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Disclosure of Conflicts of Interest
I have received travel grants and honoraria from sanofi-aventis, Pfizer, Servier, Merck, Procter & Gamble, Biovail, AstraZeneca,
Medtronic, Novartis, Boehringer-Ingelheim and Merck/Frosst/Schering
I was the Primary Investigator of studies sponsored by Pfizer, Boehringer-
Ingelheim, sanofi-aventis, and currently, GSK
LumenArea
EEM Area
Atheroma Area
Ultrasound Determination of Atheroma AreaPrecise Planimetry of EEM and Lumen Borders
with Calculation of Atheroma Cross-sectional Area
ASTEROID Study
BaselineIVUSExam
Follow-upIVUS
24 monthsrosuvastatin
Atheroma Area10.16 mm2
Lumen Area6.16 mm2
Atheroma Area5.81 mm2
Lumen Area5.96 mm2
Work-up For Stable Angina Usually Starts With W/U For Chest Pain
History is still key! No test can simply just give you an answer… Keep in mind that you may eventually face a
patient with a chest pain syndrome and test findings that are unrelated and chasing the findings is not going to help the symptoms… or the patient
Work-up for Chest Pain
Starts w/ the assessment of symptoms Always take risk factors in the consideration
before doing any tests, look at your goals - what are you doing with the results?
My ultimate benchmark is the COURAGE study – PCI provides symptom relief mainly so if you do not have cardiac sounding symptoms PCI does not do much
However, the diagnosis of CAD could change medical mgmt
The Bayes’ Theorem Pretest probability of CAD, and sensitivity and
specificity of the test => posttest probability of CAD
The patient's clinical information and exercise test results => final estimate
A typical chest pain syndrome in a 50-year-old man or a 60-year-old woman constitutes ~50 % pretest probability
The diagnostic power of EST is maximal when the pretest probability of CAD is 30 to 70%.
Framingham Risk Assessment (Women)
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486.
Total Age (years)Cholesterol(mg/dL) 20-39 40-49 50-59 60-69 70-79<160 0 0 0 0 0160-199 4 3 2 1 1200-239 8 6 4 2 1240-279 11 8 5 3 2280 13 10 7 4 2
Cigarette SmokingNonsmoker 0 0 0 0 0Smoker 9 7 4 2 1
AgeYears Points20-34 -735-39 -340-44 045-49 350-54 655-59 860-64 1065-69 1170-74 1475-79 16
CHD RiskPoints 10-y
Risk (%)
<9 <19 1
10 111 112 113 214 215 316 417 518 619 820 1121 1422 1723 2224 27
25 30
Systolic Blood PressureUntreated Treated
<120 0 0120-129 1 3130-139 2 4140-159 3 5160 4 6
HDL-C (mg/dL)Points
>60 -150-59 040-49 1<40 2
Score = 20Risk = 11%
LDL-C goal:<3.5 mmol/L
Ratio: < 5
ONTARGET Non-Inferiority Comparison
0.8 0.9 1.0 1.1 1.2
RR (95% CI)
Note that the outcomes are presented as point estimates with confidence intervals. The solid lineis the 95% CI representing 1.96 SD and the dashed line is the 97.5% CI representing the adjusted CI for each outcome
Non
-infe
riorit
y M
argi
n
Primary Composite (p = 0.0033)
CV Death / MI / Stroke (HOPE Composite)
(p = 0.0008)
Telmisartan better Ramipril better
ONTARGET
TRANSCEND
• After ONTARGET, TRANSCEND was expected to show HOPE-like results in an ACE-intolerant population of 5926 patients w/ vascular disease
• Pts received telmisartan 80 mg/d vs. placebo• CV Death/MI/Stroke/HHF: 15.7% vs. 17.0% (HR:
0.92; 95% CI 0.81-1.05, p=0.216)• CV death/MI/stroke (HOPE outcome):
13% vs. 14.8% (HR: 0.87; 95% CI 0.76-1.0 p=0.048 unadjusted)
• Adverse events: permanent discontinuation of study medication: 21.6% vs. 23.8% p=0.055
Telmisartan Meta-analysis (CV Death, MI, Stroke, CHF Hosp)
0.7 0.8 0.9 1.0 1.1 1.2
OR (95% CI)
Telmisartan better Placebo better
PROFESS
TRANSCEND
OVERALL
OVERALL <= 6M
OVERALL > 6M
No. events/No. randomized
Telmisartan1367/10146 (13.5%)
466/2954 (15.7%)
1833/13100 (14.0%)
546/13100 (4.2%)
1287/12484 (10.3%)
Placebo1463/10186 (14.4%)
505/2972 (17.0%)
1968/13158 (14.9%)
