1. 1 Guidelines Applied to Practice (GAP) American College of Cardiology, Puerto Rico Chapter

2. 2 INTRODUCTION San Juan : Hotel Intercontinental, Feb. 6, 2007 - Jorge Ortega Gil, MD Mayagüez : Casa del Médico, Feb. 7, 2007 – Marcos Velázquez, MD Ponce : Casa del Médico, Feb. 8, 2007 – José Gómez Rivera, MD Guidelines Applied in Practice (GAP) Chronic Coronary Syndromes (Chronic Stable Angina)

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5. 5 Ischemic Heart Disease in the United States The Magnitude of the Health Problem  Despite the well documented recent decline in cardiovascular mortality, IHD remains the leading cause of death  The initial clinical presentation is about the same for both chronic and acute coronary syndromes (50% each)  About 1.5 million myocardial infarctions occur each year, one third to one half are fatal 200,000 have silent infarctions 200,000 have silent infarctions  16 million people have symptomatic CAD  Approximately 2.5 % of totally asymptomatic middle-aged men have silent myocardial ischemia  One million each PCI and CABG are performed each year  Annual cost in 2004 was about $368 billion

6. 6 The ACC/AHA Guideline Classifications Class I: Evidence and / or agreement that treatment is effective Class IIa: Weight of evidence favors use Class IIb: Usefulness less well established Class III: Evidence and/ or agreement that treatment is not effective Level of evidence: A (high rank) – Based on large randomized trials B (Intermediate rank) Based on smaller trials or careful analyses C (low rank) – Based on expert consensus

7. 7 Pathophysiology & Clinical Presentations Chronic Coronary Syndromes (Chronic Stable Angina) GAP San Juan : Hotel Intercontinental, Feb. 6, 2007 - Jorge Ortega Gil, MD Mayagüez : Casa del Médico, Feb. 7, 2007 – Marcos Velázquez, MD Ponce : Casa del Médico, Feb. 8, 2007 – José Gómez Rivera, MD

8. 8 Ischemic Heart Disease - Overview Atherosclerosis Atherothrombosis Pathophysiology Clinical Presentations Silent ischemia Stable angina Acute Coronary Syndromes Parameters Anatomy: Atheroma / Atherothrombosis Subjective: Angina Objective: EKG T wave ST seg changes Chemistry: Cardiac serum biomarkers: CPK, CK-MB, Troponins Epicardial & Microvascular Spam Prevalence & severity of stenosis

9. 9 Events During Atherogenesis

10. 10 P x r 2h Wall Stress =

11. 11 ISCHEMIC CASCADE Predictable sequence of pathophysiologic events post myocardial supply/demand imbalance Biochemical metabolic actions Flow Maldistribution Hypoperfusion (Rales) Angina / SI Compliance Contractility EF LVEDP (S4) Nuclear Echo EKG TIME FROM ONSET OF ISCHEMIA ± 45 sec.

12. 12 Effect of Fixed Stenosis on Myocardial Blood Flow

13. 13 Progression of coronary plaque over time Clinical Findings Acute Coronary Syndromes Sudden Cardiac Death Acute silent occlusive process Angina pectoris Thrombogenic risk factors Atherogenic risk factors Endothelial dysfunction 20 years 60 years Age

14. 14 IHD – Clinical Spectrum Chronic  Stable Angina  Silent Ischemia  Mixed Angina  Microvascular Angina (Syndrome X)  Stunned & Hibernating Acute  Unstable Angina  Acute Myocardial Infarction (NSTEMI, STEMI)  Sudden Cardiac Death Prinzmetal Angina

15. 15 ANGINA PECTORIS  Location: Usually Substernal, Jaw & Epigastrium  Quality: Sensation of Pain / Discomfort, Oppression, Pressure, Burning, Tightness, Crushing or Squeezing. Can Resemble Ïndigestion”  Radiation: Radiates To Left Or Right Arm Or Shoulder, Jaw or Epigastrium.  Assocatie Symptoms:. Dyspnea, Diaphoresis, Weakness, Nausea, Vomiting, and/or Feeling of Anxiety Or Impending Doom  Duration: 2 Min. – 30 Min. - To Several Hours  - Relieved By TNG In 1-10 Min or Rest  Related To: Exercise, Cold, Meals, Emotion, Coitus. Rest. DIFFERENTIAL DIAGNOSIS OF CHEST PAIN  Cardiovascular: Pericarditis, Aortic Valve Disease, Aortic Dissection, Pulmonary Embolism, Mitral Valve Prolapse  Gastrointestinal: Esophageal, Biliary, Peptic ulcer, Pancreatitis  Pulmonary: Pneumothorax, Pneumonia, Pleuritis  Chest Wall: Costochondritis, Rib fracture, Herpes zoster  Psychological: Anxiety disorders Class Activity evoking angina Limits to normal activity I Prolong ed exertion None II Walking > 2 blocks Slight III Walking < 2 blocks Marked IV Minimal or rest Severe Canadian Cardiovascular Society Classification ( CCSC) Typical angina (define) : Substernal chest discomfort with a characteristic quality and duration that is Provoked by exertion or emotional stress and Relieved by rest or nitroglycerin Atypical angina ( probable): Meets 2 of the above characteristics Noncardiac chest pain : Meets one or none of the typical angina characteristics

