PH4.8 | PH4.8 | Ischemic Heart Disease Pharmacotherapy — Summary & Reflection

KEY TAKEAWAYS

Ischaemic heart disease pharmacotherapy addresses two distinct goals: symptom relief in stable angina (nitrates, beta-blockers, CCBs, ranolazine) and event prevention in ACS (antiplatelets, anticoagulants, fibrinolytics, secondary prevention). Aspirin (irreversible COX-1 inhibitor) is the backbone antiplatelet for all IHD patients; ticagrelor (reversible, non-prodrug P2Y12 inhibitor) is preferred over clopidogrel for ACS based on the PLATO trial, while prasugrel is contraindicated in prior stroke/TIA. Fibrinolysis with alteplase or tenecteplase is reserved for STEMI when PCI is unavailable within 120 minutes; streptokinase can only be used once. The long-term secondary prevention plan — DAPT 12 months + high-intensity statin + ACEi + beta-blocker — reduces recurrent events significantly. Nitrate tolerance is prevented by daily nitrate-free intervals; non-DHP CCBs must never be combined with beta-blockers. In peripheral vascular disease, cilostazol (contraindicated in HF), antiplatelet therapy, and statins form the pharmacological core. The MONABASH mnemonic guides acute STEMI management.

REFLECT

Return to the opening patient: 58-year-old with inferior STEMI, BP 100/60, HR 54, previous streptokinase 3 years ago, PCI unavailable.

1. The BP of 100/60 mmHg concerns you — can you give nitrates? What is the specific contraindication in this haemodynamic context?
2. The HR is 54 bpm. Would you give a beta-blocker IV in this situation?
3. Which fibrinolytic do you choose — and why does the prior streptokinase exposure change your decision?
4. He has inferior ST elevation (RV involvement pattern): how does this change the management of hypotension?
5. What drugs would you prescribe at discharge to reduce his 10-year cardiovascular event risk?

This case integrates pharmacology, physiology, and clinical reasoning — exactly the synthesis you will need at the bedside.