A few important recommendations : 1. Weight reduction/maintenance to 18.5- 24.9 kg/m2 2. Physical activity for 30-60 minutes/day 7 days/week 3.

Low- density lipoprotein cholesterol less than 100 mg/dL 4. Blood pressure less than 130/80 mm Hg 5. No smoking and no environmental exposure to smoke 6. Reduce intake of saturated fats (to less than 7% of total calories), trans-fatty acids, and cholesterol (to less than 200 mg/day) 7. If diabetic, glycosylated hemoglobin less than 7% 8. Influenza vaccine each year

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Coronary artery disease (CAD)
Introduction:
A general term that does not discriminate between the various phases the individual may cycle between for several decades.These phases include asymptomatic disease, stable angina, progressive angina, unstable angina, non -ST- segment elevation MI , and ST- segment elevation MI . The following mnemonic, developed for patients with chronic stable angina, can be applied to all patients with CAD. A = Aspirin and Antianginal Therapy B = -Blocker and BP C = Cigarette Smoking and Cholesterol D = Diet and Diabetes E = Education and Exercise Obviously, not all patients with CAD have diabetes or smoke cigarettes, but it is a way to remember the primary areas that should be addressed, as applicable, in all patients with CAD.

Important Terms for this section: LVEF: Left Ventricular Ejection Fraction
Left ventricular ejection fraction is the percent of blood a full left ventricle pumps into the AORTA with each cardiac cycle Normal LVEF is 55 percent; LVEF below 35 percent indicates severe heart failure. The ST segment corresponds to a period of ventricle systolic depolarization, when the cardiac muscle is contracted. Subsequent relaxation occurs during the diastolic repolarization phase. A pacemaker is a small device thats placed in the chest or abdomen to help control abnormal heart rhythms. This device uses electrical pulses to prompt the heart to beat at a normal rate. Represents the volumetric fraction of blood pumped out of the ventricle (heart) with each heart beat or cardiac cycle. It can be applied to either the right ventricle which ejects via the pulmonary valve into the pulmonary circulation or the left ventricle which ejects via the aortic valve into the systemic circulation. Represents electrical depolarization and repolarization of the left and right ventricles

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ST- segment

Pacemaker

EF: Ejection fraction

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QT-segment

A. Therapeutic Management 1. Antiplatelet therapy

a)Aspirin a. Inhibits synthesis of thromboxane A b. Indicated in all patients with CAD, unless contraindicated c. Dose at 75- 162 mg/day. d. Decreases cardiovascular events by about one-third b)Clopidogrel a. Prevents adenosine diphosphate-mediated platelet activation b. A dose of 75 mg/day if aspirin absolutely contraindicated c. Magnitude of benefit not clear; however , appears to be about that of aspirin c)Dipyridamole: should be avoided in symptomatic CAD a. Increases exercise-induced myocardial ischemia b. No benefit over aspirin in the absence of symptomatic CAD

B. Additional Therapies for Chronic Stable Angina

Definition:predictable angina symptoms with exertion Goal: Reduce symptoms of ischemia, increase physical function, and improve quality of life. In general, achieved by either: Decreasing myocardial oxygen demand OR Increasing myocardial oxygen supply

5. -Blockers
a. Pharmacologic effects: decreased inotropy and HR (decreased oxygen demand) b. Goal exercise HR of no more than 75% HR associated with angina symptoms c. Contraindications: severe bradycardia (HR less than 50 beats/minute) high degree atrioventricular block ( without pacemaker ), sick sinus syndrome (without pacemaker)

b. Place in therapy: i . A scheduled nitrate is useful in conjunction with blockade or non dihydropyridine calcium channel blocker (which blunts the reflex sympathetic tone with nitrate therapy). i i . As-needed sublingual or spray nitrate is necessary to relieve effort or rest angina i i i . In addition, as needed nitrates can be used before exercise to avoid ischemic episodes. c. Contraindications : hyper trophic obstructive cardiomyopathy, inferior wall MI , severe aortic valve stenosis, sildenafil and vardenafil within 24 hours, tadalafil within 48 hours

