What is the recommended treatment for Ischemic Heart Disease (IHD)?

Treatment of Ischemic Heart Disease

All patients with ischemic heart disease should receive aspirin 75-100 mg daily, high-intensity statin therapy (atorvastatin 80 mg or equivalent), and beta-blockers (carvedilol, metoprolol succinate, or bisoprolol), with ACE inhibitors or ARBs added for those with hypertension, diabetes, LV dysfunction (EF ≤40%), or chronic kidney disease. 1, 2, 3

Antiplatelet Therapy

• Aspirin 75-325 mg daily is mandatory for all patients with IHD unless contraindicated, with doses of 75-100 mg daily preferred as they provide equivalent benefit to higher doses with potentially lower bleeding risk 1, 2, 4, 5
• Clopidogrel 75 mg daily is the alternative for patients who cannot tolerate aspirin 1
• Dual antiplatelet therapy (aspirin plus ticagrelor or clopidogrel) should continue for 12 months following acute coronary syndrome or percutaneous coronary intervention 3
• Add a proton pump inhibitor when patients are on dual antiplatelet therapy or have high gastrointestinal bleeding risk 2, 3

Lipid-Lowering Therapy

• High-intensity statin therapy (atorvastatin 80 mg daily or rosuvastatin 40 mg daily) is recommended for all patients with IHD regardless of baseline cholesterol levels, targeting LDL-C <70 mg/dL or at least 50% reduction from baseline 1, 2, 3
• Statins should be initiated as early as possible and continued indefinitely 3
• Ezetimibe may be added if LDL-C goal is not achieved with statin monotherapy 1
• Niacin, fibrates, and bile acid sequestrants as monotherapy or adjunctive therapy have not shown improvement in patient outcomes and are not recommended 1, 6

Beta-Blocker Therapy

Beta-blockers are first-line therapy for symptom relief and should be prescribed to all patients with IHD 1, 2, 3

Specific Indications and Agents:

• Mandatory for patients with prior MI or acute coronary syndrome: continue for at least 3 years in those with normal LV function (EF >40%) 1
• Mandatory indefinitely for patients with LV systolic dysfunction (EF ≤40%) or heart failure: use only carvedilol, metoprolol succinate, or bisoprolol, which have proven mortality benefit 1, 3, 7
• Reasonable to continue beyond 3 years in all post-MI patients as long-term therapy for hypertension control 1

Dosing Strategy:

• Start with low doses (metoprolol succinate 50 mg daily or bisoprolol 2.5 mg daily) and titrate to target heart rate 60-70 bpm with systolic BP >100 mmHg 1
• Titration should occur over 1-2 weeks with monitoring of heart rate, blood pressure, and symptoms 1, 3
• Never abruptly discontinue beta-blockers in patients with coronary artery disease, as this can precipitate severe angina exacerbation, MI, or ventricular arrhythmias; taper over 1-2 weeks if discontinuation is necessary 7

ACE Inhibitors or Angiotensin Receptor Blockers

• ACE inhibitors should be prescribed for all patients with IHD who have hypertension, diabetes mellitus, LV ejection fraction ≤40%, or chronic kidney disease 1, 2
• Target blood pressure <130/80 mmHg in patients with IHD and hypertension 1
• ARBs (candesartan or valsartan) are recommended for patients with indications for ACE inhibitors but who are intolerant 1
• ACE inhibitors reduce cardiovascular death, MI, and stroke by approximately 20-22% in patients with or at high risk for CAD 1

Antianginal Medications for Symptom Control

First-Line:

• Beta-blockers are initial therapy for angina relief 1

Second-Line (when beta-blockers are contraindicated, cause unacceptable side effects, or are insufficient):

• Long-acting calcium channel blockers (amlodipine, diltiazem, or verapamil) 1
• Long-acting nitrates (isosorbide mononitrate or isosorbide dinitrate) 1
• Ranolazine can substitute for beta-blockers or be added to beta-blockers for refractory symptoms 1

Acute Relief:

• Sublingual nitroglycerin or nitroglycerin spray for immediate angina relief 1

Aldosterone Receptor Antagonists

• **Add spironolactone or eplerenone in patients with EF <40% and heart failure or diabetes who are already on ACE inhibitor/ARB and beta-blocker**, provided no renal failure (creatinine >2.5 mg/dL in men or >2.0 mg/dL in women) or hyperkalemia (K+ >5.0 mEq/L) 1, 3
• These agents reduce mortality by 15-30% in appropriate patients 1

Lifestyle Modifications

• Smoking cessation is mandatory: provide repeated counseling with pharmacotherapy (nicotine replacement, varenicline, or bupropion) 2, 3
• Cardiac rehabilitation program participation is mandatory for all post-MI patients 3
• Exercise: ≥30 minutes of moderate-intensity physical activity ≥5 times per week 1, 2
• Dietary intervention: saturated fat <7% of total calories, Mediterranean-style diet preferred 1, 2
• Weight management targeting BMI 18.5-24.9 kg/m² 1
• Sodium restriction in patients with heart failure 1

Revascularization Considerations

• Coronary artery bypass grafting (CABG) is recommended for significant (>50% stenosis) left main coronary artery disease 1
• Percutaneous coronary intervention (PCI) is reasonable for selected stable patients with unprotected left main CAD and low SYNTAX score (<22) 1
• Revascularization should be considered when angina persists despite optimal medical therapy 2
• FFR-guided revascularization provides symptom relief and prognostic benefit in patients unresponsive to antianginal treatment 8

Therapies NOT Recommended

• Estrogen therapy in postmenopausal women 1
• Vitamin C, vitamin E, or beta-carotene supplementation 1
• Folate or vitamins B6/B12 for elevated homocysteine 1
• Chelation therapy 1
• Garlic, coenzyme Q10, selenium, or chromium 1
• Acupuncture 1

Monitoring and Follow-Up

• Reassess symptoms, blood pressure, heart rate, renal function, and potassium 1-2 weeks after initiating or adjusting beta-blockers or ACE inhibitors/ARBs 3
• Repeat echocardiography in 3-6 months if LV dysfunction present to assess response to therapy 3
• Evaluate for implantable cardioverter-defibrillator if LVEF remains <35% after 3 months of optimal medical therapy 3
• Screen for depression and treat when indicated, as this may improve quality of life though cardiovascular outcomes are unchanged 1

Common Pitfalls to Avoid

• Do not use atenolol as it is less effective than other beta-blockers in reducing cardiovascular events 1
• Avoid nondihydropyridine calcium channel blockers (diltiazem, verapamil) in patients with systolic heart failure due to negative inotropic effects 1
• Do not use alpha-blockers (doxazosin) as primary antihypertensive therapy in IHD patients due to increased heart failure risk 1
• Avoid beta-blockers with intrinsic sympathomimetic activity 1
• Do not routinely add dipyridamole to aspirin as it provides no additional benefit and may worsen ischemia 1, 4