Transcript 10. Missing the metabolic approach

Missing the metabolic approach:
Four act drama of one patient, one artery
and one missing medication
Lora Nikolova
Department Cardiology and Angiology
Tokuda Hospital Sofia
Act 1
Setting the stage
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Patient characteristics (1)
 57 YO male patient
 Hypertension, Dyslipidemia, NIDDM, Gastritis
 Family history of CAD – father and brother died from MI
 Presents to the outpatient unit with UA III B (Braunwald)
(75 days after his last PCI)
 Physical exam: Non-obese, normal breathing, without rales, normal
heart sounds, HR – 70 BPM, BP - 146/75mmHg. No signs of venous
congestion
 Echo – LVEF – 61%, LVEDV/LVESV – 93/37ml, IVS/LVPW – 12/12mm,
without significant valve pathology
 Baseline medical therapy: metoprolol succinate 25mg, ASA 100mg,
Perindopril 2,5 mg, Atorvastatin 10mg; Gliclazide 30mg, Clopidogrel
75mg
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Patient characteristics (2)
 Lab results : Hb – 150; Leu – 10,0; Thr – 323; Gluc – 8,1; Tchol – 3,6; HDL-C –
0,69; Tg – 1,85; LDL-C - 2,07; CK – 57; CK-MB – 11; TnI – 0,20 (>UNL)
 Resting ECG: Sinus rhythm, inferior ischaemia
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Patient characteristics (3)
 History of revascularization procedures:
 2001 – PCI of RCAprox with BMS.
 2005 – PCI of LAD+LCX with BMS
 2008 – PCI of RCA mid/dist with 2 BMS.
 10/2009 – POBA of RCA with DEB
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What would you do?
 Discharge the patient ASAP ?
 Perform an exercise stress-test ?
 Perform a coronary angio ?
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Initial strategy
 Medical treatment
 Fondaparinux
 NTG iv
 ASA
 Clopidogrel
 Metoprolol succinate
 Perindopril
 Rosuvastatin
 Coronary angiogram
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CAG
 LAD, LCx
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CAG
 RCA
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What would you do?
 Perform an IVUS?
 Perform a FFR ?
 Perform OCT?
 Treat the lesion ?
 Leave the patient on OMT?
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Treat the lesion
 POBA with cutting
balloon
 Angiosculpt (Angioscore Inc)
3,5x20mm
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Treat the lesion
Artax PES (AachenResonance GmbH)
4.0x15mm
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Treat the lesion
Artax PES (AachenResonance GmbH)
3.5x24mm
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Treat the lesion
 Final reslut
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Post-procedure
•Remission of
chest pain
•Resolution of ECG
changes
•Negative CK, MB,
TnI
•Ready for
discharge
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Discharge
 Discharged on the second day with ambulatory therapy
 Clopidogrel 75mg
 ASA 100mg
 Rosuvastatin 10mg
 Metoprolol succinate 25mg
 Perindopril 2,5 mg
 Isosorbide dinitrate 3 x 10mg
 Gliclazide 30mg
 ………………………………?
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Did we miss something in the therapy?
 Would you choose:
 To add a CCB
 Or Metabolic strategy
 Or something else ?
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Follow-up
 Mo 1


Stress-test on treadmill by mACIP protocol – Without
significant ST abnormalities up to 10 METS, DP – 30 870.
Medical therapy - long acting nitrate discontinued due to
intolerable headache, other medications – unchanged
 Mo 3


Stress-test on treadmill by mACIP protocol negative again at
10 METs, DP – 28 060
Medical therapy - unchanged
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Two months later…
Act 2
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The same stage again…
 The patient presents again with UA III B (Braunwald)
 Concomitant therapy: metoprolol succinate 25mg, ASA 100mg,




Perindopril 2,5 mg, Rosuvastatin10mg; Gliclazide 30mg, Clopidogrel
75mg
Clinical presentation: Normal breathing, without rales, Normal heart
sounds, HR – 67 BPM, BP – 150/80. No signs of venous congestion.
TnI – 0,05 (>ULN)
Echo – LVEF – 62%, LVEDV/LVESV – 93/37ml, IVS/LVPW – 12/12mm,
without significant valve pathology.
ECG
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Restenosis again
Angiosculpt (Angioscore Inc) 3,5x12mm
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What would you suggest next?
 Refer the patient for immediate CABG
 Prevent further restenosis with oral Rapamune
 Leave him on optimized medical therapy
 Prescribe anxiolytics
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Discharge and follow up
 Post-procedure
 No chest pain
 Negative CK, MB, TnI after the procedure
 The patient is uncertain about CABG
 Based on the results of OSIRIS trial oral sirolimus was given with a
loading dose 8mg followed by maintenance dose of 2 mg/daily for 4
weeks.
 Ambulatory therapy: metoprolol succinate 25mg, ASA100mg,
Perindopril 2,5 mg, Rosuvastatin 10mg; Gliclazide 30mg, Clopidogrel
75mg, Rapamycin 2mg
 At Month 1: Negative stress-test
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Three months later…
Act 3
The patient comes ready for angio…
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CAG: CABG - definitely
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Happy ending
 The patient gives consent for CABG and is referred with normal EF, CK,
MB and slightly elevated TnI – 0,32
 CABG was performed – LAD-Lima, RCA(PD) – jump to RM I – svg.
 Discharged with ambulatory therapy:
 ASA 100mg
 Clopidogrel 75mg
 Bisoprolol 2,5mg
 Perindopril 5mg
 Famotidine 20mg
 Rosuvastatin 10mg
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One month after the happy ending…
Act 4
Angina again!!!
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What we really missed?
 Is this all to OMT?
 DAPT



X
X
X
X
(Class I, LOE A) ASA 100mg + Clopidogrel 75mg
ACE inh
(Class I, LOE A) Perindopril 5mg
Statin
(Class I, LOE A) Rosuvastatin 10mg
BB
(Class I, LOE A) Bisoprolol 2.5mg
Lower than recommended dosage – symptomatic bradycardia
CCB
(Class I, LOE A) Not prescribed hypotension
Nitrates
(Class I, LOE C) Not prescribed intolerable headache
SNI
(Class IIa, LOE B) Not prescribed symptomatic bradycardia
Metabolic agents
Not prescribed - ???
(Class IIa, LOE B)
 What we did not come up to?
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Step of last resort
 The patient was prescribed Preductal MR 35mg bid
as add on to his current therapy
 8 weeks later on telephone contact the patient reports
 Improved exercise tolerance
 Reduced angina frequency
 Increased treatment satisfaction
 Improved subjective disease perception
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What about some objective evidence?
 The patient is referred for an exercise stress-test on W12
after the CABG
 Stress-test on treadmill by mACIP protocol – without
significant ST abnormalities up to 4-5 METS, CP 19 080
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Stress-test
end
Immediately
after peak of
exercise
Recovery on
4th min
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What have we learned?
 Metabolic agent trimetazidine is effective in controlling
intractable angina
 Clinical trial data show that the benefits of trimetazidine
are multiple
 Improved excersice tolerance and QoL
 Better outcomes in terms of LVEF after revascularisation
 Safer revascularisation procedures
 Better survival in STEMI
 Preductal MR should be prescribed early in the course of
CAD for patients to gain full benefit
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Thank you
… and hope to see you again here next year for the yearly
update on the outcomes of our patient!
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