CAD

Coronary Artery DiseaseCoronary Artery Disease

Mike Dorsch, Pharm.D.,M.S., BCPSMike Dorsch, Pharm.D.,M.S., BCPS

Chronic Disease

Symptoms

Acute Disease

CADCAD

82.6 million American adults have CVD82.6 million American adults have CVD– 16.3 million have CHD or CAD16.3 million have CHD or CAD

7.9 million have had an AMI7.9 million have had an AMI

– 7 million have had a stroke7 million have had a stroke

CHD caused 1 of 6 deaths in the US 2007CHD caused 1 of 6 deaths in the US 2007

CHD is the single largest killer of US adultsCHD is the single largest killer of US adults

Every 25 secs someone has a coronary eventEvery 25 secs someone has a coronary event

Every minute someone will die from a coronary Every minute someone will die from a coronary eventevent

AHA stats 2011

PathophysiologyPathophysiology

Atherosclerosis – chronic Atherosclerosis – chronic immunoinflammatory, fibroproliferative immunoinflammatory, fibroproliferative disease fueled by lipidsdisease fueled by lipids

Many other mechanisms proposedMany other mechanisms proposed

Risk FactorsRisk Factors

AgeAge– Men ≥ 45 or women ≥ 55Men ≥ 45 or women ≥ 55

Family history of CHDFamily history of CHD– Before 55 for male or before 65 for femaleBefore 55 for male or before 65 for female

HyperlipidemiaHyperlipidemia– LDLLDL

SmokingSmokingHypertension (≥ 140/90 or on meds)Hypertension (≥ 140/90 or on meds)Low HDL (<40)Low HDL (<40)Diabetes mellitusDiabetes mellitus

Clinical presentationClinical presentation

Angina pectoris (chest pain)Angina pectoris (chest pain)– Quality – heavy pressure, SOBQuality – heavy pressure, SOB– Location – over the sternum, left arm, jawLocation – over the sternum, left arm, jaw– Duration – 0.5-30 minutesDuration – 0.5-30 minutes– Precipitating factors – exercisePrecipitating factors – exercise– Nitroglycerin reliefNitroglycerin relief– Radiation – left shoulder, jawRadiation – left shoulder, jaw

DiagnosisDiagnosis

Related to risk factorsRelated to risk factors

ECGECG

Stress testStress test– Natural or pharmacologicNatural or pharmacologic– Nuclear stress test (imaging)Nuclear stress test (imaging)

CT angiogramCT angiogram

Angiography (cardiac catheterization)Angiography (cardiac catheterization)

DefinitionDefinition

>> 50% luminal narrowing of at least one major 50% luminal narrowing of at least one major coronary artery at previous coronary coronary artery at previous coronary angiographyangiographyhistory of previous myocardial infarction, history of previous myocardial infarction, percutaneous transluminal coronary intervention percutaneous transluminal coronary intervention or coronary artery bypass graftor coronary artery bypass graftchronic stable angina pectoris associated with a chronic stable angina pectoris associated with a positive exercise tolerance test or positive exercise tolerance test or pharmacologically induced nuclear imaging or pharmacologically induced nuclear imaging or echocardiographic changes (positive nuclear echocardiographic changes (positive nuclear imaging or echocardiographic changes required imaging or echocardiographic changes required if female)if female)

ClassificationsClassifications

Stable exertional angina (chronic)Stable exertional angina (chronic)

Unstable anginaUnstable angina

Vasospastic angina (Prinzmetal)Vasospastic angina (Prinzmetal)

Chronic stable anginaChronic stable angina

Angina that is reproduced by exertionAngina that is reproduced by exertion

Canadian Cardiovascular SocietyCanadian Cardiovascular Society– Class I – normal physical activity does not Class I – normal physical activity does not

induce anginainduce angina– Class II – slight limitations in ordinary activityClass II – slight limitations in ordinary activity– Class III – marked limitations in ordinal activityClass III – marked limitations in ordinal activity– Class IV – inability to carry on any physical Class IV – inability to carry on any physical

activity w/o discomfortactivity w/o discomfortLook in Dipiro’s tables in the IHD chapterLook in Dipiro’s tables in the IHD chapter

Chronic stable anginaChronic stable angina

TreatmentTreatment– Aggressive risk factor modification!Aggressive risk factor modification!

Chronic stable anginaChronic stable angina

Smoking cessationSmoking cessation– Reduces coronary events by 50% over 2 yrsReduces coronary events by 50% over 2 yrs– High relapse rate – encourage patientsHigh relapse rate – encourage patients– TherapiesTherapies

Group counselling, self helpGroup counselling, self help

Nicotine replacement (patches, gums, inhaler)Nicotine replacement (patches, gums, inhaler)

Bupropion SR (Zyban)Bupropion SR (Zyban)

Newer agents to comeNewer agents to come

Chronic stable anginaChronic stable angina

Treat hypertensionTreat hypertension– Decreases coronary events as well as fewer Decreases coronary events as well as fewer

strokes, less renal failure and heart failurestrokes, less renal failure and heart failure– TreatmentTreatment

Defer to HTN lecturesDefer to HTN lectures

HOPE trialHOPE trial

HOPE trialHOPE trial9,297 high-risk patients, 9,297 high-risk patients, >> 55 years old, who had evidence of vascular 55 years old, who had evidence of vascular

disease or diabetes plus one other cardiovascular risk factordisease or diabetes plus one other cardiovascular risk factor

P<0.001

HOPE Investigators. NEJM 2000;342:145-53.

