Myocardial Ischemia Redefined: Optimal Care in CAD

Learning objectives To improve patient management through a better understanding of: Pathophysiology of myocardial ischemia Efficacy and safety of behavioral and pharmacologic approaches to minimize recurring ischemic episodes Clinical trials investigating multiple treatment targets Current clinical guidelines

Curriculum overview Epidemiology and prevalence of myocardial ischemia –Magnitude of the problem –Challenges in selected populations Issues in contemporary clinical practice Scientific review Clinical trial update New guidelines in myocardial ischemia management Risk stratification

Chronic ischemic heart disease: Overview Highly prevalent – million in the US Multifactorial etiology –CAD, hypertension, hypertrophic cardiomyopathy, valvular heart disease High socioeconomic burden –Depression –↓Quality of life –High costs of care Gibbons RJ et al.

Repeat revascularization is common post-PCI/CABG Kempf J et al. Presented at ESC N = 18,240 who underwent elective PCI or CABG Patients (%) Recurrent angina 2 nd revascularization

Angina increases cost of care Prior to diagnosisFollowing diagnosis ED visitsHospitalizationsED visits Kempf J et al. Presented at Scientific Forum on Quality of Care and Outcomes Res in CV Disease US managed care enrollees, n = 140,001 with asymptomatic CAD, n = 23,535 with angina Dx* Average yearly cost/patient $11,530 (asymptomatic CAD) vs $22,004 (angina) *And Rx nitrates and/or β-blockers and/or CCBs

Challenges in selected populations: Pathophysiology and implications of ischemic heart disease in women Women Elderly Diabetes Ischemic heart disease

WISE: Landmark study in women Goals: Improve diagnostic testing for ischemic heart disease in women Study pathophysiologic mechanisms for ischemia in the absence of epicardial coronary artery stenoses Evaluate the influence of menopausal status and reproductive hormone levels on diagnostic testing results Bairey Merz CN et al. J Am Coll Cardiol. 1999;33: Women’s Ischemia Syndrome Evaluation Prospective cohort study conducted at 4 US sites

WISE: Persistent chest pain in women predicts future CV events Johnson BD et al. Eur Heart J. 2006;27: With CAD HR 1.17 (0.76–1.80) P = 0.49 Without CAD HR 1.89 (1.06–3.39) P = 0.03 Event-free survival (%) Years from PChP diagnosis (at one year) NeitherPChP No CAD No PChP CAD Both n = 673 WISE participants with chest pain at baseline PChP = persistent chest pain

WISE: Persistent chest pain associated with diminished QOL No obstructive CADObstructive CAD No PChPPChP No PChP Angina symptoms Typical presentation (%) Intensity (range 1-5)2.32.6*2.6 Daily frequency (%)3049*3439* Psychological symptoms Perceived QOL † * Depression ‡ * * Anxiety ‡ * *Adjusted P ≤ 0.04 † Range: (best); ‡  score =  trait Johnson BD et al. Eur Heart J. 2006;27: Bairey Merz CN et al. J Am Coll Cardiol. 1999;33:

* * * * * WISE: CAD imposes an economic burden Shaw LJ et al. Circulation. 2006;114: N = 883 women with angiographic CAD Cumulative observed direct costs ($, thousands) Nonobstructive CAD vessel CAD2 vessel CAD3 vessel CAD Follow-up (years) 1 *P < nonobstructive vs 1-3 vessel CAD

Contemporary clinical practice of ischemic heart disease Adapted from Timmis AD et al. Heart. 2007;93: Visible Submerged Revas Healthy population Opportunity for early detection, risk stratification, and medical therapy Revas = revascularization