Click to edit Master title style - TotalCardiology€¦ · All trials 0.0 0.5 1.0 1.5 2.0 Antiplatelet better Control better Effect of antiplatelet treatment* on vascular events**

Click to edit Master title style

Secondary Prevention & Management of Stable Coronary Artery Disease

How aggressive should we be?

Ahmed Abdi Ali

Click to edit Master title styleFaculty Presenter Disclosure

Cardiology for the Non-Cardiologist

Faculty: Ahmed Abdi Ali

- Relationships with Financial Sponsors: NONE

- Grants or Research Support: NONE

- Speakers Honoraria: NONE

- Consulting Fees: NONE

- Patents: NONE

- Other: NONE

Click to edit Master title styleDisclosure of Financial Support

Cardiology for the Non-Cardiologist has received financial support from the following Pharmaceutical companies; Bayer, Bristol-Meyers Squibb/Pfizer, Servier, Novartis, Amgen, AstraZeneca and Merck in the form of unrestricted educational grants.

Potential Conflicts of Interest: None

Click to edit Master title styleMitigating Potential Bias

• While we have received unrestricted educational grants from several pharmaceutical companies, most presentations have no mention of specific products and are unrelated to the supporting companies or their products. No specific presentations will be supported or sponsored by a specific company.

• Information on specific products will be presented in the context of an unbiased overview of all products related to treating patients.

• All scientific research related to, reported or used in this CME activity in support or justification of patient care recommendations conforms to the generally accepted standards.

• Clinical medicine is based in evidence that is accepted within the profession.

Click to edit Master title styleComponents of Secondary Prevention

Antiplatelet and Anticoagulant

Blood pressure and Anti-ischemic treatment

Cholesterol treatment and Cigarette smoking cessation

Diabetes and Diet management

Exercise, Education, and Vaccination

Click to edit Master title styleCLINICAL CASE

A 64-year-old female with classic angina and a positive treadmill test has undergone angiography for verification of the diagnosis.

She has CCS Class II angina. She tends to be a therapeutic nihilist and is reluctant to take medications. She notes, however, that her ongoing symptoms are interfering with activities of daily living and quality of life.

She is a retired cardiology medical office assistant with some understanding of biostatistics.

She asks which forms of therapy would improve quality of life for the longest period of time.

She also asks which form of therapy would offer a mortality benefit possibly without symptomatic relief. Following discussions she agrees to take optimum medical therapy (OMT).

CCS antiplatelet guidelines 2018


Which of the following medications improve prognosis in chronic management for the patient with SIHD?

1. Acetylsalicylic acid

2. Clopidogrel

3. Statins

4. ACE inhibitors

5. Beta blockers




At 12 months following therapy which has a greater freedom from angina?

1. Optimum medical therapy

2. PCI plus optimum medical therapy


Question



Antiplatelet/ Anticoagulation Recommendations

Recommendation Strength of

recommendation

Level of

evidence

We recommend that all patients receive 81 mg of acetylsalicylic acid

daily indefinitely, unless contraindicated

Strong High

quality

We recommend that clopidogrel 75 mg daily be used in acetylsalicylic

acid intolerant individuals

Strong High

quality

We suggest that dual antiplatelet therapy should not be used in routine

management of SIHD or beyond the time period required as a result of

stenting

Conditional Moderate

quality

We recommend that in patients who tolerate 1 year of DAPT without a

major bleeding event and who are not at high risk of bleeding, DAPT

should be extended beyond 1 year post PCI (Strong Recommendation,

High Quality Evidence for up to 3 years of treatment). After 1 year, we

recommend a DAPT regimen of ASA 81 mg daily plus either ticagrelor 60

mg twice daily or clopidogrel 75 mg once daily (Strong Recommendation,

High Quality Evidence) or prasugrel 10 mg once daily (Weak

Recommendation, Moderate Quality Evidence).

