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

Slides: 13–21 of 21
Patient Discussion. 
At this point in the discussion you explain to him that this medication is being given in order to reduce the risk of future cardiac events even further than if he was only taking his usual medication. You counsel the patient to call you immediately if he experiences any of the adverse effects such as swelling of the lips or mouth area, which could indicate the patient has developed angioedema. You give him his own copy of the consumer guide titled, “ACE Inhibitors” and “ARBs” To Protect Your Heart? A Guide for Patients Being Treated for Stable Coronary Heart Disease, to take home with him to review and keep these important adverse effects in mind.

Patient Discussion

Patient Discussion: Other Treatments
The patient points out that the guide refers to drugs called ARBs as well as ACEIs. He mentions that if taking an ACEI is good, why are you not prescribing an ARB as well as an ACEI? A. You realize he is correct and add an ARB to his prescription. B. Because ACEIs have been proven to be significantly better than ARBs. C. The risks of taking a combination of ACEI/ARB outweigh the benefits for patients with stable ischemic heart disease and preserved LVSF. D. None of the above.

Patient Discussion: Other Treatments

Patient Discussion. 
The patient asks about the source of the information that you have given him, and you explain it is a summary of a large analysis done at a university that included many studies on the benefits and harms of adding an ACEI and/or ARB to standard therapies for patients with stable ischemic heart disease and preserved LVSF. This information was summarized in a way that would allow patients to make decisions with their doctors regarding their course of treatment. You counsel him to take this guide (“ACE Inhibitors” and “ARBs” To Protect Your Heart? A Guide for Patients Being Treated for Stable Coronary Heart Disease) home to share with his family, refer to it from time to time to remind him why he's taking the drugs, and refer to it for descriptions of the adverse effects. After this discussion, you and your patient determine that the decreased risk of nonfatal heart attack, stroke, and death are worth the risk of possibly getting a cough, high levels of potassium, or suddenly fainting.

Patient Discussion

Treatment Decision
Considering the patient’s values and his decision that the benefits outweigh the risk of harms in his situation, what do you decide to start him on? A. ACE Inhibitor. B. Alpha-blocker. C. Telmisartan. D. ACE Inhibitor + ARB.

Treatment Decision

Adverse Events from ACEIs
This patient is sent home with his medications and the consumer summary guide (“ACE Inhibitors” and “ARBs” To Protect Your Heart? A Guide for Patients Being Treated for Stable Coronary Heart Disease),  which he can continue to refer to in the event of questions. In six weeks, he returns to your office with a dry persistent cough that keeps him up at night. He has been referring to the consumer summary guide and wonders if there are any other drugs he can take to help him.

Adverse Events from ACEIs

Patient Followup
After reviewing the evidence presented in the Clinician's Guide titled, Adding ACEIs and/or ARBs to Standard Therapy for Stable Ischemic Heart Disease: Benefits and Harms, which medication is an acceptable alternative for a patient with stable ischemic heart disease with preserved left ventricular systolic function who is intolerant to an ACEI? A. Beta-blocker  B. ARB  C. Aspirin D. Alpha-blocker.

Patient Followup

Patient Followup: Potential Benefits of ARBs
Upon further review of the consumer guide with the patient, you discuss with him the potential benefits of taking an ARB which are: A. Decreased risk of one or more of the following: cardiovascular mortality, nonfatal myocardial infarction, or stroke. B. Decreased rate of angina-related hospitalizations. C. Decreased risk of blood dyscrasias. D. Decreased risk of new atrial fibrillation.

Patient Followup: Potential Benefits of ARBs

Patient Followup: Potential Harms of ARBs
The patient asks you about the adverse effects of taking an ARB.  After reviewing the clinician guide, you inform him that there is only low level evidence available about patients such as himself who are taking an ARB due to intolerable adverse effects from ACEIs. Taking an ARB may increase his risk of what? A. Hyperkalemia. B. Cough. C. Cardiovascular-related mortality. D. Revascularization.

Patient Followup: Potential Harms of ARBs

Closing Remarks
After discussing the potential benefits and the small risk of adverse effects, and considering his experience with the ACEI, you decide to start him on the ARB and schedule him a followup visit. After reviewing the consumer summary guide again with him, you remind him of the benefits and potential harms of taking an ARB. Once he is comfortable with this decision, you remind him to refer to the guide he has when he has questions regarding his treatment. In his next regularly scheduled visit, you will review his medications and ask him about any symptoms and any further questions he may have.

Closing Remarks

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