1 / 25

Management of Chronic Stable Angina

Management of Chronic Stable Angina. AIMGP Seminar Series Mirek Otremba 2007. References. ACC/AHA Guideline on Chronic Stable Angina Circ. 1999; 99:2829-2848 Update JACC 2003; 41:159-68 www.acc.org CCS Consensus on Chronic Ischemic Heart Disease

hcarroll
Download Presentation

Management of Chronic Stable Angina

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Management of Chronic Stable Angina AIMGP Seminar Series Mirek Otremba 2007

  2. References • ACC/AHA Guideline on Chronic Stable Angina • Circ. 1999; 99:2829-2848 • Update JACC 2003; 41:159-68 • www.acc.org • CCS Consensus on Chronic Ischemic Heart Disease • Can J Cardiol 2000; Vol 16 no. 12: 1515-1535 • Chronic Stable Angina • NEJM 2005; 352: 2524-33 • Noninvasive tests in patients with stable CAD • NEJM 2001; 344: 1840-45

  3. Objectives • Treatment options for chronic angina • Understand which treatments • prevent MI and death • reduce symptoms • Review the indications for revascularization (PCI or CABG)

  4. Case Presentations • How would you further investigate and/or manage the following patients? • Take a few minutes for discussion

  5. Patient No. 1 • 63 F • Smoker • Obese • Exertional angina (CCS Class 2)

  6. Patient No. 2 • 52 M • Type II DM • Exertional angina (CCS 3) • Non-invasive testing shows large anterior perfusion defect which is reversible

  7. Patient No. 3 • 73 M • Hx prior MI • Known Gr. 2 LV • Inferior reversible defect on Sestamibi • Presenting with ongoing anginal symptoms despite beta blockers, calcium channel blockers, Nitrates

  8. Overview of Treatment • The treatment of angina has 2 purposes • Prevent MI and death (prolong life) • Reduce symptoms (improve quality of life)

  9. Just a Reminder…Regarding Recommendations • Class 1 - Conditions for which there is evidence and/or general agreement that a given treatment is useful • Class 2 - Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness of a treatment

  10. Reminder - Recommendations • Class 2a - Weight of evidence/opinion is in favor of usefulness • Class 2b - Usefulness is less well established by evidence/opinion • Class 3 - Conditions for which there is evidence/opinion that the treatment is ineffective and/or harmful

  11. Prevention of MI and Death in CAD • Antiplatelet agents • ASA 81-150mg daily (Class I) • Clopidogrel 75mg daily (Class IIa): when ASA contraindicated • ASA + Clopidogrel for patients post PCI or ACS for at least 12 months (Class I)

  12. Prevention of MI and Death in CAD • β blockers (Class I) • Better evidence (Level A) in patients with previous MI. Level B with patients without MI Bisoprolol 2.5mg–10mg once daily

  13. Prevention of MI and Death in CAD • Lipid lowering therapy with Statin (Class I) • LDL target < 2.0 mmol/L • LDL target < 1.8 mmol/L in very high risk patients? (ATP III/NCEP) • Less evidence for HDL/TG therapy (Class IIa)

  14. Prevention of MI and Death in CAD • ACE Inhibitors (Class I) • HOPE trial – Ramipril • EUROPA – Perindopril • PEACE – Trandolapril (-ve study)

  15. Pharmacotherapy to Reduce Symptoms • Calcium antagonists (Class I) • β Blockers (Class I) • Nitrates (Class I) • All prolong duration of exercise before onset of angina and ST segment changes • All decrease frequency of angina

  16. Pharmacotherapy to Reduce Symptoms • Calcium antagonists (Class I) • Long acting CCB’s NOT short acting ones which are felt to increase adverse cardiac events • Use in combination or alone

  17. Pharmacotherapy to Reduce Symptoms • Long acting nitrates (Class I) • Short acting nitrates for relief of acute episodes

  18. Goal of therapy • For most patients the goal of treatment is to be completely free of angina • A return to normal activities and functional capacity • Aim for CCS class I angina or better • Address other modifiable risk factors such as cholesterol, smoking, HTN, DM, and exercise, weight

  19. Revascularization - CABG • Medical Treatment vs CABG • CABG has survival benefit when there is • Left main stenosis • 3,2, or 1 vessel disease that includes proximal LAD • 3 vessel disease (without prox. LAD), with poor LV function • CABG better in relieving symptoms

  20. Revascularization - PCI • Medical Treatment vs PCI • Equivalent in terms of survival benefit • PCI - less angina (better quality of life) • PCI vs CABG • Where CABG not indicated for survival benefits: • Equivalent except: • CABG is better in pt with DM • PCI is better when CABG too high risk • PCI pts have more angina and repeat procedures

  21. Follow-up and Monitoring • Follow up every 4 to 12 months • Repeat stress testing if significant change in clinical status • Questions to ask at follow up • Deceased level of activity? • Increase in angina symptoms or prn nitrate use? • Is pt tolerating therapy? • Other modifiable risk factors?

  22. Back to the cases...Patient 1 • 63 F • Smoker • Obese • Exertional angina (CCS Class 2) • Stress test shows small apical reversible defect • Relieve Angina Symptoms • start with Metoprolol and titrate to achieve HR 55-60; prescribe and counsel re NTG spray use • titrate BB and consider addition of longer acting NTG or CCB is symptoms persist despite BB • Prevent MI and Death • give ECASA 325 mg po od • Consider Statin and ACE-In • check and treat lipids, blood sugar, counsel re: smoking, weight reduction, stress modification • given the small single territory defect on non-invasive testing no need to investigate with angiogram

  23. Back to the cases...Patient 2 • 52 M • Type II DM • Exertional angina (CCS 3) • Non-invasive testing shows large reversible anterior perfusion defect • Relieve Symptoms: as in Patient #1 • Prevent MI and Death • ASA, Statin, and ACE-In • Treat DM, check lipids • Pt may have proximal LAD lesion and requires further evaluation with angiogram

  24. 73 M • Hx prior MI • Known Gr. 2 LV • Inferior reversible defect on Sestamibi • Presenting with ongoing anginal symptoms despite βblockers, CCBs, Nitrates Back to the cases...Patient 3 • Relieve Symptoms • Single vessel disease suspected • Ongoing symptoms despite optimal medical management --> needs angiogram • May require revascularization for symptom relief • Prevent MI and death • ASA, Statin • BB (history of MI) • ACE (Gr 2 LV) • RF modification as appropriate

  25. Summary for the Tx of CAD

More Related