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Management of the Patient with Stable Ischemic Heart Disease and Preserved Left Ventricular Systolic Function

• CME Information
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• References
• Course Presentations
• CME Posttest

CME Information

Course Overview Educational Objectives Target Audience Method of Participation

Accreditation Statement Term of Approval Peer Review Program Director

Disclaimer Disclosure Acknowledgement of Support

Course Overview

Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin-receptor blockers (ARBs) are proven therapies that reduce morbidity and mortality in patients with chronic heart failure, in those who have left ventricular systolic dysfunction (LVSD) after a heart attack, and in those who have diabetes mellitus with proteinuria. It is less clear how ACEIs contribute to the reduction of cardiovascular events in patients with stable ischemic heart disease (IHD) who also have preserved left ventricular systolic function (LVSF), as determined by a left ventricular ejection fraction (LVEF) of >40 percent. These patients have apparently intact LVSF, yet may have chest pain (angina pectoris) brought on by emotional or physical stress. These symptoms usually result from one or more clogged or diseased arteries that, in turn, reduce blood flow and oxygen supply to the heart. Therapies shown to reduce the risk for cardiovascular events in patients with IHD include aspirin, statins, β-blockers, and dual antiplatelet therapy. Other agents used for symptomatic relief include nitrates and calcium channel blockers (CCBs). A revascularization procedure to circumvent or treat a blocked vessel is another therapeutic option for patients who are unresponsive to or cannot tolerate these medications. A patient will need prolonged treatment with these medications to reduce anginal symptoms, improve quality of life, and reduce the risk of fatal and nonfatal cardiovascular events. A comparative effectiveness review was conducted to synthesize the evidence surrounding the additional cardiovascular benefits derived from adding ACEIs, ARBs, or both to the long-term care regimens of patients who have stable IHD with intact LVSF and to determine whether or not those benefits outweigh the potential side effects of these drugs.

This case study evaluates the use of ACEIs, ARBs, or both in patients with stable IHD and preserved LVSF. It was developed from Coleman CI, Baker WL, Kluger J, Reinhart K, Talati R, Quercia R, Mather J, Giovenale S, White CM. Comparative Effectiveness of Angiotensin Converting Enzyme Inhibitors or Angiotensin II Receptor Blockers Added to Standard Medical Therapy for Treating Stable Ischemic Heart Disease. Comparative Effectiveness Review No. 18. (Prepared by the University of Connecticut/Hartford Hospital Evidence-based Practice Center under Contract No. 290-2007-10067-I.) Rockville, MD: Agency for Healthcare Research and Quality. October 2009. Available at: http://www.effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productID=335

This is one of two CME activities developed from the comparative effectiveness review. The second titled, Comparative Effectiveness of Angiotensin-Converting Enzyme Inhibitors or Angiotensin II-Receptor Blockers Added to Standard Medical Therapy for Treating Patients With Stable Ischemic Heart Disease and Preserved Left Ventricular Systolic Function, is available at: http://www.effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?pageaction=displaycmeactivity&activityID=252

Educational Objectives

At the conclusion of this activity, the participant should be able to:

• Identify the benefits and harms effected by adding an angiotensin-converting enzyme inhibitor (ACEI) or an angiotensin-receptor blocker (ARB) to standard therapy for patients with stable ischemic heart disease (IHD) and preserved left ventricular systolic function (LVSF).
• Identify the benefits and harms associated with the addition of an ACEI/ARB combination to standard therapy for patients with stable ischemic heart disease and preserved left ventricular systolic function.
• Increase the ability of clinicians to communicate the benefits and harms effected by adding an ACEI, an ARB, or both to the treatment regimens of patients with stable IHD and preserved LVSF while remaining cognizant of the values and preferences and to involve patients in the decisionmaking process.

Target Audience

This CME activity is designed to meet the educational needs of physicians in cardiology and the primary care specialties, including family medicine, general practice, and internal medicine.

Method of Participation

This activity is in a text and slide format and is accompanied by references linked to PubMed abstracts.

To receive a maximum of 0.5 AMA PRA Category 1 Credit(s)™ you should:

• View the presentations in this enduring material.
• Complete the posttest (you must answer 8 out of 10 questions correctly).
• Complete and submit the CME registration and evaluation forms.

