Transcript Cardiology

ARIOPS
ARIOPS 2013 Conference
and Annual General Meeting
Cardiac ischaemia, irregularities
and interventions
Diana
Gorog
Prof. Diana Gorog
MB
BS, MD, PhD, FRCP
General Clinical
Cardiology
Update
DirectorCardiologist
for
Cardiology2013
Consultant
Consultant
Cardiologist
[email protected]
[email protected]
[email protected]
Cardiac ischaemia, irregularities and
interventions
• Angina
• Arrhythmias- risk stratification
• AF
Coronary artery disease
• No.1 cause of death in the Western
world
• ~52,000 new cases of angina in men
and ~43,000 new cases in women in UK
per annum
• CAD deaths falling, but
– morbidity increasing!
– So…more of them in the workplace.
3
Atherothrombosis: An Interaction Between
Lipids, Inflammation, and Thrombosis
Lipid-filled
Lipid-filled
plaque
plaque
Ruptured
plaque
Ruptured
plaque
with
thrombus
with
thrombus
1 1
2 2
Early
atherothrombosis
Early
atherothrombosis
3 3
4 4
5 5
2
Adapted with permission from Libby P. Sci Am. 2002;286:46-55. STRIVE
TM
Stable angina
Implementing NICE guidance
July 2011
NICE clinical guideline 126
Anti-anginal drug treatment
1. Beta blocker (e.g. bisoprolol 2.5mg o.d.)
2. Calcium channel blocker (e.g. tildiem LA 200mg
o.d.)
3. Isosorbide (e.g. ISMN SR 60mg o.d.)
4. Nicorandil 10mg b.i.d.
5. 4/5th line agents (to be initiated in secondary care)1. Ranolazine
2. Ivabradine
Investigation and revascularisation
Consider CABG or PCI
Investigation and revascularisation
When symptoms are not controlled with optimal
medical treatment:
When either procedure
appropriate, explain
risks vs. benefits of
PCI and CABG for
anatomically less
complex disease.
If no preference,
PCI may be more cost
effective procedure.
Investigation and revascularisation
When symptoms are not controlled with optimal
medical treatment:
If either appropriate, consider
potential survival advantage of
CABG over PCI for people with
multivessel disease who:
– have diabetes or
– > 65 years or
– anatomically complex 3vessel disease, ± LMS
involvement.
Investigation and revascularisation
When symptoms are controlled with medical treatment:
Consider CABG or PCI to see if
revascularisation indicated
Investigation and revascularisation
When symptoms are controlled with medical treatment:
Answer to each box must be ‘YES’ to proceed
Discuss prognosis, likelihood of having left main stem or proximal threevessel disease, the process and risks of investigation, the benefits and
risks of CABG with person with stable angina and check they are happy to
proceed?
Consider a functional or non-invasive test to identify people who might
gain a survival benefit from revascularisation?
Tests indicate extensive ischemia or likelihood of left main stem or
proximal 3-vessel disease?
Revascularisation acceptable and appropriate?
Consider PCI, or CABG if coronary angiography indicates left main stem or
proximal 3-vessel disease
Exercise ECG
• Sensitivity ~ 70%
• Specificity ~ 70%
• Markedly influenced by:
– Population studied
– Diagnostic criteria
• Test performs worse in women
than in men
• Contra-indications
– AS
– LBBB
– Uncontrolled severe HTN
Stress echocardiography
• Exercise
• Dobutamine (+ atropine)
• Sensitivity 85-95%
• Specificity 80-95%
• Improved in populations with
higher prevalence of multivessel CAD
Thallium Scan (a.k.a. myocardial
perfusion scan, MPS)
Normal
Abnormal
Sensitivity 85-90%
Prognostic/predictive value of
Stress echo or MPS
• A stress echo or MPS has a sensitivity of 80-95%
in detecting flow limiting CAD
• A normal stress echo yields an annual risk of 0.40.9%, implying excellent prognosis and v low rate
of events, even without revascularization
• In patients with ischemic LV dysfunction and a
significant amount of viable myocardium have
lower peri-op mortality, and improved survival
and reduced HF after revascularization
PALPITATIONS
PALPITATIONS
Palpitations
• Common presentation in General
Practice
• Significant social impact
• Often benign cause
• Associated with considerable
morbidity
• Nevertheless potentially lethal
• Chapter 8 of NSF for CHD
20
Arrhythmia from a Patient Perspective
• “I know something's wrong but
nobody takes me seriously”
• “My heart keeps missing beats (and
I am really worried I am going to
die)”
• Less than 10% of patients will have a
significant arrhythmia
21
Which patient is at clinical risk?
When are palpitations likely to
be an arrhythmia?
High Positive Predictive
Value of :
• Symptoms assoc. with
syncope
• Symptoms during
exercise
• Symptoms disturbing
sleep
• Regular palpitations
High Pre test odds or red
flags:
•Known Structural heart
Disease
•Family history SCD
•Personal Hx Syncope
•Male
•Increased age
24
Characteristic ECG abnormalities associated with
increased risk of/with arrhythmia:
•
•
•
•
•
Evidence of an old myocardial infarction.
