Ischemic Heart Disease | Pharmacology Mentor

1. Definition & Epidemiology

Ischemic heart disease (IHD)—also called coronary artery disease (CAD)—is defined by impaired blood supply (ischemia) to the myocardium, usually due to narrowing or obstruction of the coronary arteries by atherosclerotic plaque. IHD is the leading cause of morbidity and mortality worldwide, particularly affecting adults over age 40 and those with major cardiovascular risk factors.

2. Pathophysiology

Key Mechanism: Atherosclerosis—accumulation of cholesterol-laden plaques within coronary arteries causes luminal narrowing, reducing oxygen delivery to heart muscle.
Acute events: Rupture of an unstable plaque with subsequent thrombus formation may cause complete occlusion, resulting in acute myocardial infarction (MI).
Risk Factors:
- Non-modifiable: Age, male sex, family history/genetics.
- Modifiable: Hypertension, dyslipidemia, diabetes, obesity, smoking, sedentary lifestyle, stress, unhealthy diet.

#cardiac ischemia anatomical illustration drawn in cartoon style

3. Clinical Presentation

Stage	Symptoms	Notes
Chronic stable	Exertional chest pain (angina), fatigue, shortness of breath	Symptoms relieved by rest/nitroglycerin
Acute coronary syndrome	Persistent chest pain, diaphoresis, nausea, palpitations	May signal MI; emergency
Silent ischemia	No typical angina; atypical symptoms (esp. elderly, diabetic patients)	Detected via ECG or imaging
Heart failure	Edema, orthopnea, dyspnea	Due to chronic ischemia

4. Diagnostic Approach

Test	Principle	Diagnostic Value
ECG	Records cardiac electrical activity	Detects ischemia, arrhythmia
Stress test	Monitors heart under exertion	Provokes symptoms, unmasking ischemia
Echocardiogram	Ultrasound imaging of heart	Assess function, motion, ejection fraction
Coronary angiogram	Dye and X-ray visualizes arteries	Gold standard for obstruction
CT/MRI coronary imaging	Noninvasive, advanced assessment	Useful for non-acute evaluation
Blood tests	Troponin, CK-MB, lipid/liver/kidney profiles	Confirm MI, metabolic risk

5. Management Strategies

A. Lifestyle Modification

Mediterranean/heart-healthy diet (limit saturated fat, cholesterol, sugar).
Regular aerobic exercise (30–45 min most days).
Smoking cessation.
Weight management and stress reduction.
Blood pressure and diabetes control.

B. Pharmacologic Therapy

Drug Class	Examples	Purpose/Mechanism
Antiplatelets	Aspirin, clopidogrel	Prevent clot formation
Statins	Atorvastatin, rosuvastatin	Lower LDL, stabilize plaques
Beta-blockers	Metoprolol, atenolol	Reduce heart rate, oxygen demand
ACE inhibitors/ARBs	Enalapril, losartan	Lower blood pressure, prevent remodeling
Nitrates	Nitroglycerin	Relieve angina (vasodilation)
Calcium channel blockers	Diltiazem, amlodipine	Vasodilation, symptom relief
Newer agents	PCSK9 inhibitors, SGLT2 inhibitors (in comorbid diabetes, HF)	Reduce risk, target specific populations

Medication Adherence: Lifelong commitment; regular review for interactions and side effects.

C. Revascularization

Procedure	Indication	Highlights
Percutaneous Coronary Intervention (PCI)	Acute MI, lifestyle-resistant angina	Balloon angioplasty ± stent placement
Coronary Artery Bypass Grafting (CABG)	Left main/multivessel, DM, failed PCI	Surgical rerouting using graft

6. Follow-Up and Long-Term Care

Regular assessment: Blood pressure, lipid profile, glycemic status, ECGs.
Comorbidity management: Diabetes, kidney disease, arrhythmia.
Patient education: Symptom recognition, emergency response, medication side effects.
Cardiac rehabilitation: Supervised exercise, risk factor education, psychological support.

