50 Clinical Facts About Cardiology
Comprehensive management of cardiac conditions requires a multidisciplinary approach focused on evidence-based therapies, lifestyle modifications, and secondary prevention strategies to reduce morbidity and mortality. 1
Acute Coronary Syndrome Management
NSTEMI/UA Management
- All NSTEMI patients should be screened for diabetes with frequent monitoring of blood glucose levels 1
- Avoid hypoglycemia in all ACS patients 1
- Apply the same diagnostic and therapeutic strategies in patients with CKD as those with normal renal function (with dose adjustments) 1
- Use low- or iso-osmolar contrast media at lowest possible volume during invasive procedures 1
- Apply the same diagnostic and interventional strategies in older patients as for younger patients 1
Post-MI Pharmacotherapy
Antiplatelet therapy:
Lipid management:
- Statins recommended for all ACS patients with goal of reducing LDL-C by ≥50% from baseline and/or achieving LDL-C <1.4 mmol/L (<55 mg/dL) 1
- Add ezetimibe if LDL-C goal not achieved after 4-6 weeks on maximum tolerated statin dose 1
- Add PCSK9 inhibitor if LDL-C goal not achieved after 4-6 weeks on maximum statin plus ezetimibe 1
Neurohormonal antagonists:
- ACE inhibitors (or ARBs if intolerant) recommended for patients with heart failure with reduced LVEF (<40%), diabetes, or CKD 1
- Beta-blockers recommended for patients with systolic LV dysfunction or heart failure with reduced LVEF (<40%) 1
- Mineralocorticoid receptor antagonists (MRAs) recommended for patients with heart failure with reduced LVEF (<40%) 1
GI protection:
- Proton pump inhibitors recommended for patients on antithrombotic therapy who are at high risk of gastrointestinal bleeding 1
Post-STEMI Management
- Metoprolol tartrate for early post-MI treatment: Begin with three 5 mg IV boluses at 2-minute intervals, followed by 50 mg orally every 6 hours for 48 hours, then 100 mg twice daily maintenance 2
- For patients with severe intolerance to beta-blockers, discontinue therapy 2
- In post-STEMI patients with LV dysfunction, warfarin may be reasonable to maintain INR of 2.0-3.0 1
Secondary Prevention and Cardiac Rehabilitation
Cardiac Rehabilitation
- Cardiac rehabilitation is recommended for all patients with ACS, particularly those with multiple modifiable risk factors 1
- Cardiac rehabilitation programs should include:
- Medical evaluation
- Prescribed exercise
- Risk factor modification
- Education and counseling 1
- Cardiac rehabilitation reduces all-cause mortality, cardiovascular mortality, and improves health-related quality of life 1
- Alternative delivery approaches (home exercise, internet-based, transtelephonic monitoring) can be effective for selected stable patients 1
Lifestyle Modifications
- Comprehensive lifestyle modifications are recommended to reduce all-cause and cardiovascular mortality 1, 3, 4
- Key lifestyle interventions include:
- Smoking cessation - associated with 50% reduction in recurrent CHD risk 4
- Regular physical activity (≥4 times/week) - reduces recurrent CHD risk by 31% 4
- Mediterranean diet adherence - trend toward 23% reduction in recurrent CHD risk 4
- Weight management targeting appropriate BMI and waist circumference 1, 5
- Stress management techniques 6
- Each additional ideal lifestyle factor (non-smoking, regular physical activity, Mediterranean diet) progressively reduces recurrent CHD risk, with three factors reducing risk by 62% 4
Multidisciplinary Approach
- Involvement of multidisciplinary healthcare team (cardiologists, nurses, dietitians, physiotherapists, psychologists, pharmacists) improves outcomes 1
- Cognitive behavioral interventions help patients achieve healthy lifestyle changes 1
- Psychological interventions improve symptoms of depression and quality of life in CAD patients 1
- Annual influenza vaccination is recommended to reduce morbidity, especially in older patients 1
Special Populations
Diabetes Management in Cardiac Patients
- Screen all ACS patients for diabetes 1
- Monitor blood glucose levels frequently in patients with known diabetes or admission hyperglycemia 1
- Avoid hypoglycemia in all patients 1
Chronic Kidney Disease Considerations
- Assess kidney function by eGFR in all patients 1
- Apply same diagnostic and therapeutic strategies with appropriate dose adjustments 1
- Use low- or iso-osmolar contrast media at lowest possible volume during invasive procedures 1
Older Adults
- Apply the same diagnostic and interventional strategies as for younger patients 1
- Adapt antithrombotic agent selection and dosage based on renal function and specific contraindications 1
Patient Education and Follow-up
Patient Education
- Face-to-face patient instruction should be reinforced with written materials 1
- Education should cover:
- Disease process
- Medication adherence
- Risk factor modification
- Recognition of cardiac symptoms 1
Follow-up Care
- Structured telephone follow-up program can reinforce education and monitor progress 1
- Weekly calls for first 4 weeks after discharge can help gauge recovery and address concerns 1
- Regular assessment of social determinants of health is recommended to inform treatment decisions 1
Common Pitfalls and Caveats
- Medication interactions: Avoid ibuprofen in patients on aspirin as it blocks antiplatelet effects 1
- Underutilization of cardiac rehabilitation: Despite proven benefits, cardiac rehabilitation remains underutilized, particularly among women, racial/ethnic minorities, and those in rural areas 1
- Medication adherence challenges: Poor adherence to secondary prevention medications significantly increases risk of adverse outcomes
- Inadequate risk factor control: Failure to achieve target goals for blood pressure, lipids, and glucose control increases recurrent event risk
- Overlooking psychosocial factors: Depression and anxiety are common after cardiac events and require screening and treatment
- Insufficient follow-up: Lack of structured follow-up can lead to medication non-adherence and lifestyle regression
By implementing these evidence-based strategies in a coordinated, patient-centered approach, clinicians can significantly reduce morbidity and mortality in patients with cardiac conditions.