The estimated time to complete this activity, including review of the materials, is 0.5 hour(s).

Hardware/software requirements: Activities should be run with recent versions of common browsers, including Internet Explorer, Firefox, and Google Chrome.

If you have questions about the participation process, please e-mail the Office of Continuing Medical Education, cme@bcm.edu or phone 713.798.8237.

Accreditation/Credit Designation

Baylor College of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Baylor College of Medicine designates this enduring material activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.    

Term of Approval

July 2010 through July 2013. Original release date: July 2010

Peer Review

In March 2010, this continuing medical education online enduring material was reviewed by Frank J. Domino, M.D., an associate professor in the Department of Family and Community Health, University of Massachusetts Medical School, Worchester, Massachusetts. To ensure the continued scientific relevance of this enduring material, its content will be reviewed again in July 2011.

Disclosure: nothing to disclose.

Program Director

Glenn N. Levine, M.D., FACC, FAHA
Professor of Medicine
Baylor College of Medicine
Director, Cardiac Care Unit
Michael E. DeBakey Medical Center
Houston, Texas

Disclosure: nothing to disclose.

Disclaimer

This CME activity is designed for use by healthcare professionals for educational purposes only. Information and opinion offered by the contributors represent their viewpoints. Conclusions drawn by the participant should be derived from careful consideration of all available scientific information. Prescription information and use of medical devices should be undertaken only after confirmation of information by consulting the FDA-approved uses and information.

Baylor College of Medicine makes every effort to have accurate information presented, no warranty, expressed or implied, is offered. The participant should use his/her clinical judgment, knowledge, experience, and diagnostic decision-making before applying any information, whether provided here or by others, for any professional use.

Links are provided to other Internet sites solely for the convenience of users. Once you link to another site, you are subject to the site's terms and conditions of use including copyright and licensing restrictions.

Disclosure

The Office of Continuing Medical Education (OCME) makes every effort to develop CME activities that are scientifically based, accurate, current, and objectively presented. In accordance with the Accreditation Council for Continuing Medical Education Standards for Commercial Support ^SM, Baylor College of Medicine (BCM) has implemented a mechanism requiring everyone in a position to control the content of an educational activity (e.g., directors, planning committee members, contributors, peer reviewers) to disclose any relevant financial relationships with commercial interests (drug/device companies) and manage/resolve any conflicts of interest prior to the activity. Individuals must disclose to participants the existence or non-existence of financial relationships: l) at the time of the activity or within 12 months prior; and 2) of their spouses/partners.

Baylor College of Medicine does not view the existence of interests or relationships with commercial entities as implying bias or decreasing the value of a presentation. It is up to the participants to determine whether the interests or relationships influence the presenter with regard to exposition or conclusions.

If at any time during this activity you feel that there has been commercial or promotional bias, please inform us by using the commercial bias comments box in the evaluation form. Please answer the questions about balance in the CME activity evaluation candidly.

The following individual(s) has/have reported financial or other relationship(s) with commercial entities whose products/services may relate to the educational content of this activity:

Salim S. Virani, M.B., B.S., Contributor: speakers bureau membership – Abbott Laboratories, Daiichi Sankyo.

The following individual(s) has/have reported no financial or other relationships with commercial entities whose products/services may relate to the educational content of this activity:

Frank J. Domino, M.D., Peer Reviewer: nothing to disclose.

Glenn N. Levine, M.D., Activity Director: nothing to disclose.

Some drugs/devices identified during this activity may have United States Food and Drug Administration (FDA) clearance for specific purposes only or for use in restricted research settings. The FDA has stated that it is the responsibility of the individual physician to determine the FDA status of each drug or device that he/she wishes to use in clinical practice and to use the products in compliance with the applicable law.

Baylor College of Medicine requires that all contributors disclose an unlabeled use or investigational use (not yet approved for any purpose) of pharmaceutical and medical device products, and provide adequate scientific and clinical justification for such use. Physicians are urged to fully review all the available data on products or procedures before using them to treat patients.

Acknowledgement of Support

This activity is supported by a contract, HHSA290200810015C, from the Agency for Healthcare Research and Quality (AHRQ).

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