Chronic Management for the Patient with SIHD to Improve Prognosis

2014 Canadian Cardiovascular Society Guidelines for the Diagnosis and Management of Stable Ischemic

Heart Disease

Mancini GBJ, Gosselin G, et al., Can J Cardiol 2014


Clinical Angiographic

Prior myocardial infarction or troponin positive acute coronary syndrome

Multiple stents (≥ 3 stents implanted, ≥ 3 lesions

stented)

Diabetes Mellitus treated with oral hypoglycemics or insulin✚

Long lesion length (> 60 mm total stent length)

Chronic kidney disease (creatinine clearance ≤ 60 ml/min)

Complex lesions (bifurcation treated with 2 stents, stenting of chronic occlusion)

Prior stent thrombosis Left main or proximal LAD stenting

Multivessel PCI

✚Net benefit to diabetics in the absence of any of other high risk features is unclear

High-risk clinical and angiographic

features for thrombotic events

Click to edit Master title styleFactors associated with increased bleeding risk

1. Need for OAC in addition to DAPT

2. Advanced age (> 75 years)

3. Frailty

4. Anemia with hemoglobin < 110 g/dL

5. Chronic renal failure (creatinine clearance < 40 mL/min)

6. Low Body Weight (< 60 kg)

7. Hospitalization for bleeding within last year

8. Prior stroke/intracranical bleed

9. Regular need for NSAIDS or prednisone


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

Category % Odds Reduction

Acute MI

Acute CVA

Prior MI

Prior CVA/TIA

Other high risk

CVD(e.g. unstable angina, heart failure)

PAD(e.g. intermittent claudication)

High risk of embolism (e.g. Afib)

Other (e.g. DM)

All trials

1.00.50.0 1.5 2.0Control betterAntiplatelet better

Effect of antiplatelet treatment* on vascular events**

*Aspirin was the predominant antiplatelet agent studied**Include MI, stroke, or death

Aspirin Evidence: Secondary Prevention

Aspirin reduces the risk of adverse cardiovascular events


19,185 patients with ischemic CVA, MI, or PAD randomized to

daily aspirin (325 mg) or clopidogrel (75 mg) for 2 years

Clopidogrel provides slightly greater risk reduction than aspirin

Months of follow-up

0

3

6

0 3 6 9 12 15 18 21 24 27 30 33 36

Cu

mu

lati

ve r

isk

* (

%)

8.7% RRR, p=0.043

Aspirin

Clopidogrel

Source: CAPRIE Steering Committee. Lancet 1996;348:1329-1339CVA=Cerebrovascular accident, MI=Myocardial

infarction, PAD=Peripheral arterial disease

*Composite of myocardial infarction, ischemic stroke, or vascular death

Clopidogrel Evidence: Secondary Prevention

Clopidogrel versus Aspirin in Patients at Risk of Ischemic

Events (CAPRIE) Trial


Source: Adapted from Figure 4 in Bhatt DL et al. NEJM 2006;354:1706-1717

Months

8

6

4

2

00 6 12 18 24 30

Placebo

Clopidogrel

Incid

ence o

f C

V d

ea

th,

MI, o

r C

VA

(%

)

P = 0.22

CV=Cardiovascular, CVA=Cerebrovascular accident, CVD=Cardiovascular

disease, DAP=Dual antiplatelet, MI=Myocardial infarction

Clopidogrel Evidence: Secondary Prevention

Clopidogrel for High Atherothrombotic Risk and Ischemic

Stabilization, Management, and Avoidance (CHARISMA) Trial

15,603 patients with multiple CV risk factors or known CVD

randomized to aspirin (75-162 mg) or aspirin (75-162 mg) &

clopidogrel (75 mg) for a mean of 30 months

Routine DAP therapy offers little long-term benefit

prior atherothrombotic disease (RR 0.88; 95% CI, 0.77 to 0.99; P=0.046).

Trials Evaluating Prolonged DAPT following MI



Click to edit Master title styleDual Pathway Inhibition with Rivaroxaban Vascular Dose 2.5 mg bid + Aspirin Reduced CV Death, Stroke and MI

MACE* % HR (95% CI) p-value

Aspirin 100mg OD 5.4 - -

Rivaroxaban 5mg BID 4.9 0.90 (0.79-1.03) 0.12

Rivaroxaban 2.5mg BID +

Aspirin 100 mg OD4.1 0.76 (0.66-0.86) <0.001

PADCAD

Eikelboom JW et al. N Engl J Med 2017; DOI:

10.1056/NEJMoa1709118

Cu

mu

lati

ve

in

cid

en

ce

(%

)

