Chronic ischemic heart disease

The burden of chronic ischemic heart disease needs to be considered from a number of perspectives. First of all, there is the burden on the patient and the patient s family, who deal not only with the disease itself, but how it impacts on their lives and livelihoods. Next there is the burden to society as a... 

Radionuclide Imaging of Chronic Ischemic Heart Disease... 

Conduction system abnormalities are common in chronic heart failure, occurring in 15-30% of the population with low left ventricular ejection fraction (LVEF) [1-3]. The prevalence in ischemic heart disease is roughly similar to that seen in other forms of dilated cardiomyopathy. Conduction system disease can occur both at the time of an acute myocardial infarction as well as slowly progressing in chronic ischemic heart disease. Intraventricular conduction delays are associated with a poor prognosis in heart failure, with up to a 70% increase in the risk of death, and are also more prevalent in patients with advanced symptoms [2,4]. In ischemic heart disease, all components of the conduction system are at risk of ischemic injury, from the sinoatrial node to the His-Pukinje system. These conduction system abnormalities have the potential to impair cardiac function by a number of mechanisms. Since conduction abnormalities impair cardiac function, it is logical that pacing therapies to correct or improve these conduction abnormalities may improve cardiac function. 

Assmus B, Honold J, Lehmann R, Pistorius K, Hoffmann WK, Martin H, Schachinger V, Zeiher AM. Transcoronary transplantation of progenitor cells and recovery of left ventricular function in patients with chronic ischemic heart disease results of a randomized controlled trial. Circulation 2004 110(Suppl III) 238. 

Aspirin (75-325 mg daily) administrated on a routine basis is highly recommended in all patients with acute and chronic ischemic heart disease if the patient has no contraindications. Clopidogrel will be the possible alternate choice if aspirin is totally... 

Bales AC. Medical management of chronic ischemic heart disease. Selecting specific drug therapies, modifying risk factors. Postgrad Med 2004 115(2) 39-46. 

Montero M, Schmitt C. Recording of transmembrane action potentials in chronic ischemic heart disease and dilated cardiomyopathy and the effects of the new class III antiarrhythmic agents D-sotalol and dofetilide. J Cardiovasc Pharmacol 1996 27(4) 571-7. 

Table 2.1 Acute and chronic ischemic heart disease relationship between degree of ventricular wall involvement and electrocardiographic pattern of ischaemia, injury and necrosis.

De Bakker JM, van Capelle FJ, Janse MJ, et al. Reentry as a cause of ventricular tachycardia in patients with chronic ischemic heart disease electrophysiologic and anatomic correlation. Circulation 1988 77(3) 589-606. 

Table 4.1 Predictors of outcome in chronic ischemic heart disease ... 

This chapter will not cover the acute coronary syndromes as readers are referred to the accompanying chapter in this text. However, it should be evident that the occurrence of acute plaque rupture and thrombosis has a significant impact on the prognosis of a patient with chronic ischemic heart disease. Cardiogenic shock... 

Patients with chronic ischemic heart disease may demonstrate varying degrees of endothelial dysfunction and ischemia depending on the status of their endothelium and the presence and robustness of collateral blood supply. From a clinical perspective, this is most easily manifested by the various physiologic parameters of exercise capacity. 

The use of nuclear perfusion imaging in addition to exercise stress testing or as an alternative modality for patients unable to exercise (using pharmacologic agents) can provide important prognostic information for patients with chronic ischemic heart disease. 

Since Johann Lobstein first coined the term arteriosclerosis, or hardening of the arteries in 1833, to the Framingham Study which began in 1948 (42), to the isolation of mevastatin by Akira Endo in 1976 (43), and on to the publication of the Scandinavian Simvastatin Survival Study (4S) in 1994 (44), cholesterol levels have emerged as perhaps the most potent modifiable risk factor in the treatment of chronic ischemic heart disease. Genetic disorders such as homozygous familial hypercholesterolemia where severe atherosclerosis is present by early adolescence have helped clarify the importance of LDL cholesterol in the pathogenesis of atherosclerosis. 

In symptomatic chronic heart failure, beta-blockers are also an essential component of an optimal medical regimen, as demonstrated in several trials (95-98). Currently extended-release metoprolol succinate, carve-dilol, and bisoprolol remain the agents of choice for treatment of patients with chronic ischemic heart disease and NYHA Class II-IV symptomatic heart failure. 

As previously discussed in the LDL cholesterol section, lipid-lowering agents primarily in the form of HMG-CoA reductase inhibitors (i.e., statins) have consistently demonstrated the ability to significantly reduce the incidence of death, myocardial infarction, revascularization, and stroke and are an essential component to the treatment of patients with chronic ischemic heart disease (45). 

Not surprisingly then, the effect of smoking cessation on the prognosis of patients with chronic ischemic heart disease is substantial. In one meta-analysis by Critchley and Capewell (113), smoking cessation in patients with established CHD resulted in a crude 36% reduction in crude relative risk of all-cause mortality. The crude risk reduction for nonfatal reinfarction was 32%. 

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