Transcript Présentation PowerPoint

European guidelines on
the management of
stable coronary artery disease
Key points
&
new position for Ivabradine and Trimetazidine
Montalescot G, Sechtem U, Achenbach S, et al. 2013 ESC guidelines on the management of stable coronary artery disease: The Task Force on the management of stable coronary artery
disease of the European Society of Cardiology. Eur Heart J. 2013;34(38):2949-3003.
Aims to focus on
• To obtain relief of angina symptoms the guidelines advise:
Short-acting nitrates to provide immediate relief of angina symptoms.
Anti-ischemic drugs like -blockers, CCBs, Trimetazidine, Ivabradine…
Lifestyle changes, regular exercise training and patient education.
• To prevent the occurrence of cardiovascular events the guidelines
advise:
To reduce the incidence of acute thrombotic events and the development
of ventricular dysfunction by pharmacological or lifestyle interventions.
A combined pharmacological and revascularization strategy in patients
with severe lesions in coronary arteries.
Montalescot G, Sechtem U, Achenbach S, et al. 2013 ESC guidelines on the management of stable coronary artery disease: The Task Force on the management of stable coronary artery
disease of the European Society of Cardiology. Eur Heart J. 2013;34(38):2949-3003.
Medical management of SCAD patients
Angina relief
Event prevention
1st line
Short-acting nitrates, plus
• Lifestyle management
• Control of risk factors
• β-blockers and/or CCB
• Aspirin (if intolerance, consider clopidogrel)
• Statins
• Consider ACE inhibitors or ARBs
2nd line
Ivabradine
Long-acting nitrates
Nicorandil
Ranolazine
Trimetazidine
Chairmen opinion:*
+ consider angio → PCI-stenting or
CABG
“We recommend the old drugs as first
line treatment because they are cheap,
effective and available everywhere.”
“We have roughly the same level of evidence for all of the second line drugs and we
recommend that physicians also choose according to what is available in their country.”
Montalescot G, Sechtem U, Achenbach S, et al. 2013 ESC guidelines on the management of stable coronary artery disease: the task force on the management of stable coronary artery
disease of the European Society of Cardiology. Eur Heart J. 2013;34(38):2949-3003.
*New ESC Guidelines published on stable coronary artery disease. Eur Heart J. 2013;34:2927-2930.
Medical management of SCAD patients
Angina relief
Event prevention
1st line
Short-acting nitrates, plus
• Lifestyle management
• Control of risk factors
• β-blockers and/or CCB
• Aspirin (if intolerance, consider clopidogrel)
• Statins
• Consider ACE inhibitors or ARBs
2nd line
Ivabradine
Long-acting nitrates
Nicorandil
Ranolazine
Trimetazidine
+ consider angio → PCI-stenting or
CABG
Chairmen opinion:*
About revascularization, chairmen hopes
that “guidelines will shift physicians’
practice so that they consider optimal
medical treatment as their first course of
action in stable CAD patients”.
Montalescot G, Sechtem U, Achenbach S, et al. 2013 ESC guidelines on the management of stable coronary artery disease: the task force on the management of stable coronary artery
disease of the European Society of Cardiology. Eur Heart J. 2013;34(38):2949-3003.
*New ESC Guidelines published on stable coronary artery disease. Eur Heart J. 2013;34:2927-2930.
Specific patient profiles
• Women
 Women more frequently have CAD with stable angina and no obstructive
coronary disease.
 Women are more likely to have complications from revascularization.
• Diabetic patients
 Need different risk factor management.
• Older patients
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High-risk group with higher mortality and higher rates of myocardial infarction.
Usually undertreated, receiving less drugs.
Difficult diagnosis due to atypical symptoms.
Higher risk of complications during and after coronary revascularization.
• Comorbidities/intolerance
 Depending on comorbidities/tolerance, it is indicated to use second-line therapies
as first-line treatment in selected patients.
Montalescot G, Sechtem U, Achenbach S, et al. 2013 ESC guidelines on the management of stable coronary artery disease: the task force on the management of stable coronary artery
disease of the European Society of Cardiology. Eur Heart J. 2013;34(38):2949-3003.
Therapy to prevent MI and death
 Aspirin
Low-dose aspirin is the drug of choice in most cases and clopidogrel
may be considered for some patients.
 Statin
Target LDL-C: <1.8 mmol/L and/or >50% reduction if the target level
cannot be reached.
 Renin-angiotensin-aldosterone system blockers
ACE inhibitors are recommended for the treatment of patients with
SCAD, especially with coexisting hypertension, LVEF ≤40%, diabetes,
or chronic kidney disease, unless contra-indicated.
ARBs are recommended as an alternative therapy for patients with
SCAD when ACE inhibition is indicated but not tolerated.
Montalescot G, Sechtem U, Achenbach S, et al. 2013 ESC guidelines on the management of stable coronary artery disease: The Task Force on the management of stable coronary artery
disease of the European Society of Cardiology. Eur Heart J. 2013;34(38):2949-3003.
New ESC guidelines and Ivabradine
“Adding ivabradine 7.5 mg twice daily to atenolol therapy gave better control of heart rate and
anginal symptoms.”
“In 1507 patients with prior angina enrolled in the Morbidity-Mortality Evaluation of the If Inhibitor
Ivabradine in Patients With Coronary Artery Disease and Left Ventricular Dysfunction
(BEAUTIFUL) trial, ivabradine reduced the composite primary end point of CV death,
hospitalization with MI and HF, and reduced hospitalization for MI. The effect was
predominant in patients with a heart rate 70 bpm.”
“Ivabradine is thus an effective anti-anginal agent, alone or in combination with β-blockers.”
Montalescot G, Sechtem U, Achenbach S, et al. 2013 ESC guidelines on the management of stable coronary artery disease: The Task Force on the management of stable coronary artery
disease of the European Society of Cardiology. Eur Heart J. 2013;34(38):2949-3003.
New ESC guidelines and Trimetazidine
“Trimetazidine is an anti-ischemic metabolic modulator, with similar antianginal efficacy to propranolol in doses of 20 mg thrice daily.”
“Trimetazidine (35 mg twice daily) added to β-blockade (atenolol)
improved effort-induced myocardial ischemia, as reviewed by the EMA in
June 2012.”
In diabetic persons, Trimetazidine improved HbA1c and glycemia, while
increasing forearm glucose uptake.”
Montalescot G, Sechtem U, Achenbach S, et al. 2013 ESC guidelines on the management of stable coronary artery disease: The Task Force on the management of stable coronary artery
disease of the European Society of Cardiology. Eur Heart J. 2013;34(38):2949-3003.
Conclusion
 ESC Guidelines highlighted two aims for the pharmacological management
of stable CAD patients: obtain relief of symptoms and prevent cardiovascular
events.
 CAD patients should all receive aspirin and a statin, plus an ACE inhibitor
in case of comorbidities.
 -blockers or CCBs should be prescribed as first-line treatment to reduce
angina.
 Ivabradine and Trimetazidine (as well as long-acting nitrates, nicorandil and
ranolazine) are recommended second-line, in combination with first-line
treatment, in patients remaining symptomatic.
 Physicians should consider
revascularization procedures.
optimal
medical
treatment
before
Montalescot G, Sechtem U, Achenbach S, et al. 2013 ESC guidelines on the management of stable coronary artery disease: The Task Force on the management of stable coronary artery
disease of the European Society of Cardiology. Eur Heart J. 2013;34(38):2949-3003.