7. Prognosis and Prevention

Prognosis depends on degree of vessel involvement, comorbidity control, adherence to therapy.
Primary prevention: Risk factor control before onset.
Secondary prevention: Aggressive intervention post-MI or diagnosis to prevent recurrence or progression.

Summary Table: Textbook Comparison of Key IHD Treatments

Strategy	Primary Effect	Most Effective For	Key Textbook References
Lifestyle	Reduces overall CV risk	All patients, prevention	Braunwald, Harrison’s
Antiplatelets	Prevents acute MI	All diagnosed IHD	Katzung, G&G, NICE/ACC/AHA
Statins	Lower cholesterol, resolve plaques	Dyslipidemia, secondary prevention	G&G, ESC Guidelines
PCI	Immediate reperfusion	Acute STEMI/NSTEMI	ACC/AHA
CABG	Complete anatomical correction	Complex/multivessel disease	Harrison’s, ACC/AHA

References

Braunwald’s Heart Disease (11th Edition)
Harrison’s Principles of Internal Medicine (21st Edition)
Goodman & Gilman’s The Pharmacological Basis of Therapeutics (13th Edition, Cardiac Drugs section)
Katzung BG, Basic & Clinical Pharmacology (15th Edition)
ACC/AHA/ESC Guidelines on management of coronary artery disease

With a patient-focused, scientifically accurate approach, this chapter brings together etiology, symptomatology, diagnostic workup, therapy, and prevention as recommended by top clinical textbooks and guidelines.

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anonymous, . Ischemic Heart Disease: Causes, signs and treatment options. Pharmacology Mentor. Available from: https://pharmacologymentor.com/ischemic-heart-disease-causes-signs-and-treatment-options/. Accessed on February 6, 2026 at 15:03.

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Question 1 of 22

A 62-year-old male with a history of CAD and an ejection fraction of 40% presents with new-onset atrial fibrillation. He is experiencing symptoms of angina. He is currently on aspirin and metoprolol. Which of the following medications is **contraindicated** in this patient for rate control of his atrial fibrillation due to its potential to worsen myocardial ischemia? *

Diltiazem Digoxin Verapamil Metoprolol Amiodarone

A 50-year-old male with a history of hypertension presents with sudden, severe, tearing chest pain radiating to his back. His blood pressure is 190/110 mmHg, and his pulse is 110 bpm. An aortic dissection is suspected. Which of the following medications is **contraindicated** in the initial management of suspected aortic dissection? *

Opioid analgesics (e.g., morphine) Vasodilators (e.g., nitroprusside) Beta-blockers (e.g., labetalol) Angiotensin-converting enzyme (ACE) inhibitors (e.g., enalapril) Calcium channel blockers (e.g., verapamil)

A 65-year-old male with diabetes and hyperlipidemia is experiencing exertional angina. He is on a moderate-intensity statin and aspirin. His physician wants to add a medication to further reduce his risk of cardiovascular events. Which of the following medications, when added to statin and aspirin, has been shown to reduce cardiovascular events in patients with stable ischemic heart disease and a history of myocardial infarction or other atherosclerotic disease? *

Fenofibrate Ramipril Omega-3 fatty acids (prescription strength) Ezetimibe Niacin

A 70-year-old male with CAD and chronic kidney disease (CKD) stage 4 is admitted with unstable angina. He is to be treated with PCI. He is on aspirin. Which of the following P2Y12 inhibitors requires dose adjustment or is contraindicated in significant renal impairment? *

Ticlopidine Prasugrel Cangrelor Clopidogrel Ticagrelor

A 70-year-old male with known coronary artery disease (CAD) is admitted with an acute myocardial infarction. He is treated with percutaneous coronary intervention (PCI) and receives a drug-eluting stent. He is prescribed dual antiplatelet therapy (DAPT) with aspirin and ticagrelor. He also has a history of peptic ulcer disease. Which of the following is the most significant drug interaction to consider for this patient? *

