Ischemic heart disease (IHD), also known as coronary heart disease (CHD) or coronary artery disease (CAD), is caused by a reduction of blood flow to the heart due to atherosclerosis of the coronary arteries. Risk factors include metabolic syndrome, smoking, diabetes, hypertension and high cholesterol. Symptoms range from stable angina to acute coronary syndrome (ACS). Diagnosis involves electrocardiogram (ECG), stress testing, coronary angiography and biochemical markers. Treatment depends on severity but may include lifestyle changes, medications like nitrates, beta-blockers, calcium channel blockers, statins, aspirin and revascularization procedures like percutaneous coronary intervention (PCI) or coronary artery bypass grafting (C

1. Ischemic Heart Disease By: Ammar Abd El-Rahmann 6:12 AM 1

2. 6:12 AM 2

3. Definition 6:12 AM 3

4. 6:12 AM 4

5. 6:12 AM 5

6. Angina pectoris 6:12 AM 6

7. IHD -CHD -CAD 6:12 AM 7

8. 6:13 AM 8

9. Epidemiology 6:13 AM 9

10. Risk Factors 6:13 AM 10

11. 6:13 AM 11

12. Metabolic syndrome 6:13 AM 12

13. 6:13 AM 13

14. 6:13 AM 14

15. Pathophysiology 6:13 AM 15

16. 6:13 AM 16

17. 6:13 AM 17

18. Atherosclerosis 6:13 AM 18

19. 6:13 AM 19

20. Clinical presentation 6:13 AM 20

21. Silent ischemia 6:13 AM 21

22. The Canadian Cardiovascular Society Classification System 6:13 AM 22

23. Non-atherosclerotic Conditions that Can CauseAngina-like Symptoms 6:13 AM 23

24. Presentation of ACS 6:13 AM 24

25. 6:13 AM 25

26. 6:13 AM 26

27. 1- Physical examination 6:13 AM 27

28. 6:13 AM 28

29. 2- Electrocardiogram (ECG) 6:13 AM 29

30. Acute coronary syndrome 6:13 AM 30

31. 6:13 AM 31

32. ECG 6:13 AM 32

33. Stress testing 6:13 AM 33

34. 3- Coronary angiography 6:13 AM 34

35. 4- Biochemical Markers 6:13 AM 35

36. 4- Biochemical Markers (troponin and CK-MB) 6:13 AM 36

37. 6:13 AM 37

38. Goals of therapy 6:13 AM 38

39. Complications of ACS Cardiogenic shock ,occurring in approximately 10% of hospitalized MI patients mortality 60%. Heart failure Valvular dysfunction, left ventricular free wall rupture. Ventricular and atrialtachyarrhythmias , bradycardia, heart block Pericarditis Stroke secondary to left ventricular thrombus embolization , Venous thromboembolism 6:13 AM 39

40. Restoration of blood flow Alleviate symptoms Relief of ischemic chest discomfort. 6:13 AM 40

41. 6:13 AM 41

42. Treatment options for chronic stable angina 6:13 AM 42

43. IR Nitrates 6:13 AM 43

44. Nitrates benefits 6:13 AM 44

45. Attack relieve Sitting position is preferred & rest 0.3 to 0.4 mg NG Or ISDN sublingually No Wait 5‘ then take 2nd dose or 3rd dose or proceed Wait another 15’ for a total of 30’ Yes Spit or swallow tab relief Yes Give thanks to Allah relief No continue praying & Call ambulance 6:13 AM 45

46. Attack prophylaxis 6:13 AM 46

47. Phosphodiestrase(PDE) type 5 inhibitors & Nitrates the use of nitrates within 24 hours of sildenafil or vardenafil and within 48 hours of tadalafil is contraindicated. 6:13 AM 47