0

2

4

6

8

10

0 1 2 3

Rivaroxaban 2.5mg bid + Aspirin 100mg od

Aspirin 100mg od

Year


Blood pressure and anti-ischemic treatments


recommendation

Level of

evidence

We recommend that all patients with SIHD who also have hypertension,

diabetes, a left ventricular ejection fraction of < 40%, or chronic kidney

disease, should receive an angiotensin-converting enzyme (ACE)

inhibitor, unless contraindicated

Strong High

quality

We recommend that it is also reasonable to consider treatment with an

ACE inhibitor in all patients with SIHD

Strong High

quality

We recommend that ARBs should be used for patients who are

intolerant of ACE inhibitors

Strong High

quality

We recommend that beta-blocker therapy be used in all patients with

SIHD and left ventricular systolic dysfunction (ejection fraction < 40%)

with or without heart failure, unless contraindicated, and continued

indefinitely

Strong High

quality

Chronic Management for the Patient with SIHD to Improve Prognosis



Heart Disease


recommendation

Level of

evidence

We suggest that beta-blockers be used as first-line therapy for symptom

relief, with the dose titrated to reach a target resting heart rate of 55 to 60

bpm


quality

We suggest that beta-blockers or long-acting calcium channel blockers be

used for chronic stable angina in uncomplicated patients


quality

We suggest the addition of a long-acting nitrate when initial treatment with a

beta-blocker and/or long acting calcium channel blocker is not tolerated or

contraindicated or does not lead to adequate symptom control


quality

We recommend avoiding non-dihydropyridine calcium channel blockers in

conjunction with beta-blockers if there is risk of AV block or excessive

bradycardia

Strong High

quality

We suggest that chelation therapy, allopurinol, magnesium supplementation,

coenzyme Q10, suxiao jiuxin wan or shenshao tablets and testosterone

should not be used to attempt to improve angina or exercise tolerance


quality

We recommend that implementation and optimization of medical therapy

should be achieved within 12 to 16 weeks of an initial evaluation suggesting

presence of SIHD without high risk features during which adequacy of

symptom control and quality of life can be assessed prior to consideration of

revascularization therapy

Strong High

quality

Chronic Management of Anginal Symptoms

2014 Canadian Cardiovascular Society Guidelines for the Diagnosis and Management of Stable Ischemic Heart Disease


Click to edit Master title styleH

ype

rte

nsio

n*

Pre

vale

nc

e (

%)

18-29

National Health and Nutrition Examination Survey (NHANES) III

30-39 40-49 50-59 60-69 70-79 80+

Age

3%9%

18%

Source: JNC-VI. Arch Intern Med 1997;157:2413-2446

51%

66%72%

38%

*Hypertension defined as blood pressure >140/90 mmHg or treatment

High Blood Pressure*: Prevalence Increases with Age

The prevalence of high blood pressure increases with age

Click to edit Master title styleUsual Office BP Threshold Values for Initiation of Pharmacological Treatment

Population SBP DBP

High Risk (SPRINT population) # ≥ 130 NA

Diabetes ≥ 130 ≥ 80

Moderate * ≥ 140 ≥ 90

Low risk (no TOD or CV risk factors) ≥ 160 ≥ 100

AOBP = automated office blood pressure

TOD = target organ damage

SBP = systolic blood pressure

DBP = diastolic blood pressure

# Based on AOBP

*AOBP threshold 135/85

mmHg

Hypertension 2017


Treatment consists of health behaviour ± pharmacological management

Recommended Office BP Treatment Targets

Population SBP DBP

High Risk # < 120 NA

Diabetes < 130 < 80

All others* < 140 < 90

# Based on AOBP

*AOBP threshold 135/85 mmHg

Hypertension 2017


Number of

Participants

Hazard Ratio = 0.75 (95% CI: 0.64 to 0.89)

Standard

Intensive(243 events)

During Trial (median follow-up = 3.26

years)

Number Needed to Treat (NNT)

to prevent a primary outcome =

61

SPRINT Primary OutcomeCumulative Hazard

(319 events)


Adapt from Figure 2B in the N Engl J Med manuscript

Include NNT

All-cause MortalityCumulative Hazard

Hazard Ratio = 0.73 (95% CI: 0.60 to 0.90)

During Trial (median follow-up = 3.26

years) Number Needed to Treat

(NNT)

to Prevent a death = 90

Standard(210 deaths)

Intensive(155 deaths)

