Pharmacotherapy Case Study: Ischemic Heart Disease (Stable Angina) by Dr. Nehad Ahmed

 

Patient Profile: 65-year-old male

Subjective Data

  • Chief Complaint: “I’ve been having chest tightness when I walk uphill or carry groceries. It goes away when I rest.”
  • History of Present Illness:
    • Substernal chest pressure radiating to the left jaw and arm, lasting 5–10 minutes, triggered by exertion or stress.
    • Relieved by rest or sublingual nitroglycerin (patient borrowed a friend’s tablets; not prescribed).
    • No associated nausea, diaphoresis, or syncope.
  • Medical History:
    • Hypertension (15 years), type 2 diabetes (8 years), hyperlipidemia.
    • Smoked 1 pack/day × 30 years (quit 2 years ago).
  • Medications:
    • Amlodipine 5 mg daily (non-adherent for 3 months).
    • Metformin 1,000 mg BID.
    • No antiplatelet, statin, or nitrate use.
  • Social History:
    • Sedentary lifestyle; diet high in fried foods and carbohydrates.
    • Occasional alcohol use (2–3 beers/week).

Objective Data

  • Vitals:
    • BP: 150/88 mmHg, HR: 82 bpm, RR: 18/min, SpO₂: 97% on room air.
    • BMI: 29 kg/m².
  • Physical Exam:
    • Cardiovascular: Regular rate/rhythm, no murmurs or gallops.
    • Lungs: Clear bilaterally.
    • Extremities: No edema; peripheral pulses intact.
  • Labs:
    • LDL: 160 mg/dL, HDL: 38 mg/dL, triglycerides: 200 mg/dL.
    • HbA1c: 8.0%, fasting glucose: 140 mg/dL.
    • Troponin: Negative.
  • Diagnostic Studies:
    • ECG: Normal sinus rhythm; ST-segment depression (1.5 mm) in leads V4–V6 during chest pain.
    • Stress Echocardiogram: Inducible ischemia in the anterior wall, LVEF 55%.
    • Coronary Angiography: 70% stenosis in the left anterior descending (LAD) artery.

Assessment

  1. Primary Diagnosis:
    • Stable Angina (Class II per Canadian Cardiovascular Society [CCS]).
    • Underlying Ischemic Heart Disease (LAD stenosis).
  2. Comorbidities:
    • Hypertension, type 2 diabetes, hyperlipidemia.
  3. Risk Stratification:
    • High ASCVD risk (diabetes, smoking history, LDL >130 mg/dL).

Pharmacotherapy Plan

  1. Immediate Symptom Relief:
    • Sublingual nitroglycerin 0.4 mg PRN (max 3 doses in 15 minutes).
  2. Long-Term Management:
    • Anti-Ischemic Therapy:
      • Metoprolol succinate 25 mg daily (titrate to 100 mg to reduce myocardial oxygen demand).
      • Isosorbide mononitrate 30 mg daily (avoid tolerance with a 10–12 hour nitrate-free interval).
    • Antiplatelet Therapy:
      • Aspirin 81 mg daily (lifelong).
      • Clopidogrel 75 mg daily (dual therapy for 1 year post-diagnosis, then reassess).
    • Risk Factor Modification:
      • High-intensity statin: Atorvastatin 40 mg daily (LDL goal <70 mg/dL).
      • ACE Inhibitor: Ramipril 5 mg daily (cardioprotection in diabetes + CAD).
    • Diabetes Management: Continue metformin; monitor HbA1c.
  3. Non-Pharmacologic Interventions:
    • Cardiac Rehabilitation: Supervised exercise program.
    • Diet: Mediterranean diet, limit saturated fats and refined sugars.
    • Smoking Cessation: Reinforce abstinence.

Monitoring

  • Weekly: BP, HR (goal HR 60–70 bpm at rest), angina frequency.
  • 3-month follow-up: Lipid panel (LDL target <70 mg/dL), HbA1c, renal function.
  • Annual: Stress test or echocardiogram to assess disease progression.

Patient Education

  • Recognize ACS Symptoms: Chest pain unrelieved by nitroglycerin, sweating, or shortness of breath → seek emergency care.
  • Nitroglycerin Use: Sit down before administering; replace tablets every 6 months.
  • Adherence: Emphasize statin/antiplatelet necessity to prevent MI.

Rationale

  • Metoprolol reduces heart rate and myocardial oxygen demand, improving exercise tolerance.
  • Dual Antiplatelet Therapy (DAPT) lowers thrombotic risk in high-risk CAD.
  • Atorvastatin stabilizes plaques and reduces cardiovascular events.
  • Ramipril improves endothelial function and reduces mortality in diabetic CAD patients.
  • Lifestyle changes address modifiable risk factors (obesity, inactivity, diet).

Key Considerations:

  • Avoid NSAIDs (worsen ischemia).
  • If angina persists despite therapy, consider adding amlodipine 5 mg daily (if BP controlled) or referral for revascularization.

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