Case #863 Ischemic Heart Disease- Joseph is a 72-year-old African-American male who received a drug-eluting stent for mid–left anterior descending coronary artery stenosis 3 years ago. Now, he presents to your office with increased frequency of exertional chest pain associated with tachycardia. His symptoms tend to occur after walking 2 blocks or its equivalent.
>The American Heart Association estimates that of 17.6 million patients with coronary artery disease (CAD), nearly 10 million patients have chronic stable angina secondary to ischemic heart disease, with 500,000 new cases presenting annually.1 Clinicians have a multitude of options in the management of stable ischemic heart disease but need to overcome several barriers to achieving optimal outcomes. Current evidence on the effect of optimized medical therapy versus early interventional strategies on long-term outcomes, for instance from the COURAGE, OAT and BARI 2D studies, needs to be applied in practice. In addition to better stratifying patients based on this evidence, clinicians also need to weigh the pharmacoeconomic implications of early interventional versus medical strategies. Novel antianginal agents need to be appropriately assessed and incorporated into existing clinical paradigms, along with conventional agents, as new evidence becomes available and professional guidelines are updated. Unique complexities in certain patient groups need to be addressed, for instance, in elderly patients, in women patients, and in patients with comorbid conditions such as chronic kidney disease and diabetes.
Evidence from the COURAGE, OAT and BARI 2D trials suggests that in appropriately selected and risk stratified patients, optimized medical therapy is not inferior to early interventional strategies on long-term patient outcomes. Pharmacoeconomic analysis of the COURAGE data also found that a percutaneous coronary intervention (PCI) costs approximately $10,000 more per patient without any significant gain in life-years or quality-adjusted life-years, and the per patient cost of significant angina improvement from PCI is $150,000. Risk stratifying patients between interventional and optimal medical strategies based on the evidence instead of established practice patterns is a significant barrier to improving overall outcomes and reducing the burden of ischemic heart disease.
Apply the most current clinical evidence and guidelines regarding the stratification of patients toward optimal medical management and/or interventional therapy
Summarize the role of different therapeutic agents and their combinations in the management of ischemic heart disease
Identify the gender-specific differences in the pathophysiology, symptom manifestations, and risk stratification of patients with ischemic heart disease that can impact optimal management
Formulate ways to tailor antianginal regimens to achieve improved outcomes in patients with comorbid conditions such as diabetes, heart failure, and atrial fibrillation.
Apply the most current clinical evidence and guidelines regarding the stratification of patients toward optimal medical management and/or interventional therapy
Summarize the role of different therapeutic agents and their combinations in the management of ischemic heart disease
Identify the gender-specific differences in the pathophysiology, symptom manifestations, and risk stratification of patients with ischemic heart disease that can impact optimal management
Formulate ways to tailor antianginal regimens to achieve improved outcomes in patients with comorbid conditions such as diabetes, heart failure, and atrial fibrillation.
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