– Pathological Q waves
– Inversion of T waves
– Loss of R wave progression across the chest leads following an anterior
MI.
Left ventricular hypertrophy.
Right ventricular hypertrophy.
Evidence of Wolff–Parkinson–White syndrome
– Short PR interval.
– Slight widening of the QRS: delta wave with normal terminal QRS
segment.
– Dominant R wave in V1.
– Inverted T waves in V1 – V4.
Prolonged QT
– Calculate the corrected QT (QTc) by dividing the QT/√R-R interval.
– Normal <0.45.
Palpitations: Workup
• Good history (inc. past medical & FH)
• Check FBC, U&E and thyroid function
• 12 lead ECG
• 24 hour Holter monitor
• Ambulatory ECG
– Continuous loop event recorder
– Event recorders with auto-activation (features of both Holter
and event recorder) (e.g. Novacor)
• Echocardiogram
• Treadmill test (for sxs with or after exercise)
• Implantable loop recorder
• E.P. testing
Ambulatory ECG recording
Implantable loop recorders
– Combined arrhythmia
detection and patient
activation
– Up to 3 years
– Device can be
interrogated and data
downloaded multiple
times
“Reveal” interrogation
Echo
• LV dysfunction
– Scar
– Ischaemic
– other
• LVH
• Valvular disease
• Cardiomyopathy
– HCM
– Dilated
– arrhythmogenic
MRI
• If
– Malignant arrhythmia of unknown cause
– Frequent RVOT ectopy suggestive of runs
– Relevant FHx SCD
•
•
•
•
•
Scar (small)
Features of ARVC
Sarcoid
Amyloid
HCM
Coronary Angiogram
• Assessment of VT
– More often scar
– Ischemia may be
important in 30%
cases
VT
scar
VF
ischaemia
Which people with palpitations should I refer?
•
Following initial assessment refer all people with:
– Risk factors for a serious arrhythmia:
• A family history of sudden cardiac death below the age of 40 years.
• Presence of major structural heart disease.
– A major ECG abnormality.
– Symptoms of ventricular tachycardia or supraventricular tachycardia
– WPW
– Symptoms of serious complications from arrhythmias.
•
Following ambulatory monitoring, refer people with proven:
– Ventricular tachycardia
– Supraventricular tachycardia
– Atrial flutter
– PAF if needing ablation
AF – a modern epidemic
AF – a modern epidemic
Heeringa J et al. Eur Heart J 2006;27:949–53;
Miyasaki Y et al. Circulation 2006;114:119–25
AF management
Identification
Symptoms
Opportunistic screening
Assessment & modification of risk
Anticoagulation
(?? Rhythm control)
Arrhythmia management
Rate control
Rhythm control
Annual % risk of stroke without antithrombotic
therapy is…
CHADS2 Score
Stroke Risk %
95% CI
0
1.9
1.2 – 3.0
1
2.8
2.0 – 3.8
2
4.0
3.1 – 5.1
3
5.9
4.6 – 7.3
4
8.5
6.3 – 11.1
5
12.5
8.2 – 17.5
6
18.2
10.5 – 27.4
The CHADS2 method for estimating stroke risk was validated by a cohort study of
1,733 nonrheumatic atrial fibrillation patients aged 65 to 95 who were tracked
through Medicare claims. The patients were not given antithrombotic therapy,
such as the anticoagulant warfarin or aspirin.
Refinement of stroke assessment in
relatively low risk groups
Camm AJ, Kirchhof P, Lip GY, et al., Guidelines for the management of atrial fibrillation (ESC), Eur Heart J, 2010;31:2369–429.
CHA2DS2 - VASc Risk Scoring for AF patients and
Thromboprophylaxis Guidelines (ESC)1
Score
0
Risk
Low
Considerations
Aspirin daily or no antithrombotic
therapy
Preferred: No antithrombotic therapy
1
Moderate
Oral anticoagulant or Aspirin daily
Preferred: Oral anticoagulant
therapy
2 or more Moderate
High
/ Oral anticoagulant therapy
1. Camm et al, 2010
AF management:
Rate & rhythm control
RATE CONTROL
RHYTHM CONTROL
RATE OR RHYTHM CONTROL?
Drug therapy for Rhythm Control
Drug therapy for Rhythm Control
Composite
Mortality
J Am Coll Cardiol 2011;58:1975–85
Last 2 years – disappointing results
with promising AAD
• Dronedarone
• Amiodarone
• Cerivarone
Can we improve on what can be
achieved using these strategies?
