Treatment of Ischemic Heart Disease

Objectives of Treatment

The treatment of ischemic heart disease aims to improve myocardial perfusion, reduce the risk of cardiovascular events, and enhance the patient’s quality of life.

The main objectives of therapy are:

• Reduction of anginal symptoms.
• Prevention of atherosclerosis progression and ischemic complications.
• Improvement of ventricular function in patients with myocardial dysfunction.
• Prevention of sudden death in high-risk patients.

Therapeutic Approaches

The treatment of ischemic heart disease is based on three fundamental pillars:

• Lifestyle modifications: Essential non-pharmacological interventions for risk factor control.
• Pharmacological therapy: Use of anti-ischemic and cardioprotective drugs.
• Coronary revascularization: Interventional strategies to restore coronary blood flow.

Lifestyle Modifications

Lifestyle modifications are the first step in managing ischemic heart disease and are essential for both primary and secondary prevention.

• Smoking cessation: Smoking accelerates atherosclerosis progression and increases the risk of acute ischemic events.
• Weight control: Obesity is a major risk factor for hypertension, diabetes, and dyslipidemia.
• Physical activity: Moderate aerobic exercise (30-45 minutes at least 5 days per week) improves endothelial function and reduces cardiovascular event risk.
• Healthy diet: A Mediterranean diet rich in fruits, vegetables, fish, and unsaturated fats improves vascular function and reduces atherosclerosis risk.
• Stress management: Stress management strategies such as mindfulness and relaxation techniques can help reduce ischemic events.

Pharmacological Therapy

The pharmacological treatment of ischemic heart disease includes anti-ischemic drugs, prognosis-modifying drugs, and specific therapies for different ischemic conditions.

Anti-Ischemic Drugs

These drugs aim to reduce myocardial oxygen demand and improve coronary perfusion:

• Beta-blockers: Reduce heart rate and myocardial oxygen consumption. Indicated for stable angina and post-myocardial infarction.
• Calcium channel blockers: Diltiazem and verapamil (non-dihydropyridines) reduce heart rate and oxygen consumption; amlodipine and nifedipine (dihydropyridines) have a coronary vasodilatory effect. Useful in vasospastic angina.
• Nitrates: Coronary vasodilation and preload reduction. Used for the acute treatment of angina.
• Ranolazine: Acts by reducing late sodium current, improving myocardial diastolic function without hemodynamic effects.

Prognosis-Modifying Drugs

These drugs slow atherosclerosis progression and reduce the risk of cardiovascular events:

• Antiplatelet agents: Aspirin reduces thrombotic events, while clopidogrel is indicated in aspirin-intolerant patients or post-angioplasty.
• Statins: Essential for lowering LDL cholesterol and slowing atherosclerosis progression.
• ACE inhibitors and ARBs: Indicated for patients with left ventricular dysfunction, hypertension, or diabetes.
• Anticoagulants: Used in patients with atrial fibrillation or ventricular thrombosis.

Revascularization Strategies

Revascularization is indicated in patients with ischemia refractory to medical therapy or critical coronary stenosis.

Percutaneous Coronary Intervention (PCI)

Angioplasty with stent implantation is the first-choice technique for treating significant coronary stenoses. Main indications:

• Symptomatic stable angina not controlled with medical therapy.
• Acute coronary syndrome with or without ST-segment elevation.
• Significant coronary stenosis with documented ischemia on stress tests.

Coronary Artery Bypass Grafting (CABG)

Coronary bypass surgery is indicated in patients with:

• Multivessel coronary artery disease with left ventricular dysfunction.
• Left main coronary artery involvement.
• Multiple stenoses not amenable to angioplasty.

Specific Treatment for Different Ischemic Conditions

Each form of ischemic heart disease has specific therapeutic strategies:

Stable Angina

• Beta-blockers and calcium channel blockers as first-line therapy.
• Nitrates for symptom control.
• Statins and antiplatelet agents for secondary prevention.

Unstable Angina

• Hospitalization for monitoring and risk stratification.
• Dual antiplatelet therapy (aspirin + P2Y12 inhibitors such as clopidogrel).
• Anticoagulants (low molecular weight heparin).
• Early coronary angiography for revascularization assessment.

Myocardial Infarction (STEMI/NSTEMI)

• Urgent revascularization: Primary PCI for STEMI or early invasive strategy for NSTEMI.
• Intensive antithrombotic therapy with aspirin, P2Y12 inhibitors, and anticoagulants.
• Beta-blockers, ACE inhibitors, and statins for secondary prevention.

Vasospastic Angina

• Calcium channel blockers and nitrates as first-line therapy.
• Avoid beta-blockers, which may worsen vasospasm.
• Evaluation with provocative tests to confirm diagnosis.

Conclusion

The treatment of ischemic heart disease must be tailored based on the clinical presentation and severity of the condition. Optimizing pharmacological therapy and selecting the most appropriate revascularization strategy are crucial for improving patient prognosis and quality of life.

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