1. Chronic CAD: Diagnosis, Treatment and Guidelines 2016
Morton J. Kern MD, MSCAI, FACC, FAHA
Chief of Medicine, VA Long Beach HSC
Professor of Medicine
University California Irvine

2. Deaths attributable to cardiovascular disease
(United States: 2010).
Percentage breakdown of deaths attributable to cardiovascular disease (United States: 2010). Total may not add to 100 because of rounding. Coronary heart disease includes International Classification of Diseases, 10th Revision (ICD-10) codes I20 to I25; stroke, I60 to I69; heart failure, I50; high blood pressure, I10 to I15; diseases of the arteries, I70 to I78; and other, all remaining ICD-I0 I categories. *Not a true underlying cause. With any-mention deaths, heart failure accounts for 35% of cardiovascular disease deaths. Source: National Heart, Lung, and Blood Institute from National Center for Health Statistics reports and data sets.
Go A et al. Circulation 2014;129:e28-e292

3. Deaths attributable to diseases of the heart
(United States: 1900–2010).
Deaths attributable to diseases of the heart (United States: 1900–2010). See Glossary (Chapter 26) for an explanation of “diseases of the heart.” Note: In the years 1900 to 1920, the International Classification of Diseases codes were 77 to 80; for 1925, 87 to 90; for 1930 to 1945, 90 to 95; for 1950 to 1960, 402 to 404 and 410 to 443; for 1965, 402 to 404 and 410 to 443; for 1970 to 1975, 390 to 398 and 404 to 429; for 1980 to 1995, 390 to 398, 402, and 404 to 429; and for 2000 to 2009, I00 to I09, I11, I13, and I20 to I51. Before 1933, data are for a death registration area and not the entire United States. In 1900, only 10 states were in the death registration area, and this increased over the years, so part of the increase in numbers of deaths is attributable to an increase in the number of states. Source: National Center for Health Statistics.
Go A et al. Circulation 2014;129:e28-e292

4. 58 yo Man, Chest pain after lunch on the way to car.
Bad sushi?

5. CAD is a diffuse process with focal atherosclerotic material (plaque).
Some plaques are obstructive but not thrombotic.
Others are potentially thrombotic but not obstructive.
Myocardial Infartion=
Death of myocardial cells.
Clinical MI = symptoms, ECG and Biomarkers

6. CAD as a cause of Myocardial Ischemia and Infarction
Atherosclerotic Plaque
Normal 16

7. Angiography vs. Pathology

8. Fibrous plaque Angiography vs CTA for CAD ACS 179 LAD
Positive remodeling
Soft plaque
LAD
Motoyama et al. JACC 2007 8

9. Natural History of CAD : A story of remodeling

11. Acute Coronary Syndrome
72 year-old Man
Plaque crater, erosion
Calcific nodule
Thrombus

12. What are the Big 5 medications for CAD?BB
ASA/antiplatelet agents
Statins
Nitrates
Antihypertensive and other risk factor medications

13. NTG ASA Heparin GPB’s Beta blockers Statins CA blockers ACEI
Ranolazine
Beta blockers
CA blockers
ACEI
NTG
FIGURE 44-1 Factors influencing myocardial oxygen supply and demand. FiO2 = fraction of inspired oxygen;Hgb = hemoglobin.
Braunwald’s Heart Disease, 7th Edition

14. Diastolic Dysfunction
Ischemic Cascade
Angina
Δ ECG
Stress ECG
Systolic Dysfunction
Stress Echo/MRI
Diastolic Dysfunction
Perfusion
Abnormalities
Nuclear Imaging
Duration and severity of ischemia

15. Conditions Provoking or Exacerbating Ischemia
Increased Oxygen Demand Decreased Supply
Noncardiac
Hyperthermia Anemia
Hyperthyroidism Hypoxemia
Sympathomimetic toxicity Pneumonia
(e.g., cocaine use) Asthma
Hypertension Chronic obstructive
Anxiety pulmonary disease
Arteriovenous fistulae Pulmonary hypertension
Interstitial pulmonary fibrosis
Obstructive sleep apnea
Cardiac Sickle cell disease
HCM Sympathomimetic toxicity
Aortic stenosis (e.g., cocaine use)
Dilated cardiomyopathy Hyperviscosity
Tachycardia Polycythemia
Ventricular Leukemia
Supraventricular Thrombocytosis
Hypergammaglobulinemia

16. Spectrum of CAD Presentations
SIHD UA NSTEMI STEMI
Definition
Ischemia with activity
Ischemia without necrosis
Necrosis (nontransmural)
Transmural necrosis
Diagnosis
Symptoms, ECG, Stress testing
Negative Biomarkers
Positive biomarkers
No ECG ST-segment elevation
ECG ST-segment elevation
Treatment
The Big 5
Invasive or conservative depending on risk
Immediate reperfusion
Roger VL, Go AS, Lloyd-Jones DM, et al.. Circulation. 2011;123:e18-e209. 16

