What is the treatment for heart ischemia?

Treatment of Heart Ischemia

All patients with heart ischemia should receive guideline-directed medical therapy (GDMT) as the foundation of treatment, with beta-blockers as first-line agents for symptom control, combined with antiplatelet therapy, statins, and ACE inhibitors or ARBs, while revascularization is reserved for patients with refractory symptoms despite optimal medical management. 1

Immediate Medical Therapy

Antiplatelet Therapy

• Aspirin 75-325 mg daily should be initiated immediately in all patients with ischemic heart disease 2
• Clopidogrel 75 mg daily (with 300-600 mg loading dose) should be added for dual antiplatelet therapy 2
• This combination reduces progression of atherosclerosis and prevents coronary thrombosis 1

Beta-Blockers: First-Line for Symptom Control

• Beta-blockers are the drugs of first choice for treating hypertension and angina in patients with coronary artery disease 1
• They alleviate ischemia through negative inotropic and chronotropic effects, decreasing heart rate and increasing diastolic coronary perfusion time 1
• Cardioselective (β1) agents without intrinsic sympathomimetic activity (such as metoprolol, carvedilol, or bisoprolol) are preferred 1
• Should be administered orally within 24 hours unless contraindicated by heart failure signs, low-output state, or cardiogenic shock risk 2, 3
• Critical warning: Never abruptly discontinue beta-blockers in patients with coronary artery disease, as this can cause severe exacerbation of angina, myocardial infarction, and ventricular arrhythmias 3

ACE Inhibitors or ARBs

• ACE inhibitors should be administered orally within 24 hours if LVEF ≤0.40 or pulmonary congestion is present, provided systolic BP >100 mmHg 2
• These agents reduce remodeling after MI, improve ischemic preconditioning, and reverse angiotensin II-induced vasoconstriction 1
• ARBs (such as valsartan or candesartan) are appropriate alternatives if ACE inhibitors are not tolerated 1

Statin Therapy

• High-intensity statin therapy should be initiated immediately for secondary prevention 2
• Statins provide benefits beyond lipid lowering, including anti-inflammatory effects, improved endothelial function, and reduced platelet aggregation 1

Additional Pharmacological Management

Calcium Channel Blockers

• CCBs are added to or substituted for beta-blockers when blood pressure remains elevated, angina persists, or contraindications exist 1
• Long-acting dihydropyridine agents (such as amlodipine) are preferred when combining with beta-blockers to avoid excessive bradycardia 1
• Nondihydropyridines (diltiazem, verapamil) should not be used in patients with heart failure or LV systolic dysfunction 1

Nitrates

• Long-acting nitrates should be added if beta-blockers are inadequate for symptom control 1
• Sublingual nitroglycerin or spray is recommended for immediate control of angina 1, 2

Blood Pressure Management

Target Blood Pressure

• Target BP <130/80 mm Hg in patients with diabetes, chronic renal disease, CAD, or high cardiovascular risk (10-year Framingham risk ≥10%) 1
• Target BP <140/90 mm Hg in patients without these conditions 1
• Caution: In patients with elevated diastolic BP and CAD with evidence of myocardial ischemia, lower BP slowly and avoid diastolic BP <60 mm Hg, especially in diabetic patients or those over age 60 1

Lifestyle Modifications (Essential Foundation)

The following lifestyle changes are critical and must accompany pharmacological therapy 1:

• Heart-healthy diet with attention to sodium intake (<2g/day)
• Smoking cessation (mandatory)
• Regular aerobic exercise (as tolerated)
• Weight loss if overweight/obese
• Alcohol moderation
• Glycemic control in diabetic patients
• Recognition and treatment of hypothyroidism and obstructive sleep apnea

Revascularization Strategy

Conservative Approach First

• For patients with stable ischemic heart disease and moderate-to-severe ischemia whose symptoms can be controlled medically, optimal medical therapy alone is the appropriate initial strategy 1
• Coronary angiography should be reserved for failure of medical management 1, 2

Indications for Invasive Strategy

Proceed to coronary angiography if any of the following occur 2:

• Recurrent angina or ischemia-related ECG changes despite optimal medical therapy
• Ischemia associated with heart failure symptoms
• Hemodynamic instability
• Depressed LV function with ongoing ischemia
• Progressive or refractory symptoms despite medical management 1

Timing of Intervention

• Patients with intermediate-risk criteria (such as moderate reversible ischemia) should undergo coronary angiography within 72 hours if symptoms recur or fail to respond to medical therapy 2
• For patients without recurrent chest pain, no heart failure signs, and stable ECG, continue conservative management with catheterization reserved for medical therapy failure 2

Monitoring and Follow-Up

• Continuous ECG monitoring during initial evaluation for ST-segment shifts and arrhythmias 2
• Supplemental oxygen only if arterial saturation <90%, respiratory distress, or documented hypoxemia 2
• Patient education on sublingual nitroglycerin use and recognition of worsening ischemia symptoms before discharge 2

Critical Pitfalls to Avoid

• Never administer NSAIDs (except aspirin) during hospitalization, as they increase risks of mortality, reinfarction, hypertension, heart failure, and myocardial rupture 2
• Do not give IV beta-blockers if signs of heart failure, low-output state, or cardiogenic shock risk factors are present 2, 3
• Avoid short-acting nifedipine due to reflex sympathetic activation 1
• Do not use nondihydropyridine calcium channel blockers in patients with heart failure or LV systolic dysfunction 1
• Beta-blockers may mask hypoglycemia symptoms in diabetic patients—use caution 1

Evidence Context

The evidence strongly supports GDMT as the foundation for all patients with ischemic heart disease 1. While early trials suggested survival benefits for CABG in extensive anatomic disease, more recent evidence from the COURAGE and BARI 2D trials demonstrates that routine revascularization does not reduce death or MI compared to optimal medical therapy in stable patients 1. The ongoing ISCHEMIA trial is designed to definitively address whether routine revascularization plus GDMT reduces cardiovascular death and MI compared to GDMT alone in patients with moderate-to-severe ischemia 1. Until those results are available, the weight of current evidence supports an initial conservative strategy with GDMT, reserving revascularization for symptom control when medical therapy fails 1, 2.