Number of

Participants


Clinical Trial

HOPE 9,297 1051

0.4 0.6 0.8 1.0 1.2 1.4 1.6

N

ACE-I Better Placebo Better

EUROPA 12,218 795

PEACE 8,290 633 HR=0.89 P=0.13

HR=0.89 P=0.10

HR=0.84 P=0.005

Deaths

All Trials 33,960 >3000 HR=0.86 P<0.001

Sources:

Danchin N et al. Arch Intern Med 2006;166:787-796

The HOPE Trial Investigators. NEJM 2000;342:145-153

The EUROPA Study. Lancet 2003; 362: 782-788

The PEACE Trial Investigators. NEJM 2004;351:2058-2068

Meta-Analysis of the HOPE, EUROPA, and PEACE Trials*

RR of Mortality

*7 RCTs, 33,960 randomized patients, and 4.4 years of mean follow-up.

Other findings include a CV mortality HR=0.81, MI HR=0.82, and stroke HR=0.77

ACE-I=Angiotensin converting enzyme inhihbitor, MI=Myocardial infarction

ACE Inhibitor Evidence: Secondary Prevention


Source: Flather MD et al. Lancet 2000;355:1575–1581

TRACEEchocardiogram

EF <35%

Years

Pro

ba

bil

ity

of

Eve

nt

0

0.05

0.

1

0.15

0.2

0.25

0.3

0 1 2 3

0.35

0.4

4

ACE-I

Placebo

OR 0.74 (0.66–0.83)

SAVERadionuclid

e

EF <40%

AIREClinical and/or

radiographic

signs of HF

ACE-I=Angiotensin converting enzyme inhibitor, EF=Ejection fraction, LVSD=Left

ventricular systolic dysfunction, MI=Myocardial infarction, OR=Odds ratio

An ACE-I provides substantial benefit in post-MI LVSD



Beta-blocker

better

Placebo

better

Source: Antman E, Braunwald E. Acute Myocardial Infarction. In: Braunwald E,

Zipes DP, Libby P, eds. Heart Disease: A textbook of Cardiovascular Medicine,

6th ed., Philadelphia, PA: W.B. Sanders, 2001, 1168.

Summary of secondary prevention trials of beta-blocker therapy

Phase of

Treatment

Acute

treatment

Secondary

prevention

Overall

Total #

Patients

28,970

24,298

53,268

0.5 1.0 2.0

RR of death

RR (95% CI)

0.87 (0.77-0.98)

0.77 (0.70-0.84)

0.81 (0.75-0.87)

CI=Confidence interval, RR=Relative risk

Beta-blocker Evidence:Secondary Prevention


*Not an approved indication, †Not a planned end point

#Not approved for severe HF/mortality reduction alone

HF=Heart failure, LVSD=Left ventricular systolic dysfunction, NS=Not significant, TX=Transplant

Study Drug HF

Severity

Patients

(n)

Follow-up Mean Dosage Effects on

Outcomes

CIBIS Bisoprolol* Moderate-Severe

641 1.9 Years 3.8

mg/day

All cause mortality (p=NS)

CIBIS-II Bisoprolol Moderate-Severe

2,647 1.3 Years 7.5

mg/day

All cause mortality

34% (P<0.0001)

BEST Bucindolol* Moderate-Severe

2,708 2.0 Years 152

mg/day

All cause mortality (p=NS)

MERIT-HF Metoprolol succinate#

Mild-Moderate

3,991 1.0 Years 159

mg/day

All cause mortality

34% (P=0.0062)

MDC Metoprolol tartrate*

Mild-Moderate

383 1.0 Years 108

mg/day

Death or Need for TX (P=NS)

CAPRICORN Carvedilol Mild 1,989 1.3 Years 40

mg/day

All cause mortality 23% (P =0.03)

US Carvedilol Carvedilol Mild-Moderate

1,094 0.5 Years 45

mg/day

All-cause mortality†

65% (P=.0001)

COPERNICUS Carvedilol Severe 2,289 0.9 Years 37

mg/day

All-cause mortality

35% (P =0.0014)

SENIORS Nebivolol Moderate 2,128 3.0 Years 7.7 mg/day

All-cause mortality or CV hospitalization 14% (P =0.039)

Beta-blocker Evidence:Benefit in HF and/or LVSD


Meta regression analysis of the relationship of percentage of patients with

reperfusion therapy on the risk ratio of mortality with β-blockers.