• Yes – role of ablation
Rationale for ablation of AF
• Increased morbidity & possibly mortality with AAD
• Wish to correct the negative effects of AF on:
–
–
–
–
–
General AF symptoms
Quality of life
Heart function (esp. in pts with HF)
Stroke risk
Survival
• Ablation makes sense – it targets the mechanisms of AF:
– Initiators (PV triggers)
– Substrate (macro and micro-reentry, rotors)
2010 ESC GUIDELINES
•
•
European Society of Cardiology
Guidelines for the management of atrial fibrillation. 2010
Role of AF ablation
• Second line of treatment in patients with symptomatic AF who
have failed, or have failed to tolerate treatment with at least
one class Ic or class III drug
– Class I (Level of evidence A) indication in paroxysmal
– Class IIa persistent
– Class IIb long-standing persistent
• First line of treatment in patients with symptomatic AF in
whom AAD have not been tried
– IIa paroxysmal
– IIb other
Calikins et al. J Interv Card Electrophysiol (2012) 33:171–257
2012 HRS-EHRA-ECAS expert consensus statement for AF
Targets for AF ablation
Ablation strategies
Ablation results
• Depend on:
– Pattern of AF (paroxysmal vs. persistent vs. longlasting persistent)
– Comorbidity
– Concomitant use of AAD
– Number of ablations
AF Ablation
non-randomised comparison with medical Rx
AF-free
Survival
78 vs. 37% at
3yrs (p<0.001)
Pappone et al. JACC 03
AF Ablation
non-randomised comparison with medical Rx
• Quality of life
Quality of
life
Physical (SF-36)
Mental (SF-36)
Pappone et al. JACC 03
DOES ABLATION AFFECT
PROGNOSIS?
Rationale for ablation of AF
• Prognostic benefit?
• Comparison of:
– 4,212 consecutive pts who
underwent AF ablation
– 16,848 age/gender
matched controls with AF
(no ablation)
– 16,848 age/gender
matched controls without
AF
Bunch et al. JCE 2011
Rationale for ablation of AF
• Prognostic benefit?
•
Death
Conclusion: “AF ablation patients
have a significantly lower risk of
death, stroke, and dementia in
comparison to AF patients without
ablation. AF ablation may eliminate
the increased risk of death and stroke
associated with AF”
CVA
Bunch et al. JCE 2011 (e-pub ahead of
print)
AF ablation
• Can long-term freedom from AF be achieved?
Comparison of AF ablation vs. AAD
in randomised trials
Study
Patients Age (y)
(n)
Type of AF
Previous use
of AAD
• Randomised studies
Ablation
technique
Repeat
Crossed to
ablation in the ablation in the
ablation group AAD group
Krittayaphong
2003
55+/-10 (ablation) Paroxysmal,
30 47 +/- 15 (AAD)
Persistent
>1
PVI + LA lines
+ CTI ablation
+ RA lines
Not stated
Wazni 2005
53+/-8 (ablation)
70 54+/-8 (AAD)
No
PVI
Paroxysmal,
persistent
>2
PVI + LA lines
+/- CTI
ablation
No exact data
Persistent
>1 (mean
2.1+/-1.2)
CPVA
>2 (mean
2+/-1)
CPVA + CTI
ablation
Stabile 2005
62+/-9 (ablation)
245 62+/-10 (AAD)
Mainly
paroxysmal
Oral 2006
245 57+/-9
Pappone 2006
55+/-10 (ablation)
198 57+/-10 (AAD)
Paroxysmal
Jais 2008
Forleo 2008
112 51+/-11
63+/-9 (ablation)
70 65+/-6 (AAD)
40%
49%
87%
37%
57%
56%
9%
77%
74%
4%
42%
86%
22%
89%
23%
80%
43%
66%
16%
69.9%
7.3%
>1
>1
Packer 2010
79%
Not stated
19% within
Cryo-PVI +/- 90 days after
LA lines
1st procedure
Paroxysmal,
persistent
56.7 (ablation) 56.4
245 (AAD(
Paroxysmal
AAD
>1 (mean
1.3)
>1
55.5(ablation) 56.1
167 (AAD)
Paroxysmal
26% for AF,
6% for LA
flutter
6% for AF 3%
for LA
tachycardia
Ablation
PVI +/- LA
Mean 1.8 +/lines +/- CTI 0.8 median 2
ablation
per patient
63%
PVI +/- LA
lines +/- CTI
ablation
Not stated
Not stated
PVI +/- LA
lines +/CFAEs +/- CTI 12.6% within
ablation +/- 80 days after
RA lines
1st procedure
59%
Paroxysmal
Wilber 2010
12%
Freedom from AF
at 1 year
79%
PAROXYSMAL
AF – long term success
Single procedure success rate
Multiple procedure success rate*
171 patients, all paroxysmal, recruited between 2003-4; *after median of 1 (1-3) procedures
Ouyang et al. Circulation. 2010;122:2368-2377.
Longer-term outcome
Arrhythmia-free
survival
Single procedure success rate
– 87% - 1 year
– 81% - 2 years
– 63% - 5 years
Weerasooriya, … Haissaguerre & Jais. JACC 2011:57;160-6
AF management: summary
– Virtually no AAD improves prognosis due to the
risk of pro-arrhythmia
– Catheter ablation:
•
•
•
is vastly superior to AAD in terms of maintenance of
SR
Is vastly superior to AAD in achieving symptom
control/QOL
Avoids the risk of pro-arrhythmia and may improve
prognosis
Summary
• Angina
• tests of ischemia burden and
their prognostic usefulness
• role of revscularisation
• Arrhythmia
• Risk profiling
• AF management- role of ablation
Thank you for your attention