Aspirin and clopidogrel Aspirin and NSAIDs Ticagrelor and CYP3A4 inhibitors Aspirin and warfarin Ticagrelor and statins

A 58-year-old female with a history of hypertension and hyperlipidemia presents with exertional chest pain that resolves with rest. She denies any pain at rest. Her ECG is normal at rest. She is scheduled for a stress test. Which of the following diagnostic modalities is most appropriate to assess for significant coronary artery stenosis in this patient? *

Coronary angiography Holter monitor Cardiac MRI Echocardiogram Myocardial perfusion imaging (MPI) with stress

A 70-year-old female with a history of myocardial infarction 2 years ago presents with symptoms of heart failure. She is already on an ACE inhibitor, a beta-blocker, and a loop diuretic. Her ejection fraction is 30%. Her potassium is 4.8 mEq/L. Which of the following medications would be the most appropriate addition to her regimen to improve her prognosis? *

Digoxin Hydralazine/isosorbide dinitrate Sacubitril/valsartan Ivabradine Spironolactone

A 58-year-old female with a history of CAD presents with exertional chest pain. She is started on a high-intensity statin and aspirin. Her LDL cholesterol remains elevated at 120 mg/dL. Which of the following medications is the most appropriate addition to further lower her LDL cholesterol? *

Gemfibrozil Omega-3 fatty acids Niacin Fenofibrate Ezetimibe

A 45-year-old male with no significant past medical history presents with sudden onset of severe, substernal chest pain radiating to his jaw, accompanied by nausea and diaphoresis. His ECG shows diffuse ST-segment elevation. He is diagnosed with a massive anterior STEMI. He is allergic to aspirin. Which of the following is the most appropriate initial antiplatelet therapy in this scenario? *

Abciximab intravenously No antiplatelet therapy due to allergy Ticagrelor 180 mg PO loading dose Clopidogrel 75 mg PO daily Prasugrel 60 mg PO loading dose

A 70-year-old male with ischemic heart disease presents with chest pain and is found to have an inferior STEMI. He undergoes successful primary PCI with placement of a drug-eluting stent. He is discharged on dual antiplatelet therapy (aspirin and ticagrelor) for 12 months. He also has a history of gout and is taking allopurinol. Which of the following is a potential drug interaction to monitor for? *

Ticagrelor can increase uric acid levels, exacerbating gout Allopurinol inhibits the metabolism of ticagrelor, increasing its levels Allopurinol can increase the risk of stent thrombosis Increased risk of bleeding with ticagrelor and allopurinol Ticagrelor can cause bone marrow suppression, similar to allopurinol

A 65-year-old male presents to the emergency department with sudden onset of crushing chest pain radiating to his left arm, accompanied by diaphoresis and nausea. His vital signs are: BP 150/90 mmHg, HR 95 bpm, RR 20/min, SpO2 98% on room air. An ECG shows ST-segment elevation in leads II, III, and aVF. Which of the following is the most appropriate initial pharmacologic management for this patient? *

Oral metoprolol 25 mg PO every 6 hours Intravenous nitroglycerin infusion Clopidogrel 75 mg PO daily Sublingual nitroglycerin tablet Aspirin 81 mg PO daily

A 55-year-old male with stable angina is initiated on a beta-blocker for symptom control. He has a history of asthma. Which of the following beta-blockers would be the most appropriate choice, considering his respiratory history? *

Nebivolol Atenolol Bisoprolol Metoprolol Propranolol

A 75-year-old female with known ischemic heart disease develops acute chest pain at rest. Her ECG shows ST-segment depression in the anterior leads, and her troponin levels are elevated. She is diagnosed with an NSTEMI. Her blood pressure is 110/70 mmHg, and her heart rate is 70 bpm. She is allergic to penicillin. Which of the following medications should be avoided due to a potential cross-reactivity or contraindication? *

Heparin Nitroglycerin Metoprolol Clopidogrel Aspirin

A 60-year-old male with a history of hypertension and hyperlipidemia is experiencing stable angina. His physician is considering starting a statin. Which of the following statins would be considered a high-intensity statin, indicated for primary prevention of atherosclerotic cardiovascular disease in patients with established CAD or multiple risk factors? *

