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Practical Considerations in Chronic Ischemic Heart Disease Management. Angina treatment: Objectives. Reduce ischemia and relieve anginal symptoms Improve quality of life Prevent MI and death Improve quantity of life.

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angina treatment objectives
Angina treatment: Objectives

Reduce ischemia and relieve anginal symptoms

Improve quality of life

Prevent MI and death

Improve quantity of life

Gibbons RJ et al. ACC/AHA 2002 guidelines. www.acc.org/clinical/guidelines/stable/stable.pdf

comprehensive management of myocardial ischemia
Comprehensive management of myocardial ischemia

Symptom management

Aggressive risk factor reduction

Antiplatelet therapy

Lifestyle modification

acc aha guidelines chest pain evaluation
ACC/AHA guidelines: Chest pain evaluation

Contraindications to stress testing

Yes

Consider angiography

No

Symptoms/clinical findings warrant angiography

Yes

No

Low/intermediate risk

No

Pharmacologic imaging study

Patient able to exercise

Yes

Treatment*

Previous coronary revascularization

Yes

Exercise imaging study

No

High risk

Consider angiography

Resting ECG interpretable

No

Consider angiography/revascularization

Yes

High risk

Exercise test

Consider imaging study/angiography

Treatment*

*If adequate information on diagnosis/prognosis available

Gibbons RJ et al. ACC/AHA 2002 guidelines.

www.acc.org/clinical/guidelines/stable/stable.pdf.

acc aha guidelines chronic stable angina treatment
ACC/AHA guidelines: Chronic stable angina treatment

Sublingual NTG

Patient education

Yes

CCB,Long-acting nitrate

Prinzmetal angina?

Medications/conditions that provoke/exacerbate angina?

Yes

Treat appropriately

No

β-blocker

Routine follow-up

Serious contraindication or unsuccessful treatment

Add/substitute CCB

Consider revascularization

Serious contraindication or unsuccessful treatment

Add long-acting nitrate

Gibbons RJ et al. ACC/AHA 2002 guidelines.

www.acc.org/clinical/guidelines/stable/stable.pdf.

Unsuccessful treatment

substantial growth in pci
Substantial growth in PCI

5% national sample of Medicare beneficiaries

*Adjusted for age, gender, race

Adapted from Lucas FL et al. Circulation. 2006;113:374-9.

stable cad pci vs conservative medical management
Stable CAD: PCI vs conservative medical management

Meta-analysis of 11 randomized trials; N = 2950

Favors medical management

Favors PCI

0

1

2

Risk ratio(95% Cl)

Katritsis DG et al. Circulation. 2005;111:2906-12.

major benefit of pci angina symptom relief
Major benefit of PCI: Angina symptom relief

N = 1020 undergoing elective PCI; 1 year follow-up

Patients

(%)

Seattle Angina Questionnaire

Spertus JA et al. Circulation. 2004;110:3789-94.

cad progression major cause of post revascularization angina
CAD progression: Major cause of post-revascularization angina

5-year follow-up

P = 0.26

65

70

55

60

50

P = 0.35

40

Patients

P = 0.67

27

(%)

30

20

18

20

14

10

0

Initially treated

Untreated

Treated and

vessels only

vessels only

untreated vessels

PCI

CABG

Alderman EL et al. J Am Coll Cardiol. 2004;44:766-74.

conditions limiting repeat revascularization
Conditions limiting repeat revascularization
  • Advanced age
  • Impaired LV function
  • Multiple prior revascularizations
  • Lack of suitable conduits for revascularization
  • Diffuse disease and/or poor distal target vessels (eg, persons with diabetes)
  • Comorbid conditions that  risk of perioperative/postoperative complications

Mannheimer C et al. Eur Heart J. 2002;23:355-70.

diabetes and pci factors influencing outcome
Diabetes and PCI: Factors influencing outcome

Inflammation

Prothrombotic state

CAD progression and/or worse outcomes post PCI

Endothelial dysfunction

Restenosis

Renal dysfunction

LV dysfunction

PAD

Atherosclerotic burden

Roffi M and Topol EJ. Eur Heart J. 2004;25:190-8.

carisa ranolazine benefits patients with and without diabetes
CARISA: Ranolazine benefits patients with and without diabetes

Placebo

Ranolazine SR750 mg bid

Ranolazine SR1000 mg bid

Pinteraction = 0.81

Timmis AD et al. Eur Heart J. 2006;27:42-8.

carisa ranolazine reduces a1c
Possible mechanisms include:

Improved insulin sensitivity

Increased physical activity

CARISA: Ranolazine reduces A1C

N = 189 with diabetes on background antianginal therapy

P = 0.008

P = 0.0002

R = ranolazine SRn = 31/189 also receiving insulin

Cooper-DeHoff R and Pepine CJ. Eur Heart J. 2006;27:5-6.Timmis AD et al. Eur Heart J. 2006;27:42-8.

selective vs routine catheterization cost reduction
Selective vs routine catheterization: Cost reduction

N = 11,249 consecutive stable angina patients

Myocardial perfusion plus selective cath

Routine early cath

Pretest clinical risk

*Includes diagnostic and follow-up costs

Shaw LJ et al. J Am Coll Cardiol. 1999;33:661-9.

chronic stable angina pharmacotherapy
Chronic stable angina: Pharmacotherapy

I

IIa

IIb

III

ACC/AHA guidelines

Aspirin

β-blockers in patients with prior MI

β-blockers in patients without prior MI

Lipid-lowering therapy in patients with suspected CAD and LDL-C >130 mg/dL (target LDL-C <100 mg/dL*)

ACEI in all patients with CAD who have diabetes and/or LV systolic dysfunction

Gibbons RJ et al. ACC/AHA 2002 guidelines.

www.acc.org/clinical/guidelines/stable/stable.pdf.Grundy SM et al. Circulation. 2004;110:227-39.

