Australian Doctor 14th July Issue 14JULY2023 issue | Seite 24

Figure 8 . Left coronary artery stenosis .

outweighs ischaemic risks . 2 Decisions

regarding the duration of antiplatelet

therapy can be complex in

these patients , so should be made

in consultation with the patient and

treating cardiologist .

Initiate the highest tolerated dose of

HMG-CoA reductase inhibitors ( statins )

for a patient following hospitalisation

with ACS and continue these indefinitely

, unless they are contraindicated

or there is a history of intolerance . 2 Patients with established CAD are

immediately regarded as being at very

high risk for cardiovascular events .

For every 1mmol / L reduction in LDL

cholesterol in patients started on longterm

statin therapy , the annual risk of

a major vascular event is reduced by about 20 %. 36 Progressive lowering of cholesterol levels , with no apparent

lower limit , confers additional benefit . 2 Within the context of an individualised

care plan , a target LDL cholesterol level

less than or equal to 1.4mmol / L is now

suggested . 2

Events in younger patients ( that is ,

younger than 50 in males and younger

than 60 in females ) warrant consideration

of genetic predisposing factors

such as familial hypercholesterolaemia .

If this is confirmed on cascade screening

, it may lead to initiation of statins

among family members .

Consider ezetimibe 10mg daily in patients with suboptimal LDL cholesterol levels or who are statin

Figure 9 . Right coronary artery stenosis .

intolerant . 37

Since the publication of the last Australian and New Zealand Guidelines , evidence has demonstrated

Initiate treatment with a vasodilatory beta blocker in patients ( unless contraindicated ) with reduced LV sys-

admissions . 42 Home and centre-based forms of cardiac rehabilitation appear similarly effective in improving clin-

it peaked in the late 1960s ; however , cardiovascular disease is still a leading cause of death in Australia , with

invasive approach despite having a high absolute risk profile . 44 Further study is required into the manage-

that proprotein convertase subtilisin / kexin 9 ( PCSK9 ) inhibitors ( evolocumab and alirocumab ) further reduce lipid levels in patients who could not

tolic function ( defined as being an LV ejection fraction less than 40 %). 2 Beta blockers reduce the peripheral vascular resistance while still maintaining LV

ical and health-related quality of life outcomes in patients following MI , revascularisation or heart failure . 43 The choice of a supervised centre or home-

CAD representing more than 10 % of all deaths . 44 Improved survival in Australia and New Zealand may be attributed to our high rates of primary PCI

ment of elderly patients with multiple comorbidities . It is well documented both locally and internationally that women tend to be undertreated com-

previously meet their lipid goals on traditional therapies , and also decrease the risk of cardiovascular disease when

systolic function , stroke volume and cardiac output . 2

Historical evidence ( from the

based program may reflect local availability ; consider the individual patient ’ s preference . 43

with 50 % ( greater than England and the US ) of patients with AMI undergoing revascularisation . 44

pared with men , with resultant greater morbidity and mortality . 46 The reasons for this and strategies to address this

added to statins or ezetimibe . 39

From 2022 , GPs can prescribe evolocumab for patients with an LDL-C greater than 1.8mmol / L in the presence of symptomatic cardiovascular

pre-reperfusion era ) suggests that beta blockers reduce infarct size and reduce all-cause mortality post-MI . 41

Refer all patients who have been hospitalised with ACS for cardiac

PROGNOSIS

Lower mortality rates , particularly in the short term , have followed advancements in cardiac care . Less data are

THE FUTURE

The field of CAD is rapidly changing .

Its future direction may be guided , in part , by studies determining the opti-

inequity are a priority .

CASE STUDIES

Case study one

GERALD , 52 , presents to ED with wors-

disease , and for those with familial

rehabilitation or to a structured sec-

available on long-term survival after

mal management of anticoagulants

ening chest pain , radiating into the left

hypercholesterolaemia .

ondary prevention service . Light to

AMI . Overall , seven-year survival rates

and antiplatelet regimens that reduce

arm . He has a history of type 2 diabe-

Initiate and continue ACEIs or

moderate exercise is preferred to vig-

for patients hospitalised with an acute

the risk of ischaemia and mitigate

tes , hypertension ( treated with per-

ARBs in patients with evidence of

orous exercise , particularly in people

MI in Australia and New Zealand is

bleeding risk .

indopril ), and is a current smoker . He

heart failure , LV systolic dysfunction ,

who are habitually sedentary . Exer-

about 62 %; however , those aged under

Inflammation is a key mediator in

reports he ’ d been mowing the lawn the

diabetes or co-existent hypertension . 2 Survival following MI with or without evidence of LV systolic dysfunction or heart failure is improved using an ACE . 40 An ARB is an alternative to ACEIs in those who are intolerant of the former , with evidence suggesting similar levels of benefit in patients

cise-induced cardiac events are negligible compared with the day-to-day risk associated with being sedentary . A systematic review of 63 studies randomising 14,486 patients to either exercise-based cardiac rehabilitation or usual care with a median follow-up of 12 months showed a decline in car-

65 years undergoing revascularisation demonstrate survival rates greater than 80 %. 44 Patient characteristics linked to greater mortality are older age , being female , a history of heart failure , valvular and rheumatic disease , major cancer , cirrhosis and dementia . 44 The cardiovascular disease death rate has

the development and progression of atherosclerotic disease , with multiple clinical trials demonstrating promising results in targeting cytokines to reduce the instability of atherosclerotic plaques . 45

Evidence from Australia and New Zealand demonstrates that elderly

previous day , and feels it is likely musculoskeletal , but the ongoing nature and worsening severity of the pain made him decide to present to hospital . An ECG at the time of presentation reveals marked ST segment elevation in the anterior leads . Gerald is promptly taken to the hospital ’ s cath-

with ACS . 2

diovascular mortality and hospital

been decreasing substantially since

patients are less likely to receive an

eterisation laboratory . The culprit