Transcript Chest Pain: To Cath or Not ?

Chest Pain: To Cath or Not ?
Part I
• Georgios Papaioannou, MD
• Ioannis Karavas, MD
Newton-Wellesley Hospital
5/3/2000
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A Typical Scenario...
• 57 year old female, Mrs. X., presents to your
office with a 2 months history of exertional chest
pressure, however she does admit that she also has
the same feeling occasionally, although less
severe, at rest. Symptoms resolve in 5 min most of
the times without any intervention.
• She only has a history of HTN, her recent LDL is
130 and no other risk factors, no previous history
of CAD.
• She is on Lisinopril and HRT.
• In your office her BP is 140/90, she has a normal
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physical exam and a normal ECG.
The easy part...
• You decide to start her on Aspirin and arrange for
a ETT the next day.
• ETT results: 5 min 50 sec, achieved 85% of her
MPHR , patient developed chest pressure similar
to her initial complaint associated with 1 mm ST
in inferior leads ; she stopped the test secondary to
fatigue.
• An Echocardiogram you ordered is normal...
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The second visit is not always
easier...
I wish I knew
the anatomy!!!
• What is wrong with
me ?
• Can you fix it ?
• Will I live forever ?
4
Anatomy-driven or Ischemia
driven decision ?
• Cardiology Consultation.
• Your patient is scheduled to have a ETT with
Thallium.
• Metoprolol is added to the regimen. ( No ! The
dose is not complex...)
“Ischemia-guided” or “selective invasive approach”...
It will take me a while to know the anatomy!!!
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ACC/AHA Coronary Angiography
Guidelines
• Initially published in 1987.
• Intend to assist physicians in clinical decision
making.
• Define practices that meet the needs of most
patients in most circumstances.
• Last updated 5/1999.
• Closely linked to recent demands of Evidence based Medicine.
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Classification
• I: General agreement
about usefulness/
efficacy.
• II: Conflicting evidence
- Divergence of opinion.
IIa: Evidence /
Opinion is in favor.
IIb: Less well
established.
• III: Not useful /
effective, may be
harmful.
Level of
Evidence
• A: Multiple
randomized Clinical
trials.
• B: Single randomized
or non randomized
trials.
• C: Expert Consensus.
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Risks of cardiac catheterization
Unfortunately there are risks...
•
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•
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•
•
•
•
Mortality
Myocardial Infarction
Cerebrovascular accident
Arrhythmia
Vascular complications
Contrast reaction
Hemodynamic complications
Perforation of heart chamber
Other
TOTAL
0.11%
0.05%
0.07%
0.38%
0.43%
0.37%
0.26%
0.03%
0.28%
1.70%
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Major Predictors of Major
Complications:
Operator’s skills
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Moribund condition.
Shock.
Acute MI < 24 hrs.
Renal insufficiency.
Cardiomyopathy.
Aortic Valve disease.
Mitral valve disease.
CHF.
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Utilization...
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1993: 1,078,000 catheterizations annually.
48% in people > 65 years old.
Men more likely than women.
Whites more likely than blacks (114/100000 ).
Medicare: 38%  from 1991-1995.
Given current trends and a prediction of 40%
population growth, by 2010  3 million
catheterizations in the USA annually!!!
If you also consider that Greece follows the
USA trends with a 10-15 years interval ... I will
most likely have a good professional life!!!
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Type of acute reperfusion in different types of
hospitals
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JACC 2000;35:371-9)
In-Hospital procedures in ACS
CABG<24 hs*
9
2
CABG*
*P<0.05
14
PTCA<6 hs*
22
45
5
PTCA*
60
22
Cath<6 hs*
Invasive Hospitals
Conservative Hospitals
58
10
Cath*
85
51
0
20
JACC 2000;35:895-902.
40
60
80
100
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Use of Angiography within 90 days of
Index Hospitalization for AMI
(No cumulative mortality difference!)
New York (30%)
Texas (45%)
100
80
P<0.001
P<0.001
P= 0.83
P<0.001
60
40
20
0
Q/NP
NQ/NP
NEJM 1995;333:573-8.
Q/P
NQ/P
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Characteristics of Hospitals in the USA
and Ontario, Canada
(No survival benefit in 1 year...)
100
90
80
70
60
50
40
30
20
10
0
91.7
USA
CANADA
55.4
34.9
24.6
20
5.2
None
Cath Lab
NEJM 1997;336:1500-5.
