Medical Therapy (Stable Ischemic Heart Disease)

Medical Therapy (Stable Ischemic Heart Disease)

BackgroundIn the patient with chronic coronary artery disease (CAD), the goals of medical therapy are to ameliorate angina and/or prevent recurrent major cardiovascular (CV) events (secondary prevention). The initial approach to all patients should be focused upon eliminating unhealthy behaviors and effectively promoting lifestyle changes that reduce CV riskIn addition, medical therapies that retard progression (or promote regression) of atherosclerosis, stabilize atherosclerotic plaques, or prevent thrombosis should be administered to decrease the risk of MI and death. Such therapies include antiplatelet agents, ACE inhibitors, and lipid-lowering therapy. In the patient with diabetes, tight glycemic control was assumed to be important in secondary CV prevention, but recent studies show that this approach increases the risk of CV death and complications

Terapia anTIPLAQUETARIAAASTodo CAD a menos que est contraindicado33% reduccin eventos vaculares serios (nonfatal MI, nonfatal stroke, and vascular death)75-162 mg/ da

EstatinasLDL < 70 o una reduccin > 50%

estatinas

IECAIndicado en paciente con disfuncin sistlica, HTA, DM2 y ERC.Adems, existe evidencia en prevencin de MACE en pacientes con enfermedad coronaria establecida o alto riesgo de enfermedad coronaria y funcin sistlica conservada.No hay estudios con ARAII

Kaplan-Meier time to event curves for the primary endpoint of three large randomized, placebo-controlled trials of ACE inhibitors for patients at high risk for or with established cardiovascular disease without heart failure. A, Cumulative incidence of cardiovascular death, MI, or stroke with ramipril versus placebo among patients in the HOPE trial. B, Cumulative incidence of cardiovascular death, MI, or cardiac arrest with perindopril or placebo in the European Trial on the EUROPA trial. C, Cumulative incidence of cardiovascular death, MI, or coronary revascularization in the PEACE trial.10

Beta-BloqueadoresDisminuyen FC, contractilidad, conduccin AV y actividad ectpica. Aumenta perfusin en rea isqumica (prolongando distole). No hay RCT en Angina Crnica.Similar efecto antianginoso que BCCa

B BloqueoUnicos que han demostrado prevenir recurrencia y mejorar la sobrevida post IAM

Bloqueadores de Canales de CaNo DihidripiridnicosVerapamilo: menos diabetes y depresin que Bbloq.Diltiazem: Similar perfil a verapamiloDihidropiridnicosNifedipino liberacin prolongadaAmlodipino: seguro. Disminuye eventos (estudio CAMELOT).Utilidad al combinarlos con B-BloqNitratosVasodilatacin arteriolar y venosa. Aumenta el NO y disminuye la precargaAccin corta (tratamiento agudo)Nitroglicerina Sublingual 0,3-0,6 mgIsosorbide Dinitrato 5 mg sublingual. Efecto ms lento y ms prolongado.

Accin larga (prevencin)Isosorbide Dinitrato: Efectivo en disminuir sntomas a corto plazo, estudios a largo plazo sin beneficio.Isosorbide mononitrato: Efecto antianginoso con altas dosisParches Transdrmicos: no cubren 24 horas, duran 3-5 horas. Sin datos sobre su uso.