Khai Pham Gia

Vietnam Cardiovascular Organization

Cardiovascular Hospital

Hanoi University of MedicineHanoi University of Medicine

Hanoi, Vietnam

Declared no potential conflict of interest.

Hypertension in Patients with

Coronary Artery Disease Coronary Artery Disease

Prof. Pham Gia Khai, MD. PhD. FACC. FESC

Case

• 61 yrs. F.

• HTN: 10 yrs: well controlled for 5 yrs; recent 5 yrs. Not well controlled

• DM: 5 yrs. Rx: SU + Metformin• DM: 5 yrs. Rx: SU + Metformin

• Atypical chest pain

• Dyspnea on exertion

• ECG: LV hypertrophy; cannot rule out CAD

• Cardiac Echo: LVDd: 57 mm; EF: 45%

MCQ (slide 4)

• Diagnosis of Hypertension :

• (A) Systolic ≥ 140 mmHg and

• Diastolic ≥ 90 mmHg

• (B) Systolic ≥ 140 mmHg and Choose the right answer

• Diastolic < 90 mmHg

• (C) Sporadic Hypertension on 24 hr Holter recording

• Diagnosis of Diabetes mellitus• Diagnosis of Diabetes mellitus

• (A) Fasting Blood Glucose ≥ 7 mmol/L (≥ 126 mg/L) and/or HbA1C ≥ 6.5

• (B) Fasting Blood Glucose ≥ 7 mmol/L and 2hr post-prandial Blood Glucose ≥ 7.8 mmol/L

• (C) Both (A) and (B) Choose the right answer

• Diagnosis of coronary heart disease

• (A) Chest pain relieved by Nitrates, cardiac enzymes normal

• (B) Chest pain not relieved by Nitrates, cardiac enzymes normal

• (C) Suggestive coronary angiogram, cardiac enzymes normal

• (D) Elevated cardiac enzymes, but coronary angiogram normal

• Choose the right answer

ECG

Questions ???

• Relationship between HTN and CAD

• What is the difference of CAD profile in HTN

vs normotensive patients?

• Pretest possibility of CAD? %?• Pretest possibility of CAD? %?

• Which is the best test for diagnosis of CAD in

this patients?

• Optimal strategy for CAD pts with HTN?

mo

rta

lity

risk

an

d9

5%

CI)

mo

rta

lity

risk

an

d9

5%

CI)

BP levels are directly related to ischemic heart

disease at any decade of age

256

128

64

32

256

128

64

32

Age at risk:

80–89 years

70–79 years

60–69 years

50–59 years

Age at risk:

80–89 years

70–79 years

60–69 years

50–59 years

IHD

mo

rta

lity

(flo

ati

ng

ab

solu

teri

sk

IHD

mo

rta

lity

(flo

ati

ng

ab

solu

teri

sk

16

8

4

2

1

0

16

8

4

2

1

0

90

Lewington et al. Lancet 2002;360:1903–13

50–59 years

120 140 160 180

Usual SBP (mmHg)

50–59 years

70

Usual DBP (mmHg) 80

Incidence of MI and total stroke by systolic BP

strata in the in the Framingham population

D’Agostino RW, et al. BMJ 1991; 303:385-389

Intensive Lowering BP levels increases risk of MIin patients at high or very high CV risk

primary

outcome,%

60

50

40

30

20

Mortality increases with follow-up DBP < 70 mmHgin the INVEST trial

Patientswith

primaryoutcome,n56 389 1003 596 174 33 17

Totalpatients,n 176 2239 11306 7376 1230 202 46

Meansystolicbloodpressure,mmHg

Patientswith

primaryoutcome124.3 131.7 135.1 143.7 160.2 171.6 186.0

Patientswithout

primaryoutcome127.0 129.1 131.0 138.8 154.2 169.4 187.5

Inciden

ceofprimary

100 % had coronary heart disease; treatment with beta blocker or calcium channel blocker

.

