Coronary heart disease medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Goals for treating coronary artery disease include lowering blood pressure, maintaining HbA1c levels to less than 7%, and lowering LDL cholesterol. Long-term treatment will generally depend on the symptoms and severity of disease, and include aspirin, ACE inhibitors, and other ani-coagulant and anti-platelet regimens. The mainstay of treatment for stable angina which occurs with exertion, includes nitroglycerin. When unstable angina causes symptoms at rest, or in the setting of an acute myocardial infarction, the immediate therapy is morphine, oxygen, nitrate and aspirin. Angioplasty may also be required in cases of acute coronary syndrome.
Medical Therapy
Goals of Treatment
- Goals for treating people who have coronary artery disease:
- Blood pressure less than or equal to 140/90 (even lower for some patients with diabetes, kidney disease, and heart failure)
- Glycosylated hemoglobin (HbA1c) levels less than or equal to 7%
- LDL cholesterol level less than or equal to 100 mg/dL (even lower for some patients)
- Treatment depends on symptoms and how severe the disease is. Medications to treat CHD, include:
- ACE inhibitors to lower blood pressure and protect the heart and kidneys.
- Aspirin, with or without clopidogrel (Plavix) or prasugrel (Effient) to help prevent blood clots from forming in the arteries and reduce risk of having a heart attack.
Medical Therapy for Angina
Angina that occurs regularly with activity, upon awakening, or at other predictable times is termed stable angina and is associated with high grade narrowings of the heart arteries. The symptoms of angina are often treated with nitrate preparations such as nitroglycerin, which come in short-acting and long-acting forms, and may be administered transdermally, sublingually or orally. Many other more effective treatments, especially of the underlying atheromatous disease, have been developed.
Angina that changes in intensity, character or frequency is termed unstable. Unstable angina may precede myocardial infarction, and requires urgent medical attention. It is treated with morphine, oxygen, intravenous nitroglycerin, and aspirin. Interventional procedures such as angioplasty may be done.
- Beta-blockers to lower heart rate, blood pressure, and oxygen use by the heart. These reduce the risk of arrhythmias and improve survival after a heart attack or with heart failure.
- Calcium channel blockers to relax arteries, lower blood pressure, and reduce strain on the heart.
- Diuretics to lower blood pressure and treat congestive heart failure.
- Nitrates (such as nitroglycerin) to stop chest pain and improve blood supply to the heart.
- Statins to lower cholesterol.
Contraindicated medications
Coronary heart disease is considered an absolute contraindication to the use of the following medications:
- Drospirenone and Ethinyl estradiol
- Ethynodiol diacetate and ethinyl estradiol
- Hydralazine
- Frovatriptan
- Hyoscyamine
- Norethindrone acetate and Ethinyl estradiol
- Norgestimate and Ethinyl estradiol
- Norgestrel and Ethinyl estradiol
- Norelgestromin and Ethinyl Estradiol
- Sumatriptan
- Phentermine
2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease
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ACCF/AHA/SCAI 2011 Guideline for Percutaneous Coronary Intervention and 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death[1][2] (DO NOT EDIT)
Intravenous Antiplatelet Therapy in Sudden Ischemia Heart Disease (SIHD)[1]
| Class IIa |
| "1. In patients undergoing elective PCI treated with unfractionated heparin (UFH) and not pretreated with clopidogrel, it is reasonable to administer a GP IIb/IIIa inhibitor (abciximab, double-bolus eptifibatide, or high-bolus dose tirofiban).[3][4][5] (Level of Evidence: B)" |
| Class IIb |
| "1. In patients undergoing elective PCI with stent implantation treated with unfractionated heparin (UFH) and adequately pretreated with clopidogrel, it might be reasonable to administer a GP IIb/IIIa inhibitor (abciximab, double-bolus eptifibatide, or high-bolus dose tirofiban).[3][6][7][8] (Level of Evidence: B)" |
Ventricular Arrhythmias with High Lipids[2]
| Class I |
| "1. Statin therapy is beneficial in patients with CHD to reduce the risk of vascular events, possibly ventricular arrhythmias, and SCD. (Level of Evidence: A)." |
| Class IIb |
| "1. n-3 polyunsaturated fatty acid supplementation may be considered for patients with ventricular arrhythmias and underlying CHD. (Level of Evidence: B)" |
References
- ↑ 1.0 1.1 Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH (2011). "2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: Executive Summary A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions" (PDF). Journal of the American College of Cardiology. 58 (24): 2550–83. doi:10.1016/j.jacc.2011.08.006. PMID 22070837. Retrieved 2011-12-08. Text "PDF" ignored (help); Unknown parameter
|month=ignored (help) - ↑ 2.0 2.1 Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M; et al. (2006). "ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (writing committee to develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society". Circulation. 114 (10): e385–484. doi:10.1161/CIRCULATIONAHA.106.178233. PMID 16935995.