• β-blockers reduced mortality in pre-reperfusion[IRR=0.86, 95% CI=0.79-0.94] but not in the reperfusion era(IRR=0.98, 95% CI=0.92-1.05) where there was reduction (short-term) in myocardial infarction(IRR=0.72, 95% CI=0.62-0.83) and angina(IRR=0.80, 95%CI=0.65-0.98) but increase in heart failure(IRR=1.10, 95% CI=1.05-1.16), cardiogenic shock(IRR=1.29, 95% CI=1.18-1.41) and drug discontinuation.

• In contemporary treatment of MI, β-blockers have no mortality benefit but reduce myocardial infarction and angina (short-term) with increase in heart failure, cardiogenic shock and drug discontinuation

Bangalore S, et al. The American Journal of Medicine, 2014 http://dx.doi.org/10.1016/j.amjmed.2014.05.032


Cholesterol treatment and cigarette smoking cessation


We recommend that all patients receive a statin in accordance with CCS

2012 Dyslipidemia Guidelines

Strong High

quality


Heart Disease

Mancini GBJ, Gosselin G, et al., Can J Cardiol 2014 Anderson et al. Can J Cardiol 2013; 29:151-67


Approach to Risk Management

Anderson et al. Can J Cardiol 2016; 32:1263-82


0

5

10

15

20

25

30

CH

D E

ve

nts

(%

)

R² = 0.9029p < 0.0001

LDL Cholesterol (mg/dl)Adapted and Updated from O’Keefe, J. et al., J Am Coll Cardiol 2004;43:2142-6.

30 50 70 90 110 130 150 170 190 210

4S

CARELIPID

HPS

PROVE IT –TIMI 22IMPROVE IT66

52

TNT

The Statin Decade:For LDL: “Lower is Better”


HMG-CoA Reductase Inhibitor Evidence:Effect of Intensive Therapy

Cholesterol Treatment Trialists’ (CTT) CollaborationMeta-analysis of 169,138 patients randomized to at least

2 years of statin therapy

0 1 2 3 4 5

01

01

52

0

LDL cholesterol level (mmol/L)

Five

yea

r ri

sk o

f a

maj

or

vasc

ula

r ev

ent,

%

Control

21% relative riskreduction per mmol/LStatin

16% relative riskreduction per 0.5 mmol/LMore statin

There is a proportionate reduction in CV events with greater LDL-

cholesterol reductionSource: Cholesterol Treatment Trialists’ Collaboration. Lancet 2010;376:1670-1681

CV=Cardiovascular, LDL=Low density lipoprotein


Smoking Prevalence in the United States

Source: CDC, Morbidity and Mortality Weekly Report 2007;56:1157-1161

National Health Interview Survey

Estimated percentage of current smokers in the United States by sex

There has been a decrease in the prevalence of cigarette smoking in

men and women over time


0.1 1.0 10Ceased smoking Continued smoking

RR (95% Cl)Study

Aberg, et al. 1983 0.67 (0.53-0.84)

Herlitz, et al. 1995 0.99 (0.42-2.33)

Johansson, et al. 1985 0.79 (0.46-1.37)

Perkins, et al. 1985 3.87 (0.81-18.37)

Sato, et al. 1992 0.10 (0.00-1.95)

Sparrow, et al. 1978 0.76 (0.37-1.58)

Vlietstra, et al. 1986 0.63 (0.51-0.78)

Voors, et al. 1996 0.54 (0.29-1.01)

Source: Critchley JA et al. JAMA 2003;290:86-97 *Includes those with known coronary heart disease

Cigarette Smoking Cessation Evidence: Risk of Non-fatal Myocardial Infarction*


Source: Jorenby DE et al. JAMA 2006;296:56-63

Varenicline vs. Bupropion

P<0.001 (weeks 9-12), P=0.004 (weeks 9-52)

Cigarette Smoking Cessation Evidence: Primary Prevention

1,027 smokers randomized to 12 weeks of varenicline (titrated to 1 mg bid),

bupropion (titrated to 150 mg bid), or placebo

Varenicline provides greater rates of abstinence than bupropion


Diabetes and diet management


Start metformin immediately

Consider a second concurrent

antihyperglycemic agent

Start healthy behaviour interventions

(nutritional therapy, weight management, physical activity) +/- metformin

A1C <1.5% above targetSymptomatic hyperglycemia

and/or metabolic decompensationA1C 1.5% above target

Initiate insulin +/-

metformin

If not at glycemic

target within 3 months,

start/increase

metformin

If not at glycemic target

HE

ALT

HY

BE

HA

VIO

UR

IN

TE

RV

EN

TIO

NS

Clinical CVD?

