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Practical Considerations in Chronic Ischemic Heart Disease Management

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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Practical Considerations in Chronic Ischemic Heart Disease Management

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  1. Practical Considerations in Chronic Ischemic Heart Disease Management

  2. 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

  3. Comprehensive management of myocardial ischemia Symptom management Aggressive risk factor reduction Antiplatelet therapy Lifestyle modification

  4. CAD: Treatment challenges

  5. 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.

  6. 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

  7. 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.

  8. 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.

  9. 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.

  10. 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.

  11. 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.

  12. 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.

  13. 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.

  14. 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.

  15. 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.

  16. 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)

  17. 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

  18. CRUSADE: Discharge medications following UA/NSTEMI N = 35,897 patients without contraindications Patients (%) Oct 2004–Sept 2005 CRUSADE. www.crusadeqi.com

  19. 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.

  20. 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.

  21. 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.

  22. 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

  23. 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.

  24. 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.

  25. 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.

  26. 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.

  27. 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

  28. 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.

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