60 > 60 to 70 > 70 to 80 > 80 to 90 > 90 to 100 > 100 to 110 > 110

Diastolic Blood Pressure, mmHg

20

10

0

Messerli et al. Ann Intern Med 2006;144:884–893

confiden

ceintervals

ofeven

ts,%

Cardiovascular mortality increases with follow-up SBP

< 120 mmHg in the ONTARGET trial

30

25

20

3

2.5

2

Hazard

ratio,95%

confiden

ce

Adjusted

4.5-yearrisk

75 % had coronary heart disease at baseline treatment with ACEi and/or ARB.

112 121 126 130 133 136 140 143 149 160

15

10

5

0

1.5

1

0.5

0

Sleight et al J. Hypertens 2009;27:1360–1369

ACCORD-BPLA Trial

Intensive Lowering of BP levels did not improve CADoutcomes in the diabetic patients

CushamW, et al. N Engl J Med 2010;362:1575-85

ROADMAP: Lowest SBP and/or highest SBP reductionquartile are associated with increasedCV mortality in patients with CHD

SBP reductionLast SBP before event

* 26-MAY-2010

mmHgmmHg

Cohort of patients with pre-existing CHD (n=1104)

mortality

(%)

Olmesartan Placebo

ROADMAP: The increased mortality was only seen inpatients with pre-existing cardiovascular disease (CVD)

p = 0.02

Card

iovasularmortality

26-MA0

Incidence of MI and Strokein Hypertensive patients with CAD

stratified by Diastolic Blood Pressure levels

INVEST Trial

Messerli, et al. Ann Intern Med 2006;144:884–893

The Diagnostic dilemma of CAD in hypertensive

patients

• Chest pain is a common but also non-specific symptom inhypertensive patients both with and without CAD.

• Non invasive screening tests are not able to accurately

discriminate between hypertensive patients with and withoutassociated CAD.associated CAD.

• International guidelines are elusive on the recommended

diagnostic pathway for detection of CAD in this group ofpatients.

• Early CV risk stratification and evaluation of markers of organ

damage may improve diagnostic efficacy.

Chin D, Battistoni A, Tocci G, Passerini J, Parati G, Volpe M. Am J Hypertens. 2012 ; 25:1226-35 .

• Exercise ECG tests have a low specificity and sensitivity for

CAD determination, especially in hypertensive patients.

• This group of patients often have baseline ECG changes,

Exercise ECG

• This group of patients often have baseline ECG changes,

especially in patients with LVH.

Chin D, Battistoni A, Tocci G, Passerini J, Parati G, Volpe M. Am J Hypertens. 2012;25: 1226-35.

Exercise ECG

Weaknesses:

•

•

•

Suboptimal sensitivity.

Low sensitivity in identifying single vessel disease.

the test is not diagnostic in situations where there are• the test is not diagnostic in situations where there are

baseline ECG changes (such as evidence of leftventricular strain secondary to left ventricular

•

•

hypertrophy, left bundle branch block).

Low specificity in certain population of patients (such as

pre-menopausal women).

To increase the accuracy of the test it is necessary to

achieve 85% of the maximum heart rate.

Exercise ECG

Weaknesses:

•

•

•

Suboptimal sensitivity.

Low sensitivity in identifying single vessel disease.

the test is not diagnostic in situations where there are• the test is not diagnostic in situations where there are

baseline ECG changes (such as evidence of leftventricular strain secondary to left ventricular

•

•

hypertrophy, left bundle branch block).

Low specificity in certain population of patients (such as

pre-menopausal women).

To increase the accuracy of the test it is necessary to

achieve 85% of the maximum heart rate.

Stress echocardiography

Strengths:

• higher sensitivity and specificity than the exrecise ECG test.

• it has a higher prognostic value compared to the exercise ECG

(in fact even in the presence of a positive exercise ECG test, a

negative stress echocardiogram predicts a low risk for coronarynegative stress echocardiogram predicts a low risk for coronary

events).

•Higher sensitivity during exercise or with dobutamine, compared

to using other vasodilating agents.

•It enables assessment of other concomitant structural cardiac

abnormalities, such as valvular heart disease.

•Lack of radiation.Chin D, Battistoni A, Tocci G, Passerini J, Parati G, Volpe M. Am J

Hypertens. 2012;25: 1226-35.

Weaknesses:

• lower sensitivity in identifying one vessel disease or

moderate stenosis.

