Evidenced Based Guidelines: Ischemic Heart Disease
Submitted by Madeleine Augier RN BSN
The University of Tampa, NUR 680
Ischemic heart disease is the leading cause of death worldwide. In fact, this disease has remained the leading cause of death globally in the past fifteen years (World Health Organization, 2018). With this statistic, it is imperative to educate the public on how to reduce risk factors, but also necessary for nurse practitioners to provide primary prevention and improve correct diagnosis and treatment.
Ischemic heart disease (IHD), most commonly known as coronary artery disease, is defined as “the presence of atherosclerotic plaques in one or more of the major coronary arteries that supply blood to the heart or the muscle (Lewis & Davis, 2013).” Ischemia occurs when there is an imbalance between myocardial oxygen supply and a demand that is commonly caused by plaques that impede blood flow to tissue distal to the stenosis.
There are two different types of IHD:
- Stable ischemic heart disease: Often manifests with having stable angina, or chest pain, that is usually retrosternal or substernal that is precipitated by physical or emotional stress. The chest pain has a predictable pattern and is relieved by rest or sublingual nitroglyercin (Lewis & Davis, 2013). Fihn et al. (2012), of American College of Cardiology Foundation (ACCF)/ American Heart Association (AHA) reports that stable ischemic heart disease includes known stable or suspected IHD, including those with new onset chest pain that are deemed to have low-risk unstable angina (UA). Low risk angina is classified as those under the age of 70 years with symptoms of chest pain during exertion lasting less than 20 minutes that does not accelerate, with a normal 12-lead EKG, and no elevation of cardiac enzymes.
- Unstable ischemic heart disease: Often referred to as acute coronary syndrome (ACS), with either unstable angina, acute non-ST elevation myocardial infarction, or acute ST elevation myocardial infarction. The patient will often present with angina at rest, new onset angina that markedly limits physical activity, or increasing angina that is more frequent and longer with less activity (Simons & Breall, 2019).
As mentioned, heart disease is the leading cause of death worldwide. It is estimated that 6.7% of all American adults over the age of 20 years has IHD. The prevalence of IHD amongst males is 7.4% and 6.2% for females (Benjamin et al., 2019).
The most common cause of ischemic heart disease is from atherosclerosis, which can affect one or all three of the major epicardial coronary arteries. Atherosclerosis occurs when there is an accumulation of intracellular and extracellular lipids, proliferation of vascular smooth muscle cells, formation of scar tissue, and calcification (Porth, 2015). This forms a growing plaque inside the vessel which can eventually occlude the vessel or predispose to thrombus formation leading to a reduction in blood flow. The plaque buildup in the arteries leads to the inability of the coronary arteries to supply blood to meet the metabolic demands of the heart which can present as chest pain and lead to either ACS or IHD depending on the severity.
(Lewis & Davis, 2013)
||Signs and Symptoms
When did your chest pain start?
What were you doing when the chest pain started?
What makes your symptoms better or worse?
Do you or anyone in your family have a history of heart disease?
Do you have a history of high cholesterol?
Do you smoke or drink alcohol?
General/Constitutional: inspect for pallor, fever, dizziness, fatigue, diaphoresis, and signs of acute distress.
Cardiovascular: Auscultate rate and rhythm. Assess for S1, S2 and any heart murmurs, rubs, or gallops.
Respiratory: Auscultate lungs and assess for any adventitious lung sounds. Assess for symmetric respirations, tachypnea, labored breathing, or use of accessory muscles. Palpate for any tenderness to chest.
Peripheral/Extremities: Assess peripheral pulses for bounding or absent pulses. Palpate extremities for edema. Assess for cyanosis or clubbing of the nails.
The goals of management of ischemic heart disease are to:
- Promote a heart healthy lifestyle
- Symptom relief (decreasing frequency and severity of angina)
- Prevent secondary myocardial infarction
- Increase in functional capacity and longevity
Dietary modifications: low fat diet, reduce sodium intake, increase fruits and vegetable intake.