48. 6:13 AM 48

49. Long acting nitrates (NTG – ISDN – ISMN) 6:13 AM 49

50. Long acting nitrates use in IHD 6:13 AM 50

51. Nitrate tolerance 6:13 AM 51

52. How to avoid tolerance ? 6:13 AM 52

53. Common Side effects 6:13 AM 53

54. 6:13 AM 54

55. β-Blockers 6:13 AM 55

56. Benefits from β blockers 6:13 AM 56

57. β blockers use in IHD 6:13 AM 57

58. β blockers use in IHD 6:13 AM 58

59. β blockers contraindications 6:13 AM 59

60. Relative contraindications 6:13 AM 60

61. β-Blockers use with particular caution 6:13 AM 61

62. β-blockers adverse effects 6:13 AM 62

63. 6:17 AM 63

64. Ca channel blockers (CCB) 6:17 AM 64

65. Benefits of CCB 6:19 AM 65

66. Verapamil and Diltiazem are generally more effective anti-anginal agents than the dihydropyridine CCBs 6:20 AM 66

67. CCB use in IHD 6:22 AM 67

68. CCB contraindications Verapamil & diltiazemin severe bradycardia or AV conduction disease. 6:22 AM 68

69. CCB use with particular caution 6:24 AM 69

70. 6:25 AM 70

71. Ranolazine 6:25 AM 71

72. Benefit of ranolazine 6:25 AM 72

73. Risks & Adverse effects 6:27 AM 73

74. Risks & Adverse effects 6:27 AM 74

75. 6:31 AM 75

76. Prevent ACS & coronary artery reocclusion 6:32 AM 76

77. Life style modifications slow the progression of IHD, and decrease the risk for IHD-related complications. 6:33 AM 77

78. Life style modifications 6:33 AM 78

79. Exercise 6:34 AM 79

80. 6:35 AM 80

81. Aspirin & antiplatelet therapy 6:37 AM 81

82. Aspirin & antiplatelet therapy 6:38 AM 82

83. 6:38 AM 83

84. Statins (HMG-Co A Reductase inhibitors) 6:40 AM 84

85. Statins (HMG-Co A Reductase inhibitors) 6:40 AM 85

86. 6:42 AM 86

87. ACE inhibitors 6:43 AM 87

88. ACE inhibitors indications 6:44 AM 88

89. Percutaneous Coronary Intervention (PCI) 6:44 AM 89

90. Percutaneous Coronary Intervention (PCI) 6:45 AM 90

91. 6:45 AM 91

92. Coronary Artery Bypass Graft Surgery (CABG) 6:45 AM 92

93. 6:45 AM 93

94. Fibrinolytic therapy for ACS 6:45 AM 94

95. Fibrinolytic therapy for ACS 6:45 AM 95

96. Fibrinolytic therapy for ACS 7:09 AM 96

97. Relative ContraindicationsACC/AHA guidlines 7:14 AM 97

98. Fibrinolytic VS Primary PCI 7:26 AM 98

99. 7:27 AM 99

100. Counseling of chronic stable angina 7:28 AM 100

101. Counseling of Chronic Stable Angina for attack 7:28 AM 101

102. 7:29 AM 102

103. 7:30 AM 103

104. Assess effectiveness of therapy 7:31 AM 104

105. Monitor disease progression 7:32 AM 105

106. Monitor adverse effects of drugs 7:32 AM 106

107. Case study A.E., a 65-year-old man, has been treated for chronic angina pectoris for 4 years. He refuses cardiac catheterization and revascularization; however, his coronary risk factors include a strong family history of cardiovascular disease and hyperlipoproteinemia. He experienced rheumatic fever at age 12; 5 years ago, his mitral valve was replaced. At that time, he had two-vessel CAD with 80% and 85% occlusion and an LV EF of 30% (normal, 55%). 7:34 AM 107

108. Current medications include a prescription for: SL nitroglycerin; warfarin 5 mg for 5 days/week and 2.5 mg for 2 days/week; metoprolol 50 mg every day; enalapril 10 mg every day; digoxin 0.125 mg/day (serum digoxin concentration drawn 18 hours after the last dose is 0.7 ng/mL); oral simvastatin 40 mg every day; and furosemide 40 mg/day. 7:35 AM 108

109. At his regular follow-up visit with his cardiologist, A.E. reports an increase in weekly anginal attacks over the last 2 months during his daily routine of working in his yard. Current vital signs include a blood pressure of 110/60 mmHg and a resting heart rate of 60 beats/minute. 7:36 AM 109

110. What therapeutic options would be available for A.E. for additional control of his chronic stable angina? A.E. is at goal heart rate and his blood pressure is well controlled on his current regimen, but he continues to have anginal symptoms. A –veinotrope CCB should not be given because A.E. has evidence of poorly controlled heart failure (EF of 30%). A long-acting nitrate is an option, but this could lower his blood pressure more than is desired. A dihydrpyridine (amlodipine &felodipine) may also lower blood pressure of A.E. Because of the lack of hemodynamic effects, ranolazine is a reasonable option for A.E., in addition to continuing metoprolol. 7:37 AM 110

111. References http://www.theheart.org/article/194187.do http://cme.medscape.com/viewarticle/474936 http://www.fda.gov/ohrms/dockets/ac/00/slides/3622s2_01_2-Squibb-cohen/sld005.htm www.nucleosinc.com www.emedtv.com 7:41 AM 111

112. We are the clinical pharmacy folk So, physicians you ‘d better stop talk When it is a drug issue Hold your pencils & we hold chalk 7:41 AM 112