18. Heart Attack Warning Signs
Chest discomfort
Pressure
Squeezing
Fullness
Pain
Discomfort in other areas of the upper body
Arms
Jaw
Neck
Back
Stomach
Shortness of Breath
Cold sweat, nausea or lightheadedness
**Women have atypical presentations!! Be more wary

19. Current Management for Acute Coronary Syndromes
high risk of in-hospital death
low risk of in-hospital death, unless MI develops
Treatment goal: stabilize with aspirin heparin & monitor for MI development
Treatment goal: immediate restoration of coronary blood flow
+ Cardiac enzymes
– Cardiac Enzymes
High- risk features
Low - risk features
If no cath lab, Fibrinolytic therapy
Direct PCI
Scheduled PCI
Manage medically

20. Thygesen, K. et al. Circulation 2007;116:2634-2653

21. Plalque Rupture Spasm, low BP Sudden Death, no CK PCI related
Stent Thrombosis
CABG related
Thygesen, K. et al. Circulation 2007;116: 21

23. 7 Factors of the TIMI Risk Score for UA/NSTEMI

25. CAD CP algorithm

26. Exercise Pharmacologic 1. ECG - 2. ECHO 4. Dobutamine Echo
The 5 Common Cardiac Stress Testing Modalities
Exercise Pharmacologic
1. ECG -
2. ECHO Dobutamine Echo
3. Nuclear 5. Adenosine Nuclear

27. Who needs Stress Testing?
2014 ESC/EACTS Guidelines on myocardial revascularization

28. Echo stress
Echo stress
ECG stress only Nuclear stress
ECG stress only Nuclear stress

29. Indications for revascularization in Stable CAD or silent ischemia
2014 ESC/EACTS Guidelines on myocardial revascularization

30. Recommendation for CABG/PCI in Stable CAD with anatomy suitable for both procedures
2014 ESC/EACTS Guidelines on myocardial revascularization

31. BP control <140/90 or <130/80 DM, CR
BP maintence add meds as nec to BB/ACE
Lipids Add plant stanol/sterols 2g/
Lipids LDL-C <70mg/dl or high dose statin is reasonable (IIa)
Lipids If LDL-C at base, rx to <70mg/dl is reasonable

32. From: 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines
J Am Coll Cardiol. 2014;63(25_PA): doi: /j.jacc
ABI indicates ankle-brachial index; ASCVD, atherosclerotic cardiovascular disease; CAC, coronary artery calcium; hs-CRP, high-sensitivity C-reactive protein; LDL-C, low-density lipoprotein cholesterol; MI, myocardial infarction; and RCT, randomized controlled trial.

33. From: 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines
J Am Coll Cardiol. 2014;63(25_PA): doi: /j.jacc
ABI indicates ankle-brachial index; ASCVD, atherosclerotic cardiovascular disease; CAC, coronary artery calcium; hs-CRP, high-sensitivity C-reactive protein; LDL-C, low-density lipoprotein cholesterol; MI, myocardial infarction; and RCT, randomized controlled trial.

34. From: 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines
J Am Coll Cardiol. 2014;63(25_PA): doi: /j.jacc
ALT indicates alanine transaminase; ASCVD, atherosclerotic cardiovascular disease; CK, creatine kinase; FH, familial hypercholesterolemia; LDL-C, low-density lipoprotein cholesterol; and ULN, upper limit of normal.

35. From: 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines
J Am Coll Cardiol. 2014;63(25_PA): doi: /j.jacc
ABI indicates ankle-brachial index; ALT, alanine transaminase; ASCVD, atherosclerotic cardiovascular disease; CAC, coronary artery calcium; CK, creatine kinase; FH, familial hypercholesterolemia; LDL-C, low-density lipoprotein cholesterol; MI, myocardial infarction; RCT, randomized controlled trial; and ULN, upper limit of normal.

36. From: 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines
J Am Coll Cardiol. 2014;63(25_PA): doi: /j.jacc
ABI indicates ankle-brachial index; ALT, alanine transaminase; ASCVD, atherosclerotic cardiovascular disease; CAC, coronary artery calcium; CK, creatine kinase; FH, familial hypercholesterolemia; LDL-C, low-density lipoprotein cholesterol; MI, myocardial infarction; RCT, randomized controlled trial; and ULN, upper limit of normal.

37. Exercise Testing I
IIa
IIb
III
In patients entering a formal cardiac rehabilitation program after PCI, treadmill exercise testing is reasonable.
Routine, periodic stress testing of asymptomatic patients after PCI without specific clinical indications should not be performed. I
IIa
IIb
III
No Benefit 37

38. 2014 ESC/EACTS Guidelines on myocardial revascularization

39. Can treatment of Chronic CAD prevent sudden death?