Practical Office Management of Stable Angina

Transcription

1 Practical Office Management of Stable Angina All you need to know about it in 30 minutes Andy Ignaszewski MD FRCPC Head, Division of Cardiology PHC Physician Director, PHC Heart Centre Clinical Professor, UBC Vancouver BC

2 Copyright 2017 by Sea Courses Inc. All rights reserved. No part of this document may be reproduced, copied, stored, or transmitted in any form or by any means graphic, electronic, or mechanical, including photocopying, recording, or information storage and retrieval systems without prior written permission of Sea Courses Inc. except where permitted by law. Sea Courses is not responsible for any speaker or participant s statements, materials, acts or omissions.

3 Why Men Die Before Women

4 Why Men Die Before Women

5 Why Men Die Before Women

6 Why Men Die Before Women

7 Stable Angina Diagnosis Testing Prognostication Medications that reduce CV events Medications that improve angina Role of PCI/CABG

8 Diagnosis of CAD Typical angina (definite) 1) Characteristic substernal chest discomfort 2) Precipitated by exertion or emotional stress 3) Relieved by rest or NTG Atypical angina (probable) Meets 2 of the above Non-cardiac chest pain Meets 1 of the above

9 Diagnosis of CAD in the Elderly Circ1999;99 Non-anginal Atypical angina Typical angina chest pain Age M F M F M F

10 Further investigations Bloodwork? Echo ETT MIBI/Stress echo CT angio Cath Hb, FBS, Lipids,Cr Able to exercise, Normal ST Class II Unable to exercise/abn ST

11 ETT- Diagnosis Sensitivity 68%/ Specificity 80% Probability of CAD 90% 50% Pre-test probability Bayesian Analysis 20% 5% 1% affects 99% 80% Post-test probability

12 ETT- Prognosis Bad Good Exercise duration < 3min > 8min BP Response Drop 50mmHg ST Depression 2mm 1mm

13 MIBI/Stress echo Useful for diagnosis and prognosis Sensitivity ~ 85% Specificity ~ 85% Exercise Vs Persantine Order when Baseline ECG abn or inability to exercise Order when ETT results are at odds

14 MIBI Prognosis Bad Good Large defect (>10%) Multiple defects Poor LVEF Normal Small Good LVEF Mortality EF 20% 40% 60%

15 CAD Prognosis EF Ischemia VT Angina severity does not correlate with extent of disease!

16 Do I Need to Refer? Yes Rest/Post MI Hi Risk ETT -2mmST -Drop in BP -Defect>10%/Multiple Poorly controlled Sx No Exertional Low Risk ETT -1mm ST -Normal BP rise -Defect<10% Well controlled Sx

17 Case 60 Yr old woman Mrs. Anne Gina Chest pain on walking 3 blocks Positive ETT SCA shows 1 of 3 arteries narrowed 90% Will she live longer with PCI?

18 Clinical Outcomes Utilizing Revascularization and AGgressive drug Evaluation CCSII/III 58% 2/3 multi-vessel 90% inducible ischemia -23% single defect -67% multiple PCI + Opt 2287 pts Stable angina >70% Stenosis Evidence of ischemia Mean F/U 4.6 yrs yrs Exclusions Severe ischemia Stage 1 Refractory CHF/Shock EF < 30% Not suitable for PCI Revasc within 6 months Opt Death/MI 19% 18.5% 1.05 Death/MI/CVA 20% 19.5% 1.05 ACS Hospital 12.4% 12.8% 0.96 MI 13.2% 12.3% 1.07 Death 7.6% 8.3% 0.87 Simva/ Eze 70% LDL<2.2 65% SBP <130 94% DBP <85 45% A1c < 7 Further PCI 21.1% 32.6% 0.66* p<0.001

19 COURAGE: Freedom from angina Time point (y) PCI (%) Medical therapy(%) p Baseline NS < NS Boden WE et al. N Engl J Med 2007; available at:

20 COURAGE Results As an initial management strategy in pts with CAD, PCI did not reduce the risk of death/mi or other major CV events when added to optimum medical therapy One million stent procedures in US annually ~85% in stable pts Up to 2/3 of these could be avoided

21 CAD 1) Which artery causes chest pain? 1 80% 2 20% 2) Which artery causes the heart attack? Stenting treats 3 cm of 5 km of vascular endothelium

