Management of Management of Chronic Stable AnginaChronic Stable Angina

AIMGP Seminar SeriesAIMGP Seminar Series

Mirek Otremba 2007Mirek Otremba 2007

ReferencesReferences

ACC/AHA Guideline on Chronic Stable AnginaACC/AHA Guideline on Chronic Stable AnginaCirc. 1999; 99:2829-2848Circ. 1999; 99:2829-2848Update JACC 2003; 41:159-68Update JACC 2003; 41:159-68www.acc.orgwww.acc.org

CCS Consensus on Chronic Ischemic Heart CCS Consensus on Chronic Ischemic Heart DiseaseDisease

Can J Cardiol 2000; Vol 16 no. 12: 1515-1535Can J Cardiol 2000; Vol 16 no. 12: 1515-1535

Chronic Stable AnginaChronic Stable AnginaNEJM 2005; 352: 2524-33NEJM 2005; 352: 2524-33

Noninvasive tests in patients with stable CADNoninvasive tests in patients with stable CADNEJM 2001; 344: 1840-45NEJM 2001; 344: 1840-45

ObjectivesObjectives

Treatment options for chronic anginaTreatment options for chronic angina

Understand which treatmentsUnderstand which treatments preventprevent MI and death MI and death reducereduce symptoms symptoms

Review the indications for Review the indications for revascularization (PCI or CABG)revascularization (PCI or CABG)

Case PresentationsCase Presentations

How would you further investigate How would you further investigate and/or manage the following patients?and/or manage the following patients?

Take a few minutes for discussionTake a few minutes for discussion

Patient No. 1Patient No. 1

63 F63 F SmokerSmoker ObeseObese Exertional angina (CCS Class 2)Exertional angina (CCS Class 2)

Patient No. 2Patient No. 2

52 M52 M Type II DMType II DM Exertional angina (CCS 3)Exertional angina (CCS 3) Non-invasive testing shows large anterior Non-invasive testing shows large anterior

perfusion defect which is reversibleperfusion defect which is reversible

Patient No. 3Patient No. 3

73 M73 M Hx prior MIHx prior MI Known Gr. 2 LVKnown Gr. 2 LV Inferior reversible defect on SestamibiInferior reversible defect on Sestamibi Presenting with ongoing anginal symptoms Presenting with ongoing anginal symptoms

despite beta blockers, calcium channel despite beta blockers, calcium channel blockers, Nitrates blockers, Nitrates

Overview of TreatmentOverview of Treatment

The treatment of angina has 2 purposesThe treatment of angina has 2 purposes

Prevent MI and death (Prevent MI and death (prolong lifeprolong life))

Reduce symptoms (Reduce symptoms (improve quality of lifeimprove quality of life))

Just a Reminder…Regarding Just a Reminder…Regarding RecommendationsRecommendations

Class 1Class 1 - Conditions for which there is - Conditions for which there is evidence and/or general agreement that a evidence and/or general agreement that a given treatment is usefulgiven treatment is useful

Class 2Class 2 - Conditions for which there is - Conditions for which there is conflicting evidence and/or a divergence of conflicting evidence and/or a divergence of opinion about the usefulness of a treatmentopinion about the usefulness of a treatment

Reminder - RecommendationsReminder - Recommendations

Class 2aClass 2a - Weight of evidence/opinion is in - Weight of evidence/opinion is in favor of usefulnessfavor of usefulness

Class 2bClass 2b - Usefulness is less well established - Usefulness is less well established by evidence/opinionby evidence/opinion

Class 3Class 3 - Conditions for which there is - Conditions for which there is evidence/opinion that the treatment is evidence/opinion that the treatment is ineffective and/or harmfulineffective and/or harmful

Prevention of Prevention of MI and DeathMI and Death in CAD in CAD

Antiplatelet agentsAntiplatelet agents ASAASA 81-150mg daily (Class I) 81-150mg daily (Class I) ClopidogrelClopidogrel 75mg daily (Class IIa): when ASA 75mg daily (Class IIa): when ASA

contraindicatedcontraindicated ASA + ClopidogrelASA + Clopidogrel for patients post PCI or for patients post PCI or

ACS for at least 12 months (Class I)ACS for at least 12 months (Class I)

Prevention of Prevention of MI and DeathMI and Death in CAD in CAD

β blockersβ blockers (Class I) (Class I)

Better evidence (Level A) in patients with previous MI. Better evidence (Level A) in patients with previous MI. Level B with patients without MILevel B with patients without MI

Bisoprolol 2.5mg–10mg once daily

Prevention of Prevention of MI and DeathMI and Death in CAD in CAD

Lipid lowering therapy with Statin (Class I)Lipid lowering therapy with Statin (Class I) LDL target < 2.0 mmol/LLDL target < 2.0 mmol/L LDL target < 1.8 mmol/L in very high risk LDL target < 1.8 mmol/L in very high risk

patients? (ATP III/NCEP)patients? (ATP III/NCEP)

Less evidence for HDL/TG therapy (Class Less evidence for HDL/TG therapy (Class IIa)IIa)

Prevention of Prevention of MI and DeathMI and Death in CAD in CAD

ACE Inhibitors (Class I)ACE Inhibitors (Class I) HOPE trial – RamiprilHOPE trial – Ramipril EUROPA – PerindoprilEUROPA – Perindopril PEACE – Trandolapril (-ve study)PEACE – Trandolapril (-ve study)

Pharmacotherapy to Reduce Pharmacotherapy to Reduce SymptomsSymptoms

Calcium antagonists (Class I)Calcium antagonists (Class I)ββ Blockers (Class I) Blockers (Class I)Nitrates (Class I)Nitrates (Class I)