HOPE trialHOPE trial

MI/Stroke/MI/Stroke/CV DeathCV Death

CV DeathCV Death MIMI StrokeStroke TotalTotalMortalityMortality

22% Risk Reduction22% Risk Reductionp<0.001p<0.001

25% Risk Reduction25% Risk Reductionp<0.001p<0.001

20% Risk Reduction20% Risk Reductionp=<0.001p=<0.001

31% Risk Reduction31% Risk Reductionp=<0.001p=<0.001

16% Risk 16% Risk ReductionReductionp=0.006p=0.006

Non CV DeathNon CV Death

0% Risk Reduction0% Risk Reductionp=0.78p=0.78

HOPE Investigators. NEJM 2000;342:145-53.

Chronic stable anginaChronic stable angina

HypercholesterolemiaHypercholesterolemia– Reducing LDL reduces events (primary or Reducing LDL reduces events (primary or

secondary prevention)secondary prevention)– TreatmentTreatment

Defer to Lipid lecturesDefer to Lipid lectures

StatinsStatins

Goal LDL <100 or <70Goal LDL <100 or <70

Scandinavian Simvastatin Survival Scandinavian Simvastatin Survival Study (4S)Study (4S)

Years since randomizationYears since randomization

% S

urv

ivin

g%

Su

rviv

ing

30% risk reduction

p = 0.0003

The Lancet, Vol 344, November 19, 1994The Lancet, Vol 344, November 19, 1994

4,444 patients with CAD4,444 patients with CAD

Scandinavian Simvastatin Survival Scandinavian Simvastatin Survival Study (4S)Study (4S)

11.5%11.5%

8.2%8.2%

Chronic stable anginaChronic stable angina

ObesityObesity– BMI >32 kg/mBMI >32 kg/m22 is associated with increase is associated with increase

mortalitymortality– TreatmentTreatment

Dietary modificationDietary modification

Exercise programExercise program

Pharmacologic therapyPharmacologic therapy– Newer agents coming to marketNewer agents coming to market

Chronic stable anginaChronic stable angina

Control diabetesControl diabetes– DM is a CAD equivalentDM is a CAD equivalent– TreatmentTreatment

Refer to DM lecturesRefer to DM lectures

ACEi, statinACEi, statin

Newer agents coming to marketNewer agents coming to market

Chronic stable anginaChronic stable angina

Antiplatelet therapyAntiplatelet therapy– ASA 81-325mg dailyASA 81-325mg daily

Antithrombotic TrialistsAntithrombotic Trialists’’ Collaboration Collaboration

Antithrombotic Trialists’ Collaboration. BMJ 2002; 324: 71–86.

*Vascular events = myocardial infarction, stroke or vascular death

Category % Odds Reduction

Acute myocardial infarction

Acute stroke

Prior myocardial infarction

Prior stroke/transient ischemic attack

Other high riskCoronary artery disease

(e.g. unstable angina, heart failure)Peripheral arterial disease

(e.g. intermittent claudication)High risk of embolism (e.g. atrial fibrillation)Other (e.g. diabetes mellitus)All trials

1.00.50.0 1.5 2.0Control betterAntiplatelet better

Vasospastic angina (Prinzmetal)Vasospastic angina (Prinzmetal)

Vasospasm that occurs at the site of a Vasospasm that occurs at the site of a coronary arterycoronary artery

Vasospastic angina (Prinzmetal)Vasospastic angina (Prinzmetal)

Clinical presentationClinical presentation– Spontaneous and occurs at rest, with no Spontaneous and occurs at rest, with no

clear association with exertionclear association with exertion– Pain often cyclical (ie, same time of day), Pain often cyclical (ie, same time of day),

usually midnight to early a.m.usually midnight to early a.m.– Pain is similar to angina of effort but may be Pain is similar to angina of effort but may be

longer in durationlonger in duration– Pain may resolve spontaneously or with SL Pain may resolve spontaneously or with SL

nitroglycerinnitroglycerin

Vasospastic angina (Prinzmetal)Vasospastic angina (Prinzmetal)

DiagnosisDiagnosis– Same as chronic stable anginaSame as chronic stable angina– Can give ergonovine, acetylcholine, or Can give ergonovine, acetylcholine, or

methacholine to provoke vasospasmmethacholine to provoke vasospasm

Vasospastic angina (Prinzmetal)Vasospastic angina (Prinzmetal)

TreatmentTreatment– NitratesNitrates– Calcium channel blockersCalcium channel blockers

QuestionsQuestions