Lovastatin 40 mg daily Pravastatin 20 mg daily Simvastatin 10 mg daily Rosuvastatin 5 mg daily Atorvastatin 80 mg daily

A 65-year-old male with a history of MI is on optimal medical therapy including a beta-blocker, ACE inhibitor, and statin. He continues to experience angina despite these medications. Which of the following medications is considered a second-line agent for symptom relief in stable angina? *

All of the above Amlodipine Verapamil Ranolazine Ivabradine

A 55-year-old male presents with acute chest pain suggestive of an MI. His ECG shows ST-segment elevation in leads V1-V4. He is rushed to the cardiac catheterization lab for primary percutaneous coronary intervention (PCI). He is to receive dual antiplatelet therapy (DAPT). Which of the following P2Y12 inhibitors is generally preferred in the setting of primary PCI for STEMI? *

Clopidogrel Ticagrelor Ticlopidine Prasugrel Cangrelor

A 68-year-old male with stable angina is on optimal medical therapy, including a beta-blocker, aspirin, and a high-intensity statin. He continues to have exertional angina that limits his daily activities. His physician is considering adding a third antianginal agent. Which of the following medications is a direct vasodilator that can be used to improve anginal symptoms by reducing myocardial oxygen demand through peripheral vasodilation? *

Ivabradine Isosorbide mononitrate Ranolazine Amlodipine Trimetazidine

A 68-year-old female presents with acute onset of dyspnea and chest pain that started 2 hours ago. Her ECG shows ST-segment depression in the anterior leads. Cardiac enzymes reveal elevated troponin I. She is diagnosed with a non-ST-elevation myocardial infarction (NSTEMI). Which of the following is the most appropriate initial management strategy? *

Observe for 24 hours and repeat cardiac enzymes Start aspirin and a P2Y12 inhibitor, and consider anticoagulation Initiate beta-blocker therapy and aspirin only Administer intravenous thrombolytics Immediate coronary angiography and revascularization

A 62-year-old male presents with new-onset shortness of breath and fatigue. He has a history of CAD and a previous myocardial infarction 5 years ago. His ejection fraction is 35%. He is currently on lisinopril, metoprolol, and furosemide. His vital signs are stable. Which of the following medications is most likely to improve his long-term prognosis and reduce hospitalizations for heart failure? *

Hydralazine Spironolactone Sacubitril/valsartan Carvedilol Digoxin

A 75-year-old male with a history of ischemic heart disease develops acute shortness of breath and chest pain. He is diagnosed with acute decompensated heart failure and a concurrent myocardial infarction. He is hemodynamically unstable with hypotension. Which of the following medications should be used with extreme caution or avoided in this patient due to its negative inotropic effects and potential to worsen hypotension? *

ACE inhibitors Aspirin Furosemide Beta-blockers Nitroglycerin

A 60-year-old male with a history of CAD is admitted with an NSTEMI. He is started on aspirin and ticagrelor, and anticoagulation with heparin. He develops a rash and pruritus after 2 days of ticagrelor. His troponin levels are still rising. Which of the following is the most appropriate management for his ticagrelor-induced rash? *

Discontinue ticagrelor and consider a glycoprotein IIb/IIIa inhibitor Discontinue ticagrelor and switch to prasugrel Continue ticagrelor and add an antihistamine Discontinue ticagrelor and switch to clopidogrel Discontinue ticagrelor and restart aspirin monotherapy

A 72-year-old male with a history of CAD and atrial fibrillation is on warfarin for stroke prevention. He presents with worsening exertional chest pain. He is prescribed sublingual nitroglycerin, which provides temporary relief. His physician is considering adding a medication to improve his exertional capacity. Which of the following medications would be most appropriate, considering his anticoagulation status and history? *

Amlodipine Diltiazem Ivabradine Ranolazine Verapamil

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Ischemic Heart Disease: Causes, signs and treatment options