Transcript Chronic CAD
Chronic CAD: Diagnosis, Treatment and Guidelines 2016 Morton J. Kern MD, MSCAI, FACC, FAHA Chief of Medicine, VA Long Beach HSC Professor of Medicine University California Irvine Deaths attributable to cardiovascular disease (United States: 2010). Go A et al. Circulation 2014;129:e28-e292 Deaths attributable to diseases of the heart (United States: 1900–2010). Go A et al. Circulation 2014;129:e28-e292 58 yo Man, Chest pain after lunch on the way to car. Bad sushi? CAD is a diffuse process with focal atherosclerotic material (plaque). Some plaques are obstructive but not thrombotic. Others are potentially thrombotic but not obstructive. Myocardial Infartion= Death of myocardial cells. Clinical MI = symptoms, ECG and Biomarkers CAD as a cause of Myocardial Ischemia and Infarction Normal Atherosclerotic Plaque Angiography vs. Pathology Angiography vs CTA for CAD ACS 179 Fibrous plaque Positive remodeling Soft plaque LAD Motoyama et al. JACC 2007 Natural History of CAD : A story of remodeling •Acute Coronary Syndrome •72 year-old Man •Plaque crater, erosion •Calcific nodule •Thrombus What are the Big 5 medications for CAD? 1. 2. 3. 4. 5. BB ASA/antiplatelet agents Statins Nitrates Antihypertensive and other risk factor medications NTG ASA Heparin GPB’s Statins Beta blockers CA blockers ACEI NTG Ranolazine Braunwald’s Heart Disease, 7th Edition Ischemic Cascade Angina Δ ECG Stress ECG Systolic Dysfunction Stress Echo/MRI Diastolic Dysfunction Perfusion Abnormalities Nuclear Imaging Duration and severity of ischemia Conditions Provoking or Exacerbating Ischemia Increased Oxygen Demand Decreased Supply Noncardiac Hyperthermia Hyperthyroidism Sympathomimetic toxicity (e.g., cocaine use) Asthma Hypertension Anxiety Arteriovenous fistulae Cardiac HCM Aortic stenosis Dilated cardiomyopathy Tachycardia Ventricular Supraventricular Anemia Hypoxemia Pneumonia Chronic obstructive pulmonary disease Pulmonary hypertension Interstitial pulmonary fibrosis Obstructive sleep apnea Sickle cell disease Sympathomimetic toxicity (e.g., cocaine use) Hyperviscosity Polycythemia Leukemia Thrombocytosis Hypergammaglobulinemia Spectrum of CAD Presentations SIHD Definition Diagnosis Treatment Ischemia with activity UA Ischemia without necrosis NSTEMI STEMI Necrosis (nontransmural) Transmural necrosis Symptoms, Negative Biomarkers ECG, Stress testing No ECG ST-segment elevation The Big 5 Positive biomarkers Invasive or conservative depending on risk ECG ST-segment elevation Immediate reperfusion Roger VL, Go AS, Lloyd-Jones DM, et al.. Circulation. 2011;123:e18-e209. Proportion of Veteran VHA outpatients aged 65+ with at least one instance of cardiovascular conditions, FY10 30% 25% 20% 15% 10% 5% 0% WV MV Heart Attack Warning Signs • • • • • Chest discomfort – Pressure – Squeezing – Fullness – Pain Discomfort in other areas of the upper body – Arms – Jaw – Neck – Back – Stomach Shortness of Breath Cold sweat, nausea or lightheadedness **Women have atypical presentations!! Be more wary Current Management for Acute Coronary Syndromes high risk of in-hospital death Treatment goal: immediate restoration of coronary blood flow If no cath lab, Fibrinolyti c therapy Direct PCI low risk of in-hospital death, unless MI develops Treatment goal: stabilize with aspirin heparin & monitor for MI development + Cardiac enzymes – Cardiac Enzymes Highrisk features Low risk features Scheduled PCI Manage medically Thygesen, K. et al. Circulation 2007;116:2634-2653 Plalque Rupture Spasm, low BP Sudden Death, no CK PCI related Stent Thrombosis CABG related Thygesen, K. et al. Circulation 2007;116:2634-2653 7 Factors of the TIMI Risk Score for UA/NSTEMI CAD CP algorithm The 5 Common Cardiac Stress Testing Modalities Exercise 1. ECG 2. ECHO 3. Nuclear Pharmacologic 4. Dobutamine Echo 5. Adenosine Nuclear Who needs Stress Testing? EuroIntervention 2015;10:1024-1094 published online ahead of print September 2014 2014 ESC/EACTS Guidelines on myocardial revascularization Proportion of stress test type out of all stress tests conducted in MEN Veteran VHA outpatients (N=157,140) Proportion of stress test type out of all stress tests conducted in WOMEN Veteran VHA outpatients (N=7,198) 5.56% Echo stress 4.16% Echo stress 40.93% 46.72 % ECG stress only 47.72 % ECG stress only 54.92% Nuclear stress Echo Stress Test Nuclear Stress Test VETERANS HEALTH ADMINISTRATION Nuclear stress Non-Imaging Stress Test 28 Indications for revascularization in Stable CAD or silent ischemia EuroIntervention 2015;10:1024-1094 published online ahead of print September 2014 2014 ESC/EACTS Guidelines on myocardial revascularization Recommendation for CABG/PCI in Stable CAD with anatomy suitable for both procedures EuroIntervention 2015;10:1024-1094 published online ahead of print September 2014 2014 ESC/EACTS Guidelines on myocardial revascularization BP control BP maintence Lipids Lipids Lipids <140/90 or <130/80 DM, CR add meds as nec to BB/ACE Add plant stanol/sterols 2g/ LDL-C <70mg/dl or high dose statin is reasonable (IIa) If LDL-C 100-70 at base, rx to <70mg/dl is reasonable From: 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines J Am Coll Cardiol. 2014;63(25_PA):2889-2934. doi:10.1016/j.jacc.2013.11.002 From: 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines J Am Coll Cardiol. 2014;63(25_PA):2889-2934. doi:10.1016/j.jacc.2013.11.002 From: 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines J Am Coll Cardiol. 2014;63(25_PA):2889-2934. doi:10.1016/j.jacc.2013.11.002 From: 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines J Am Coll Cardiol. 2014;63(25_PA):2889-2934. doi:10.1016/j.jacc.2013.11.002 From: 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines J Am Coll Cardiol. 2014;63(25_PA):2889-2934. doi:10.1016/j.jacc.2013.11.002 Exercise Testing I IIa IIb III In patients entering a formal cardiac rehabilitation program after PCI, treadmill exercise testing is reasonable. I IIa IIb III Routine, periodic stress testing of asymptomatic patients after PCI without specific clinical indications should not be performed. No Benefit EuroIntervention 2015;10:1024-1094 published online ahead of print September 2014 2014 ESC/EACTS Guidelines on myocardial revascularization Can treatment of Chronic CAD prevent sudden death?