STABLE ISCHEMIC HEART DISEASE-

HOW IS IT DIFFERENT FROM ACS..?

DEV PAHLAJANI MD, FACC, FSCAI

HOD Interventional Cardiology

Breach Candy Hospital, Mumbai

SIHD – VS – ACS / AMI

Stable ischemic heart disease (SIHD), Acute coronary

syndrome (ACS): Product of same atherosclerosis (ATH)

Process

Symptoms And Clinical Presentations

Prognosis Indices

Therapeutic Approach

PHASES OF ATHEROSCLEROSIS

THE TIME COURSE OF ATHEROSCLEROSIS

ACUTE INF MI LM

• 82 years male• Mild hypertension, diabetes mellitus • Inferior wall myocardial infarction (MI) 1994 ps stent mid

right coronary artery (RCA)• Acute MI 8hrs duration• Tenecteplase• Transferred

Stable Ischemic

Heart Disease

Stable Coronary

Heart Disease

PhysiologyCAD

+Non

CAD-Ischemia

Anatomy - Coronary Artery Disease

USA Literature

British Literature

MP BNH INF MI LM

MP BNH INF MI LM

PLAQUE CHARACTERIZATION

PATHOPHYSIOLOGY

• RS 65 years Male

• Anterior MI

• Tenecteplase 3HRS.

Role of fibrous cap:

adapt. from Libby P, Circulation 91 (1995)

APPEARANCE OF ATHEROSCLEROTIC PLAQUES

lumenlumen lipid-corelipid-

core

media

fibrous cap

"shoulder region"

"stable" plaque "vulnerable" plaque

CT ATTENUATION CLASSIFICATION OF PLAQUE

CT COR ANGIO MIXED PLAQUE

PLAQUE CHARACTER

Correlation of coronary plaque composition on multi-scale computed tomography with clinical presentation with acute coronary syndromes as compared with stable coronary artery disease (plaque level logistic regression analysis with the application of generalized estimating equation method).

Plaque Characteristics

ACS(plaque n=179)

Stable CAD(plaque n=118)

OR(95%CL)

P-value

Number of non-calcified plaques

57 (32%) 14 (12%) 3.9(1.6-9.5)

0.003

Number of mixed plaques 105 (59%) 32 (27%) 3.4 (1.6-6.9)

0.001

Number of Calcified plaques

17 (9%) 72 (61%) 0.06(0.02-0.2)

<0.001

Why most patients are asymptomatic?

PATHOPHYSIOLOGICAL CHARACTERISTICS OF VULNERABLE PLAQUES

Danger !Large lipid core

Low smooth muscle cells

Thin fibrous cap

High macrophagesfom Davies, Circulation 94 (1996)

Factors needed to produce a vulnerable plaque:

HEALED THROMBUS

HEALED

O2 SUPPLY O2 DEMAND

CORONARY – BLOOD FLOW STENOSIS

THE POSSIBLE SEQUENTIAL CHANGES OF ATHEROSCLEROTIC ARTERY ( BASED ON THE

POSTMORTEM ANALYSIS OF 136 LMCA )

Glagov S, et al. NEJM 1987;316;1371-53.

Early Phase : OvercompensationVss Enlargement > Plaque Accumulation

Late Phase : DecompensationVs Enlargement < Plaque Accumulation

Risk stratification

ACS VS SIHD

4.78.3

13.2

19.9

26.2

40.9

0

10

20

30

40

50

60

0/1 2 3 4 5

TIMI Risk Score for UA/NSTEMI

D/M

I/U

R b

y 14

Day

s (%

)

Antman RM et al JAMA 2000, 284, 835

% Population 4.3 17.3 32.0 29.3 13.0 3.4

6-7

SABATINE AND ANTMAN TIMI RISK SCORE FOR UA/NSTEMI

TACTICS – TIMI 18

12.816.1

19.5

11.8

20.3

30.6

0

5

10

15

20

25

30

35

Low (0-2) Intermed (3-4) High (5-7)