- ↑ 3.0 3.1 Valgimigli M, Percoco G, Barbieri D, Ferrari F, Guardigli G, Parrinello G, Soukhomovskaia O, Ferrari R (2004). "The additive value of tirofiban administered with the high-dose bolus in the prevention of ischemic complications during high-risk coronary angioplasty: the ADVANCE Trial". Journal of the American College of Cardiology. 44 (1): 14–9. doi:10.1016/j.jacc.2004.03.042. PMID 15234398. Retrieved 2011-12-15. Unknown parameter
|month=ignored (help) - ↑ "Randomised placebo-controlled and balloon-angioplasty-controlled trial to assess safety of coronary stenting with use of platelet glycoprotein-IIb/IIIa blockade". Lancet. 352 (9122): 87–92. 1998. PMID 9672272. Retrieved 2011-12-15. Unknown parameter
|month=ignored (help) - ↑ "Novel dosing regimen of eptifibatide in planned coronary stent implantation (ESPRIT): a randomised, placebo-controlled trial". Lancet. 356 (9247): 2037–44. 2000. doi:10.1016/S0140-6736(00)03400-0. PMID 11145489. Retrieved 2011-12-15. Unknown parameter
|month=ignored (help) - ↑ Kastrati A, Mehilli J, Schühlen H, Dirschinger J, Dotzer F, ten Berg JM, Neumann FJ, Bollwein H, Volmer C, Gawaz M, Berger PB, Schömig A (2004). "A clinical trial of abciximab in elective percutaneous coronary intervention after pretreatment with clopidogrel". The New England Journal of Medicine. 350 (3): 232–8. doi:10.1056/NEJMoa031859. PMID 14724302. Retrieved 2011-12-15. Unknown parameter
|month=ignored (help) - ↑ Mehilli J, Kastrati A, Schühlen H, Dibra A, Dotzer F, von Beckerath N, Bollwein H, Pache J, Dirschinger J, Berger PP, Schömig A (2004). "Randomized clinical trial of abciximab in diabetic patients undergoing elective percutaneous coronary interventions after treatment with a high loading dose of clopidogrel". Circulation. 110 (24): 3627–35. doi:10.1161/01.CIR.0000148956.93631.4D. PMID 15531766. Retrieved 2011-12-15. Unknown parameter
|month=ignored (help) - ↑ Hausleiter J, Kastrati A, Mehilli J, Schühlen H, Pache J, Dotzer F, Glatthor C, Siebert S, Dirschinger J, Schömig A (2004). "A randomized trial comparing phosphorylcholine-coated stenting with balloon angioplasty as well as abciximab with placebo for restenosis reduction in small coronary arteries". Journal of Internal Medicine. 256 (5): 388–97. doi:10.1111/j.1365-2796.2004.01398.x. PMID 15485474. Retrieved 2011-12-15. Unknown parameter
|month=ignored (help)