Khai Pham Gia. Vietnam Cardiovascular Organization Cardiovascular Hospital. Hanoi, Vietnam. Declared no potential conflict of interest.

Transcription

1 Khai Pham Gia Vietnam Cardiovascular Organization Cardiovascular Hospital Hanoi University of Medicine Hanoi, Vietnam Declared no potential conflict of interest.

2 Hypertension in Patients with Coronary Artery Disease Prof. Pham Gia Khai, MD. PhD. FACC. FESC

3 Case 61 yrs. F. HTN: 10 yrs: well controlled for 5 yrs; recent 5 yrs. Not well controlled DM: 5 yrs. Rx: SU + Metformin Atypical chest pain Dyspnea on exertion ECG: LV hypertrophy; cannot rule out CAD Cardiac Echo: LVDd: 57 mm; EF: 45%

4 MCQ (slide 4) Diagnosis of Hypertension : (A) Systolic 140 mmhg and Diastolic 90 mmhg (B) Systolic 140 mmhg and Choose the right answer Diastolic < 90 mmhg (C) Sporadic Hypertension on 24 hr Holter recording Diagnosis of Diabetes mellitus (A) Fasting Blood Glucose 7 mmol/l ( 126 mg/l) and/or HbA1C 6.5 (B) Fasting Blood Glucose 7 mmol/l and 2hr post-prandial Blood Glucose 7.8 mmol/l (C) Both (A) and (B) Choose the right answer Diagnosis of coronary heart disease (A) Chest pain relieved by Nitrates, cardiac enzymes normal (B) Chest pain not relieved by Nitrates, cardiac enzymes normal (C) Suggestive coronary angiogram, cardiac enzymes normal (D) Elevated cardiac enzymes, but coronary angiogram normal Choose the right answer

5 ECG

6 Questions??? Relationship between HTN and CAD What is the difference of CAD profile in HTN vs normotensive patients? Pretest possibility of CAD? %? Which is the best test for diagnosis of CAD in this patients? Optimal strategy for CAD pts with HTN?

7 BP levels are directly related to ischemic heart diseaseatanydecadeofage IHD mortal lity (floating absolute risk kand95%ci) Ageatrisk: years years years years IHD morta ality (floating absolute risk kand95%ci) Ageatrisk: years years years years Usual SBP(mmHg) 0 70 Usual DBP(mmHg) Lewington et al. Lancet 2002;360:

8 IncidenceofMIandtotalstrokebysystolicBP strata in the in the Framingham population D Agostino RW, et al. BMJ 1991; 303:

9 Intensive Lowering BP levels increases risk of MI inpatientsathighorveryhighcvrisk

10 Mortality increases with follow-up DBP < 70 mmhg in the INVEST trial Incidence of pr rimary outcome,% Patientswith primaryoutcome,n 60 > 60 to 70 > 70 to 80 > 80 to 90 > 90 to 100 > 100 to 110 > 110 Diastolic Blood Pressure, mmhg Totalpatients,n Meansystolicbloodpressure,mmHg Patientswith primaryoutcome Patientswithout primaryoutcome % had coronary heart disease; treatment with beta blocker or calcium channel blocker Messerli et al. Ann Intern Med 2006;144:

11 Cardiovascular mortality increases with follow-up SBP <120mmHgintheONTARGETtrial 30 3 ofevents,% Adjusted 4.5-year risk Hazardratio,95%con nfidence intervals 75% had coronary heart disease at baseline treatment with ACEi and/or ARB. Sleight et al J. Hypertens 2009;27:

12 ACCORD-BPLA Trial Intensive Lowering of BP levels did not improve CAD outcomes in the diabetic patients Cusham W, et al. N Engl J Med 2010;362:

13 ROADMAP: Lowest SBP and/or highest SBP reduction quartile are associated with increased CV mortality in patients with CHD Last SBP before event SBP reduction mmhg mmhg Cohort of patients with pre-existing CHD (n=1104) * 26-MAY-2010

14 ROADMAP: The increased mortality was only seen in patients with pre-existing cardiovascular disease(cvd) tality(%) Olmesartan Placebo p = 0.02 Cardiovasular mort 26-MA0

15 INVEST Trial Incidence of MI and Stroke in Hypertensive patients with CAD stratified by Diastolic Blood Pressure levels Messerli, et al. Ann Intern Med 2006;144:

16 The Diagnostic dilemma of CAD in hypertensive patients Chestpainisacommonbutalsonon-specificsymptomin hypertensive patients both with and without CAD. Non invasive screening tests are not able to accurately discriminate between hypertensive patients with and without associated CAD. International guidelines are elusive on the recommended diagnostic pathway for detection of CAD in this group of patients. Early CV risk stratification and evaluation of markers of organ damage may improve diagnostic efficacy. ChinD,BattistoniA,TocciG,PasseriniJ,ParatiG,VolpeM.AmJHypertens.2012;25:

17 ExerciseECG Exercise ECG tests have a low specificity and sensitivity for CAD determination, especially in hypertensive patients. This group of patients often have baseline ECG changes, especially in patients with LVH. ChinD,BattistoniA,TocciG,PasseriniJ,ParatiG,VolpeM.AmJHypertens.2012;25:

18 ExerciseECG Weaknesses: Suboptimal sensitivity. Low sensitivity in identifying single vessel disease. the test is not diagnostic in situations where there are baseline ECG changes (such as evidence of left ventricular strain secondary to left ventricular hypertrophy, left bundle branch block). Low specificity in certain population of patients (such as pre-menopausal women). To increase the accuracy of the test it is necessary to achieve 85% of the maximum heart rate.

