1. Missing the metabolic approach: Four act drama of one patient, one artery and one missing medication
Lora Nikolova Department Cardiology and Angiology Tokuda Hospital Sofia
Bulgarian Endovascular Course 2011

2. Act 1
Setting the stage
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3. Patient characteristics (1)
57 YO male patient
Hypertension, Dyslipidemia, NIDDM, Gastritis
Family history of CAD – father and brother died from MI
Presents to the outpatient unit with UA III B (Braunwald)
(75 days after his last PCI)
Physical exam: Non-obese, normal breathing, without rales, normal heart sounds, HR – 70 BPM, BP - 146/75mmHg. No signs of venous congestion
Echo – LVEF – 61%, LVEDV/LVESV – 93/37ml, IVS/LVPW – 12/12mm, without significant valve pathology
Baseline medical therapy: metoprolol succinate 25mg, ASA 100mg, Perindopril 2,5 mg, Atorvastatin 10mg; Gliclazide 30mg, Clopidogrel 75mg
Bulgarian Endovascular Course 2011

4. Patient characteristics (2)
Lab results : Hb – 150; Leu – 10,0; Thr – 323; Gluc – 8,1; Tchol – 3,6; HDL-C – 0,69; Tg – 1,85; LDL-C - 2,07; CK – 57; CK-MB – 11; TnI – 0,20 (>UNL)
Resting ECG: Sinus rhythm, inferior ischaemia
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5. Patient characteristics (3)
History of revascularization procedures:
2001 – PCI of RCAprox with BMS.
2005 – PCI of LAD+LCX with BMS
2008 – PCI of RCA mid/dist with 2 BMS.
10/2009 – POBA of RCA with DEB
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6. What would you do? Discharge the patient ASAP ?
Perform an exercise stress-test ?
Perform a coronary angio ?
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7. Initial strategy Medical treatment Coronary angiogram Fondaparinux
NTG iv
ASA
Clopidogrel
Metoprolol succinate
Perindopril
Rosuvastatin
Coronary angiogram
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8. CAG
LAD, LCx
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9. CAG
RCA
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10. What would you do? Perform an IVUS? Perform a FFR ? Perform OCT?
Treat the lesion ?
Leave the patient on OMT?
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11. Treat the lesion POBA with cutting balloon
Angiosculpt (Angioscore Inc)
3,5x20mm
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12. Treat the lesion Artax PES (AachenResonance GmbH) 4.0x15mm
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13. Treat the lesion Artax PES (AachenResonance GmbH) 3.5x24mm
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14. Treat the lesion
Final reslut
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15. Post-procedure Remission of chest pain Resolution of ECG changes
Negative CK, MB, TnI
Ready for discharge
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16. Discharge Discharged on the second day with ambulatory therapy
Clopidogrel 75mg
ASA 100mg
Rosuvastatin 10mg
Metoprolol succinate 25mg
Perindopril 2,5 mg
Isosorbide dinitrate 3 x 10mg
Gliclazide 30mg
………………………………?
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17. Did we miss something in the therapy?
Would you choose:
To add a CCB
Or Metabolic strategy
Or something else ?
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18. Follow-up
Mo 1
Stress-test on treadmill by mACIP protocol – Without significant ST abnormalities up to 10 METS, DP –
Medical therapy - long acting nitrate discontinued due to intolerable headache, other medications – unchanged
Mo 3
Stress-test on treadmill by mACIP protocol negative again at 10 METs, DP –
Medical therapy - unchanged
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19. Two months later…
Act 2
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20. The same stage again…
The patient presents again with UA III B (Braunwald)
Concomitant therapy: metoprolol succinate 25mg, ASA 100mg, Perindopril 2,5 mg, Rosuvastatin10mg; Gliclazide 30mg, Clopidogrel 75mg
Clinical presentation: Normal breathing, without rales, Normal heart sounds, HR – 67 BPM, BP – 150/80. No signs of venous congestion.
TnI – 0,05 (>ULN)
Echo – LVEF – 62%, LVEDV/LVESV – 93/37ml, IVS/LVPW – 12/12mm, without significant valve pathology.
ECG
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21. Bulgarian Endovascular Course 2011

22. Angiosculpt (Angioscore Inc) 3,5x12mm
Restenosis again
Angiosculpt (Angioscore Inc) 3,5x12mm
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23. What would you suggest next?
Refer the patient for immediate CABG
Prevent further restenosis with oral Rapamune
Leave him on optimized medical therapy
Prescribe anxiolytics
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24. Discharge and follow up
Post-procedure
No chest pain
Negative CK, MB, TnI after the procedure
The patient is uncertain about CABG
Based on the results of OSIRIS trial oral sirolimus was given with a loading dose 8mg followed by maintenance dose of 2 mg/daily for 4 weeks.
Ambulatory therapy: metoprolol succinate 25mg, ASA100mg, Perindopril 2,5 mg, Rosuvastatin 10mg; Gliclazide 30mg, Clopidogrel 75mg, Rapamycin 2mg
At Month 1: Negative stress-test
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25. The patient comes ready for angio…
Three months later…
Act 3
The patient comes ready for angio…
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26. CAG: CABG - definitely
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27. Happy ending
The patient gives consent for CABG and is referred with normal EF, CK, MB and slightly elevated TnI – 0,32
CABG was performed – LAD-Lima, RCA(PD) – jump to RM I – svg.
Discharged with ambulatory therapy:
ASA 100mg
Clopidogrel 75mg
Bisoprolol 2,5mg
Perindopril 5mg
Famotidine 20mg
Rosuvastatin 10mg
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28. One month after the happy ending…
Act 4
Angina again!!!
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29. What we really missed? What we did not come up to? Is this all to OMT?
DAPT (Class I, LOE A) ASA 100mg + Clopidogrel 75mg
ACE inh (Class I, LOE A) Perindopril 5mg
Statin (Class I, LOE A) Rosuvastatin 10mg
BB (Class I, LOE A) Bisoprolol 2.5mg
Lower than recommended dosage – symptomatic bradycardia
CCB (Class I, LOE A) Not prescribed hypotension
Nitrates (Class I, LOE C) Not prescribed intolerable headache
SNI (Class IIa, LOE B) Not prescribed symptomatic bradycardia
Metabolic agents Not prescribed - ???
(Class IIa, LOE B)
What we did not come up to?
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30. Step of last resort
The patient was prescribed Preductal MR 35mg bid as add on to his current therapy
8 weeks later on telephone contact the patient reports
Improved exercise tolerance
Reduced angina frequency
Increased treatment satisfaction
Improved subjective disease perception
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31. What about some objective evidence?
The patient is referred for an exercise stress-test on W12 after the CABG
Stress-test on treadmill by mACIP protocol – without significant ST abnormalities up to 4-5 METS, CP
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32. Immediately after peak of exercise
Stress-test end
Immediately after peak of exercise
Recovery on 4th min
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33. What have we learned?
Metabolic agent trimetazidine is effective in controlling intractable angina
Clinical trial data show that the benefits of trimetazidine are multiple
Improved excersice tolerance and QoL
Better outcomes in terms of LVEF after revascularisation
Safer revascularisation procedures
Better survival in STEMI
Preductal MR should be prescribed early in the course of CAD for patients to gain full benefit
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34. Thank you
… and hope to see you again here next year for the yearly update on the outcomes of our patient!
Bulgarian Endovascular Course 2011