*Optional goal of <70 mg/dL in patients at very high risk (ATP III Update)

crusade nonpharmacologic interventions at discharge
CRUSADE: Nonpharmacologic interventions at discharge

N = 35,897 patients with UA/NSTEMI; Oct 2004–Sept 2005

Patients (%)

Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines

CRUSADE. www.crusadeqi.com

crusade discharge medications following ua nstemi
CRUSADE: Discharge medications following UA/NSTEMI

N = 35,897 patients without contraindications

Patients (%)

Oct 2004–Sept 2005

CRUSADE. www.crusadeqi.com

how important is ihd in women
Leading cause of death

Mostly due to IHD and stroke

More common cause of death than cancer

Compared to men

Present at older age

Less likely to be diagnosed and treated

Higher CVD mortality

Estimated annual cost: >$400 billion

How important is IHD in women?

Problem will increase as population ages and epidemics of obesity, metabolic syndrome, and diabetes continue

AHA. http://www.americanheart.org/downloadable/heart/1136818052118Females06.pdf.Pepine CJ. J Am Coll Cardiol. 2004;43:1727-30.

aha guidelines chest pain evaluation in women
AHA guidelines: Chest pain evaluation in women

Diabetes, abnormal rest ECG, questionable exercise capacity

Normal rest ECG, able to exercise

Intermediate risk

Exercise treadmill test

Stress cardiac imaging

Able to exercise or symptoms with low-level exercise

Low risk

Unable to exercise

Exercise stress

Pharmacologic stress

Moderately/severely abnormal test Reduced LVEF

Normal or mildly abnormal testNormal LVEF

Risk factor modification ± anti-ischemic Rx

Cardiac catheterization

Mieres JH et al. Circulation. 2005;111:682-96.

ihd vasculopathy gender differences
IHD vasculopathy: Gender differences

Structural features (macro- and microvessels)

  • Smaller size
  • Increased stiffness (fibrosis, remodeling, etc)
  • More diffuse disease
  • More plaque erosion vs rupture
  • Rarefaction (drop out), disarray, microemboli, etc

Functional features (macro- and microvessels)

  • Endothelial dysfunction
  • Smooth muscle dysfunction (Raynaud’s, migraine, CAS)
  • Vasculitis (Takayasu’s, rheumatoid, SLE, CNSV, giant cell, etc)

CAS = coronary artery spasm

SLE = systemic lupus erythematosis

CNSV = central nervous system vasculitis

Pepine CJ et al. J Am Coll Cardiol. 2006;47:30S-5.

ischemia in women microvascular dysfunction
Diminished coronary flow reserve

Microvascular dysfunction exists in ~50% of women presenting with chest pain and normal or near-normal coronary angiograms who had flow reserve measured

Ischemia in women: Microvascular dysfunction

Reis SE et al. J Am Coll Cardiol. 1999;33:1469-75.

Reis SE et al. Am Heart J. 2001;141:735-41.

Pepine CJ et al. J Am Coll Cardiol. 2006;47:30S-5.

Women’s Ischemia Syndrome Evaluation (WISE) study cohorts

less obstructive cad women vs men
Less obstructive CAD: Women vs men

Patients undergoing elective diagnostic angiography for angina

Women

Men

ACC-National Cardiovascular Data Registry™. J Am Coll Cardiol. 2006.

women have more adverse outcomes vs men
Women have more adverse outcomes vs men

Angina

~2x  morbidity/mortality

MI

~1.5x  1-year mortality

CABG

~2x  morbidity/mortality

CAD

Heart failure

~2x  incidence

Pepine CJ. J Am Coll Cardiol. 2004;43:1727-30.

higher incidence of major cv events in women
Higher incidence of major CV events in women

Euro Heart Survey of Stable Angina; n = 1547 women, n = 2478 men

Overall angina population

Women

Men

Angina with angiographic CAD

Incidence (%)

Women

Men

Daly C et al. Circulation. 2006;113:490-8.

increased risk of death mi in women with cad
Increased risk of death/MI in women with CAD

0.15

0.10

0.05

0

Euro Heart Survey of Stable Angina; n = 718 men, n = 276 women with angiographic CAD

Log rank: P = 0.02

Cumulative event probability

0

3

6

9

12

15

18

Time since entry (months)

Men

Women

Daly C et al. Circulation. 2006;113:490-8.

crusade gender and discharge medications
CRUSADE: Gender and discharge medications

N = 35,897 patients with UA/NSTEMI

100

80

60

Patients (%)

40

20

0

Aspirin

-blocker

ACEI

Statin

Clopidogrel

Discharge medications

Women

Men

Oct 2004–Sept 2005

P values not reported

CRUSADE. www.crusadeqi.com

euro heart survey undertreatment of women
Euro Heart Survey: Undertreatment of women

Euro Heart Survey of Stable Angina; n = 1582 women, n = 2197 men

100

*

*

80

60

*

*

Patients (%)

40

20

0

Antiplatelet

ASA

Lipid-

Statin

-blocker

lowering

Women

Men

*P < 0.001

Daly C et al. Circulation. 2006;113:490-8.