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General Cardiology Update 2013 Prof. Diana Gorog MB BS, MD, PhD, FRCP Consultant Cardiologist Cardiac ischaemia, irregularities.

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Presentation on theme: "General Cardiology Update 2013 Prof. Diana Gorog MB BS, MD, PhD, FRCP Consultant Cardiologist Cardiac ischaemia, irregularities."— Presentation transcript:

1 General Cardiology Update 2013 Prof. Diana Gorog MB BS, MD, PhD, FRCP Consultant Cardiologist Cardiac ischaemia, irregularities and interventions Diana Gorog Clinical Director for Cardiology Consultant Cardiologist ARIOPS ARIOPS 2013 Conference and Annual General Meeting

2 Cardiac ischaemia, irregularities and interventions Angina Arrhythmias- risk stratification AF

3 Coronary artery disease No.1 cause of death in the Western world ~52,000 new cases of angina in men and ~43,000 new cases in women in UK per annum CAD deaths falling, but – morbidity increasing! – So…more of them in the workplace. 3

4 Adapted with permission from Libby P. Sci Am. 2002;286: Atherothrombosis: An Interaction Between Lipids, Inflammation, and Thrombosis STRIVE TM 2 Lipid-filled plaque Ruptured plaque with thrombus Early atherothrombosis Lipid-filled plaque Ruptured plaque with thrombus Early atherothrombosis Lipid-filled plaque Ruptured plaque with thrombus Early atherothrombosis Lipid-filled plaque Ruptured plaque with thrombus Early atherothrombosis

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6 Stable angina Implementing NICE guidance July 2011 NICE clinical guideline 126

7 Anti-anginal drug treatment 1.Beta blocker (e.g. bisoprolol 2.5mg o.d.) 2.Calcium channel blocker (e.g. tildiem LA 200mg o.d.) 3.Isosorbide (e.g. ISMN SR 60mg o.d.) 4.Nicorandil 10mg b.i.d. 5.4/5 th line agents (to be initiated in secondary care)- 1.Ranolazine 2.Ivabradine

8 Investigation and revascularisation Consider CABG or PCI

9 Investigation and revascularisation When either procedure appropriate, explain risks vs. benefits of PCI and CABG for anatomically less complex disease. If no preference, PCI may be more cost effective procedure. When symptoms are not controlled with optimal medical treatment:

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12 Investigation and revascularisation If either appropriate, consider potential survival advantage of CABG over PCI for people with multivessel disease who: – have diabetes or – > 65 years or – anatomically complex 3- vessel disease, ± LMS involvement. When symptoms are not controlled with optimal medical treatment:

13 Investigation and revascularisation When symptoms are controlled with medical treatment: Consider CABG or PCI to see if revascularisation indicated

14 Investigation and revascularisation When symptoms are controlled with medical treatment: Discuss prognosis, likelihood of having left main stem or proximal three- vessel disease, the process and risks of investigation, the benefits and risks of CABG with person with stable angina and check they are happy to proceed? Consider a functional or non-invasive test to identify people who might gain a survival benefit from revascularisation? Tests indicate extensive ischemia or likelihood of left main stem or proximal 3-vessel disease? Consider PCI, or CABG if coronary angiography indicates left main stem or proximal 3-vessel disease Revascularisation acceptable and appropriate? Answer to each box must be ‘YES’ to proceed

15 Sensitivity ~ 70% Specificity ~ 70% Markedly influenced by: –Population studied –Diagnostic criteria Test performs worse in women than in men Contra-indications –AS –LBBB –Uncontrolled severe HTN Exercise ECG

16 Stress echocardiography Exercise Dobutamine (+ atropine) Sensitivity 85-95% Specificity 80-95% Improved in populations with higher prevalence of multi- vessel CAD

17 Thallium Scan (a.k.a. myocardial perfusion scan, MPS) NormalAbnormal Sensitivity 85-90%

18 Prognostic/predictive value of Stress echo or MPS A stress echo or MPS has a sensitivity of 80-95% in detecting flow limiting CAD A normal stress echo yields an annual risk of %, implying excellent prognosis and v low rate of events, even without revascularization In patients with ischemic LV dysfunction and a significant amount of viable myocardium have lower peri-op mortality, and improved survival and reduced HF after revascularization

19 PALPITATIONS PALPITATIONS

20 Palpitations Common presentation in General Practice Significant social impact Often benign cause Associated with considerable morbidity Nevertheless potentially lethal Chapter 8 of NSF for CHD 20

21 Arrhythmia from a Patient Perspective “I know something's wrong but nobody takes me seriously” “My heart keeps missing beats (and I am really worried I am going to die)” Less than 10% of patients will have a significant arrhythmia 21