21.8
3.1
PTCA+CABG
6.7
Angiography
2.8
Revascularization
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OASIS Registry: Median in-hospital stays in
days: Only  in refractory angina (USA/Brazil)
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14
10
12
8
10
8
7
5
5
USA
Australia
Brazil
Canada
Hungary
Polland
6
4
2
0
USA
Australia
Brazil
Canada
Am J Cardiology 1999;84:7M-12M.
Hungary
Polland
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Status of Cardiac symptoms at One year
after MI
P<0.001
45
40
35
30
25
20
15
10
5
0
45
P<0.001
34
29
21
P=0.60
P<0.001
14
16
9
USA
CANADA
3
Any Chest
Pain
Angina
Any Dyspnea
Severe
Dyspnea
GUSTO Substudy, NEJM 1994;331:1130-5.
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Cost - Effectiveness
Little studies...
• Angiography is frequently coupled with a
revascularization procedure.
• Stress PET shows the lowest cost per effect or per
cost/QALY in patients with PCAD < 0.70.
• At a pretest probability > 70% (middle aged man
with typical angina) proceeding to angiography as
the first test has the lower cost...
Circulation 1995;91:54-65.
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Estimated medical care Costs: ACIP Study
Am J Cardiology 1999;84:1311-1316.
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Cumulative costs in stable CAD: ACIP Study
Am J Cardiology 1999:84:1311-1316.
Who needs an angiogram?
• ? A stable patient that
has been unstable
recently...
• ? An unstable patient
that has been
stabilized medically...
• It also matters who
makes the decision...
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Recommendations for angiography in the
setting of known or suspected CAD
• High risk criteria on noninvasive testing
regardless of anginal severity.
• CCS class III or IV angina on medical
treatment.
• Cardiac arrest survivors, Sustained
monomorphic or nonsustained polymorphic
ventricular tachycardia.
Class I recommendation, ACC/AHA Guidelines 1999;33:1768.
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Stable Angina
Noninvasive test results predicting high risk
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Severe resting LVEF (< 35%).
High risk treadmill score (score < –11).
Severe exercise left ventricular dysfunction (<35%).
Stress induced large perfusion defect (particularly anterior).
Stress induced multiple moderate perfusion defects.
Large, fixed defect with LV dilatation or  lung uptake.
Echocardiographic wall motion abnormality at low dose of
dobutamine (<10 mg/kg/min) or low heart rate (<120 bpm).
• Stress Echo evidence of extensive ischemia.
NEJM 1991;325:1435-9.
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Risk Stratification
• There are no randomized trials to compare treatment
strategies based only on noninvasive data.
• But there are available trials which use angiographic
data to stratify patients with stable angina:
 High risk (Left main, 3-vessel disease, proximal LAD,
 EF).
 Moderate risk (Multivessel CAD, normal EF).
 Low risk (Single vessel CAD, normal EF).
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CABG vs Medical Therapy
Duke University Study, Am J Cardiology 1997;80(9A):2I-10I.
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CABG vs Medical Treatment: CASS Study:
10 year survival in single vessel disease
Circulation 1990;82:1629-1646.
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PTCA vs Medical Management
Duke University Study, Am J Cardiology 1997:80:(9A):2I-10I.
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Months
PTCA vs Medical treatment in
stable single vessel CAD
6
46
5
45
4
37
3
36
2
25
1
24
64
60
60
56
54
52
P<0.01
• No trial demonstrated a
survival benefit of PTCA.
• Almost all trials showed
Medical therapy
improved quality of life
PTCA
with PTCA.
• The prognosis of single
vessel disease and mild
symptoms is excellent.
9
9
0
Patients without angina
0
50
100
ACME Study, Circulation 1995;92:1710-9.
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Also consider Coronary Angiography:
Class IIa / Level of Evidence C
• CCS class III or IV which improves to I or
II with medical therapy.
• Class I or II that fails to respond to therapy.
• Serial “identical” noninvasive testing
showing progressively worsening
abnormalities.
• A “need to know” situation in high risk
professionals.
ACC/AHA Guidelines, JACC 1999;33:1770.
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Acute Coronary Syndromes
(ACS)
• Unstable Angina
• Non STE MI
• STE MI
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High risk Predictors
(Death or Nonfatal MI)
• >20 min Chest pain or
• Elevated Serum
angina at rest.
cardiac markers:
* Troponin I & T
• Dynamic ST changes.
* CPK-MB.
• Previous PCI or GABG.
* Myoglobin.
• Worsening MR, S3 gallop.
