Καηεσθσνηήριες οδηγίες για ηην εκηίμηζη και ηη διάγνωζη ηης ζηαθερής ζηηθάγτης Francisco de Goya, 1820 Δημήηριος Ρίτηερ, MD, FESC, FAHA Διεσθσνηής Καρδιολογικής Κλινικής Εσρωκλινικής Αθηνών
Angina: A diagnosis based on history Characteristics of pain Location Duration Triggers/relieving factors Heberden W. Some account of a disorder of the breast. Medical Transactions 2, 59-67 (1772): Royal College of Physicians Typical Definite Probable Atypical Possible Non cardiac CP Pre test probability of CAD Angina ESCGuidelines Stable Angina EHJ 2006; AHA/ACC GL Gibbons et al. Circulation 1999 2
3 Typical Progression of Coronary Atherosclerosis
4 Stable angina pectoris Prevalence in Europe Prevalence in community studies (Rose questionnaire) Age (ys) Males Females 45-54 2-5% 0.1-1% 65-74 10-20% 10-15% 20.000-40.000 individuals per million population (2-4%) ESC Guidelines Eur Heart J 2006
Stable Angina remains an important health burden in Europe A frequent and disabling condition: 20.000 40.000 cases per million inhabitants. Initial presentation in #50% of patients with angiographically proven CAD. Increasing prevalence with ageing Costly:2.6% of the overall health care expenditures in the EU (44 725 million ) Management of stable angina pectoris. Recommendations of the Task Force of the European Society of Cardiology. Eur Heart J. 2006; 27(11):1341-1381 1997. J Leal et al. Economic burden of cardiovascular diseases in the enlarged European Union. Eur Heart J. 2006; 27,1610-1619. Lenzen MJ, Eur Heart J 2005, 26,1165
6 Symptoms of Angina Classic (Typical) Atypical, Noncardiac Sensations in chest of squeezing, heaviness, pressure, weight, vise-like aching, burning, tightness Radiation to shoulder, neck, jaw, inner arm, epigastrium (can occur without chest component); band-like discomfort Relatively predictable Lasts 3-15 min Abates when stressor is gone or nitroglycerin is taken Pain that is pleuritic, sharp, pricking, knife-like, pulsating, lancinating, choking Involves chest wall; is positional, tender to palpation; can be inframammary; radiation patterns highly variable Random onset Lasts seconds, minutes, hours, or all day Variable response to nitroglycerin
7 Classification of Angina Canadian cardiovascular society (CCS) class Definition Comments I II III IV Ordinary physical activity does not cause angina Slight limitation of ordinary activity Marked limitation of ordinary physical activity Inability to carry on any activity without discomfort Angina only with extraordinary exertion at work or recreation Angina with walking more than 2 blocks on a level surface or climbing more than 1 flight of stairs at a normal pace Walking 1 to 2 blocks on a level surface or climbing 1 flight of stairs at a normal pace Angina at rest or with minimal activity or stress
Rose Angina Questionaire Responses required to define a case in brackets 1. Have you ever had any pain or discomfort in your chest? (yes) 2. Do you get it when you walk uphill or hurry? 3. Do you get it when you walk at an ordinary pace on the level? If the answer to question Q 2 or Q 3 is yes, then proceed to Q4 4. What do you do if you get it while walking? (stop or slow down) 5. If you stand still what happens? (relieved) 6. How soon? (10 minutes or less) 7. Location? (central chest or left arm) Rose G. Chest pain questionnaire. Milbank Mem Fund Q. 1965; 43: 32 39. 8
Stable Angina: Stable Ischemic Heart Disease Advanced atherosclerosis Reduced ability of the coronary vessels to meet requirements of myocardium Symptoms range from asymptomatic ischemic episodes to severely debilitating pain or breathlessness Ischaemic aetiology : large vessel disease to diffuse microvascular disease +/- prior MI (50% de novo) Increased risk of future MI ESCGuidelines Stable Angina EHJ 2006; AHA/ACC GL Gibbons et al. Circulation 1999 9
10 Παθοθσζιολογία Αςυμφωνία ςτην προςφορά και τη ζθτηςη οξυγόνου κατά τη διάρκεια τησ ιςχαιμίασ Chaitman BR. Circulation 2006;113:2462-2472. Belardinelli L, et al. Eur Heart J 2004;6(suppl I):I3-I7. Opie LH, et al. In: Opie LH, Gersh BJ, eds. Drugs for the Heart. 6th ed. Philadelphia, Pa: Elsevier Saunders; 2005:5,33,56,58,280 10
11 Common Stress- testing Procedures for the Evaluation of Chest Pain Test Estimated Sensitivity (%) Estimated Specificity (%) Standard treadmill or bicycle exercise Exercise stress echocardiography Doputamine stress echocardiography Exercise myocardial perfusion SPECT, with quantitative analysis Pharmacologic myocardial perfusion SPECT, with quantitative analysis Electron-beam computed tomography 65-70 70-75 80-85 80-85 80-85 85-90 85-90 85-90 80-90 80-90 - -
Pre-test Probability Prevalence of coronary stenosis at autopsy Age Men Women % % 30-39 1.9 0.3 40-49 5.5 1 50-59 9.7 3.2 60-69 12.3 7.5 Diamond, G. A. and Forrester, J. S., 1979; Chaitman et al 1981. 12
SILENT ISCHEMIA Ischemic changes on ECGs in the absence of clinically-recognized symptoms Most common in diabetics due to neuropathy As significant as chronic stable angina in terms of the subsequent risk of ACS events, as well as mortality and morbidity.
