From the Guidelines
For a 59-year-old smoker with cardiomyopathy, coronary artery disease (CAD), and dyspnea on exertion, immediate smoking cessation and a comprehensive medical management approach are crucial to improve morbidity, mortality, and quality of life. The patient's management should be guided by the latest evidence-based guidelines, including the 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA guideline for the management of patients with chronic coronary disease 1.
Medical Management
The medical management should include:
- A beta-blocker (such as metoprolol 25-100 mg twice daily) for cardiomyopathy and CAD, as recommended by the 2023 guideline 1
- An ACE inhibitor (like lisinopril 5-40 mg daily) for cardiomyopathy and hypertension, if present
- A statin (atorvastatin 40-80 mg daily) for lipid lowering and to reduce cardiovascular risk
- Aspirin 81 mg daily for CAD, unless contraindicated
- Diuretics like furosemide 20-40 mg daily may help manage fluid retention causing dyspnea
Lifestyle Modifications
Lifestyle modifications are essential to reduce cardiovascular risk and improve symptoms:
- Immediate smoking cessation, with consideration of smoking cessation aids such as nicotine replacement therapy, varenicline, or bupropion
- A low-sodium diet (less than 2 grams daily) and fluid restriction if heart failure is present
- Encouragement of habitual physical activity, including aerobic and resistance exercise, as recommended by the 2023 guideline 1
- Cardiac rehabilitation to improve exercise capacity and reduce morbidity and mortality
Diagnostic Evaluation
A comprehensive cardiac evaluation is necessary to assess the patient's condition and guide management:
- Echocardiography to assess ejection fraction and cardiac function
- Stress testing to evaluate for inducible ischemia
- Possibly cardiac catheterization to evaluate coronary anatomy and consider revascularization, if indicated
By following this multifaceted approach, addressing both the underlying cardiac conditions and modifiable risk factors, the patient's morbidity, mortality, and quality of life can be improved. The 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA guideline 1 and the 2019 ESC guidelines for the diagnosis and management of chronic coronary syndromes 1 provide the foundation for this evidence-based management strategy.
From the Research
Cardiomyopathy and CAD with Dyspnea on Exertion
- A 59-year-old smoker experiencing dyspnea on exertion may be at risk for cardiomyopathy and coronary artery disease (CAD) 2, 3.
- Cardiomyopathy can be separated into primary and secondary categories, resulting in varied phenotypes including dilated, hypertrophic, and restrictive patterns 2.
- Hypertrophic cardiomyopathy is the most common primary cardiomyopathy and can cause exertional dyspnea, presyncope, atypical chest pain, heart failure, and sudden cardiac death 2.
- Dyspnea is associated with worse prognosis than typical angina for patients referred for non-invasive CAD imaging 3.
Relationship between Dyspnea and CAD
- Both dyspnea and typical angina are associated with higher rates of obstructive CAD compared to those without dyspnea or typical angina 3.
- Dyspnea, but not typical angina, is associated with coronary plaque in proximal vessel portions 3.
- The symptom of exertional dyspnea in patients with heart failure is not determined by abnormalities in ventilatory function or demand 4.
Treatment and Management
- ACE inhibitors, such as lisinopril, have been shown to reduce mortality and cardiovascular morbidity in patients with myocardial infarction and CAD 5, 6.
- Clinical pharmacy services can increase the percentage of patients with CAD and diabetes receiving the goal dosage of ACE inhibitors 6.
- Treatment of cardiomyopathy may include appropriately staged therapy for heart failure, activity restriction, evaluation for implantable cardioverter-defibrillator placement, and consideration of heart transplantation in refractory cases 2.