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Description : presentation, approach, diagnosis, management

Tags : cardiology

Published on : Nov 26, 2020 | Views : 3169 | Downloads : 29

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STABLE ISCHEMIC HEART DISEASE Maria Loricon R. Oliva, MD First year Adult Cardiology fellow
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STABLE ISCHEMIC HEART DISEASE (SIHD) Introduction, pathogenesis, risk factors Approach to diagnosis Invasive and noninvasive testing Lifestyle modification, medical therapy, revascularization
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References
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STABLE ISCHEMIC HEART DISEASE (SIHD) Spectrum of chronic stable angina, asymptomatic ischemia, prior myocardial infarction, prior coronary revascularization, nonobstructive coronary artery diseases 2019 ESC guidelines for CCS CAD categories: Acute Coronary Syndrome or Chronic Coronary Syndrome (CCS) Clinical scenarios: Stable anginal symptoms New onset HF or LV dysfunction Post ACS Post revascularization Suspected vasospastic disease Detected CAD after screening 2019 ESC Guidelines for the Diagnosis and Management of Chronic Coronary Syndromes. 2020. European Heart Journal
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Pathogenesis Cause: atheromatous plaque that obstructs or narrows the epicardial coronary arteries Accumulation of lipoprotein particles in the intima  leucocyte recruitment and adhesion  imbibed in the intimal layer  FOAM CELL  smooth muscle cell migration, proliferation, apoptosis  fibrofatty lesion Source: Zipes, et al. (2019). Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine, 11th ed. Elsevier
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Approach Step 1: Basic assessment Step 2: Identify comorbidities Step 3: Basic testing Step 4: Assessment of pretest probability and clinical likelihood of CAD Step 5: Establishing a diagnosis using noninvasive functional imaging or invasive procedures for myocardial ischemia before treatment is reasonable Step 6: Once the diagnosis is established, patient’s event risk will be determined for future therapeutic decisions Step 7: Therapeutics, lifestyle changes, need for revascularization https://www.pharmaceutical-journal.com
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Basic testing Resting ECG and ambulatory monitoring Biochemical Testing : (Class 1 recommendation) CBC estimated GFR Thyroid function test Lipid profile Biomarkers for cardiac injury – hs troponin T or I 2019 ESC Guidelines for the Diagnosis and Management of Chronic Coronary Syndromes. 2020. European Heart Journal
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Echocardiography Cardia Cardiac Magnetic Resonance (CMR) cardiac anatomy and systolic function late gadolinium enhancement CMR – typical pattern of scarred myocardium of post MI patients Chest xray does not provide information for diagnosis 2019 ESC Guidelines for the Diagnosis and Management of Chronic Coronary Syndromes. 2020. European Heart Journal
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Assessment of pretest probability and clinical likelihood of CAD must be based on patient’s age, sex, and nature of symptoms, and those presenting with dyspnea or none ESC guidelines use the Diamond and Forrester data >15% PTP – groups of patient with high likelihood of having CAD; whose non invasive test results would likely be indicative of CAD < 5% PTP - low probability of CAD 5-15% PTP – needs assessment of clinical modifiers before considering diagnosis of CAD 2019 ESC Guidelines for the Diagnosis and Management of Chronic Coronary Syndromes. 2020. European Heart Journal
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Exercise Stress Test beneficial for: symptomatic, moderate probability of CAD and resting ECG is normal functional limitation, severity of ischemia, prognosis in patients with intermediate PTP asymptomatic patients: not recommended appropriate in certain groups: plan to begin vigorous exercise, those with high risk professions, those with extensive atherosclerosis in non invasive imaging Stress Myocardial Perfusion Imaging able to identify and localize multivessel CAD, has prognostic value (for future cardiac events) incremental to clinical data and stress ECG can be offered to patients with repolarization abnormalities disadvantages: expensive, radiation exposure Non-invasive tests Source: Zipes, et al. (2019). Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine, 11th ed. Elsevier
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Stress echocardiography detects regional wall motion abnormalities induced by ischemia, able to localize and quantify ischemic myocardium, response of EF to stress Cardiac Magnetic Resonance Imaging assess myocardial viability—predicts functional recovery after revascularization can accurately characterize LV function, delineate pattern of ischemic myocardium Cardiac Computed Tomography Can assess total coronary atherosclerotic burden, angiography of the coronary arterial tree (CCTA), fractional flow reserve (FFR) and quantification of ventricular function Coronary artery calcification (CAC) - Most beneficial in asymptomatic patients with intermediate risk CAD – high CAC reclassify patient from intermediate  high risk CCTA – can be offered in symptomatic patients with intermediate risk CAD and indeterminate stress ` ECG result Source: Zipes, et al. (2019). Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine, 11th ed. Elsevier
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2019 ESC Guidelines for the Diagnosis and Management of Chronic Coronary Syndromes. 2020. European Heart Journal
