Management of Ischemic Heart Disease
All patients with ischemic heart disease require immediate initiation of guideline-directed medical therapy (GDMT) consisting of antiplatelet agents, beta-blockers, statins, and ACE inhibitors or ARBs, combined with aggressive risk factor modification—this forms the foundation of treatment regardless of whether revascularization is pursued. 1, 2, 3
Initial Assessment and Risk Stratification
Begin with a resting 12-lead ECG for all patients with suspected ischemic heart disease. 1, 3 Evaluate left ventricular function with echocardiography in patients who have prior MI, pathological Q waves, heart failure symptoms, complex ventricular arrhythmias, or undiagnosed heart murmurs. 3
Stratify patients into low, intermediate, or high-risk categories based on clinical features and diagnostic testing results to guide the intensity of therapy and need for invasive evaluation. 3 High-risk features include extensive coronary disease, reduced left ventricular ejection fraction, and ongoing symptoms despite medical therapy. 1
Guideline-Directed Medical Therapy (GDMT)
Antiplatelet Therapy
Initiate aspirin 75-325 mg daily immediately in all patients with ischemic heart disease unless contraindicated. 4 For patients with acute coronary syndrome (unstable angina or NSTEMI), add clopidogrel 300 mg loading dose followed by 75 mg daily for up to one year, which reduces cardiovascular death, MI, or stroke by 20% compared to aspirin alone. 4
Beta-Blockers
Beta-blockers are first-line therapy for symptom relief and improved survival, particularly in patients with prior MI or reduced ejection fraction. 3, 5 Use metoprolol, carvedilol, or bisoprolol as preferred agents. 1
Critical warning: Never abruptly discontinue beta-blockers in patients with coronary artery disease—severe exacerbation of angina, MI, and ventricular arrhythmias can occur. 5 When discontinuing, taper gradually over 1-2 weeks while monitoring closely. 5
Contraindications include severe first-degree AV block, second- or third-degree heart block, severe bronchospastic disease, and decompensated heart failure. 5 However, cardioselective beta-blockers can be used cautiously in mild-to-moderate reactive airway disease with bronchodilators readily available. 1
ACE Inhibitors or ARBs
Start ACE inhibitors early (within 24 hours) in all patients with ischemic heart disease, especially those with anterior or large infarcts, previous infarction, heart failure, depressed LVEF, or tachycardia—this reduces mortality by 0.5-0.8% at 4 weeks. 1
Use ARBs (such as valsartan) as an alternative when ACE inhibitors are not tolerated; they are equally effective for reducing cardiovascular events. 1 Do not combine ACE inhibitors with ARBs, as this increases adverse events without improving survival. 1
Statin Therapy
Prescribe moderate-to-high intensity statin therapy for all patients with ischemic heart disease regardless of baseline LDL cholesterol. 3 Focus on achieving substantial LDL reduction rather than specific numerical targets. 3
Anti-Ischemic Medications
Nitrates provide symptom relief and can be used as needed (sublingual) or in long-acting formulations for chronic management. 1, 3 However, nitrates do not reduce mortality and should not be used at the expense of proven therapies like beta-blockers or ACE inhibitors. 1
Calcium channel blockers (CCBs) are indicated when beta-blockers are contraindicated or inadequate for symptom control. 3 Use long-acting dihydropyridines (amlodipine, nifedipine) or non-dihydropyridines (diltiazem, verapamil). 1
Critical pitfall: Never combine beta-blockers with non-dihydropyridine CCBs due to increased risk of bradyarrhythmias and heart failure. 3 Avoid CCBs entirely in patients with severe LV dysfunction or pulmonary edema, as they can increase mortality. 1
Trimetazidine is a second-line metabolic modulator for patients with contraindications to first-choice agents or those remaining symptomatic despite optimal therapy. 6 It is particularly useful in patients with hypotension, as it does not affect hemodynamics. 6 Contraindicated in Parkinson's disease and severe renal impairment. 6
Blood Pressure Management
Target blood pressure is <130/80 mm Hg in patients with ischemic heart disease. 1 However, avoid lowering diastolic BP below 60 mm Hg, as this can worsen myocardial ischemia by reducing coronary perfusion pressure. 1 In older patients with wide pulse pressures, lowering systolic BP may cause very low diastolic values—monitor carefully for worsening ischemia. 1
Acute Coronary Syndrome Considerations
In STEMI patients, uncontrolled hypertension is a contraindication to fibrinolytic therapy due to intracranial hemorrhage risk. 1 Lower BP without delay in hypertensive patients receiving antiplatelet or anticoagulant drugs. 1
Aldosterone antagonists may be useful in STEMI with LV dysfunction and heart failure, but monitor serum potassium closely and avoid in patients with creatinine ≥2.5 mg/dL (men) or ≥2.0 mg/dL (women), or potassium ≥5.0 mEq/L. 1
Risk Factor Modification
Smoking cessation is mandatory—counsel all patients and provide pharmacotherapy or referral to cessation programs. 3
Dietary modifications include reduced intake of saturated fats, trans fats, and cholesterol, with increased consumption of fresh fruits, vegetables, and low-fat dairy products. 3 Sodium restriction is essential for BP control. 3
Daily physical activity and weight management are critical—prescribe specific exercise recommendations based on functional capacity. 3
Diabetes management requires aggressive glycemic control, as diabetes significantly increases ischemic heart disease risk. 2
Revascularization Strategy
Consider coronary artery bypass grafting (CABG) for:
- Left main disease (≥50% stenosis) 3
- Three-vessel disease, especially with reduced LV function 3
- Complex multivessel disease with high SYNTAX score 3
Consider percutaneous coronary intervention (PCI) for:
- Single-vessel disease with persistent symptoms despite optimal medical therapy 3
- Multivessel disease with low SYNTAX score (0-22) 3
- Large ischemic myocardial burden 7
- Severe refractory angina despite maximal medical therapy 7
Important context: The ISCHEMIA trial established that medical therapy is noninferior to revascularization in patients with moderate-to-severe ischemia for preventing cardiovascular events. 7 Therefore, initial management with optimal medical therapy is appropriate for most stable patients, reserving revascularization for those with high-risk anatomy or refractory symptoms. 7, 8
Heart Failure Management in Ischemic Heart Disease
Approximately 75% of patients hospitalized with heart failure have hypertension, and most have systolic BP ≥140 mm Hg. 1 Hypertension contributes to both systolic and diastolic heart failure by causing LV hypertrophy, impaired contractility, and ventricular remodeling. 1
Beta-blockers, ACE inhibitors, and aldosterone antagonists form the cornerstone of therapy for ischemic heart failure with reduced ejection fraction. 1 These agents not only control BP but also improve survival and prevent disease progression. 1
Special Populations
Women and elderly patients often present with atypical symptoms including nausea, vomiting, midepigastric discomfort, or sharp chest pain rather than classic angina. 2 Consider anti-ischemic therapy for women with nonobstructive CAD and demonstrable ischemia, even with mild coronary stenosis (>0% but <50%). 3
Diabetic patients may benefit from ranolazine over trimetazidine due to proven benefits on glycemic control. 6
Shared Decision-Making
Engage patients in shared decision-making about diagnostic and therapeutic options, explaining risks, benefits, and costs in comprehensible terms. 1 When informed about absolute benefits, patients often elect to postpone or forego invasive procedures. 1 Two patients with similar disease severity may prefer different approaches based on personal beliefs, economic situation, or life stage. 1