Stable Ischemic Heart Disease. Ivan Anderson, MD RIHVH Cardiology

Transcription

1 Stable Ischemic Heart Disease Ivan Anderson, MD RIHVH Cardiology

2 Outline Review of the vascular biology of atherosclerosis Why not just cath everyone with angina? Medical management of ischemic cardiomyopathy Who is appropriate for an interventional strategy (angiography +/- percutaneous coronary intervention)

3 Outline Review of the vascular biology of atherosclerosis Why not just cath everyone with angina? Medical management of ischemic cardiomyopathy Who is appropriate for an interventional strategy (angiography +/- percutaneous coronary intervention)

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5 Atheroma Formation

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7 Epigenetic Approach to Epidemiology. AP Feinberg. N Engl J Med 2018;378:

8 Fatty Deposits are in Orange and Red Thoracic Aorta Increasing Age from teens to mid 30s Abdominal Aorta Right Coronary Artery JAMA 281:727, 1999

9 Obstructive Lesions Have Evidence of Multiple Plaque Rupture Events Histologically Stenosed Coronary Artery Plaque Rupture Events Circulation. 2001;103:

10 Coronary Flow with Normal Epicardial Coronary Arteries and in Disease Large ability to change coronary flow as pressure elevates Limited ability to change coronary flow with highgrade stenosis Braunwald s Heart Disease

11 Am J Cardiol 1974; 33(1):87-94 Dog Experiment

12 Pressure Drop as a Function of % Stenosis Hyperemic Response Mean Flow Precipitous Drop in Coronary perfusion pressure with stenosis > 70% 70 Am J Cardiol 1974; 33(1):87-94

13 J Am Coll Cardiol. 2009;54:

14 Outline Review of the vascular biology of atherosclerosis Why not just cath everyone with angina? Medical management of ischemic cardiomyopathy Who is appropriate for an interventional strategy (angiography +/- percutaneous coronary intervention)

15 Outline Review of the vascular biology of atherosclerosis Why not just cath everyone with angina? Medical management of ischemic cardiomyopathy Who is appropriate for an interventional strategy (angiography +/- percutaneous coronary intervention)

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17 JAMA 2011: 12% of PCI Inappropriate JAMA. 2011;306(1)53-61

18 Potential Harm with Revascularization CABG or PCI should not be performed with the sole intent to improve survival in patients with stable ischemic heart disease with: Insignificant coronary stenosis (<70% or FFR > 0.80) Only mild ischemia on non-invasive testing or subtend only a small area of viable myocardium Involve only the RCA or Circumflex Circulation. 2012;126:e354-e471

19 Nuclear Substudy of the COURAGE Trial Improved Survival with >5% Ischemia Reduction Stent Group Medical Rx Circulation. 2008;117:

20 Long-Term Survival with CABG, PCI, and Medical Therapy J Thorac Cardiovasc Surg 1996;111:

21 Long-Term Survival with CABG, PCI, and Medical Therapy J Thorac Cardiovasc Surg 1996;111:

22 Long-Term Survival with CABG, PCI, and Medical Therapy Least Blockages 5% Most Blockages 20% 25+% J Thorac Cardiovasc Surg 1996;111:

23 Endothelial Dysfunction After Stenting J Thorac Cardiovasc Surg 1996;111:

24 Risk of Mortality with Dual Antiplatet Therapy ~5% in mortality w DAPT Lancet October 17; 386(10003):

25 Outline Review of the vascular biology of atherosclerosis Why not just cath everyone with angina? Medical management of ischemic cardiomyopathy Who is appropriate for an interventional strategy (angiography +/- percutaneous coronary intervention)

26 Outline Review of the vascular biology of atherosclerosis Why not just cath everyone with angina? Medical management of ischemic cardiomyopathy Who is appropriate for an interventional strategy (angiography +/- percutaneous coronary intervention)

27 Determinants of Myocardial Oxygen Demand Braunwald s Heart Disease

28 Medical Therapy Anti-anginals Beta blocker: 3 years after ACS, every with EF 40%, possibly lifelong (potent anti-anginal) Calcium channel blockers (DHB and non-dhb): for symptom relief Long-acting nitrates: for symptom relief Sublingual nitroglycerin for immediate relief Ranolazine with or without beta blockers External counterpulsation (EECP) (DHB = dihydropyridine) Circulation. 2012;126:e354-e471

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30 Medical Therapy Other Aspirin: lifelong, mg PO daily Plavix (clopidogrel) 75 mg PO daily if ASA allergic ACE-I: esp if DM EF 40% Hypertension CKD Circulation. 2012;126:e354-e471

31 Treat Co-morbidities Smoking cessation Diet Exercise

32 Class III (Can Cause Harm) Estrogen in postmenopausal women Vitamin C, E, beta-carotene Treatment of elevated homocysteine with folate, B6 or B12 Chelation therapy Garlic, CoQ10, selenium, chromium Circulation. 2012;126:e354-e471

33 Outline Review of the vascular biology of atherosclerosis Why not just cath everyone with angina? Medical management of ischemic cardiomyopathy Who is appropriate for an interventional strategy (angiography +/- percutaneous coronary intervention)

34 Outline Review of the vascular biology of atherosclerosis Why not just cath everyone with angina? Medical management of ischemic cardiomyopathy Who is appropriate for an interventional strategy (angiography +/- percutaneous coronary intervention)

35 Cath em 1 significant coronary stenosis and angina despite maximal medical therapy or contraindication to medical therapy High-risk test characteristics > 5% area of ischemia on nuclear stress test Large, reversible anterior defect Depressed left ventricular ejection fraction High risk based on score calculators (e.g. EuroScore)

36 Euro Heart Score BMJ. 2006;332:262 7.

37 BMJ. 2006;332: Euro Heart Score

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39 Questions

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44 Mechanisms of Improved Vascular Endothelial Function with EECP Increased coronary perfusion pressure Decreased peripheral resistance Recruitment of collaterals Attenuation of oxidative stress and proinflammatory cytokines Promotion of angiogenesis and vasculogenesis Peripheral training effect

45 Endothelial dysfunction and The Endothelial Organ Atherosclerosis One of the largest organs in the body (weighs 1.8 kg in a 70 kg person, maybe 2 nd to the skin) A 70 kg person has ~ 1 trillion endothelial cells The endothelial surface is the size of ~ 6 tennis courts