22 Which patient is at clinical risk?

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24 When are palpitations likely to be an arrhythmia? High Positive Predictive Value of : Symptoms assoc. with syncope Symptoms during exercise Symptoms disturbing sleep Regular palpitations High Pre test odds or red flags: Known Structural heart Known Structural heartDisease Family history SCDFamily history SCD Personal Hx SyncopePersonal Hx Syncope Male Male Increased age Increased age 24

25 Characteristic ECG abnormalities associated with increased risk of/with arrhythmia: Evidence of an old myocardial infarction. –Pathological Q waves –Inversion of T waves –Loss of R wave progression across the chest leads following an anterior MI. Left ventricular hypertrophy. Right ventricular hypertrophy. Evidence of Wolff–Parkinson–White syndrome –Short PR interval. –Slight widening of the QRS: delta wave with normal terminal QRS segment. –Dominant R wave in V1. –Inverted T waves in V1 – V4. Prolonged QT –Calculate the corrected QT (QTc) by dividing the QT/√R-R interval. –Normal <0.45.

26 Palpitations: Workup Good history (inc. past medical & FH) Check FBC, U&E and thyroid function 12 lead ECG 24 hour Holter monitor Ambulatory ECG –Continuous loop event recorder –Event recorders with auto-activation (features of both Holter and event recorder) (e.g. Novacor) Echocardiogram Treadmill test (for sxs with or after exercise) Implantable loop recorder E.P. testing

27 Ambulatory ECG recording

28 –Combined arrhythmia detection and patient activation –Up to 3 years –Device can be interrogated and data downloaded multiple times Implantable loop recorders

29 “Reveal” interrogation

30 Echo LV dysfunction –Scar –Ischaemic –other LVH Valvular disease Cardiomyopathy –HCM –Dilated –arrhythmogenic

31 MRI If –Malignant arrhythmia of unknown cause –Frequent RVOT ectopy suggestive of runs –Relevant FHx SCD Scar (small) Features of ARVC Sarcoid Amyloid HCM

32 Coronary Angiogram Assessment of VT –More often scar –Ischemia may be important in 30% cases VT scar VF ischaemia

33 Which people with palpitations should I refer? Following initial assessment refer all people with:initial assessment –Risk factors for a serious arrhythmia: A family history of sudden cardiac death below the age of 40 years. Presence of major structural heart disease. –A major ECG abnormality. –Symptoms of ventricular tachycardia or supraventricular tachycardia –WPW –Symptoms of serious complications from arrhythmias. Following ambulatory monitoring, refer people with proven:ambulatory monitoring –Ventricular tachycardia –Supraventricular tachycardia –Atrial flutter –PAF if needing ablation

34 AF – a modern epidemic

35 Heeringa J et al. Eur Heart J 2006;27:949–53; Miyasaki Y et al. Circulation 2006;114:119–25

36 AF management Arrhythmia management Rate control Rhythm control Assessment & modification of risk Anticoagulation (?? Rhythm control) Identification Symptoms Opportunistic screening

37 Annual % risk of stroke without antithrombotic therapy is… CHADS 2 Score Stroke Risk % 95% CI CI – – – – – – – 27.4 The CHADS2 method for estimating stroke risk was validated by a cohort study of 1,733 nonrheumatic atrial fibrillation patients aged 65 to 95 who were tracked through Medicare claims. The patients were not given antithrombotic therapy, such as the anticoagulant warfarin or aspirin. cohort studyMedicareantithromboticwarfarinaspirincohort studyMedicareantithromboticwarfarinaspirin

38 Refinement of stroke assessment in relatively low risk groups Camm AJ, Kirchhof P, Lip GY, et al., Guidelines for the management of atrial fibrillation (ESC), Eur Heart J, 2010;31:2369–429.

39 ScoreRiskConsiderations 0LowAspirin daily or no antithrombotic therapy Preferred: No antithrombotic therapy 1Moderate Oral anticoagulant or Aspirin daily Preferred: Oral anticoagulant therapy 2 or moreModerate / High Oral anticoagulant therapy CHA 2 DS 2 - VASc Risk Scoring for AF patients and Thromboprophylaxis Guidelines (ESC) 1 1.Camm et al, 2010

40 AF management: Rate & rhythm control

41 RATE CONTROL

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43 RHYTHM CONTROL

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45 RATE OR RHYTHM CONTROL?