16. 16 CAD - Clinical Spectrum  Chronic ischemic heart disease Ischemia precipitated by increased myocardial oxygen demand in the setting of a fixed, not vulnerable atherosclerotic lesion. It is called Stable Angina when the clinical characteristics (Angina attacks) do not change in frequency, duration, precipitating causes, or easy with the angina is relieved, for at least 60 days. Ischemia precipitated by increased myocardial oxygen demand in the setting of a fixed, not vulnerable atherosclerotic lesion. It is called Stable Angina when the clinical characteristics (Angina attacks) do not change in frequency, duration, precipitating causes, or easy with the angina is relieved, for at least 60 days. -Silent Ischemia, -Mixed Angina -Syndome X -Stunning & Hibernating. -Silent Ischemia, -Mixed Angina -Syndome X -Stunning & Hibernating.  Acute Coronary Syndromes (ACS) Ischemia or infarction are caused from a primary reduction in coronary flow, precipitated by plaque disruption and subsequent thrombus formation: Ischemia or infarction are caused from a primary reduction in coronary flow, precipitated by plaque disruption and subsequent thrombus formation: Unstable Angina, NSTEMI, STEMI Unstable Angina, NSTEMI, STEMI Prinzmetal Angina Prinzmetal Angina

17. 17 Is the objective evidence-ST segment shifts- of myocardial ischemia which is not associated with angina or angina equivalents. Silent Ischemia ST seg. depression Iceberg’s sign Angina

18. 18 Mixed Angina  Exertional Angina Plus Angina at Rest or Cold- induced Angina or Emotion-Induced Angina.  Angina at Variable Thresholds of Exercise. Classic Angina Prinzmetal Angina Transient ST seg depression Transient ST seg elevation

19. 19 Pathophysiology: Dynamic small vessel constriction (vasospasm) (positive stress testing)

20. 20  Prolonged bouts of chest pain at rest with EKG ST seg. elevation. PRINZMETAL OR VARIANT ANGINA A = Marked transitory ST Elevation during a bout of severe chest pain B = Thirty min. after A (Normal EKG) Pathophysiology: profound spasm of one of the three major epicardial coronary arteries.

21. 21 Post-ischemic LV Dysfunction Impaired LV contractility despite the presence of viable myocytes Acute phenomenon – The LV dysfunction is due to short periods of coronary occlusion, and persists for minutes, hours or even days after blood flow has been restored. This process is reversible spontaneously. Chronic phenomenon – The LV dysfunction is the result of months or years of chronic ischemia. This process requires revascularization ( PCI, CABG) in order to restore contractility.

22. 22 Chronic Coronary Syndromes Treatment  Pharmacologic Antithrombotics Antithrombotics Beta-Blockers Beta-Blockers ACE-Inhibitors ACE-Inhibitors Lipid-Lowering Agents (+stantins) Lipid-Lowering Agents (+stantins) Aggressive Risk Factors Modifications Aggressive Risk Factors Modifications Influenza Vaccine Influenza Vaccine  Revascularization Mechanical: PCI, CABG Mechanical: PCI, CABG

23. 23 Treatment of Chronic Ischemic Heart Disease I. Medical A) Antianginal and Anti-ischemic therapy  - Blockers; Calcium antagonists;Nitroglycerin and Nitrates B) Pharmacotherapy to prevent Myocardial Infarction and Death Antiplatelet / Antithrombotic agents Lipid – Lowering agents Angiotensin – converting enzymes inhibition (ACE-I)  – Blockers C) Risk Factor Modification Smoking cessation; Blood pressure control D) Influenza Vaccine II. Mechanical Revascularization A) Percutaneous coronary intervenntion (PCI): Conventional Angioplasty (PTCA) Stents implantation: Bare metal & drug - eluting stents B) Surgical - Coronary artery bypass graft (CABG)

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25. 25 Guidelines Applied to Practice (GAP) American College of Cardiology, Puerto Rico Chapter

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27. 27 Holter * EBCT *MRI LVG /