What are the main treatment strategies for ischemic heart disease?

Treatment is based on lifestyle modifications, pharmacological therapy (antiplatelet agents, statins, beta-blockers, ACE inhibitors) and revascularization procedures such as angioplasty or bypass.

When is coronary revascularization indicated?

Revascularization is indicated in cases of refractory angina, critical coronary stenoses, acute myocardial infarction or failure to respond to optimal medical therapy.

Which drugs reduce mortality in ischemic heart disease?

Statins, beta-blockers, ACE inhibitors/ARBs and antiplatelet agents reduce the risk of cardiovascular events and mortality in patients with ischemic heart disease.

What are the main goals of therapy?

Reduce symptoms, prevent disease progression and complications, improve ventricular function and survival.

Are lifestyle modifications truly effective?

Yes, quitting smoking, adopting a healthy diet, regular physical activity and weight control significantly reduce cardiovascular risk.

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Treatment of Ischemic Heart Disease

Treatment Objectives

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 cardiac death in high-risk patients.

Therapeutic Approaches

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

Lifestyle modifications: Non-pharmacological interventions essential for controlling risk factors.
Pharmacological therapy: Use of anti-ischemic and cardioprotective drugs.
Coronary revascularization: Interventional strategies to restore coronary blood flow.

Lifestyle Modifications

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

Smoking cessation: Smoking accelerates the progression of atherosclerosis and increases the risk of acute ischemic events.
Body weight control: Obesity is an important 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 the risk of cardiovascular events.
Healthy diet: A Mediterranean diet rich in fruits, vegetables, fish, and unsaturated fats improves vascular function and reduces the risk of atherosclerosis.
Stress management: Stress management strategies, such as mindfulness and relaxation techniques, can contribute to the reduction of ischemic events.

Pharmacological Therapy

Pharmacological treatment of ischemic heart disease includes anti-ischemic agents, drugs with prognostic benefit, and specific therapies for different ischemic conditions.

Anti-ischemic drugs

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

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

Drugs with prognostic benefit

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

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

Revascularization Strategies

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

Percutaneous Coronary Intervention (PCI)

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

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

Coronary Artery Bypass Grafting (CABG)

Coronary bypass is indicated in patients with:

Multivessel coronary disease with left ventricular dysfunction.
Involvement of the left main coronary artery.
Multiple stenoses not amenable to angioplasty.

(further details are available on the dedicated page on revascularization strategies)

Specific Therapy 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-choice therapy.
Avoid beta-blockers, which may worsen vasospasm.
Evaluation with provocative testing to confirm the diagnosis.

Conclusion

The therapy of ischemic heart disease must be individualized according to the clinical presentation and severity of the disease. Optimization of pharmacological treatment and the selection of the most appropriate revascularization strategy are crucial for improving prognosis and patients' quality of life.

References

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Ibanez B, et al. 2023 ESC Guidelines for the management of acute coronary syndromes. European Heart Journal. 2023;44(35):2999-3104.
Knuuti J, et al. Diagnostic imaging in ischemic heart disease. JACC Cardiovascular Imaging. 2022;15(4):455-472.
Patel MR, et al. Appropriate use criteria for coronary revascularization. J Am Coll Cardiol. 2021;78(7):813-834.
Douglas PS, et al. Role of non-invasive imaging in the assessment of stable ischemic heart disease. Circulation. 2021;143(10):983-1002.
Shah AS, et al. High-sensitivity cardiac troponin and diagnosis of myocardial infarction. NEJM. 2020;382(7):644-654.
Marwick TH, et al. Stress echocardiography for the detection of coronary artery disease. J Am Coll Cardiol. 2019;74(22):2932-2949.
Greenland P, et al. Coronary calcium scoring and risk stratification. JAMA. 2018;319(14):1421-1432.
Gersh BJ, et al. Chronic coronary syndromes: pathophysiology and clinical management. Lancet. 2019;394(10203):939-952.
Fihn SD, et al. ACCF/AHA Guidelines for the management of patients with stable ischemic heart disease. Circulation. 2017;136(12):e1-e65.