19 ExerciseECG Weaknesses: Suboptimal sensitivity. Low sensitivity in identifying single vessel disease. the test is not diagnostic in situations where there are baseline ECG changes (such as evidence of left ventricular strain secondary to left ventricular hypertrophy, left bundle branch block). Low specificity in certain population of patients(such as pre-menopausal women). To increase the accuracy of the test it is necessary to achieve 85% of the maximum heart rate.

20 Stress echocardiography Strengths: higher sensitivity and specificity than the exrecise ECG test. ithasahigherprognosticvaluecomparedtotheexerciseecg (infacteveninthepresenceofapositiveexerciseecgtest,a negative stress echocardiogram predicts a low risk for coronary events). Higher sensitivity during exercise or with dobutamine, compared to using other vasodilating agents. It enables assessment of other concomitant structural cardiac abnormalities, such as valvular heart disease. Lack of radiation. ChinD,BattistoniA,TocciG,PasseriniJ,ParatiG,VolpeM.AmJ Hypertens. 2012;25:

21 Weaknesses: lower sensitivity in identifying one vessel disease or moderate stenosis. theinabilitytovisualisetheentireleftventricleina single window in certain patient groups. the assessment of the images is operator-dependent. it is mainly a qualitative, rather than a quantitative assessment. an inadequate acoustic window in certain patient groups limits the sensitivity and specificity of the test(such as Chronic obstructive pulmonary disease patients) ChinD,BattistoniA,TocciG,PasseriniJ,ParatiG,VolpeM.AmJHypertens.2012;25:

22 Strengths: SPECT Quantitative method, which reduces operator bias and inter-observer variability. l New nuclear techniques such as the gated SPECT, enable a contemporary functional and perfusional assessment of the myocardium, hence increasing the specificity of the diagnosis of coronaropathy. Weaknesses: l l Poor spatial resolution( approx. 1cm). The need to use radioactive material limits the use of this diagnostic technique as a regular screening test in hypertensive patients. ChinD,BattistoniA,TocciG,PasseriniJ,ParatiG,VolpeM.AmJ Hypertens. 2012;25:

23 Coronaryangiography remainsthe GoldStandard???

24 CoronaryangiographyinHT - In patients without known CAD undergoing elective invasive angiography the diagnostic yield is relatively low -ThisisparticularlytrueforHTwithLVH. - CV risk profiling in HT is of clinical value NEJM 2010 PatelMRetal,

25 ThemajorityofpatientswithHypertension haveothercoronaryriskfactors Framingham Study Kannel, Am J Hypertens, 2000; 13: 3S-10S

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29 INTERHEART Study Risk of acute myocardial infarction associated with exposure to multiple risk factors Yusuf S, et al. Lancet 2004;364:937 52

30 CVriskcharts Estimation of ten-year risk of fatal cardiovascular disease in Europe: the SCORE project. Eur Heart J 24:987Z 1003.

31 Clinical Likelihood of Disease (pretest) (ESC 2013) Thisriskismodified if - ECG indicates abnormalities -LVEF<50%

32 3 Step Algorithm for Diagnosis CAD (ESC 2013 Guidelines) Determine the Clinical Likelihood of Disease STEP % Testing for CAD >85% <15% Nothing Can it apply for Hypertensive Patient? Does the patient have coronary artery stenoses? - Evidence of ischemia - Visualization of coronary stenoses STEP2 YES 1. Optimal Medical Therapy 2. Assessment of Risk(mortality) - Extent of ischemia - Coronary anatomy STEP3 HIGH or symptoms Severe Symptoms Invasive Angiography & Revascularization

33 CHD RISK Risk score LOW INTERMEDIATE HIGH LVH Identify the most appropriate imaging technique on the basis of different criteria, suchas : -Gender -Patient structure -Baseline ECG changes High threshold positive test NON LVH Exercise ECG Consider clustering of major CV risk factors and anginal typical symptoms. Positive Calcium score Carotid artery atherosclerosis by US low threshold positive test Stress echocardiography Coronary CT POSITIVE TEST Cardiac Radionuclide Imaging Cardiac MRI CORONARY ANGIOGRAPHY

34 Early and accurate CV risk stratification in hypertensive patients Early identification of patients at high risk of developing coronary heart disease Helps to target early therapeutic interventions to prevent coronary morbidity and mortality