TIMI Risk Score for UA/NSTEMI

D/M

I/A

CS

by

6 m

on

ths

INV CONS

New Eng. J. Med, 2001, 344 : 1879

21 % risk reduction (p=0.048)

36 % risk reduction (p=0.018)

SELF REPORTED ANGINA, STRESS ECHO-937 PTS MEAN FOLLOW UP 3.9 YRS

Survival rate free of myocardial infarction or coronary heart disease death by presence of weekly angina or inducible ischemia at baseline, adjusted for age, sex, race, history or myocardial infarction, history of congestive heart failure, glycosylated hemoglobin level, creatinine clearance, left ventricular ejection fraction, systolic blood pressure, and diastolic blood pressure (p < .001).

TROPONINS SIHD NEJM,2009,2361,26,2538

Hs Trop SIHD N Eng J Med 2009,2361,26,2538

TREATMENT OF SIHD

ASPIRIN IN SIHD

REACH REGISTRY JACC 2014,63,12

1. No prior ischemic event (n=13,091)

OUTCOME EVENTS (%) HR P VALUE

All-cause death,MI or stroke

980 (7.5%) 1.11 0.13

All-cause death,MI, stroke or Bleeding

1040 (7.9%) 1.12 0.10

CV death, MI or stroke 597 (4.6%) 1.18 0.06

All-cause mortality 775 (5.9%) 0.97 0.74

CV mortality 382 (2.9%) 0.97 0.76

Nonfatal MI 125 (1.0%) 1.23 0.34

Nonfatal stroke 102 (0.8%) 1.86 0.0039

REACH REG : NO PREVIOUS MI BENEFIT ONLY IN PATIENTS WITH PRIOR MI

JAMA 308, 1340, 2012

CAD PROGNOSTIC INDEXExtent of CAD Prognostic

Weight(0-100)

5 – YearSurvival

Rate (%)*

1-vessel disease, 75% 23 93

1-vessel disease, 50% to 74% 23 93

1-vessel disease, ≥ 95% 32 91

2-vessel disease 37 88

2-vessel disease, both ≥ 95% 42 86

1-vessel disease, ≥ 95% proximal LAD artery 48 83

2-vessel disease, ≥ 95% LAD artery 48 83

2-vessel disease, ≥ 95% proximal LAD artery 56 79

3-vessel disease 56 79

3-vessel disease, ≥95% in ≥1 vessel 63 73

3-vessel disease, 75% proximal LAD artery 67 67

3-vessel disease, ≥95% proximal LAD artery 74 59

CURRENT TREATMENT FOR CORONARY ARTERY DISEASE

7% 2%

91%

PCI CABG Medical

Current treatment breakdown for 15 million Americans with self-reported coronary artery disease.

JACC 2007, 50, 16, 1598

TRENDS IN PCI BEFORE THE COURAGE TRIAL

Population Based Rates

of PCI by Year in

Hospital Referral Regions

(HRRs) With Cardiac

Hospitals

Years

Rate

per

10,

000

JAMA. 2007;297(9):962-968.

Changes in Geographic Variation in the Use of Percutaneous Coronary

Intervention for Stable Ischemic Heart Disease After Publication of the Clinical

Outcomes Utilizing Revascularization and Aggressive Drug Evaluation

(COURAGE) Trialby Arun V. Mohan, Reza Fazel, Pei-Hsiu Huang, Yu-Chu Shen,

and David Howard

Circ Cardiovasc Qual Outcomes 2014;7:125-130

Quarters

Perc

ent B

y In

dica

tion

Courage March 2007P value <0.01

Among the stable angina patient population, there was a peak 25% decline in percutaneous coronary intervention (PCI) for stable angina after COURAGE

relative to pre-COURAGE Quarter 1 2006. Change was maintained through June 2009. Circulation: Cardiovascular Quality and Outcomes.2011; 4: 300-305

A

Circulation: Cardiovascular Quality and Outcomes.2011; 4: 300-305

There was a significant decline in total percutaneous coronary intervention (PCI) volumes over the study period from January 2006 to June 2009.

