Clinical Pharmacology · MU Sofia

28. Rational drug prescribing in patients with ischemic heart disease.

Covers drug treatment of ischaemic heart disease in two parts: chronic coronary syndrome (stable angina) and acute coronary syndromes. For stable angina it separates drugs that prevent events, such as antiplatelet therapy, high-intensity statins and ACE inhibitors or ARBs, from drugs that relieve angina, including first and second line agents and nitrate interactions. A summary table sets out the preventive drugs, and the acute section covers immediate treatment, STEMI, dual antiplatelet therapy and long-term post-MI medication.

Inside: 3 sections · 1 table · 17 flashcards · 2 min

Topic 28 of 30 in the MU Sofia syllabus for Clinical Pharmacology (Medicine, Year 5). The free AceMed note covers it in 3 sections, about 273 words (2 min of reading), with 17 flashcards.

In this note

  1. Introduction
  2. Chronic coronary syndrome (stable angina)
  3. Acute coronary syndromes

Introduction

Ischaemic heart disease (IHD) ranges from chronic coronary syndrome (stable angina) to acute coronary syndromes (unstable angina, NSTEMI, STEMI). Drug treatment has two goals: relieve symptoms and prevent events (MI, death).

Chronic coronary syndrome (stable angina)

1. Drugs that prevent events (for everyone)

2. Drugs that relieve angina

  • Short-acting nitrate (sublingual nitroglycerin spray or tablet) for attacks and before exertion.
  • First line: β-blocker (bisoprolol, metoprolol) or calcium channel blocker (amlodipine; verapamil or diltiazem if β-blocker not suitable); combine β-blocker + dihydropyridine CCB if needed. Target resting heart rate 55–60.
  • Second line: long-acting nitrates (isosorbide mononitrate, with a nitrate-free interval to prevent tolerance), ranolazine, ivabradine, nicorandil, trimetazidine.
  • Nitrates are contraindicated with PDE-5 inhibitors (sildenafil): severe hypotension. Do not combine verapamil or diltiazem with a β-blocker (bradycardia, heart block).
  • Revascularisation (PCI, CABG) if symptoms persist on drugs or anatomy is high-risk (left main, three-vessel disease with low EF).

Acute coronary syndromes

  1. Immediate: aspirin 150–300 mg loading dose; nitrates and opioids for pain; oxygen only if SpO₂ < 90%.
  2. STEMI: primary PCI within 120 min (or fibrinolysis if PCI is not possible in time).
  3. Dual antiplatelet therapy (DAPT): aspirin + a P2Y₁₂ inhibitor (ticagrelor or prasugrel, clopidogrel if high bleeding risk) for 12 months, plus anticoagulation (heparin, fondaparinux) in the acute phase.
  4. Long term after MI: aspirin for life, high-intensity statin, β-blocker (especially if EF reduced), ACE inhibitor, MRA if EF ≤ 40% with HF or diabetes; cardiac rehabilitation.

Avoid NSAIDs (raise cardiovascular risk and bleeding with DAPT); give a proton pump inhibitor to patients on DAPT with bleeding risk.

Every patient with coronary disease gets aspirin and a high-intensity statin to prevent events; β-blockers or calcium channel blockers and nitrates are for symptoms.

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