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Management of the Patient with Stable Ischemic Heart Disease and Preserved Left Ventricular Systolic Function

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Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II-receptor blockers (ARBs) are proven therapies that reduce morbidity and mortality in patients with left ventricular systolic dysfunction (LVSD) with chronic heart failure, and have also shown to reduce the progression of nephropathy in patients with diabetes mellitus and proteinuria. It is less clear how ACEIs contribute to the reduction of cardiovascular events in patients with stable IHD who also have preserved left ventricular systolic function (LVSF), as determined by a left ventricular ejection fraction (LVEF) >40%. These patients have relatively intact LVSF, yet may present with chest pain (angina pectoris) brought on by emotional or physical stress. These symptoms are usually due to one or more clogged or diseased arteries that result in reduced blood flow and oxygen supply to the heart. Therapies shown to reduce the risk for cardiovascular events in IHD patients include aspirin, statins, beta-blockers, and dual anti-platelet therapy. Other agents used for symptomatic relief include nitrates and calcium channel blockers (CCB). A revascularization procedure to circumvent or treat a blocked vessel is another therapeutic option for patients unresponsive or intolerant to these medications. A patient will need prolonged treatment with these medications to reduce anginal symptoms, increase quality of life, and reduce the risk of fatal and nonfatal cardiovascular events. A comparative effectiveness review was conducted to synthesize the evidence surrounding the additional cardiovascular benefits from adding ACEIs and/or ARB therapy to the long-term care regimens of stable IHD patients with intact LVSF, and if those benefits outweigh the potential side effects of these drugs. This case study will seek to evaluate ACEIs and/or ARBs in stable ischemic heart disease patients with preserved LVSF.
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Management of the Patient with Stable Ischemic Heart Disease and Preserved Left Ventricular Systolic Function

Keywords: case study | stable ischemic heart disease | left ventricular systolic function | angiotensin-converting enzyme inhibitors | angiotensin II-receptor blockers
Case Overview Patient is a 55-year old male with a history of stable ischemic heart disease. He had a percutaneous coronary intervention (PCI) with a stent to the left anterior descending (LAD) coronary artery six months ago. He has a history of hypertension. He is currently asymptomatic. His current medication regimen includes aspirin 81 mg po daily, simvastatin 80 mg po daily, clopidogrel 75 mg po daily, and metoprolol 50 mg po daily.
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Case Overview

On physical examination, the patient has a blood pressure of 138/85 mm Hg, his heart rate is 65 bpm, his lungs are clear to auscultation, and his heart exam reveals a normal S1 and S2, no S3 or S4 gallop, and a 1/6 early systolic ejection murmur present in the right upper sterna border. Lab results include an echocardiogram obtained two months ago for auscultation of a systolic murmur revealed mild aortic sclerosis but no significant valvular pathology.  The ejection fraction was 50-55% with mild hypokinesis of the distal anterior wall. His LDL-C was 65 mg/dl, Cr 1.1 mg/dl, and potassium 4.2 mmol/L.
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Physical Examination

Clinical Decision Considering that the patient’s history of stable ischemic heart disease puts him at risk for future recurrent cardiac events and after considering current evidence and guidelines, is it reasonable to consider adding an ACEI to this patient's standard medical therapy? A. Yes B. No.
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Clinical Decision

Pharmacologic Effects of Antagonists on the Renin-Angiotensin-Aldosterone System Despite standard therapy, patients with stable ischemic heart disease and preserved left ventricular systolic function continue to be at risk for future cardiovascular events. This slide represents several pathways involved in the Renin-Angiotensin-Aldosterone System (RAAS), which is critical for regulating blood pressure, electrolyte balance, and fluid volume homeostasis and plays a pivotal role in the pathogenesis of hypertension, congestive heart failure, and diabetic nephropathy. Pharmacological antagonists of this system include angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II-receptor blockers (ARBs). These drugs block adverse effects of the RAAS by blocking the activity of angiotensin II through different mechanisms as shown in the slide: ACEIs act on the RAAS by blocking the conversion of angiotensin I into angiotensin II and inhibiting the breakdown of bradykinin, which is a potent vasodilator. ARBs block the angiotensin II type-1 receptor and reduce the pharmacologic effects of angiotensin II, regardless of whether angiotensin II is created by the angiotensin-converting enzyme or by pathways independent of this enzyme.
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Pharmacologic Effects of Antagonists on the Renin-Angiotensin-Aldosterone System