• High risk criteria on
• Hemodynamic instability.
noninvasive testing.
• Pulmonary edema related
to ischemia or EF<40%.
ACC SS 3/2000 : Controversies in Interventional Cardiology.
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Low risk patients
The goal is to determine whether revascularization is indicated.
• Class IIb recommendation:
Low short-term-risk unstable angina, without
high criteria on noninvasive testing (Level of
evidence C)
• Intensive medical therapy and noninvasive
evaluation including echocardiography for
risk stratification is the way to go...
JACC 1999;33:1756-1824.
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Intermediate or High risk patients
The goal is whether revascularization is emergent,
urgent or ... at least beneficial!!!
• Intensive Medical management.
* Aspirin.
* Standard or low molecular weight heparin.
* Glycoprotein IIb/IIIa inhibitors.
• Patients who do not respond after (one hour) of
aggressive therapy or have recurrence after initial
stabilization emergent or urgent angiography
should be performed - Class I recommendation.
ACC/AHA Coronary Angiography Guidelines JACC 1999;33:1773.
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What happens if a high risk patient
stabilizes after initial treatment ?
• AHCPR proposes an “early invasive” or “early
conservative” strategy...
• ACC recommends coronary angiography in high or
intermediate risk patients that stabilize after initial
treatment - Class I (Level of evidence A).
• ACC also recommends angiography in “initially low
short-term-risk unstable angina that is subsequently
high on non invasive testing” - Class I (Level of
evidence B).
JACC 1999;33:1756-1824.
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ACS: Timing of Intervention
• TIMI IIIB
• VANQWISH
• MATE
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•
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•
DANAMI
OASIS REGISTRY
FRISC-II
MITI REGISTRY
ACS: No difference.
NQWMI: Invasive worse.
ACS: Medicine vs Angioplasty-N
difference in long term.
Post MI: Invasive better (CEP).
ACS: No difference.
ACS: Invasive 22% better.
NQWMI: Invasive better.
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One Year Results in TIMI IIIB
(Unstable Angina)
20
18
16
14
12
10
8
6
4
2
0
10.7 11.5
8.6
3.6
Early Invasive
Early Conservative
9.1
3.6
1.9
1.0
Death*
MI*
Death or Stroke*
MI*
JACC 1995;26:1643-1650.
*P=NS
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TIMI IIIB: Repeat Hospital Admission,
Anginal Status, Antiaginal Medications
Early Invasive
100
90
80
70
60
50
40
30
20
10
0
Early Conservative
*P=NS
71
69
P<0.005
P<0.001
33
36
36
26
8
14
Readmission 6 wk Readmission 1yr Antianginal Meds
1yr*
No Angina*
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JACC 1995;26:1643-1650.
FRISC - II Study
•
•
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•
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Intermediate and High risk patients.
Dalteparin vs Placebo.
“Early” Invasive vs Conservative.
Dalteparin instead of standard Heparin.
Even the Invasive Group received  4 days
of Dalteparin.
• Stents at 61/70% in PCI.
• Abciximab in 10/10% in PCI.
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Lancet 1999;354:708-715.
FRISC - II Trial in ACS
(6 months data)
20
18
16
14
12
10
8
6
4
2
0
**P=0.031
*P=0.045
12.1
10.1
P=0.10
1.9
9.4
7.8
Early Invasive
Conservative
2.9
Death
MI*
Lancet 1999;354:708-715.
Death and
MI**
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TIMI IIIB - VANQWISH - FRISC II
Differences in Revascularization rates
100
90
80
70
60
50
40
30
20
10
0
TIMI IIIB
VANQWISH
FRISC II
77
64
58
44
33
37
26
10
0 0
Invasive Group
Conservative
Group
Stents
0 0
GIIbIIIa
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Summary: After the trials...
• Pathophysiology of unstable angina is clear.
• Management of ACS is still controversial.
• High risk patients seem to benefit from
“early” invasive approach.
• Use of LMWH, GIIbIIIa inhibitors, Statins.
• Use of stents in combination with potent
antiplatelet therapy.
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The struggle for evidence...
Socrates (469-399 BC)
Aristotle (384-322 BC)
Plato (428-347 BC)
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The persistence in evidence...
G. Galilei (1564-1642 AC)
N. Copernicus (1473-1543 AC)
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The journey to evidence...
“When you sail for Ithaca
wish that your trip be long,
full of adventures,
full of knowledge...”
K. P. Kavafis (1863-1933)
Odysseus and Penelope.
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