Heberden W. Some account of a disorder of the breast.

1. Angina They who are afflicted with it, are seized while they are walking, (more especially if it be up hill, and soon after eating) with a painful and most disagreeable sensation in the breast, which seems as if it would extinguish life, if it were to increase or continue; but the moment they stand still, all this uneasiness vanishes. Heberden W. Some account of a disorder of the breast. Medical Transactions 2, 59-67 (1772) London: Royal College of Physicians.

2. myocardial O2 supply Coronary artery disease atherosclerosis spasm vasculitic disorders post radiation therapy Severe anaemia Causes of Angina myocardial O2 demand • Left ventricular hypertrophy • hypertension • aortic stenosis • aortic regurgitation • hypertrophic cardiomyopathy • Right ventricular hypertrophy • pulmonary hypertension • pulmonary stenosis • Rapid tachyarrhythmias

3. 1st diagnosed angina by calendar period and age group 7735 men randomly selected from one GP practice in each of 24 British towns British Regional Heart Study Lampe, F. C et al. BMJ 2005;330:1046

4. Importance of Demographic Changes • Aging • Female preponderance • Obesity • Diabetes

5. Deaths from cardiovascular disease Deaths from lung cancer Deaths from breast cancer 60 Deaths fromcardiovasculardisease 50 40 Deaths frombreast cancer Percentage of All Deaths 30 20 Deaths fromlung cancer 10 0 >85 0ﾐ4 5ﾐ9 75ﾐ79 10ﾐ14 15ﾐ19 20ﾐ24 25ﾐ29 30ﾐ34 35ﾐ39 40ﾐ44 45ﾐ49 50ﾐ54 55ﾐ59 60ﾐ64 65ﾐ69 70ﾐ74 80ﾐ84 Age Group (y) Demographic Changes: Female Preponderance Putting therisk of breast cancer in perspective Note: the proportion of deaths due to breast cancer never exceeds 20%. Data from Ontario Cancer Registry. Phillips K-A et al. N Engl J Med. 1999;340:141.

6. Indications for Specialist Cardiological Referral • New onset angina • Exclusion of angina in high risk individuals with atypical symptoms • Worsening angina in patient with previously stable symptoms • New or recurrent angina in patient with history of: • myocardial infarction • coronary revascularisation • Assessment of occupational fitness (eg airline pilots)

7. Diagnosis of Angina • History • Noninvasive testing • Ischaemia • ETT • Myocardial perfusion imaging • Stress echo • Disease imaging • Calcium imaging (EBCT, MSCT) • Angiography

8. Diagnosis of Angina A. History, History, History, History, • character • location • radiation • duration • provocation

9. V4 V5 V6 Rest 3’ exercise 6’ exercise Peak exercise Recovery Diagnosis of Angina B. Noninvasive investigation: exercise ECG Diagnostic features • Planar or down-sloping ST depression Prognostic features • Poor exercise tolerance • Early ST depression • Severe ST depression • Exertional arrhythmias • Exertional hypotension

10. Reversible defects: ischaemia Exercise Rest Fixed defects: infarction Exercise Rest Diagnosis of Angina B. Noninvasive investigation: isotope perfusion imaging Diagnostic features • Reversible perfusion defects (ischaemia) • Fixed perfusion defects (infarction) Prognostic features • extent and severity of perfusion defects (fixed or reversible) • degree of lung uptake of radio-isotope (reflecting level of pulmonary capillary pressure) • calculated ventricular volume and ejection fraction

11. Diagnosis of Angina C. Arteriography Invasive Non-invasive

12. Diagnosis of CAD: Probability Analysis

13. baseline 2 years expected Angina grade and perceived health status by part 2 of Nottingham Health Profile (NHP) in RITA II • work • tasksaround home • social life • home relationships • sex life • hobbies and interests • holidays Pocock et al Circulation 1996

14. Reduce • O2 demand • heart rate • BB • procorolan • LV wall tension • BB • Nitrates • Nicorandil • CaBs • ranolazine • contractility • BB • CaBs • modify energy metabolism • trimetazidine • Increase • O2 delivery • Coronary flow • Nitrates • CaBs • Nicorandil • Revasc Angina: symptom relief with drugs

15. Angina: 2° prevention • aspirin → all patients • statins → all patients - to target 4 and 2 (?) • ACE-I → all patients (?) • clopidogrel → all patients after PCI or if intolerant of aspirin

16. Coronary revascularisation: PCI Before stenting After stenting

17. Coronary revascularisation: CABG

18. PTCA vs medical: meta-analysis of 6 trials Bucher et al BMJ 2000

19. PTCA vs medical: meta-analysis Cardiac death or myocardial infarction Katritsis, D. G. et al. Circulation 2005;111:2906-2912

20. Choice of revasc procedure: considerations • Coronary anatomy • Patient choice • Procedural risk: death, stroke, AMI • Symptomatic benefit • Repeat revascularisation • Prognostic benefit

21. Risk-based management strategy in angina High risk of coronary artery disease >80% Intermediate risk of coronary artery disease 20-80% Low risk of coronary artery disease <20% eg: typical angina in men >40 or women >60 years all other patients with typical or atypical angina eg: atypical angina in men <30 or women <50 years Non-invasive ischaemia testing eg exercise ECG, myocardial perfusion imaging Anti-anginal drug therapy. In selected cases cardiac catheterization with a view to coronary revascularization Rule out non-cardiac causes of chest pain before undertaking further cardiac investigation

23. Prognosis of incident angina: contemporary data

24. Different faces of chronic angina Women - prognosis equal to men Nitrate angina (n>90,000) Test +ve angina (n>27,000) Hemingway et al JAMA 2006

25. The end

26. Isotopeperfusion imaging Reversible defects: ischaemia Exercise Rest Fixed defects: infarction Exercise Rest Diagnosis of Angina B. Noninvasive investigation Exercise ECG