Ischaemic Heart Disease Management

Ischaemic heart disease management in the acute phase comes down to one early decision and one common backbone. Every patient with a suspected heart attack receives the same drug protocol: aspirin plus a second antiplatelet agent, a high-dose statin, a beta blocker where blood pressure and heart rate allow, and nitrates for pain. The ECG (electrocardiogram) then decides whether the patient also needs immediate reperfusion.

Dr. Rohit Goel, Principal Consultant, Cardiology at Max Hospital, Gurugram, India, at the time of the session (currently Associate Director - Cardiology at Max Hospital, Gurugram, India), built his masterclass for referring doctors around that sequence. His summary was blunt: once ischaemic heart disease is confirmed, the management is standard and "we should follow everywhere". What changes from one hospital to the next is not the protocol but the resources available to deliver it, above all whether a catheterisation laboratory (cath lab) and an interventional cardiologist are within reach.

This guide covers the full pathway: the three forms of acute coronary syndrome, the emergency drug protocol, the management of non-ST-elevation heart attack and unstable angina, care after angioplasty or thrombolysis, two special situations raised by doctors in the session, and the rehabilitation and prevention that determine what happens after discharge. Two companion articles go deeper on how a heart attack is diagnosed with the ECG, cardiac biomarkers and echo and on choosing between thrombolysis and primary angioplasty for STEMI.

What ischaemic heart disease and acute coronary syndrome mean

Ischaemic heart disease is the condition in which narrowed or blocked coronary arteries fail to deliver enough oxygenated blood to the heart muscle. Its acute, dangerous phase is acute coronary syndrome (ACS): a sudden reduction in coronary blood flow, usually from a clot forming on a ruptured cholesterol plaque, that threatens or causes death of heart muscle.

ACS takes three forms, and the distinction drives every treatment decision that follows:

STEMI means the artery is, in most cases, completely blocked, and every minute of occlusion costs heart muscle. NSTEMI and unstable angina reflect a partially blocked or intermittently blocked artery. Dr. Goel explained that the biomarkers tell the two apart: if troponin I or CK-MB, proteins released into the blood when heart muscle is damaged, is raised, the diagnosis is NSTEMI; if everything is normal, it is unstable angina, and the diagnosis then rests on a careful clinical history and examination. The diagnostic work-up is set out in detail in the companion article on ECG and cardiac biomarkers.

Heart attack mortality: why the first hours decide the outcome

Dr. Goel put mortality in STEMI at up to 30 to 50% if the patient is not treated properly, and stressed that adequate treatment is very important. The ECG changes of STEMI appear within 15 to 30 minutes of symptom onset, and they persist for as long as the artery stays closed, for up to 48 hours.

Ischaemic heart disease management: the emergency drug protocol

Every ACS patient starts on the same emergency drug protocol, whatever the ECG shows. The management of STEMI and NSTEMI is the same, he said, "except for thrombolysis". On arrival in the emergency department:

1. Secure intravenous access and put the patient on bed rest.
2. Give oxygen. Dr. Goel includes oxygen in the initial package. Current European Society of Cardiology (ESC) guidance reserves it for patients whose oxygen saturation is below 90%, because routine oxygen brings no benefit when saturation is normal.
3. Load with aspirin. Aspirin is given to every patient. Dr. Goel's protocol slide gave 150 mg, and in his closing summary he loaded with 325 mg; mainstream guidelines place the oral loading dose in the range of 150 to 325 mg.
4. Add a second antiplatelet agent (a P2Y12 inhibitor, a drug that blocks a platelet receptor called P2Y12 so that platelets clump less readily). One of three molecules is given with aspirin, depending on availability. Dr. Goel's first choice where possible is ticagrelor.
5. Start a high-dose statin, atorvastatin or rosuvastatin.
6. Give a beta blocker if blood pressure and heart rate allow.
7. Relieve pain with morphine or nitrates: sublingual glyceryl trinitrate, or a short- or long-acting nitrate.

Clopidogrel, prasugrel and ticagrelor loading doses

Dr. Goel gave the loading doses for the three agents that can accompany aspirin:

Prasugrel and ticagrelor are more potent and more effective than clopidogrel, but they carry a higher risk of bleeding. Dr. Goel's rule is to check the patient first: if the patient is not elderly and has no liver or kidney disease, so that the bleeding risk is low, prasugrel or ticagrelor should be used. Prasugrel is also contraindicated in patients with a previous stroke or transient ischaemic attack.

Statin dose after a heart attack

Dr. Goel advises a high-dose statin, atorvastatin or rosuvastatin. High-intensity therapy is 40 to 80 mg daily for atorvastatin and 20 to 40 mg daily for rosuvastatin.

STEMI treatment: immediate reperfusion

For STEMI, the drugs above are only the first step. The blocked artery must be reopened, a step called reperfusion (restoring blood flow through the artery). Primary angioplasty, in which the artery is opened with a balloon and stent in a catheterisation laboratory, is the treatment of choice. Dr. Goel's threshold is practical: if the patient can reach a hospital with a catheterisation laboratory within 90 to 120 minutes, refer; if transfer will take longer or the facility does not exist, thrombolyse. Heparin is given alongside. The full decision, including eligibility, the thrombolytic agents and the contraindications, is covered in Thrombolysis vs Primary Angioplasty for STEMI: When to Refer. Cost guidance for the procedure is on the angioplasty with stent cost page.

