Stable Angina: Indication for revascularization and best medical therapy

Transcription

1 Stable Angina: Indication for revascularization and best medical therapy Cardiology Basics and Updated Guideline 2018 Chang-Hwan Yoon, MD/PhD Cardiovascular Center, Department of Internal Medicine Bundang Hospital

2 Case 1. 운동시흉통으로내원한 30 세남자 1년전부터시작된운동시흉통 - 고혈압으로 5년전부터약물복용중 - 당뇨, 흡연력은없음. - 등산시좌흉부에쥐어짜는듯한통증 - 호흡곤란이약간동반됨. 최근까지악화는없음. 흉통의원인으로고려해야할질환들은?

3 흉통환자의감별진단

4 Clinical classification of chest pain

5 Main features of SCAD

6 Clinical pre-test probabilities in patients with stable chest pain symptoms

7 Initial diagnostic management of patients with suspected SCAD

8 환자의 12- 유도심전도, 흉부 X- 선

9 환자의심초음파도

10 Case 1. 운동시흉통으로내원한 30 세남자 1년전부터시작된운동시흉통 - 고혈압으로 5년전부터약물복용중 - 당뇨, 흡연력은없음. - 등산시좌흉부에쥐어짜는듯한통증 - 호흡곤란이약간동반됨. 최근까지악화는없음. Hypertrophic cardiomyopathy 상기환자에게사용할수있는치료법은?

11 비후성심근증의치료 Medical treatment - Beta-blocker - Verapamil Surgical or interventional treatment - Standard CHF Tx. in the case of acute decompensation

12 Medical management of patients with SCAD

13 Major side-effects, contra-indications, drug drug interactions (DDI) and precautions of anti-ischaemic drugs

14 Major side-effects, contra-indications, drug drug interactions (DDI) and precautions of anti-ischaemic drugs

15 Case 2 M/63 Hypertension CCS II typical chest pain since 1 year ago

16 Initial diagnostic management of patients with suspected SCAD

17 Non-invasive testing in patients with suspectedscadand an intermediate pre-test probability

18 Case 2 M/63 Hypertension CCS II typical chest pain since 1 year ago gated myocardial SPECT LAD territory perfusion defect (>10%)

19 Definitions of risk for various test modalities

20 High risk (3% annual death or MI) 1. Severe resting LV dysfunction (LVEF 35%) not readily explained by noncoronary causes 2. Resting perfusion abnormalities 10% of the myocardium in patients without prior history or evidence of MI 3. Stress ECG findings including 2 mm of ST-segment depression at low workload or persisting into recovery, exercise-induced ST-segment elevation, or exerciseinduced VT/VF 4. Severe stress-induced LV dysfunction (peak exercise LVEF 45% or drop in LVEF with stress 10%) 5. Stress-induced perfusion abnormalities encumbering 10% myocardium or stress segmental scores indicating multiple vascular territories with abnormalities 6. Stress-induced LV dilation 7. Inducible wall motion abnormality (involving 2 segments or 2 coronary beds) 8. Wall motion abnormality developing at low dose of dobutamine (10 mg/kg/min) or at a low heart rate (120 beats/min) 9. CAC score 400 Agatston units 10. Multivessel obstructive CAD (70% stenosis) or left main stenosis (50% stenosis) on CCTA

21 Management based on risk determination for prognosis in patients with chest pain and suspected SCAD

22 CAG

23 CAG

24 Global strategy of intervention in stable coronary artery disease (SCAD) patients with demonstrated ischaemia

25 Indications for revascularization of stable coronary artery disease patients on optimal medical therapy

26 PCI to LAD Endeavor Resolute 3.0x18 mm

27 Case 3 M/71 DM 4 months ago, chest pain Treadmill test positive (high risk)

28 CAG

29 CAG

30 PCI or CABG in stable coronary artery disease without left main coronary artery involvement

31 Case 4 F/85 Hypertension, dyslipidemia History of stroke and atrial fibrillation Apical hypertrophic cardiomyopathy with normal LV systolic function CCS II, chest pain

32 CAG : CABG? in very old lady, a. fib, stroke, HCMP

33 Case 5 57 year old male No other risk factor other than current smoking Admitted for exertional chest pain, 4~5MA, Fc II, aggravated recently

34 p-rca CTO with good retrograde flow (Rentrop score III)

35 Retrograde wiring Multiple POBA After initial POBA Xience Xience Xience Final angiogram

36 Case 6 Female / 75YO chest pain & dyspnea on exertion (CCS II) Hx of previous PCI and multiple stenting

37

38 PCI or CABG in stable coronary artery disease with left main coronary artery involvement

39 Case 4 F/89 DM on insulin, hypertension 12 years ago, PCI to LAD at another hospital and LV dysfunction : EF 35% Angina, CCS II

40 CAG

41 Indications for revascularization of stable coronary artery disease patients on optimal medical therapy

42 PCI or CABG for ischemic symptoms and heart failure? (Angina included!!) HR 0.50 Revasc. Med Rx CABG PCI Med Rx 4200 patients with HF referred for angiography in Alberta Adjusted for baseline risk and propensity for revascularization 2538 underwent revascularization; 1690 managed medically Majority of patients had ischemic syndromes Medical management was suboptimal Revascularization with CABG or PCI associated with improved survival Signal for differential outcome, favoring CABG Tsuyuki et al, CMAJ 2006

43 AWESOME trial Patients were enrolled only if they had 1 of 5 risk factors for adverse outcomes with CABG (prior CABG; myocardial infarction within 7 days; left ventricular ejection fraction [LVEF] < 35%; age >70 years; or intraaortic balloon required to stabilize). Eligible patients who were deemed by their physicians and by study investigators to be suitable for CABG and PCI were asked to participate in the randomized trial. p=0.46 p=0.16 p=0.001 Morrison, 2001, JACC

44 Decision Regarding Coronary Revascularization in Heart Failure

45 Stenting to RCA

46 PCI to LCX 2.75X24mm Driver stent implantation

47 Stenting and peri-procedural antiplatelet strategies in stable coronary artery disease patients

48 Take home messages Clinical pre-test probabilities Non-invasive tests and risk stratification OMT vs. Revascularization Revascularization for survival or symptom PCI vs CABG depending on clinical parameters anatomy technical issue local isssue

49 Thank you for your attention