Clinical Pharmacology and Therapeutics

DRUGS USED IN ISCHAEMIC HEART DISEASE 203
Because of the risks of haemorrhage, patients are not generally
treated with fibrinolytic drugs if they have recently
(within the last three months) undergone surgery, are pregnant,
have evidence of recent active gastro-intestinal bleeding,
symptoms of active peptic ulcer disease or evidence of severe
liver disease (especially if complicated by the presence of
varices), have recently suffered a stroke or head injury, have
severe uncontrolled hypertension, have a significant bleeding
diathesis, have suffered recent substantial trauma (including
vigorous chest compression during resuscitation) or require
invasive monitoring (e.g. for cardiogenic shock). The position
regarding diabetic or other proliferative retinopathy is controversial.
If ophthalmological advice is locally and immediately
available, this is no longer universally regarded as an absolute
contraindication to fibrinolysis.
Case history
A 46-year-old advertising executive complains of exerciserelated
pain when playing his regular daily game of squash
for the past three months. Ten years ago he had a gastric
ulcer, which healed with ranitidine, and he had experienced
intermittent indigestion subsequently, but was otherwise
well. His father died of a myocardial infarct at the age
of 62 years. He smokes 20 cigarettes per day and admits
that he drinks half a bottle of wine a day plus ‘a few gins’.
Physical examination is notable only for obesity (body mass
index 30 kg/m 2 ) and blood pressure of 152/106 mmHg.
Resting ECG is normal and exercise ECG shows significant
ST depression at peak exercise, with excellent exercise tolerance.
Serum total cholesterol is 6.4 mmol/L, triglycerides
are 3.8 mmol/L and HDL is 0.6 mmol/L. γ-Glutamyl transpeptidase
is elevated, as is the mean corpuscular volume
(MCV). Cardiac catheterization shows a significant narrowing
of the left circumflex artery, but the other vessels are
free from disease.
Question
Decide whether each of the following statements is true or
false.
Immediate management could reasonably include:
Comment
This patient has single-vessel disease and should be started
on medical management with advice regarding diet, smoking
and reduction of alcohol consumption. He should continue
to exercise, but would be wise to switch to a less
extreme form of exertion. Taking a GTN spray before playing
squash could have unpredictable effects on his blood
pressure. A long-acting nitrate may improve his exercise
tolerance, and low-dose aspirin will reduce his risk of
myocardial infarction. In view of the history of ulcer and
indigestion, consideration should be given to checking for
Helicobacter pylori (with treatment if present) and/or reinstitution
of prophylactic acid suppressant treatment. His dyslipidaemia
is a major concern, especially the low HDL
despite his high alcohol intake and regular exercise. It will
almost certainly necessitate some form of drug treatment
in addition to diet. His blood pressure should improve with
weight reduction and reduced alcohol intake. However, if
it does not and if the angina persists despite the above
measures, a β-adrenoceptor antagonist may be useful
despite its undesirable effect on serum lipids. If angina is
no longer a problem, but hypertension persists, a longacting
α-blocker (which increases HDL) would be worth
considering.
FURTHER READING
Carbajal EV, Deedwania P. Treating non-ST-segment elevation ACS.
Pros and cons of current strategies. Postgraduate Medicine 2005; 118:
23–32.
Opie LH, Commerford PJ, Gersh BJ. Controversies in stable coronary
artery disease. Lancet 2006; 367: 69–78.
Sura AC, Kelemen MD. Early management of ST-segment elevation
myocardial infarction. Cardiology Clinics 2006; 24: 37–51.
(a) an ACE inhibitor;
(b) GTN spray to be taken before playing squash;
(c) no reduction in alcohol intake, as this would be
dangerous;
(d) referral for angioplasty;
(e) isosorbide mononitrate;
(f) a low dose of aspirin;
(g) nicotine patches;
(h) dexfenfluramine.
Answer
(a) False
(b) False
(c) False
(d) False
(e) True
(f) True
(g) False
(h) False