Background Current ACC/AHA guidelines recommend strict risk factor

1. 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

2. 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

3. 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

4. Non-obstructive CAD and outcomes • GRACE registry: ACS patients with NOCAD – 14-17% combined adverse cardiovascular outcome @ 6 months Heart 2009;95:20-26

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

6. 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)

7. 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

8. 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)

15. 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

16. 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

17. Limitations • Small scale study • Single center, retrospective and observational • Smoking data incomplete Future goals: • Ongoing prospective study

18. Thank you • Questions?