Angina with normal coronary anatomy Mostly women Chest pain has features of angina Often positive stress test Further evaluation shows no evidence of significant obstructive coronary disease Microvascular disease often present No significant extra mortality Substantial excess morbidity
Impaired microvascular perfusion in the anginal syndrome 0,2 P = 0.02 P = 0.002 Diminished microvascular perfusion P = NS P < 0.001 Myocardial perfusion index* 0,1 0 Endocardium Epicardium Endocardium Epicardium Rest Control (n = 10) Adenosine infusion Chest pain with normal coronary angiogram (n = 20) *Assessed via magnetic resonance imaging Panting JR et al. N Engl J Med. 2002;346:1948-53.
Less obstructive CAD: Women vs men Patients undergoing elective diagnostic angiography for angina 100 Patients with >50% stenosis (%) 80 60 40 20 0 <40 40-49 50-59 60-69 70-79 >79 Age (years) Women Men ACC-National Cardiovascular Data Registry. J Am Coll Cardiol. 2006.
17 Stable CAD: Multiple treatment options Lifestyle intervention PCI Reduce symptoms Treat underlying disease Medical therapy CABG
Extent of ischaemia predicts prognosis and response to revascularisation Hachamovitch, R. et al. Circulation 2003;107:2900-2907 18
19 Stable CAD: PCI vs Conservative Medical Management Meta-analysis of 11 randomized trials; N = 2950 Favors PCI Favors Medical Management Death Cardiac death or MI Nonfatal MI CABG PCI P 0.68 0.28 0.12 0.82 0 1 2 Risk ratio (95% Cl) 0.34 Katritsis DG et al. Circulation. 2005;111:2906-12.
21 COURAGE Primary EP: Survival Free of Death or MI Randomization to PCI + OMT vs. OMT 1.0 0.9 Optimal Medical Therapy (OMT) Intensive, Guideline- Driven Medical Therapy & Lifestyle Intervention In 0.8 0.7 0.6 0.5 PCI + OMT Hazard ratio: 1.05 95% CI (0.87-1.27) P = 0.62 Both Groups 0.0 0 1 2 3 4 5 6 Years 7 Source: Boden et al. N Engl J Med. 2007; 356:1503-16.
222 ηραηηγικές θεραπείας COURAGE: Επαναγγείωζη (PCI) ένανηι βέληιζηης θαρμακεσηικής αγωγής (OMT) Weintraub WS, et al. N Eng J Med 2008;359:677-87
NICE CG 95 Recent Onset Chest Pain March 2010 (CG 123 Stable Angina 2011) NICE CG 94 Acute Coronary Syndromes March 2010
Stable Angina Which Drug to Choose? β-blocker or calcium antagonist Depending on comorbidity, contraindications and patient preference Change to alternative If treatment unsuccessful or not tolerated Combine β-blocker or calcium antagonist If treatment unsuccessful Monotherapy with: A long-acting nitrate or Ivabradine or Nicorandil or Ranolazine If treatment unsuccessful Choice depends on comorbidities, contraindications, patient preference and drug costs Combination of β-blocker or calcium antagonist with: A long-acting nitrate or Ivabradine or Nicorandil or Ranolazine When β-blocker or calcium antagonist not tolerated or combination unsuccessful Choice reasons as above NICE Guidance GL 126 July 2011 Add third anti-anginal Symptoms not controlled and awaiting revasc, or revasc not considered appropriate or acceptable
From: Diagnosis of Stable Ischemic Heart Disease: Ann Intern Med. 2012;157(10):729-734. doi:10.7326/0003-4819-157-10-201211200-00010 Diagnosis of patients suspected of having ischemic heart disease. CCTA = computed coronary tomography angiography; CMR = cardiac magnetic resonance; ECG = electrocardiogram; echo = echocardiography; IHD = ischemic heart disease; MPI = myocardial perfusion imaging; UA = unstable angina; UA/NSTEMI = unstable angina/non ST-segment elevation myocardial infarction. * See Table 2 of reference 2 for short-term risk of death or nonfatal myocardial infarction in patients with UA/NSTEMI. CCTA is reasonable only for patients with intermediate probability of IHD.
Risk assessment of patients with stable ischemic heart disease. CCTA = coronary computed tomography angiography; CMR = cardiac magnetic resonance; ECG = electrocardiogram; echo = electrocardiography; LBBB = left bundle branch block; MPI = myocardial perfusion imaging. Ann Intern Med. 2012;157(10):729-734. doi:10.7326/0003-4819-157-10-201211200-00010 From: Diagnosis of Stable Ischemic Heart Disease: Summary
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