See next page

AT DIAGNOSIS OF TYPE 2 DIABETES2018


YES

Start antihyperglycemic agent with

demonstrated CV benefit

empagliflozin (Grade A, Level 1A)

liraglutide (Grade A, Level 1A)

canagliflozin* (Grade C, Level 2)

NO


* Avoid in people with prior lower extremity amputation

Empagliflozin reduced CV eventsCV death, non-fatal MI, or non-fatal stroke

Zinman B et al. N Engl J Med 2015; DOI: 10.1056/NEJMoa1504720

Months

Pati

en

ts w

ith

even

t(%

)

HR 0.86

95.02% CI (0.74, 0.99)

P < 0.001 for non-inferiority

p=0.04 for superiority

Placebo

Empagliflozin

No. of patients

Empagliflozin 4687 4580 4455 4328 3851 2821 2359 1534 370

Placebo 2333 2256 2194 2112 1875 1380 1161 741 166

PBO EMP

A

HR P NNT3

CV death, MI, stroke (%) 12.1 10.5 0.86 0.04 63

CV deaths (%) 5.9 3.7 0.62 <0.001 46

Nonfatal MI (%) 5.2 4.5 0.87 0.22

Nonfatal stroke (%) 2.6 3.2 1.24 0.16

Hosp. heart failure (%) 4.1 2.7 0.65 0.002 72

All-cause mortality (%) 8.3 5.7 0.68 <0.001 39

2018 Diabetes Canada CPG – Chapter 23. Cardiovascular Protection in People with Diabetes

Neal B et al. N Engl J Med 2017; DOI:10.1056/NEJMoa1611925

No. of patients

Canagliflozin 5795 5566 4343 2555 2460 2363 1661

Placebo 4347 4153 2942 1240 1187 1120 789

Canagliflozin

Placebo

HR 0.86

95% CI (0.75, 0.97)



Outcome

(per 1000 pt-y)

PBO CANA HR P or 95% CI NNT 5

CV death, MI, stroke 31.5 26.9 0.86 0.02 44

CV deaths 12.8 11.6 0.87 (0.72-1.06)

Nonfatal MI 11.6 9.7 0.85 (0.69-1.05)

Nonfatal stroke 8.4 7.1 0.90 (0.71-1.15)

Hosp. heart failure 8.7 5.5 0.67 (0.52-0.87) 63

All-cause mortality 19.5 17.3 0.87 (0.74-1.01)

Canagliflozin reduced CV eventsCV death, non-fatal MI, or non-fatal stroke


Patients at risk

Liraglutide 4668 4593 4496 4400 4280 4172 4072 3982 1562 424

Placebo 4672 4588 4473 4352 4237 4123 4010 3914 1543 407

Marso SP et al. N Engl J Med 2016;375(4):311-22.

Time from randomization (months)

Pati

en

ts w

ith

eve

nt

(%)

HR 0.87

95.02% CI (0.78, 0.97)



Placebo

Liraglutide

PBO LIRA HR P NNT4

CV death, MI, stroke (%) 14.9 13.0 0.87 0.01 53

CV death (%) 6.0 4.7 0.78 0.007 77

Nonfatal MI (%) 6.8 6.0 0.88 0.11

Nonfatal stroke (%) 3.8 3.4 0.89 0.30

Hosp. heart failure (%) 5.3 4.7 0.87 0.14

All-cause mortality (%) 9.6 8.2 0.85 0.02 72

Liraglutide reduced CV eventsCV death, non-fatal MI, or non-fatal stroke



Exercise, education, and vaccination


• Patients with Stable Ischemic Heart Disease• Moderate-Vigorous Physical Activity


Heart Disease


• Patients with Stable Ischemic Heart Disease

• Cardiac Rehabilitation Referral


Heart Disease


Canadian Cardiovascular Society Guidelines

2014 Diagnosis and Management of Stable Ischemic Heart Disease

Consideration of Revascularization Therapy



recommendati

on

Level of

evidence

We recommend that coronary angiography be considered

early in patients who are identified to have high risk non-

invasive test features

Strong High

quality

We recommend that patients who develop medically

refractory symptoms or inadequate CV quality of life on

medical therapy should undergo elective coronary

angiography in anticipation of possible revascularization

procedures

Strong High

quality

Consideration of

Revascularization Therapy

Click to edit Master title styleWhen to intervene beyond medication…


END


Patients with Chronic CAD or PAD Remain At Risk of Vascular Events Despite Current Optimal Medical Therapy

