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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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

  • 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


  • 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

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

    Heart 2009;95:20-26


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


    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)


    • 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


    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

    • 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

    • 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

    • Small scale study

    • Single center, retrospective and observational

    • Smoking data incomplete

      Future goals:

    • Ongoing prospective study


    Thank you

    • Questions?


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