Quarters

Num

ber o

f PCI

s

P value <0.01

LESSONS FROM COURAGE TRIAL

N Engl J Med. 2007;356:1503-1516

PCI outcomes in Patients with Stable Obstructive Cor. Art Disease Meta analysis

• Five trials –5286 patients• Ischemia by stress testing, echo, nuclear, FFR• 231 days-5yrs follow up-median 5 yrs.

Stergiopoulos et al. JAMA Int. Med 2014

Stergiopoulos K, et al. . JAMA Intern Med. 2014

Percutaneous Coronary Intervention Outcomes in Patients With Stable Obstructive Coronary Artery Disease and Myocardial

Ischemia A Collaborative Meta-analysis of Contemporary Randomized Clinical Trials

Percutaneous Coronary Intervention Outcomes in Patients With Stable Obstructive Coronary Artery Disease and Myocardial Ischemia A Collaborative Meta-analysis of

Contemporary Randomized Clinical Trials

In patients with stable CAD and objectively documented myocardial ischemia,PCI with MT was not associated with a

reduction indeath, nonfatal MI, unplanned revascularization, or angina compared with MT alone.

Stergiopoulos K, et al. . JAMA Intern Med. 2014

Meta analysis

• 67 Hospital referral regions examined for PCI changes in SIHD before 2006 and after 2008

• COURAGE Trial 2007 • 272659 PCI’s from 526 hospital in SIHD• After COURAGE, PCI’s volume declined by 25%

for SIHD vs 12% for ACS (p = 0.001)– Highest decline was 35% in highest tertile vs 18%

in lowest tertile

Circ Cardiovasc Qual Outcomes, Feb 2014 Vol 7(1):125-130

Changes in Geographic Variation in the Use of Percutaneous Coronary Intervention for Stable Ischemic Heart Disease After

Publication of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) Trial

• Substantial decline in the number of PCI for stable ischemic heart disease (SIHD)

• Decline was also observed for PCI for acute coronary syndrome (ACS)

• Changes in the numbers were strikingly observed in the post COURAGE trial period

• Greater change in the hospitals with high levels of utilization of PCI

Mohan A et al. Circ Cardiovasc Qual Outcomes 2014;7:125-130

Changes in Geographic Variation in the Use of Percutaneous Coronary Intervention for Stable Ischemic Heart Disease After Publication of

the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) Trial

• PCI volume declined by 25% (p<0.001) for SIHD

• Procedures performed for ACS decreased by12% (p<0.001)

• Those with the highest utilization pre COURAGE had the maximum decline

• 35% decline in highest tertile versus 18 % in lowest

Mohan A et al. Circ Cardiovasc Qual Outcomes 2014;7:125-130

Changes in Geographic Variation in the Use of Percutaneous Coronary Intervention for Stable Ischemic Heart Disease After Publication of the

Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) Trial

Circ Cardiovasc Qual Outcomes, 2014 Vol 7(1):125-130

There was a substantial decline in the use of and geographic variation in PCI for SIHD

after the publication of the COURAGE trial. However, geographic variation in the use

of PCI for SIHD remained high.

Changes in Geographic Variation in the Use of Percutaneous Coronary Intervention for Stable Ischemic Heart Disease After

Publication of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) Trial

The decline in geographic variation could indicate that many low risk SIHD patients who could have been

managed with OMT were the subjects of referrals for PCI

Decline in the PCI numbers for SIHD and geographic variation

Reasons : • Compelling results of COURAGE trial • Adherence to appropriateness criteria• guidelines• Reimbursement schedules by the insurance companies• Media attention as regards to the overuse of the stents

JACC

Elective Cor. Angio

• 76 Card. Cath Labs• 2007-2010• 22538 elective cor angio• 4829 (21.4%) normal

VARIATIONS IN COR ANGIO IN SIHD JACC 63,5,2014

CONCLUSIONS

• Athero basis of SIHD and ACS• Changes in symptoms and prognosis due to

pathophysiological process• Generally SIHD has good short and medium term prognosis• Beta blockers beneficial only in prior MI• Aspirin effective if prior ischaemia• Surgery not indicated in majority • Treatment should be directed to plaqe

regression/passivisation