Harmful Activities of Angiotensin II Through the stimulation of angiotensin II type-1 receptors, angiotensin II may have several potentially harmful activities including: A. Induction of aldosterone production, which can cause sodium retention and increased fluid retention that, in turn, leads to an increase in blood pressure. B. Increased aldosterone production, which can possibly lead to promotion of pathogenic remodeling (i.e., atherosclerosis and fibrosis). C. Constriction of blood vessels, which can lead to increased blood pressure. D. Potential reduction in the availability of nitric oxide through the production of free radicals and the induction of endothelial dysfunction. E. All the above.
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Harmful Activities of Angiotensin II

Patient Discussion: Treatment You suggest to this patient that they discuss the possibility of adding an ACEI to his current medications. In order to do this, you review with him a patient guide titled, “ACE Inhibitors” and “ARBs” To Protect Your Heart? A Guide for Patients Being Treated for Stable Coronary Heart Disease, from the Effective Health Care Program website at: http://effectivehealthcare.ahrq.gov. You explain to him that the guide is based on a review of multiple studies about specific medications for patients with stable ischemic heart disease.
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Patient Discussion: Treatment

Patient Discussion: Informed Decisionmaking To help the patient make an informed decision about adding an ACEI or an ARB, you: A. Tell the patient about the evidence of the benefits and harms for ACEI , or of ARBs if you suspect he is intolerant to ACEI. B. Discuss the evidence in light of the patient’s personal medical history, current lab results, and examination findings. C. Discuss the impact that adding an additional medication would have on the patient’s lifestyle, ensuring that the patient would adhere to the regimen. D. Discuss the cost of the medication and the impact the additional cost might have on the patient, ensuring that the cost of the medication might not impact adherence. E. Discuss the likelihood of benefits and adverse effects, if they are known, and incorporate his personal preferences into weighing the individual benefits and risks when agreeing on a course of action. F. All of the above.
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Patient Discussion: Informed Decisionmaking

Patient Discussion: Potential Benefits of ACEIs You explain that current research shows there is good evidence that adding an ACEI to his usual care may offer him: A. Reduced risk of mortality. B. Reduced risk of nonfatal myocardial infarction. C. Reduced risk of heart failure-related hospitalizations. D. All the above.
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Patient Discussion: Potential Benefits of ACEIs

Patient Discussion: Potential Benefits of ACEIs In explaining the evidence of benefits, the patient asks, “If I take this, I won’t have another heart attack?” You: A. Agree with him and write the prescription. B. Caution him that the studies are generalized and that the evidence may not apply to his specific case. C. Show him the pictograph in the consumer guide titled, “ACE Inhibitors” and “ARBs” To Protect Your Heart? A Guide for Patients Being Treated for Stable Coronary Heart Disease, of the evidence concerning the modest likelihood of benefit so that he can see the probability of facing a fatal heart attack with or without the medicine. Review the likelihood of the other benefits using the same pictograph as a model. D. Explain to him that the likelihood of benefit is minimal, and that taking an ACEI may not make that much of a difference.
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Patient Discussion: Potential Benefits of ACEIs

Patient Discussion: Potential Harms of ACEIs You then discuss the possible risks of adverse effects from taking an ACEI, so that the patient can weigh the benefits and harms with you to determine an appropriate decision. You explain that research has found that he may experience: A. Nothing. B. Hypotension. C. Hypertension. D. Need for future revascularizations. E. Syncope, cough, and hyperkalemia.
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Patient Discussion: Potential Harms of ACEIs

Shared Decisionmaking: Considering Patient Values In reviewing the decision with the patient to add an ACEI to their standard therapy, you: A. Discuss the likelihood of benefit this medication would have for this patient. B. Discuss the likelihood of adverse events this medication might have for this patient. C. Discuss the impact that adding an additional medication would have on the patient’s lifestyle, ensuring that the patient would adhere to the regimen. D. Discuss the cost of the medication and the impact the additional cost might have on the patient, ensuring that the cost of the medication might not impact adherence. E. All of the above.
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Shared Decisionmaking: Considering Patient Values

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