NSTEMI and unstable angina management

NSTEMI and unstable angina are managed with the same emergency drugs as STEMI, but these patients are never thrombolysed. The emergency department management mirrors that of STEMI: intravenous access, oxygen, aspirin, clopidogrel or another P2Y12 inhibitor, a statin, a beta blocker and sublingual nitrates. In place of thrombolysis they receive an anticoagulant: unfractionated heparin, low molecular weight heparin or fondaparinux, depending on availability.

Medical management is the starting point, but Dr. Goel does not stop there. Coronary angiography, followed by angioplasty or bypass surgery as the anatomy dictates, is planned in three situations:

• The patient is not improving on medical management.
• The patient has been stabilised, so that further treatment can be planned.
• The patient is at high risk, in particular of developing heart failure, ventricular arrhythmia or hypotension. These patients should go immediately.

Where bypass surgery is the right revascularisation, the CABG cost page sets out the cost guidance.

Glycoprotein IIb/IIIa inhibitors: a narrower role today

Glycoprotein IIb/IIIa inhibitors are powerful intravenous antiplatelet drugs that block the final step of platelet aggregation. There are three: abciximab, tirofiban and eptifibatide. Dr. Goel explained that they were used quite commonly about 10 years ago, when stent quality and the procedure itself were not well standardised. With better stents, wider awareness and wider availability of catheterisation laboratories, their use has fallen.

Today he reserves them for high-risk patients: those with a high thrombotic burden or a delayed presentation, and those in whom angiography shows a large clot in the artery. The reason for the decline is bleeding risk, in the brain, in the stomach and at the local puncture site.

Medicines after angioplasty or thrombolysis

Once the artery has been opened, by angioplasty or by thrombolysis, the long-term regimen begins. Dr. Goel's standard treatment for both STEMI and NSTEMI after the acute phase is:

• Aspirin with clopidogrel or ticagrelor (dual antiplatelet therapy).
• Rosuvastatin or atorvastatin.
• A beta blocker.
• An ACE inhibitor if blood pressure is high, the patient is diabetic, or left ventricular function (the pumping strength of the heart's main chamber, measured as ejection fraction) is poor.
• Glucose control for patients with diabetes: insulin where needed in hospital and, long term, preferably agents with proven cardiovascular benefit such as SGLT2 inhibitors or GLP-1 receptor agonists.
• Nitrates where needed.

Every patient also needs an echocardiogram to assess heart function, and enrolment in a cardiac rehabilitation programme, in hospital or after discharge.

Two special situations: pregnancy and myocardial bridging

Treating a heart attack in pregnancy

When a pregnant woman has a heart attack, Dr. Goel's principle is that the mother's life comes first. In his practice aspirin, clopidogrel, statins, beta blockers, heparin and low molecular weight heparin can be used, while ACE inhibitors should not be given. Thrombolysis is relatively contraindicated in pregnancy, and primary angioplasty is the preferred reperfusion: these patients should be referred for it, after the risk to the fetus has been explained. ESC guidance on cardiovascular disease in pregnancy recommends against statins during pregnancy and advises clopidogrel only when strictly needed and for the shortest duration, so these choices are made case by case with obstetric input.

Myocardial bridging treatment

Myocardial bridging is a congenital variant in which a segment of a coronary artery runs through the heart muscle rather than over it, so the artery is squeezed with each heartbeat. It can cause chest pain. Dr. Goel starts with medical management: beta blockers, calcium channel blockers, nicorandil or nitrates. If chest pain persists despite medicines, his next step is surgery: bypass, or surgical unroofing (myotomy) of the bridged segment, the other recognised operation. In his experience angioplasty does not succeed in these cases, and stenting a bridge carries recognised risks of stent fracture, perforation and restenosis.

Cardiac rehabilitation after a heart attack

A cardiac rehabilitation programme, in Dr. Goel's framework, has five components: patient education, risk factor assessment, lifestyle change, peer support and structured exercise. He keeps ACS patients in hospital for two to three days, or up to five, and was emphatic that discharge is the start of the next phase, not the end of treatment: patients need medical management over the following three to six months, reduction of their risk factors and a proper lifestyle. In detail:

1. Patient education about the disease, its risk factors and the medicines, so that adherence improves.
2. Assessment of risk factors: diabetes, hypertension, smoking, alcohol use and obesity.
3. Lifestyle change, starting with ending a sedentary routine.
4. Peer support: a forum where patients with the same condition meet, discuss problems and solutions, and keep each other motivated to take their medicines and attend frequent follow-up.
5. A structured exercise programme once the patient is stable, followed by education for long-term care and follow-up.

Primary and secondary prevention of heart attack

Primary prevention aims to stop a first heart attack; secondary prevention aims to stop the next one. Dr. Goel drew a clear line between the two:

• Primary prevention applies to people who have cardiovascular risk factors but no clinical evidence of vascular disease yet. The aim is to prevent the first heart attack or acute coronary syndrome.
• Secondary prevention applies to people who already have vascular disease: a previous heart attack or angina, a stroke or transient ischaemic attack, or peripheral vascular disease. For them the plan is aggressive risk factor modification, lifestyle change, exercise, continuous medicines and tight control of diabetes and hypertension.

Related reading

The questions referring doctors put to Dr. Goel, on drug safety in pregnancy, glycoprotein IIb/IIIa inhibitors, prognosis without thrombolysis and aortic dissection, are answered in full in the Live Discussion. His clinical background is on his doctor profile. For long-term coronary artery disease, including when bypass is preferred over a stent, see Dr. Biswarup Purkayastha's guide to coronary artery disease, and for the pathophysiology of plaque rupture and PCI technique, Dr. Vikas Thakran's acute coronary syndrome guide. More cardiology content is collected on the cardiology specialty page.