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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
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Act 1 Setting the stage Bulgarian Endovascular Course 2011
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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
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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 Bulgarian Endovascular Course 2011
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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 Bulgarian Endovascular Course 2011
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What would you do? Discharge the patient ASAP ?
Perform an exercise stress-test ? Perform a coronary angio ? Bulgarian Endovascular Course 2011
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Initial strategy Medical treatment Coronary angiogram Fondaparinux
NTG iv ASA Clopidogrel Metoprolol succinate Perindopril Rosuvastatin Coronary angiogram Bulgarian Endovascular Course 2011
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CAG LAD, LCx Bulgarian Endovascular Course 2011
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CAG RCA Bulgarian Endovascular Course 2011
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What would you do? Perform an IVUS? Perform a FFR ? Perform OCT?
Treat the lesion ? Leave the patient on OMT? Bulgarian Endovascular Course 2011
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Treat the lesion POBA with cutting balloon
Angiosculpt (Angioscore Inc) 3,5x20mm Bulgarian Endovascular Course 2011
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Treat the lesion Artax PES (AachenResonance GmbH) 4.0x15mm
Bulgarian Endovascular Course 2011
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Treat the lesion Artax PES (AachenResonance GmbH) 3.5x24mm
Bulgarian Endovascular Course 2011
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Treat the lesion Final reslut Bulgarian Endovascular Course 2011
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Post-procedure Remission of chest pain Resolution of ECG changes
Negative CK, MB, TnI Ready for discharge Bulgarian Endovascular Course 2011
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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 ………………………………? Bulgarian Endovascular Course 2011
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Did we miss something in the therapy?
Would you choose: To add a CCB Or Metabolic strategy Or something else ? Bulgarian Endovascular Course 2011
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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 Bulgarian Endovascular Course 2011
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Two months later… Act 2 Bulgarian Endovascular Course 2011
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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 Bulgarian Endovascular Course 2011
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Bulgarian Endovascular Course 2011
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Angiosculpt (Angioscore Inc) 3,5x12mm
Restenosis again Angiosculpt (Angioscore Inc) 3,5x12mm Bulgarian Endovascular Course 2011
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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 Bulgarian Endovascular Course 2011
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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 Bulgarian Endovascular Course 2011
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The patient comes ready for angio…
Three months later… Act 3 The patient comes ready for angio… Bulgarian Endovascular Course 2011
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CAG: CABG - definitely Bulgarian Endovascular Course 2011
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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 Bulgarian Endovascular Course 2011
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One month after the happy ending…
Act 4 Angina again!!! Bulgarian Endovascular Course 2011
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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? Bulgarian Endovascular Course 2011
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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 Bulgarian Endovascular Course 2011
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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 Bulgarian Endovascular Course 2011
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Immediately after peak of exercise
Stress-test end Immediately after peak of exercise Recovery on 4th min Bulgarian Endovascular Course 2011
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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 Bulgarian Endovascular Course 2011
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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
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