Myocardial Ischemia Redefined: Optimal Care in CAD

1. Myocardial Ischemia Redefined:Optimal Care in CAD

2. Learning objectives To improve patient management through a better understanding of: • Pathophysiology of myocardial ischemia • Efficacy and safety of behavioral and pharmacologic approaches to minimize recurring ischemic episodes • Clinical trials investigating multiple treatment targets • Current clinical guidelines

3. Curriculum overview • Epidemiology and prevalence of myocardial ischemia • Magnitude of the problem • Challenges in selected populations • Issues in contemporary clinical practice • Scientific review • Clinical trial update • New guidelines in myocardial ischemia management • Risk stratification

4. Chronic ischemic heart disease: Overview • Highly prevalent • 6.5-16.5 million in the US • Multifactorial etiology • CAD, hypertension, hypertrophic cardiomyopathy, valvular heart disease • High socioeconomic burden • Depression • ↓Quality of life • High costs of care Gibbons RJ et al. www.acc.org.

5. Repeat revascularization is common post-PCI/CABG N = 18,240 who underwent elective PCI or CABG 50 46 40 30 30 Patients(%) 20 10 0 Recurrentangina 2nd revascularization Kempf J et al. Presented at ESC. 2007.

6. Angina increases cost of care US managed care enrollees, n = 140,001 with asymptomatic CAD, n = 23,535 with angina Dx* Average yearly cost/patient $11,530 (asymptomatic CAD) vs $22,004 (angina) ED visits ED visits Hospitalizations Prior to diagnosis Following diagnosis Kempf J et al. Presented at Scientific Forum on Quality of Care and Outcomes Res in CV Disease. 2006. *And Rx nitrates and/or β-blockers and/or CCBs

7. Challenges in selected populations: Pathophysiology and implications of ischemic heart disease in women Women Ischemic heart disease Diabetes Elderly

8. WISE: Landmark study in women Prospective cohort study conducted at 4 US sites Goals: • Improve diagnostic testing for ischemic heart disease in women • Study pathophysiologic mechanisms for ischemia in the absence of epicardial coronary artery stenoses • Evaluate the influence of menopausal status and reproductive hormone levels on diagnostic testing results Women’s Ischemia Syndrome Evaluation Bairey Merz CN et al. J Am Coll Cardiol. 1999;33:1453-61.

9. WISE: Persistent chest pain in women predicts future CV events n = 673 WISE participants with chest pain at baseline 1 0.9 Without CAD HR 1.89 (1.06–3.39)P = 0.03 Event-freesurvival (%) 0.8 0.7 With CAD HR 1.17 (0.76–1.80)P = 0.49 0.6 0 1 2 3 4 5 6 Years from PChP diagnosis (at one year) Neither PChPNo CAD No PChPCAD Both PChP = persistent chest pain Johnson BD et al. Eur Heart J. 2006;27:1408-15.

10. WISE: Persistent chest pain associated with diminished QOL *Adjusted P ≤ 0.04 †Range: 1 - 10 (best); ‡score = trait Johnson BD et al. Eur Heart J. 2006;27:1408-15. Bairey Merz CN et al. J Am Coll Cardiol. 1999;33:1453-61.

11. WISE: CAD imposes an economic burden N = 883 women with angiographic CAD 80 70 * * * 60 * 50 Cumulative observed direct costs ($, thousands) 40 * 30 20 10 0 1 2 3 4 5 Follow-up (years) Nonobstructive CAD 1 vessel CAD 2 vessel CAD 3 vessel CAD *P < 0.0001 nonobstructive vs 1-3 vessel CAD Shaw LJ et al. Circulation. 2006;114:894-904.

12. Contemporary clinical practice of ischemic heart disease Opportunity for early detection, risk stratification, and medical therapy Healthy population Revas = revascularization Adapted from Timmis AD et al. Heart. 2007;93:786-91.