35 Diagnostic flow chart of CAD in hypertensive patients FRS/SCORE Target organ damage LOW RISK INTERMEDIATE RISK HIGH RISK LVH Non LVH Stress echo CCT RNI Positive test CMR High threshold positive test EXERCISE EKG Low threshold positive test CORONARY ANGIOGRAPHY

36 3 Step Algorithm for SCAD (ESC Guidelines 2103) Determine the Clinical Likelihood of Disease STEP % Testing for CAD >85% <15% Nothing Does the patient have coronary artery stenoses? - Evidence of ischemia - Visualization of coronary stenoses STEP2 YES 1. Optimal Medical Therapy 2. Assessment of Risk (mortality) - Extent of ischemia - Coronary anatomy Severe Symptoms STEP3 HIGH or symptoms Invasive Angiography & Revascularization European Heart Journal doi: /eurheartj/eht296

37 All CAD Patients need Optimal Medical Management, NOT all Patients need Revascularization Angina relief 1st line Event prevention Short-acting nitrates plus β-blockers or CCB heart rate Consider CCB-DHP if low HR or intolerance/contraindications Consider β-blockers + CCB-DHP if CCS angina >2 Lifestyle management Control of risk factors Educate patient May add or switch (1st time for some cases) 2nd line Aspirin Stains Consider ACEi or ARBs Ivabradine Long-acting nitrates Nicorandil Ranolazine* Trimetazidine* Consider angio PCI-stenting or CABG European Heart Journal doi: /eurheartj/eht296 *Data for diabetics If intolerance consider clopidogrel ESC Guidelines 2013

38 Control well global CV Risk Factors is the key for the Treatment of CAD

39 Framingham Heart Study Risk of acute myocardial infarction associated with exposure to multiple risk factors % 5 year CVD risk pe er 100 persons <1% 3% 6% 12% 18% 24% 33% Reference group TC =7mmol/L & smoker & HDL =1mmol/L male & diabetes 60 yrs Reference group: female aged 50 years, TC=4 mmol/l, HDL=1.6 mmol/l, non smoker, no diabetes, at SBP levels of 110, 120, 130, 140, 150, 160, 170 & 180 mmhg Derived from Anderson et al. Am Heart J 1991;

40 Use of the IMPACT mortality model to explain the fall in CHD deaths in England & Wales Bridging science and health policy in cardiovascular disease: focus on lipid management A Report from a Session held during the 7th International Symposium on Multiple Risk Factors in CV Diseases: Prevention and Intervention Health Policy, in Venice, Italy, on 25 October, 2008 Derived from Atherosclerosis Supplements 10 (2009) 3 21

41 Benefit of global CVRF control 10% Reduction in BP 10% Reduction in Total-C + = 45% Reduction in CVD Emberson et al. Eur Heart J. 2004;25:

42 Benefit of global CVRF control 0 Treatment Based on lipids (statin) Treatment Based on BP Treatment Based on Overall Absolute Risk (ASA, lipids, BP) Predicted Reduction in Major CVD (%) Treatment thresholds Top 10% Top 20% Top 30% Adapted from Emberson et al. Eur Heart J. 2004;25:

43 MCQ (slide 44) Stratification of risk factors (A) No (B) Yes Choose the right answer Risk factors as has been proved BP Cholesterol Age Smoking DM Gender (A) Ranking No (B) Ranking Yes Choose the right answer Pretest as established by ESC 2013 Chest pain (Present-Atypical-Absent) Age Gender (A) Meaning Yes (B) Meaning No

44 Treatment of HTN in Patients with CAD

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47 Pharmacological Treatment of Hypertension in the Management of Ischemic Heart Disease Hypertension. 2015;65: DOI: /HYP

48 Revascularization Strategy for Stable Ischemic Heart Disease Patients with Multivessel Disease and Hypertension CABG vs PCI? + Optimal Medical Treatment

49 Not all SCAD patients benefit from revascularization

50 Not all SCAD patients benefit from revascularization

51 Indications for Revascularization in patients with stable angina or silent ischaemia European Heart Journal doi: /eurheartj/ehu278

52 Recommendation for the type of revascularization (CABG or PCI) inpatients with SCAD with suitable coronary anatomy for both procedures and low predicted surgical mortality European Heart Journal doi: /eurheartj/ehu278

53 MCQ (slide 53) Risk stratification for appropriate approach in diagnosis and treatment (A) Should be done (B) Optional because of patient and local infrastructure Choose the appropriate answer Choose the appropriate answer Treatment of HTN and accompanying diseases (A) Treat HTN first (B) Treat HTN and accompanying diseases (C) The approach to diagnosis and treatment should be adapted to individual basis

54 What did we do with our patient Stress ECG: not preferred (LV hypertrophy) Echo stress: > 15% Myocardium ischemic Risk stratification: high risk Optimal Medical Rx: DAPT (aspirin + clopidogrel) Statin ACEi Betablocker Insulin + Metformine Coronary Angiography and Intervention

55 Cor. angiogram

56 Post PCI (total revascularization)

57 Many Thanks