Coronary artery disease: Getting back to basics



This story appears courtesy of Clinician Reviews.

By Lisa Hack

SAN DIEGO—The first challenge with patients who potentially have coronary artery disease (CAD) is to “appropriately risk stratify them,” began physician assistant Daniel Thomas Thibodeau, MHP, PA-C, DFAAPA, in a presentation at the annual Cardiology, Allergy, and Respiratory Disease Summit.

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He emphasized the importance of relying on tried and true guidelines, such as those that have been published by the American Heart Association/American College of Cardiology, to determine a patient’s risk. He explained that providers need to consider patient age; family history; whether the patient has comorbidities such as hypertension, diabetes mellitus, dyslipidemia, or obesity; whether the patient smokes; and race/ethnicity. “A 65-year-old black male who has hypertension, diabetes, a family history of CAD, and who is a pack-a-day smoker has a high-risk profile for heart disease,” Thibodeau illustrated.

“Then you place that [risk profile] in the context of why the patient is sitting in front of you,” Thibodeau continued at the conference, held by Global Academy for Medical Education. Does the patient have an acute, chronic, or subacute condition? Is the patient presenting with a cardiac complaint of chest pain or pressure?

Match the test to the patient
Then perhaps the biggest challenge, Thibodeau continued, is determining which stress test to order. To choose from the vast array of stress tests available, providers must consider, “What’s the likelihood of getting a positive test? That’s what you’re looking for. You’re looking for disease. What test do I want to order to provoke this patient enough to show that he/she has disease?” Thibodeau explained.

To narrow the testing options, Thibodeau said you begin by answering some basic questions. For example, can the patient exercise? If the patient is young and has some symptoms but her risk is low, then a simple treadmill test will probably suffice. If the patient is older with some orthopedic issues and can’t walk well, then a pharmacologic stress test will probably be necessary, Thibodeau explained. “Or perhaps you have a patient who cannot exercise and has severe chronic obstructive pulmonary disease and you require a dobutamine stress echocardiography to look at cardiac function and areas of wall motion abnormalities.”   

Thibodeau remarked of his situation, “PAs do all the stress tests in the hospital, and oftentimes you’re sent an order [for a test] that the patient simply can’t do,” underscoring the need to order a test that is appropriate for the patient’s abilities.

With treatment don’t forget the fundamentals
Thibodeau said that we need to take “a global approach to treatment” that generally includes daily aspirin, beta blockers, control of hypertension, antiplatelet therapy (or dual antiplatelet therapy when appropriate), and control of dyslipidemia and other comorbidities.

“As much as we advance in the treatment of patients with CAD, it still comes down to fundamentals,” Thibodeau remarked. “We’re making better stents that are smaller and more flexible. We have less bleeding complications [as a result of newer agents], but at the end of the day, it still comes down to educating patients and making sure the patient is adhering to prescribed therapy,” said Thibodeau.

He said that unintentional (eg, forgetting, shift work/work restrictions, confusion, lack of knowledge) and intentional (eg, fear of adverse effects or dependency, mistrust, lack of belief in benefits) obstacles to effective treatment are for the most part “tangible things that we as practitioners can do a better job at by just taking a little bit more time with patients. Talking about expectations and giving them a little bit more of a knowledge base about their disease can go miles when it comes to therapy,” Thibodeau explained.

Of course, with all the newer antiplatelet therapies that are available, providers need to keep up with bleeding profiles, what to do if patients bleed, and when patients should come off agents for procedures. Some of the newer agents are cost-prohibitive, Thibodeau added. But even for those, he explained, there are often assistance programs available for patients so that they can at least get a 90-day supply to, for example, protect a recently placed stent.

“When it comes to stenting patients, all you’re trying to do is protect that stent for the first 90 days so epithelialization can occur to cover the stent and keep the patency going. Once you’re past 90 days, you’re feeling a little bit more at ease,” Thibodeau said.

“But sometimes patients come off the drug a little too early and you really worry about new in-stent stenosis or thrombosis because of adherence problems. So, it’s really a matter of sitting down and educating patients about why those medications are important. And making sure that you keep communicating with them,” Thibodeau continued.

Thibodeau explained that providers also need to speak with patients about the adverse effects they may expect or may be experiencing. “For example, some patients who take ticagrelor experience shortness of breath or cough that usually subsides after a week. So, you have to explain to patients, ‘I know you’re feeling this way, but it will go away, and the benefits very much outweigh the risks.’”

“It’s surprising how as much as stuff changes, so little changes when it comes to all the reasons why we still have trouble. It’s because of simple things—adherence, education, cost. It’s all the same fundamental problems that we’ve experienced for decades. It’s that simple,” Thibodeau concluded.


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