All prolong All prolong durationduration of exercise before onset of of exercise before onset of angina and ST segment changesangina and ST segment changesAll decrease All decrease frequencyfrequency of angina of angina

Pharmacotherapy to Reduce Pharmacotherapy to Reduce SymptomsSymptoms

Calcium antagonists (Class I)Calcium antagonists (Class I)Long acting CCB’s NOT short acting ones which are felt to Long acting CCB’s NOT short acting ones which are felt to increase adverse cardiac eventsincrease adverse cardiac eventsUse in combination or aloneUse in combination or alone

Pharmacotherapy to Reduce Pharmacotherapy to Reduce SymptomsSymptoms

Long acting nitrates (Class I)Long acting nitrates (Class I)

Short acting nitrates for relief of acute Short acting nitrates for relief of acute episodesepisodes

Goal of therapyGoal of therapy

For most patients the goal of treatment is For most patients the goal of treatment is to be completely to be completely free of anginafree of angina

A return to A return to normal activitiesnormal activities and functional and functional capacitycapacity

Aim for CCS class I angina or betterAim for CCS class I angina or better

Address other modifiable risk factors such Address other modifiable risk factors such as as cholesterol, smoking, HTN, DM, and cholesterol, smoking, HTN, DM, and exercise, weightexercise, weight

Revascularization - CABGRevascularization - CABG

Medical Treatment vs CABGMedical Treatment vs CABGCABG has survival benefit when there isCABG has survival benefit when there is

Left mainLeft main stenosis stenosis

3,2, or 1 vessel disease that includes 3,2, or 1 vessel disease that includes proximal LADproximal LAD

33 vessel disease (without prox. LAD), with vessel disease (without prox. LAD), with poor LV functionpoor LV function

CABG better in relieving symptomsCABG better in relieving symptoms

Revascularization - PCIRevascularization - PCI

Medical Treatment vs PCIMedical Treatment vs PCIEquivalent in terms of survival benefitEquivalent in terms of survival benefitPCI - less angina (better quality of life)PCI - less angina (better quality of life)

PCI vs CABGPCI vs CABGWhere CABG not indicated for survival benefits:Where CABG not indicated for survival benefits:

Equivalent except:Equivalent except:CABG is better in pt with DMCABG is better in pt with DMPCI is better when CABG too high riskPCI is better when CABG too high riskPCI pts have more angina and repeat proceduresPCI pts have more angina and repeat procedures

Follow-up and MonitoringFollow-up and Monitoring

Follow up every 4 to 12 monthsFollow up every 4 to 12 months

Repeat stress testing if significant change Repeat stress testing if significant change in clinical statusin clinical status

Questions to ask at follow upQuestions to ask at follow up Deceased level of activity?Deceased level of activity? Increase in angina symptoms or prn nitrate use?Increase in angina symptoms or prn nitrate use? Is pt tolerating therapy?Is pt tolerating therapy? Other modifiable risk factors?Other modifiable risk factors?

Back to the cases...Back to the cases...Patient 1Patient 1

Stress test shows small apical reversible defectStress test shows small apical reversible defect Relieve Angina SymptomsRelieve Angina Symptoms

start with Metoprolol and titrate to achieve HR 55-60; start with Metoprolol and titrate to achieve HR 55-60; prescribe and counsel re NTG spray useprescribe and counsel re NTG spray usetitrate BB and consider addition of longer acting NTG or titrate BB and consider addition of longer acting NTG or CCB is symptoms persist despite BBCCB is symptoms persist despite BB

Prevent MI and DeathPrevent MI and Deathgive ECASA 325 mg po odgive ECASA 325 mg po odConsider Statin and ACE-InConsider Statin and ACE-Incheck and treat lipids, blood sugar, counsel re: smoking, check and treat lipids, blood sugar, counsel re: smoking, weight reduction, stress modificationweight reduction, stress modificationgiven the small single territory defect on non-invasive given the small single territory defect on non-invasive testing no need to investigate with angiogramtesting no need to investigate with angiogram

63 FSmokerObeseExertional angina (CCS Class 2)

Relieve SymptomsRelieve Symptoms: as in Patient #1: as in Patient #1 Prevent MI and DeathPrevent MI and Death

ASA, Statin, and ACE-InASA, Statin, and ACE-In

Treat DM, check lipidsTreat DM, check lipids

Pt may have proximal LAD lesion and requires further Pt may have proximal LAD lesion and requires further evaluation with angiogramevaluation with angiogram

52 MType II DMExertional angina (CCS 3)Non-invasive testing shows large reversible anterior perfusion defect

Back to the cases...Back to the cases...Patient 2Patient 2

Relieve SymptomsRelieve SymptomsSingle vessel disease suspected Single vessel disease suspected Ongoing symptoms despite optimal medical Ongoing symptoms despite optimal medical management --> needs angiogrammanagement --> needs angiogramMay require revascularization for symptom reliefMay require revascularization for symptom relief

Prevent MI and deathPrevent MI and deathASA, StatinASA, StatinBB (history of MI)BB (history of MI)ACE (Gr 2 LV)ACE (Gr 2 LV)RF modification as appropriateRF modification as appropriate

73 MHx prior MIKnown Gr. 2 LVInferior reversible defect on SestamibiPresenting with ongoing anginal symptoms

despite ββ blockers, CCBs, Nitrates

Back to the cases...Back to the cases...Patient 3Patient 3

Summary for the Tx of CADSummary for the Tx of CAD