight
 Quit smoking, if you smoke
 Exercise, as directed by your doctor
 Lose weight, if you are overweight or obese
 Reduce stress
 For the first time, flu shots are recommended in patients with chronic cardiovascular disease.
 Treat underlying medical conditions that may aggravate myocardial ischemia such as
hypertension, tachycardia, fever, thyrotoxicosis, anemia, or hypoxemia
 Modification of activities that exacerbated angina (cold weather, postprandial exercise)
Drug Therapy for Stable Angina:
 Aspirin/Antiplatelet therapy
 BB
 CCB
 Nitroglycerin
 Long-acting nitrates
Drug Therapy for Unstable Angina:
 Bed rest with continuous ECG monitoring for ischemia and arrhythmia detection in patients
with ongoing rest pain
 Aspirin/antiplatelet therapy
 NTG
 Supplemental O2
 Morphine PRN
 BB
 ACEI
 Nondihydropyridine CCB (verapamil or diltizem)
Monitoring
(Efficacy and
Toxicity
Parameters)
Additional Treatment of Risk Factors:
 Treatment of hypertension according to JNC VI
 Management of diabetes
 LDL-lowering therapy in patients with documented or suspected CAD and LDL cholesterol
greater than or equal to 130 mg/dL, with a target LDL of less than 100mg/dL
Indices of Therapeutic Effect:
Stable Angina:
 Decrease frequency of chest pain and TNG administration
 Increase exercise tolerance
Unstable Angina:
 Relieve chest pain and improvement of pattern of pain
 No evolution to MI
For complete monitoring parameters for individual agents/classes see Pharmacological Treatment
Options Chart.
Molly Roberts, PharmD Candidate 2007
University of Maryland School of Pharmacy
Pharmacotherapy Presentation – Pharmaceutical Care Rotation
Happy Harry’s Pharmacy Patient Care Center, Perryville, MD