Physical activity: 30-60 minutes of moderate aerobic activity 5-7 days per week supplemented by an increase of daily activities
Weight loss: goal of BMI between 18.5 and 24.9
Alcohol intake: no more than 1 serving/day. Serving= 4 oz. of wine, 12 oz, beer, 1 oz. spirits
Pharmaceutical Therapy for Stable IHD
Role and Precautions
Calcium Channel Blockers:
Role: reduce angina by relaxing vascular smooth muscle, which decrease preload and afterload allowing a decrease in oxygen demand.
Role: anti-platelet therapy, reduction of clot formation
Role: help decrease formation of coronary plaques
(Lewis & Davis, 2013)
- Importance of non-pharmaceutical therapy: exercise, weight loss, and heart healthy diet
- Self-monitoring skills: how to pace their activities and set goals based on stress, anxiety, or depression on symptoms.
- Action plan: develop a plan for what to do if they experience recurrent angina. Advise to stop activity any time symptoms occur, take a sublingual nitroglycerin (unless contraindicated). If symptoms continue after a total of 3 doses, call EMS.
- Adherence: importance of maintaining a healthy lifestyle and adhering to prescribed medications
- Educating every visit on the importance of smoking cessation.
Patients with suspected coronary artery disease should be referred to a cardiologist for further diagnostic tests. Patients with chronic stable ischemic heart disease require follow-up on a regular basis, often every 6-12 months (Lewis & Davis, 2013). At each visit a detailed history and physical should be performed.
It is important to obtain:
- A change in physical activity
- Any change in frequency, severity, or pattern of angina
- Tolerance of and compliance with medial program
- Modification of risk factors
- The development of new or worsened comorbid illnesses
- Laboratory studies with blood glucose and lipid profile
- EKG if change in history and physical
- Benjamin, E. J., Muntner, P., Alonso, A., Bittencourt, M. S., Callaway, C. W., Carson, A. P.,...Virani, S. S. (2019). Heart disease and stroke statistics- 2019 update. Circulation, 139(10), e56-e528. doi:https://doi.org/10.1161/CIR.0000000000000659
- Fihn, S. D., Blankenship, J. C., Alexander, K. P., Byrne, J. G., Fonarow, G. C., Levine, G. N.,...Smith, P. K. (2014). 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurse Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. The Journal of Thoracic and Cardiovascular Surgery, 149(3), e5-e23. doi:http://dx.doi.org/10.1016/j.jtcvs.2014.11.002
- Fihn, S. D., Gardin, J. M., Abrams, J., Berra, K., Blankenship, J. C., Dallas, A. P.,...Williams, S. V. (2012). 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: Executive summary. Journal of the American College Cardiology, 60(24), 2564-2603. doi:http://dx.doi.org/10.1016/j.jacc.2012.07.012
- Lewis, J. M., & Davis, L. L. (2013). Management of Stable Ischemic Heart Disease. The Journal for Nurse Practitioners, 9(10), 661-668. doi:http://dx.doi.org/10.1016/j.nurpra.2013.08.020
- National Heart, Lung, And Blood Institute. (2017). Ischemic heart disease. Retrieved from http://www.nhlbi.nih.gov/health-topics/ischemic-heart-disease
- Porth, C. M. (2015). Essentials of pathophysiology: Concepts of altered health states (4 ed.). Philadelphia: Lisa McAllister.
- Simons, M., & Breall, J. A. (2019). Overview of the acute management of non-ST elevation acute coronary syndromes. Up to Date. Retrieved from https://www-uptodate-com.esearch.ut.edu/contents/overview-of-the-acute-management-of-non-st-elevation-acute-coronary- syndromes?search=acute%20coronary%20syndrome
- World Health Organization. (2018). The top 10 causes of death. Retrieved from http://www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-death