Is guideline based risk factor control optimal in non obstructive coronary artery disease compared t...
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Is guideline based risk factor control optimal in non obstructive coronary artery disease compared to obstructive coronary artery disease? A Veterans Affairs Study

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Background Current ACC/AHA guidelines recommend strict risk factor

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Background current acc aha guidelines recommend strict risk factor

Is guideline based risk factor control optimal in non obstructive coronary artery disease compared to obstructive coronary artery disease? A Veterans Affairs Study

Tarun W Dasari, Harsh Golwala, Michael Koehler, AneeshPakala, SiddharthWayangankar, Eliot Schechter, Mazen Abu-Fadel, UdhoThadaniDepartment of Medicine, Cardiovascular section, University of Oklahoma Health Sciences Center, and Veterans Administration Medical Center, Oklahoma City, Oklahoma

No financial disclosures


Background current acc aha guidelines recommend strict risk factor

  • Background

  • Current ACC/AHA guidelines recommend strict risk factor

  • control in patients with Coronary Artery Disease (CAD)

  • irrespective of the extent and severity

  • Use of Aspirin, Thienopyridine, Statins, Angiotensin

  • converting enzyme inhibitor and Beta blockers

  • Goal blood pressure of ≤ 140/90 mm Hg in patients without diabetes and ≤130/80 mm Hg in diabetics

  • Goal Low Density Lipoprotein (LDL) ≤100mg/dL (Class IA) and preferably < 70 mg/dL (Class IIA)

  • Hemoglobin A1C level ≤ 7% in diabetics


Background current acc aha guidelines recommend strict risk factor

  • In angiographic studies in STEMI patients the underlying culprit lesion was deemed to be non obstructive

  • Thus non obstructive atherosclerotic lesions may not be entirely benign

  • Approximately a fifth of elective coronary angiography are reported as having NOCAD

  • Arch Intern Med. 2006;166:1391-5Eur Heart Jour. 1988;12:1317-23


  • Non obstructive cad and outcomes

    Non-obstructive CAD and outcomes

    • GRACE registry: ACS patients with NOCAD – 14-17% combined adverse cardiovascular outcome @ 6 months

    Heart 2009;95:20-26


    Background current acc aha guidelines recommend strict risk factor

    • Primary hypotheses:Risk factor control may be inferior in non obstructive CAD patients as compared to obstructive CAD


    Materials and methods

    Materials and Methods

    • Retrospective analysis

    • Patients undergoing coronary angiography that showed OCAD or NOCAD, between Jan 2006- Jun 2006 at the Oklahoma City VA Medical Center and where 1 year follow-up data was available were included

    • Non-obstructive CAD was defined as 70% stenosis in the major epicardial vessels or < 50% left main stenosis and obstructive CAD was defined as ≥70% stenosis in the major epicardial vessels or ≥ 50% left main stenosis)


    Background current acc aha guidelines recommend strict risk factor

    • Demographic, clinical and laboratory data were collected at baseline and 1 year

    • Baseline: After the angiogram was completed

    • Follow up data collection: at 12±2 months

    • Clinic notes/ Inpatient notes/Discharge summaries were reviewed

    • Medications and laboratory data were obtained from VA electronic database

    • Remote data was cross checked if local data unavailable


    Background current acc aha guidelines recommend strict risk factor

    Statistical analysis:

    Non-parametric methods: Wilcoxon Sum ranked test was used to compare means within groups and Mann Whitney U test for independent samples and chi-square tests for proportions, at a significance level of 0.05

    Data analysis using SPSS 17.0(Chicago)


    Discussion

    Discussion

    • Use of Aspirin is less than ideal in both OCAD and NOCAD patients

    • The use of statins were significantly lower in NOCAD group both at baseline and 1 year

    • Among OCAD group the use of statins and angiotensin converting enzyme inhibitors (ACEi) and systolic BP were better at 1 yr compared to baseline

    • Among NOCAD group there was little improvement in the use of aspirin, statins, beta-blockers, ACEI/ARB at end of 1 yr when compared to baseline


    Conclusions

    Conclusions

    • The use of evidence based medical therapy may be less than ideal regardless of the extent of CAD

    • This is more evident in NOCAD group suggesting physicians may be less aggressive in the use of such therapies

    • Better strategies for risk factor control and use of evidence based medical therapy will be required to achieve the desirable goal

    • Long term prospective data is needed to quantify clinical impact of such differences in treatment


    Limitations

    Limitations

    • Small scale study

    • Single center, retrospective and observational

    • Smoking data incomplete

      Future goals:

    • Ongoing prospective study


    Thank you

    Thank you

    • Questions?


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