22 Survival Benefit of Revascularization in Severe CAD LM>50% 3VD>70% 2VD>70%, prox LAD

23 Future Revasc. Eval. Diabetics Optimal Management 32,966 screened 3309 eligible 1900 enrolled 1900 DM >70% in 2 or more major coronary A. LMCA excluded Mean Age 63.1 Yrs (83% 3VD) NEJM Dec 20/2012 Intense Medical Rx 5 Yr. Outcomes DES DAPT>12 months CABG 94.4% IMA graft Mean F/U 3.8 Yrs 1 0 Death/MI/CVA 26.6% 18.7%(RRR 30%) p=0.005 Death 16.3% 10.9% p=0.049 MI 13.9% 6.0% p<0.001 Stroke 2.4% 5.2% p=0.03

24 In patients with diabetes with multivessel disease, CABG is associated with a 30% decrease in death/mi/cva compared with PCI Absolute reduction 7.9% Based on new evidence, most pts with multivessel disease should be treated with CABG rather than PCI Level of evidence: Strong

25 What about severe CAD? SYNTAX 5 yr results 1800 pts. complex CAD Europe/US 1095 Pts. 3 VD 549 pts. CABG IMA grafts 546 pts. DES 1 st Taxus MACE 24.2% 37.5% p<0.001 Mortality 9.2% 14.6% p=0.006 CV Death 4.0% 9.2% p<0.001 MI 3.3% 10.6% p<0.001 CVA 3.4% 3.0% p 0.66 Revasc. 12.6% 25.4% p<0.001 In pts with 3 VD, CABG superior to stenting with 35% reduction in death, 66% reduction in MI, and 50% reduction in need for repeat revasularization DES=CABG in lowest 20% of SYNTAX scores.

26 What works: 16 Stop Smoking INTERHEART: Smoking and myocardial infarction OR (99% CI) Never # of cigarettes Lancet 2004; 364: Risk of MI is similar to those who have never smoked within Yusuf S et al. Lancet ; yrs 364:

27 Medications for Prognosis Class 1 ASA 75mg Statin ACEI (BP/LV/CHF/DM) Bblocker (MI/CHF) Class 2a ACEI in all CAD Plavix if ASA allergy Class I: All pts with CAD should receive flu vaccine Call EMS if chest pain does not improve/worsens 5 minutes after Two NTG sprays

28 Symptom Relief Class I Short acting nitrates B-blocker > CCB > NTG > Nicorandil If Sx persists despite B-blocker, add DHP CCB Class IIa If B blocker intolerant, try sinus node inhibitor If CCB mono/combination not effective, substitute Nitrates or nicorandil IIb Metabolic agents

29 Proven CV medicines Post MI Independent and additive None ASA β-blockers Lipid lowering ACEI RRR 25% 25% 30% 25% Event rate 8% 6% 4.5% 3.0% 2.3% Cumulative benefits 50-75% + smoking cessation Adapted by Salim Yussuf, Lancet 2002

30 Vitamin E* Vitamin C Folate/B12/B6 Beta Carotene* Rx not useful/effective and in some cases harmful* Coenzyme Q10 HRT* Calcium NSAIDS* Avandia* In Pts with prior MI There will be 6 extra deaths/100 pts yrs treated with COX 2 inhibitor

31 Do Vitamins reduce CVD? $24 billion in heath supplement sales in /3 of US populationn takes daily multivitamin Physicians Health Study Launched ,641 male physicians>50 yrs 5% had Hx of MI/CVA Median F/U 11.2 yrs: 1732 CV events Multivitamin Placebo JAMA 2012 Major CV events 11/1000 Pt-yrs 10.8/1000 Pt-yrs NS Long term treatment with multivitamins did not reduce MI/ CVA/ CHF/Angina/ Coronary revascularization or CV mortality/ All cause mortality

32 Meta-analysis Omega-3 and CV Events JAMA 2012 Omega g/day EPA 0.77 g/day DHA 0.06 g/day Randomized clinical trials of Omega 3 > 1Yr 20 studies (13 secondary) 68,680 pts Two trials dietary counseling Seventeen trials supplements Mean duration 2 years (longest 6.2 yrs) No. events RR p Deaths NS CV Death NS Sudden death NS MI NS Stroke NS

33 Initial studies(1989) demonstrate benefit of omega 3 in reducing CV events Later studies show diminishing benefit and non-significance Current analysis shows no benefit of omega 3 in reducing mortality/cv mortality/mi/stroke Studies consistent over past 5 yrs.

34 Stable Angina Diagnosis Testing Prognostication Medications that improve angina Medications that improve survival PCI CABG Less More History Labs/ECG ETT>MIBI/Stress echo>cta Regular testing Class III BB>CCB>NTG ER if 2 sprays NTG ASA/Statin> ACEI/BB

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