1. Management of Chronic Stable Angina AIMGP Seminar Series Mirek Otremba 2007

2. References ACC/AHA Guideline on Chronic Stable Angina Circ. 1999; 99:2829-2848 Update JACC 2003; 41:159-68 www.acc.org CCS Consensus on Chronic Ischemic Heart Disease Can J Cardiol 2000; Vol 16 no. 12: 1515-1535 Chronic Stable Angina NEJM 2005; 352: 2524-33 Noninvasive tests in patients with stable CAD NEJM 2001; 344: 1840-45

3. Objectives Treatment options for chronic angina Understand which treatments prevent MI and death prevent MI and death reduce symptoms reduce symptoms Review the indications for revascularization (PCI or CABG)

4. Case Presentations How would you further investigate and/or manage the following patients? Take a few minutes for discussion

5. Patient No. 1 63 F 63 F Smoker Smoker Obese Obese Exertional angina (CCS Class 2) Exertional angina (CCS Class 2)

6. Patient No. 2 52 M 52 M Type II DM Type II DM Exertional angina (CCS 3) Exertional angina (CCS 3) Non-invasive testing shows large anterior perfusion defect which is reversible Non-invasive testing shows large anterior perfusion defect which is reversible

7. Patient No. 3 73 M 73 M Hx prior MI Hx prior MI Known Gr. 2 LV Known Gr. 2 LV Inferior reversible defect on Sestamibi Inferior reversible defect on Sestamibi Presenting with ongoing anginal symptoms despite beta blockers, calcium channel blockers, Nitrates Presenting with ongoing anginal symptoms despite beta blockers, calcium channel blockers, Nitrates

8. Overview of Treatment The treatment of angina has 2 purposes Prevent MI and death (prolong life) Prevent MI and death (prolong life) Reduce symptoms (improve quality of life) Reduce symptoms (improve quality of life)

9. Just a Reminder…Regarding Recommendations Class 1 - Conditions for which there is evidence and/or general agreement that a given treatment is useful Class 2 - Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness of a treatment

10. Reminder - Recommendations Class 2a - Weight of evidence/opinion is in favor of usefulness Class 2b - Usefulness is less well established by evidence/opinion Class 3 - Conditions for which there is evidence/opinion that the treatment is ineffective and/or harmful

11. Prevention of MI and Death in CAD Antiplatelet agents ASA 81-150mg daily (Class I) ASA 81-150mg daily (Class I) Clopidogrel 75mg daily (Class IIa): when ASA contraindicated Clopidogrel 75mg daily (Class IIa): when ASA contraindicated ASA + Clopidogrel for patients post PCI or ACS for at least 12 months (Class I) ASA + Clopidogrel for patients post PCI or ACS for at least 12 months (Class I)

12. Prevention of MI and Death in CAD β blockers (Class I) Better evidence (Level A) in patients with previous MI. Level B with patients without MI Bisoprolol 2.5mg–10mg once daily

13. Prevention of MI and Death in CAD Lipid lowering therapy with Statin (Class I) LDL target < 2.0 mmol/L LDL target < 2.0 mmol/L LDL target < 1.8 mmol/L in very high risk patients? (ATP III/NCEP) LDL target < 1.8 mmol/L in very high risk patients? (ATP III/NCEP) Less evidence for HDL/TG therapy (Class IIa)

14. Prevention of MI and Death in CAD ACE Inhibitors (Class I) HOPE trial – Ramipril HOPE trial – Ramipril EUROPA – Perindopril EUROPA – Perindopril PEACE – Trandolapril (-ve study) PEACE – Trandolapril (-ve study)

15. Pharmacotherapy to Reduce Symptoms Calcium antagonists (Class I) β Blockers (Class I) Nitrates (Class I) All prolong duration of exercise before onset of angina and ST segment changes All decrease frequency of angina

16. Pharmacotherapy to Reduce Symptoms Calcium antagonists (Class I) Long acting CCB’s NOT short acting ones which are felt to increase adverse cardiac events Use in combination or alone

17. Pharmacotherapy to Reduce Symptoms Long acting nitrates (Class I) Short acting nitrates for relief of acute episodes

18. Goal of therapy For most patients the goal of treatment is to be completely free of angina A return to normal activities and functional capacity Aim for CCS class I angina or better Address other modifiable risk factors such as cholesterol, smoking, HTN, DM, and exercise, weight

19. Revascularization - CABG Medical Treatment vs CABG CABG has survival benefit when there is Left main stenosis 3,2, or 1 vessel disease that includes proximal LAD 3 vessel disease (without prox. LAD), with poor LV function CABG better in relieving symptoms

20. Revascularization - PCI Medical Treatment vs PCI Equivalent in terms of survival benefit PCI - less angina (better quality of life) PCI vs CABG Where CABG not indicated for survival benefits: Equivalent except: Equivalent except: CABG is better in pt with DM PCI is better when CABG too high risk PCI pts have more angina and repeat procedures

21. Follow-up and Monitoring Follow up every 4 to 12 months Repeat stress testing if significant change in clinical status Questions to ask at follow up Deceased level of activity? Deceased level of activity? Increase in angina symptoms or prn nitrate use? Increase in angina symptoms or prn nitrate use? Is pt tolerating therapy? Is pt tolerating therapy? Other modifiable risk factors? Other modifiable risk factors?

22. Back to the cases... Patient 1 Stress test shows small apical reversible defect Relieve Angina Symptoms Relieve Angina Symptoms start with Metoprolol and titrate to achieve HR 55-60; prescribe and counsel re NTG spray use titrate BB and consider addition of longer acting NTG or CCB is symptoms persist despite BB Prevent MI and Death Prevent MI and Death give ECASA 325 mg po od Consider Statin and ACE-In check and treat lipids, blood sugar, counsel re: smoking, weight reduction, stress modification given the small single territory defect on non-invasive testing no need to investigate with angiogram 63 F Smoker Obese Exertional angina (CCS Class 2)

23. Relieve Symptoms: as in Patient #1 Relieve Symptoms: as in Patient #1 Prevent MI and Death Prevent MI and Death ASA, Statin, and ACE-In Treat DM, check lipids Pt may have proximal LAD lesion and requires further evaluation with angiogram 52 M Type II DM Exertional angina (CCS 3) Non-invasive testing shows large reversible anterior perfusion defect Back to the cases... Patient 2

24. Relieve Symptoms Relieve Symptoms Single vessel disease suspected Ongoing symptoms despite optimal medical management --> needs angiogram May require revascularization for symptom relief Prevent MI and death Prevent MI and death ASA, Statin BB (history of MI) ACE (Gr 2 LV) RF modification as appropriate 73 M Hx prior MI Known Gr. 2 LV Inferior reversible defect on Sestamibi β Presenting with ongoing anginal symptoms despite β blockers, CCBs, Nitrates Back to the cases... Patient 3

25. Summary for the Tx of CAD