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49 Drug therapy for Rhythm Control

50 J Am Coll Cardiol 2011;58:1975–85 Composite Mortality Drug therapy for Rhythm Control

51 Last 2 years – disappointing results with promising AAD Dronedarone Amiodarone Cerivarone

52 Can we improve on what can be achieved using these strategies? Yes – role of ablation

53 Rationale for ablation of AF Increased morbidity & possibly mortality with AAD Wish to correct the negative effects of AF on: – General AF symptoms – Quality of life – Heart function (esp. in pts with HF) – Stroke risk – Survival Ablation makes sense – it targets the mechanisms of AF: – Initiators (PV triggers) – Substrate (macro and micro-reentry, rotors)

54 2010 ESC GUIDELINES European Society of CardiologyEuropean Society of Cardiology Guidelines for the management of atrial fibrillation. 2010Guidelines for the management of atrial fibrillation. 2010

55 Role of AF ablation Second line of treatment in patients with symptomatic AF who have failed, or have failed to tolerate treatment with at least one class Ic or class III drug – Class I (Level of evidence A) indication in paroxysmal – Class IIa persistent – Class IIb long-standing persistent First line of treatment in patients with symptomatic AF in whom AAD have not been tried – IIa paroxysmal – IIb other Calikins et al. J Interv Card Electrophysiol (2012) 33:171– HRS-EHRA-ECAS expert consensus statement for AF

56 Targets for AF ablation

57 Ablation strategies

58 Ablation results Depend on: – Pattern of AF (paroxysmal vs. persistent vs. long- lasting persistent) – Comorbidity – Concomitant use of AAD – Number of ablations

59 Pappone et al. JACC 03 AF-freeSurvival 78 vs. 37% at 3yrs (p<0.001) AF Ablation non-randomised comparison with medical Rx

60 Pappone et al. JACC 03 Quality of life Physical (SF-36) Mental (SF-36) AF Ablation non-randomised comparison with medical Rx Quality of life Quality of life

61 DOES ABLATION AFFECT PROGNOSIS?

62 Prognostic benefit? Comparison of: – 4,212 consecutive pts who underwent AF ablation – 16,848 age/gender matched controls with AF (no ablation) – 16,848 age/gender matched controls without AF Rationale for ablation of AF Bunch et al. JCE 2011

63 Rationale for ablation of AF Prognostic benefit? Conclusion: “AF ablation patients have a significantly lower risk of death, stroke, and dementia in comparison to AF patients without ablation. AF ablation may eliminate the increased risk of death and stroke associated with AF” Bunch et al. JCE 2011 (e-pub ahead of print) Death CVA

64 AF ablation Can long-term freedom from AF be achieved?

65 Comparison of AF ablation vs. AAD in randomised trials Randomised studies StudyPatients (n) Age (y)Type of AFPrevious use of AAD Ablation technique Repeat ablation in the ablation group Crossed to ablation in the AAD group Freedom from AF at 1 year AblationAAD Krittayaphong /-10 (ablation) 47 +/- 15 (AAD) Paroxysmal, Persistent>1 PVI + LA lines + CTI ablation + RA linesNot stated 79%40% Wazni /-8 (ablation) 54+/-8 (AAD) Mainly paroxysmalNoPVI12%49% 87%37% Stabile /-9 (ablation) 62+/-10 (AAD) Paroxysmal, persistent>2 PVI + LA lines +/- CTI ablationNo exact data57% 56%9% Oral /-9Persistent >1 (mean 2.1+/-1.2)CPVA 26% for AF, 6% for LA flutter77% 74%4% Pappone /-10 (ablation) 57+/-10 (AAD)Paroxysmal >2 (mean 2+/-1) CPVA + CTI ablation 6% for AF 3% for LA tachycardia42% 86%22% Jais /-11Paroxysmal>1 PVI +/- LA lines +/- CTI ablation Mean 1.8 +/- 0.8 median 2 per patient63% 89%23% Forleo /-9 (ablation) 65+/-6 (AAD) Paroxysmal, persistent>1 PVI +/- LA lines +/- CTI ablationNot stated 80%43% Wilber (ablation) 56.1 (AAD)Paroxysmal >1 (mean 1.3) PVI +/- LA lines +/- CFAEs +/- CTI ablation +/- RA lines 12.6% within 80 days after 1st procedure59% 66%16% Packer (ablation) 56.4 (AAD(Paroxysmal>1 Cryo-PVI +/- LA lines 19% within 90 days after 1st procedure79% 69.9%7.3%

66 AF – long term success Single procedure success rate Multiple procedure success rate* Ouyang et al. Circulation. 2010;122: patients, all paroxysmal, recruited between ; *after median of 1 (1-3) procedures PAROXYSMAL

67 Longer-term outcome Arrhythmia-free survival – 87% - 1 year – 81% - 2 years – 63% - 5 years Weerasooriya, … Haissaguerre & Jais. JACC 2011:57;160-6 Single procedure success rate

68 AF management: summary – Virtually no AAD improves prognosis due to the risk of pro-arrhythmia – Catheter ablation: is vastly superior to AAD in terms of maintenance of SR Is vastly superior to AAD in achieving symptom control/QOL Avoids the risk of pro-arrhythmia and may improve prognosis

69 Thank you for your attention Angina Angina tests of ischemia burden and tests of ischemia burden and their prognostic usefulness role of revscularisation role of revscularisation Arrhythmia Arrhythmia Risk profiling Risk profiling AF management- role of ablation AF management- role of ablation Summary


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