ABIM - Ischemic Heart Disease Symptoms and Treatments

Here are key facts for ABIM from the Ischemic Heart Disease Symptoms and Treatments tutorial, as well as points of interest at the end that are not directly addressed in this tutorial but should help you prepare for the boards. See the tutorial notes for further details and relevant links.

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1. Angina pectoris is the hallmark of ischemic heart disease, characterized by pain or discomfort in the chest, which often radiates through the upper extremities, face, and other areas of the body, and is due to the heart's inability to meet its metabolic needs. 2. Stable angina is characterized by predictable triggers, duration, and frequency; resolves with rest and/or nitrates. 3. Unstable angina is unpredictable, does not resolve with rest or medications, and is a medical emergency, as it can lead to myocardial infarction. 4. Non-ischemic causes of angina include aortic stenosis, anemia, arrhythmias, and hypertrophic cardiomyopathy. 5. Silent ischemia refers to asymptomatic ischemic heart disease; "silent" does not mean "harmless," and is associated with increased morbidity and mortality. 1. Stable angina (effort angina): triggered by physical or mental exertion, such as climbing a flight of stairs or psychological stress; resolves with rest and/or nitrates. 2. Unstable angina: new onset or worsening angina that is unpredictable; occurs spontaneously during activity or rest; does not resolve with rest or medications; a form of acute coronary syndrome. 3. Vasospastic angina (variant/Prinzmetal angina): occurs when vasospasm contracts vessels and reduces blood flow; occurs spontaneously and often at rest, typically at night or early morning; most common in women and cigarette smokers; responds to nitrates and calcium-channel blockers but not beta-blockers. 4. Microvascular angina: result of coronary microvascular dysfunction or vasospasm; accounts for chest pain in up to half of patients without obstructive coronary artery disease; occurs with exertion and at rest but may respond less well to nitrates.

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1. Sex, age, and race may influence which symptoms are present and how they are interpreted. 2. Levine's sign, a clenched fist held over the sternum, is a gesture many patients use to describe chest discomfort. 3. Patients report discomfort radiating to the shoulders, arms, neck, and jaw. 4. Patients of African descent often experience gastrointestinal discomfort that may be misinterpreted as indigestion or heart burn. 5. Women with ischemic heart disease more frequently experience light-headedness, dizziness, and persistent fatigue. 6. Other common symptoms include dyspnea (difficulty breathing) and excessive sweating. 1. Diagnosis of ischemic heart disease may involve ECG, echocardiogram, stress testing, angiograms, and CT scans. 2. Although angina is often due to obstructive coronary artery disease, angina can occur in the absence of clinically significant blockage. 3. For microvascular angina, positron emission tomography (PET) or cardiac magnetic resonance (CMR) can assess coronary microvascular blood flow. 1. Life-style modifications, such as smoking cessation and a heart-healthy diet are generally recommended. 2. Nitroglycerin, often administered as a tablet that dissolves under the tongue, dilates vessels and prevents spasms; can be taken prophylactically or in response to an angina episode. 3. Beta-blockers slow the heart rate, reducing myocardial oxygen demands; can exacerbate vasospastic angina. 4. Calcium channel blockers promote vessel dilation; particularly effective for vasospastic angina. 5. Sodium channel inhibitors (Ranolazine) increase myocardial relaxation, reducing oxygen demand and increasing blood flow. 6. ACE-inhibitors promote vessel dilation. 7. Statins reduce hyperlipidemia, vessel inflammation, and endothelial dysfunction. 8. Daily aspirin may be prescribed for patients with elevated risk, but benefits must be weighed against the risk of bleeding. 9. Percutaneous coronary intervention (angioplasty) uses a catheter with balloon to widen obstructed vessels; stents may be added to help keep vessels open. 10. Coronary artery bypass grafting (CABG) involves grafting portions of vessels (saphenous vein, radial artery, left internal mammary artery) to bypass obstructions. 11. Refractory angina refers to ischemia with angina that persists despite medical intervention; innovative treatments for these "no-option" patients are eagerly sought.

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Below is information not explicitly contained within the tutorial but important for ABIM. 1. ASCVD risk calculation guides primary prevention with statins and aspirin therapy. 2. Cardiac CT calcium scoring helps stratify intermediate-risk patients for primary prevention. 3. High-sensitivity CRP and other inflammatory markers may provide additional risk stratification. 4. Stress testing modality selection should be based on pretest probability and patient factors. 1. CTO (Chronic Total Occlusion) PCI may improve angina in selected patients with refractory symptoms. 2. Appropriate Use Criteria for revascularization guide clinical decision-making between medical therapy, PCI, and CABG. 3. FFR (Fractional Flow Reserve) and iFR (Instantaneous wave-Free Ratio) guide intervention for intermediate lesions. 4. PCSK9 inhibitors and other newer lipid-lowering therapies are indicated for very high-risk patients not at goal on maximally tolerated statins.