492/13158 (3.7%)
1476/12575 (11.7%)
p-value
0.067
0.205
0.026
0.075
<0.001
TRANSCEND
Comparison of Event RatesHOPE Endpoint: MI, Stroke or CV Death
P R R T P T
%/yr
1
2
3
4
4.2
3.4 3.34 2.923.02 2.98
∆ = 22%∆ = 13%
A Really COURAGEous Trial
2287 patients with stable angina and At least one >80% angioplastiable stenosis (5%) or a positive stress MIBI with at least one >70% and
angioplastiable stenosis (95%) were randomized for aggressive medical therapy + PCI
Sponsored by the VA and CIHR; Pharmaceutical support was channeled through
VA
Medical Therapy
ASA 81-325 mg/d or Plavix if ASA-intolerant Anti-ischemic therapy: LA metoprolol,
amlodipine, isosorbide mononitrate, Lipid-lowering w/ simvastatin + ezetimibe to a
target LDL 1.55-2.2; after this was achieved an attempt was made to raise HDL-levels above 1.0 mmol/l and to lower TG levels to below 1.69 mmol/l
PCI And Outcomes
Complete revascularization was attempted Stenting was the expectation but DES were NA Clinical success: angiographic success + no in-
hospital MI/emergency CABG or death
Primary outcome: Death/MI Secondary outcome: D/MI + stroke and UA Further outcome assessments: QOL, use of
resources, cost-effectiveness
Results: PCI Group
2/3 of pts had multivessel disease 90% had a positive MIBI, 2/3 several defects PCI was angiographically successful in 93% of
those assigned, clinical success (full revascula-rization and no MI) in 89%
41% received >1 stent (only 31 DES)
Results: Medical Group
Significantly more proximal LAD disease @5 yrs 70% had an LDL<2.2 mmol/l, median
1.84 + 0.03 (baseline: 2.5!) 65% and 94% had a BP<130/85 mmHg 45% of diabetics had a HbA1C<7.0% BMI did not decrease Smokers: 23% - 20% at 5 yrs NS differences between the groups
Prevalence of Angina
Angina free patients:PCI Medical therapyBaseline 1 yr 3 yrs 5 yrs Baseline 1 yr 3 yrs 5yrs12% 66 72 74 13 58 67 72NS <0.001 0.02 NS
QOL was better as well – reported at ACC 2007
Subgroups: multivessel disease, prior MI, DM had similar results
Freedom from Angina: COURAGE vs. CASS
12 13
6658
7267
74 72
0
10
20
30
40
50
60
70
80
Baseline 1 Year 3 Year 5 Year
PCI + OMTOMTP
erce
nt
Boden et al. N Engl J Med 2007; 356: 1503-1516.Rogers et al. Circulation 1990;82:1647-1658.
22 22
66
30
63
38
0
10
20
30
40
50
60
70
80
Baseline 1 Year 5 Year
CABGMED
Courtesy of Dr. GBJ Mancini
Discussion - Conclusions Initial aggressive medical management of stable
angina is a good strategy Atherosclerosis is a diffuse disease and opening
up one critical stable stenosis will not change the prognosis (doesn’t tend to cause ACS)
If it fails, PCI is excellent to quickly relieve symptoms but it doesn’t prevent death and MI
Don’t forget that these were stable patients, COURAGE doesn’t apply to ACS patients!
Diff chronic chest pain vs. real stable angina
How Is This Going To Change Our Practice? - Debatable
Even more meticulous risk stratification – ?Ca+ Framingham scores and EST if moderate risk
Maybe in chronic stable angina a cath is not warranted right away – missing the window?
We still need a cath in refractory or ?cases even to rule CAD in or out – CT/MR the future?
At the time of the decision how good the pt’s medical management is – already on max. Rx?
Consent: no benefit re: prevention of MI/D Focus more on the unstable patient
How Has COURAGE Changed My Practice?
I’m not cathing these patients less often But I choose medical Rx more often afterwards I screen even less often for ischemia where it is
not clinically obvious (a-fib, pre-op w/u, atypical CP and few or no risk factors, etc.)
Because if these high risk patients didn’t really benefit for invasive mgmt, asymptomatic pts would benefit even less – although your risk factor mgmt is more aggressive w/ bad CAD
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