8.2

5.8

3.1 3.03.5

6.7

5.3

2.9 2.63.1

0

2

4

6

8

10

12

ATT Collaboration CAPRIE CHARISMA PEGASUS TRA2P-TIMI 50

Pri

mary

en

dp

oin

t: M

AC

E (

%/y

ea

r)†

Control Intervention

% Use of key

therapies in

intervention arm

Control Aspirin Aspirin Clopidogrel Placebo

+ Aspirin

Clopidogrel

+ Aspirin

Placebo

+ Aspirin

Ticagrelor

+ Aspirin

Vorapaxar Placebo

+ Aspirin

Thienopyridine

ACEI/ARBMeta-analysis

of 16 trials

NR up to 85.3 80.4 73.5

Statin/

lipid-loweringNR 77.1–89.3 92.4 91.0

1. ATT Collaboration. Lancet 2009;373:1849–1860; 2. CAPRIE Steering Committee. Lancet 1996;348:1329–1339; 3. Bhatt DL et

al. J Am Coll Cardiol 2007;49:1982–1988; 4. Bonaca MP et al. N Engl J Med 2015;372:1791–1800; 5. Morrow DA et al. N Engl J

Med 2012;366:1404–1413

0.81

(0.75–0.87)

0.91*

(0.84–1.0)

0.83

(0.72–0.96)

0.84

(0.74–0.94)

0.87

(0.80–0.94)

1 2 3 4 5

CAD

Click to edit Master title styleComparison between the HOPE and PEACE trials

Patients enrolled in the PEACE trial were lower risk*

MI,

Ca

rdia

c d

ea

th,

or

Str

ok

e (

%)

Source: The PEACE Trial Investigators. NEJM 2004;351:2058-2068 CHD=Coronary heart disease, MI=Myocardial infarction

*Reflects better blood pressure control, revascularization,

and use of other risk-reducing medications (i.e., antiplatelet

therapy, beta-blocker, lipid-lowering medication)

Years

HOPE, placebo

HOPE, active drug

(ramipril)

PEACE, placebo




Source: Yusuf S et al. Lancet. 2004;364:937-952

36

127

10

20

33

0

20

40

60

80

100

Smoking Fruits/

Veg

Exercise Alcohol Psycho-

social

Lipids All 9 risk

factors

PA

R (

%)

1418

90

Diabetes Abdominal

obesity

Hyper-

tension

Lifestyle factors

50

INTERHEART Study

n=15,152 patients and 14,820 controls in 52 countries

MI=Myocardial infarction, PAR=Population

attributable risk (adjusted for all risk factors)

Attributable Risk Factorsfor a First Myocardial Infarction


Source: Yokoyama M et al. Lancet 2007;369:1090-1098

Japan Eicosapentaenoic acid Lipid Intervention Study (JELIS)

*Composite of cardiac death, myocardial infarction, angina, PCI, or CABG

Years

Omega-3 Fatty Acids Evidence:Primary and Secondary Prevention

18,645 patients with hypercholesterolemia randomized to EPA (1800 mg) with a

statin or a statin alone for 5 years

Omega-3 fatty acids provide CV benefit, particularly in secondary prevention

CV=Cardiovascular, EPA=Eicosapentaenoic acid


Boekholdt et al. J Am Coll Cardiol. 2014;64(5):485-495.

• Meta-analysis of 8

statin trials (n=38,153):

• >40% did not reach

LDL-C target (<1.8

mmol/L) on high dose

statin

• Patients achieving LDL-C <1.3 mmol/L are at lower CVD risk than those

achieving an LDL-C of 1.9 to <2.6 mmol/L

1.00

0.75

0.50

0.25 10

20

30

40

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Achieved On-statin LDL Levels

On-Statin LDL-C Levels and Risk for Major

Cardiovascular Events

In-Trial Achieved LDL-C

Documents

Click to edit Master title style - TotalCardiology€¦ · All trials 0.0 0.5 1.0 1.5 2.0 Antiplatelet better Control better Effect of antiplatelet treatment* on vascular events**