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Indications: patients with high clinical likelihood for CAD, symptomatic unresponsive to optimal medical therapy, angina at low level exercise survived sudden cardiac death or ventricular arrhythmia who develop symptoms and signs of HF indicated if non-invasive tests suggests high event risk defined as cardiac mortality >or= 3%/yr Coronary Angiography Source: Zipes, et al. (2019). Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine, 11th ed. Elsevier
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Medical Management 5 Aspects of comprehensive medical management (1) identification and treatment of associated diseases that can precipitate or worsen angina and ischemia Correction of anemia, therapy for occult thyrotoxicosis, fever, infections and tachycardia (2) reduction of coronary risk factors (3) application of pharmacologic and nonpharmacologic interventions for secondary prevention (4) pharmacologic management of angina (5) revascularization by PCI or CABG, when indicated Source: Zipes, et al. (2019). Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine, 11th ed. Elsevier
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Control of Risk Factors and Lifestyle modifications Hypertension BP goal < 140/90 mm Hg, avoid diastolic BP below 60 mm Hg in elderly patients Dyslipidemia LDL-C less than 70 mg/dL Diabetes Mellitus for older patients and those with preexisting CVD, a less stringent HbA1c target of 8% or lower is recommended Obesity most favorable outcomes in CVD patients were consistently seen among individuals with overweight or mild-moderate obesity (“obesity paradox”) worse outcomes among normal-weight individuals and those with extreme obesity (BMI ≥40 kg/m2)
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Pharmacologic Management A. Anti ischemic treatment Betablockers (BBs) or nondihydropyridine calcium channel blockers (CCBs) – recommended as first choice of antianginal medication Reassess after 2-3 weeks after initiation Heart rate: 55-60 bpm Nitrates provide immediate relief of effort angina nitroglycerin 0.3-0.6 mg tablet SL, or 0.4 mg spray to the tongue q5 min until the pain disappears (max of 1.2 mg has been taken within 15 min) Isosorbide dinitrate 5 mg tab SL has a slightly slower onset of action than nitroglycerin Long acting nitrates – 2nd line anti anginal treatment when BBs and CCBs is contraindicated or inadequate
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dihydropyridine CCBs amlodipine – 10mg tab OD; reduces coronary revascularizations and hospitalizations for angina for 24months Ivabradine non inferior to atenolol and amlodipine for angina relief in patients with chronic coronary syndrome dose: 7.5mg tab BID Nicorandil nitrate derivative of nicotinamide Ranolazine – selective inhibitor of late inward Na current; contraindicated in patients with QT prolongation Trimetazidine – contraindicated in patients with Parkinson’s Suggested stepwise strategy for long term anti-ischaemic drug therapy in patients with chronic coronary syndromes and specific baseline characteristics 2019 ESC Guidelines for the Diagnosis and Management of Chronic Coronary Syndromes. 2020. European Heart Journal
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2019 ESC Guidelines for the Diagnosis and Management of Chronic Coronary Syndromes. 2020. European Heart Journal
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Pharmacologic Management B. Event Prevention Antiplatelet medications aspirin reduces the incidence of MACE in men and women with previous MI or stroke, and after CABG dual antiplatelet therapy (DAPT) is the mainstay antithrombotic therapy after MI and/or PCI After PCI for stable angina – 6 months after ACS – duration of 12 months is recommended (DAPT study, PEGASUS TIMI trial) Low dose anticoagulation vitamin K antagonists reduced the risk of recurrent atherothrombotic events at a cost of significantly increased risk of bleeding –- not routinely used as secondary prevention
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2019 ESC Guidelines for the Diagnosis and Management of Chronic Coronary Syndromes. 2020. European Heart Journal
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2019 ESC Guidelines for the Diagnosis and Management of Chronic Coronary Syndromes. 2020. European Heart Journal
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Pharmacologic Management B. Event Prevention Chronic anticoagulation atrial fibrillation (AF), venous thromboembolic disease, or mechanical heart valves for those with low ischemic risk, and bleeding risk is increased – may discontinue antiplatelet when triple therapy (DAPT + OAC) is necessary, recommendations: limiting exposure to triple therapy to the shortest possible duration targeting the lower range of international normalized ratio (INR) for warfarin avoiding the more potent P2Y12 antagonism of prasugrel and ticagrelor administering proton pump inhibitors (PPIs) to prevent gastrointestinal (GI) bleeding (class 1A)
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2019 ESC Guidelines for the Diagnosis and Management of Chronic Coronary Syndromes. 2020. European Heart Journal
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2019 ESC Guidelines for the Diagnosis and Management of Chronic Coronary Syndromes. 2020. European Heart Journal
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Statins and other lipid-lowering drugs Renin-angiotensin-aldosterone system blockers 2019 ESC Guidelines for the Diagnosis and Management of Chronic Coronary Syndromes. 2020. European Heart Journal
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Revascularization Objective : symptom relief and/or improvement of prognosis PCI or CABG may effectively relieve angina, reduce the use of antianginal medications, improve exercise capacity and quality of life compared with medical therapy alone the decision for revascularization are based: clinical presentation & documentation of ischemia IMPORTANT: always evaluate the individual risk-benefit ratio before revascularization
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