However, there is still a small gap between the clinical practice of coronary heart disease and the guidelines for diagnosis and treatment of coronary heart disease, which is reflected in the following: patients are not managed in a standardized way after they are discharged from the hospital when they are well; they are relaxing the lifestyle taught during their stay in the hospital; their compliance with medication is also reduced, especially they reduce or even stop some medications to improve their prognosis on their own; The presence of suspicious symptoms does not attract attention or timely consultation; elderly patients with mobility problems, neglecting follow-up, etc. The above factors are not conducive to the prognosis of patients with coronary heart disease. Comprehensive community interventions can not only reduce the risk factors of coronary heart disease, but also reduce the incidence of cardiac events and death rate of patients with coronary heart disease. Stable coronary heart disease patients with stable disease after consultation and treatment in tertiary hospitals should be included in community-based chronic disease management, with long-term follow-up treatment and disease monitoring in community hospitals, and then referred to tertiary hospitals for coronary angiography or revascularization if signs of unstable lesions appear.
I. Long-term standardized treatment regimen maintenance and community monitoring of adverse drug reactions.
Long-term therapeutic drugs for the treatment of coronary artery disease include drugs to reduce cardiovascular events and improve prognosis and drugs to relieve angina pectoris. The drugs routinely used and the adverse reactions to be observed are as follows.
1, aspirin
Aspirin as a basic drug for the treatment of coronary heart disease, its role in the primary and secondary prevention of coronary heart disease has been affirmed, can significantly reduce the risk of thrombotic events in patients with coronary artery disease. The American College of Physicians (ACP) guidelines for the primary treatment of coronary artery disease with chronic stable angina indicate that all patients with acute and chronic ischemic heart disease, whether symptomatic or asymptomatic, should be routinely treated with aspirin (75-325 mg/d), provided there are no contraindications. Currently, 100 mg/d is commonly used in China.
Enteric tablets are the best dosage form of aspirin and are released slowly in the intestine without damaging the gastric mucosa. Aspirin side effects are closely related to the dose. In addition to regulating the use of the correct dose, long-term aspirin application should be followed up regularly to observe adverse reactions such as gastrointestinal discomfort and bleeding. A dual antiplatelet regimen in combination with clopidogrel is not currently recommended for the treatment of chronic stable coronary artery disease.
2. Clopidogrel
Clopidogrel is dependent on cytochrome P450 (CYP) oxidative metabolism. When aspirin is not tolerated or contraindicated, clopidogrel is used as an alternative. The current dose is 75 mg/d. The AHA/ACC recommends the use of aspirin and clopidogrel in combination for at least 12 months after PCI.
The combination interferes with the platelet inhibitory effects of clopidogrel. It has been demonstrated that high doses of calcium channel blockers and proton pump inhibitors (PPIs) affect the antiplatelet effect of clopidogrel by affecting CYP2C19 and CYP2C9 metabolism. Smoking increases CYP1A2 activity and can lead to the conversion of clopidogrel to other active metabolites, producing platelet resistance to clopidogrel.
3, statin lipid-lowering drugs
There is sufficient and substantial evidence-based medical evidence that only statin lipid-lowering drugs can effectively reduce cardiovascular events and total mortality. The target LDL-C value for treatment of patients with coronary artery disease should be <2,6 mmol/L or lower <2,07 mmol/L.
The proportion of adverse reactions occurring with conventional dose statins is very small, and there may be individual reasons for the occurrence of adverse reactions. Be alert to the risk of side effects of high-dose statin in the elderly, in patients with hepatic or renal impairment, and in patients with potential risk of interaction with other drugs. Lipids need to be reviewed in 4-6 weeks of treatment to assess treatment compliance and medication safety and adjust statin dose.
4.Angiotensin converting enzyme inhibitor (ACEI)
ACEI can prevent cardiovascular complications in patients with stable coronary artery disease. It is often used for stable angina pectoris, especially in patients with coronary artery disease who have diabetes, post-myocardial infarction left ventricular insufficiency (LVEF < 40%) or heart failure.
5.β-blockers
Beta-blockers can reduce angina attacks, increase exercise tolerance, and reduce the risk of death and reinfarction. All β-blockers are equally effective in controlling angina, and most patients with stable coronary artery disease have an increased event rate at a heart rate of ≥70 beats/min, with a recommended target heart rate of ≤60 beats/min.
Patients with chronic obstructive pulmonary disease and patients with asthmatic bronchitis should use a highly selective beta-blocker, such as bisoprolol. Heart failure, severe bradycardia, conduction abnormalities, severe peripheral arterial disease, asthma and severe obstructive bronchial disease contraindicate their use.
6.Calcium ion antagonist (CCB)
Long-acting CCB can reduce angina attacks, and for angina induced by coronary spasm, CCB can be the first choice. Dihydropyridines have the effect of accelerating the heart rate, and often need to be combined with beta-blockers. Non-dihydropyridines (diltiazem and verapamil) have vasodilating and negative inotropic effects, and are contraindicated in severe heart failure, severe bradycardia, conduction block, and hypotension.
Peripheral edema, constipation, palpitations, and facial flushing are common side effects of all CCBs.
7.Nitrates
Nitrates are mainly used for the treatment of angina pectoris and do not require long-term use for patients without angina pectoris. Different preparations must be used according to different treatment windows. The treatment of acute attacks is preferred sublingual, ineffective to consider the worsening of angina pectoris. Long-term use can lead to drug resistance. Nitrates increase heart rate reflexively by vasodilatation and are recommended in combination with beta-blockers.
Adverse effects include headache, flushing, reflex increase in heart rate, and hypotension.
8.Trimetazidine
The anti-anginal mechanism of trimetazidine is mainly to regulate metabolism, optimize myocardial energy consumption, increase coronary artery reserve, and reduce angina attacks. It is often used in combination with other drugs.
The main follow-up contents of community outpatient clinic.
Outpatient follow-up visit to understand the patient’s conscious symptoms, including: 1, whether the level of physical activity has decreased; 2, the degree of treatment tolerance; 3, whether there are new concomitant diseases, the severity of existing concomitant diseases; whether their treatment has aggravated angina; 4, whether the frequency and severity of angina attacks have worsened; 5, whether the risk factors have been successfully eliminated and the awareness of risk factors has increased.
Outpatient follow-up to assess patient compliance with medications: including all anti-anginal drugs currently used and antiplatelet therapy.
Biochemical monitoring, including: lipids (total cholesterol, triglycerides, HDL cholesterol, LDL cholesterol), monitoring of glycated hemoglobin (in patients with diabetes), renal function, liver function, and muscle enzymes.
Patients with chronic coronary artery disease should be referred to a general hospital for specialist treatment in the following cases.
1.First occurrence of angina pectoris
2, no typical chest pain episodes, but dynamic abnormal changes in the electrocardiogram ST-T
3.Old myocardial infarction found for the first time
4.Suspected myocardial infarction
5.Unstable angina pectoris
6.Heart failure with recent occurrence
7, chronic heart failure that is deteriorating
8, need to adjust the prevention and control program
(1) Adjustment of arrhythmia treatment drugs
(2) Intensive drug therapy but still have significant limitations in general activities
(3) Unsatisfactory control of risk factors requiring drug therapy