8. Aldosterone receptor blockers

a. Place in therapy: i . Can be used in patients post MI without significant renal dysfunction (SCr should be less than 2.5 mg/dL for men and 2.0 mg/dL for women) or hyperkalemia ( K should be less than 5.0 mEq/L) who are receiving a blocker and ACE inhibitor (or ARB), have an EF of 40% or less, and have either HF or diabetes mellitus

6. Calcium channel blockers

a. Pharmacologic effects i . Decrease coronary vascular resistance and increase coronary bloodflow (increase oxygen supply) i i . Negative inotropy, to varying degrees; nifedipine much greater than amlodipine and felodipine(decrease oxygen demand) i i i . Decrease HR (verapamil and diltiazem only) b. Place in therapy: i . Added to -blocker therapy to achieve HR goals i i . Instead of -blocker therapy when unacceptable adverse effects emerge i i i . Short acting calcium antagonists (nifedipine, nisoldipine)have been associated with increased cardiovascular events and should be avoided (except in slow release formulations) c. Contraindications for non dihydropyridines : systolic HF, severe bradycardia, high degree atrioventricular block (without pacemaker ), and sick sinus syndrome (without pacemaker) d. Contraindications for dihydropyridines: LV dysfunction (except amlodipine and felodipine)

2. Lipid-lowering therapy
a. Low-density lipoprotein cholesterol should be less than 100 mg/dL. b. Reduction in LDL-C to less than 70 mg/dL or use of a high-dose statin is reasonable. e. Canconsider the addition of plant stanols/sterols (2 g/day) or viscous fiber (greater than10 g/day) to lower LDL- C f. For risk reduction,encourage omega-3 fatty acids in the form of fish or capsule (1 g/day)in all patients.

9. Ranolazine
a. Pharmacologic effects i . Inhibits myocardial fatty acid oxidation, causing increased glucose oxidation(a less oxygen-consuming process) i i . Increases oxygen efficiency b. Place in therapy: i . Ideal role is not clear .Currently, either as monotherapy or as an add-on to maximally tolerated conventional therapy (-blocker plus calcium channel blocker plus nitrate) with continued symptoms i i . Important points: (A)Heart rate or BP effects are not present; thus, bradycardia and hypotension are not a concern. (B)Dose related QT prolongation (C)Metabolized by CYP3A (1)Avoid in hepatic dysfunction or disease. (2)Avoid use with strong 3A inhibitors including ketoconazole, itraconazole, clarithromycin, nefazodone, nelfinavir, ritonavir, indinavir, and saquinavir. (3)Avoid use with 3A inducers such as rifampin, rifabutin, rifapentine, phenobarbital, phenytoin, carbamazepine, and St.Johns wort. (4)Limit the dose to 500 mg 2 times/day in patients receiving including diltiazem, verapamil, aprepitant, erythromycin, fluconazole, and grapefruitjuice.

3. Angiotensin-converting enzyme inhibitors

a. Angiotensin-converting enzyme inhibitors (specifically ramipril 10 mg/day)have been shown to greatly decrease cardiovascular events in patients with CAD (and no LV dysfunction) at high risk of subsequent cardiovascular events. b. An ACE inhibitor should be considered in patients with an LVEF of 40% or less and in patients with hypertension and established CAD, diabetes mellitus, and/or chronic kidney disease. c. Consider using in lower -risk patients with a mildly reduced or normal LVEF in whom cardiovascular risk factors are well controlled and revascularization has been performed. d. Postulated mechanisms: plaque stabilization

7. Nitrates
a. Pharmacologic effects i . Endothelium-dependent vasodilation, dilates epicardial arteries and collateral vessels (increased oxygen supply) i i . Decreased LV volume because of decreased preload mediated by vasodilation (decreased oxygen demand)

4. Angiotensin II receptor blockers

a. Recommended for those with hypertension