• the inability to visualise the entire left ventricle in a

single window in certain patient groups.

•the assessment of the images is operator-dependent.•the assessment of the images is operator-dependent.

• it is mainly a qualitative, rather than a quantitative

assessment.

• an inadequate acoustic window in certain patient groups

limits the sensitivity and specificity of the test (such as

Chronic obstructive pulmonary disease patients)Chin D, Battistoni A, Tocci G, Passerini J, Parati G, Volpe M. Am J Hypertens. 2012;25: 1226-35.

SPECT

Strengths:

•

l

Quantitative method, which reduces operator biasand inter-observer variability.

New nuclear techniques such as the “gated” SPECT,

enable a contemporary functional and perfusionalassessment of the myocardium, hence increasing theassessment of the myocardium, hence increasing thespecificity of the diagnosis of coronaropathy.

Weaknesses:

l

l

Poor spatial resolution ( approx. 1cm).

The need to use radioactive material limits the use

of this diagnostic technique as a regular “screening”test in hypertensive patients.

Chin D, Battistoni A, Tocci G, Passerini J, Parati G, Volpe M. Am J

Hypertens. 2012;25: 1226-35.

Coronary angiography

remains theremains the

“Gold Standard” ???

Coronary angiography in HT

- In patients without known CAD undergoing elective

invasive angiography the diagnostic yield is relatively low

- This is particularly true for HT with LVH.

- CV risk profiling in HT is of clinical value

Patel MR et al ,

NEJM 2010

The majority of patients with Hypertension

have other coronary risk factorsFramingham Study

Kannel, Am J Hypertens, 2000; 13: 3S-10S

INTERHEART Study

Risk of acute myocardial infarction associated with

exposure to multiple risk factors

Yusuf S, et al. Lancet 2004;364:937–52

CV risk charts

Estimation of ten-year risk of fatal cardiovascular disease in Europe: the SCORE project. Eur Heart J 24:987Z 1003.

Clinical Likelihood of Disease (pretest) (ESC 2013)

This risk is modified if

- ECG indicates abnormalities

- LV EF < 50%

- Visualization of coronary stenoses

< 15%

Nothing

STEP 1

15-85%> 85%

3 Step Algorithm for Diagnosis CAD (ESC 2013 Guidelines)

Determine the Clinical Likelihood of Disease

Testing for CAD

Does the patient have coronary artery stenoses?

- Evidence of ischemia

Severe Symptoms

HIGH

or symptoms

1. Optimal Medical Therapy

2. Assessment of Risk (mortality)

- Extent of ischemia

- Coronary anatomy

STEP 3

Invasive Angiography

& Revascularization

STEP 2

YES

Can it apply for

Hypertensive

Patient?

LOW

CHD RISK

Risk score

INTERMEDIATE HIGH

NON LVHLVH• Consider clustering

of major CV risk factors

and anginal typical

Exercise ECG

High thresholdpositive test

low thresholdpositive test

CORONARY ANGIOGRAPHY

Identify the most appropriate

imaging technique on the

basis of different criteria,

such as :

-Gender

-Patient structure

-Baseline ECG changes

Stress

echocardiographyCoronary CT

Cardiac

RadionuclideImaging

Cardiac MRI

POSITIVE TEST

and anginal typical

symptoms.

•Positive Calcium score

•Carotid artery

atherosclerosis by US

Early and accurate CV risk stratification

in hypertensive patients

Early identification of patients at high risk

of developing coronary heart diseaseof developing coronary heart disease

Helps to target early therapeutic interventions

to prevent coronary morbidity and mortality

Diagnostic flow chart of CAD in hypertensive patients

FRS/SCORE

Target organ damage

HIGH

RISK

LOW

RISK

INTERMEDIATE

RISK

NonLVH Non

LVHLVH

Stress

echoCCT CMRRNI EXERCISE EKG

High

threshold

positive test

Low threshold

positive test

Positive test

CORONARY ANGIOGRAPHY

- Visualization of coronary stenoses

< 15%

Nothing

STEP 1

15-85%> 85%

3 Step Algorithm for SCAD (ESC Guidelines 2103)

Determine the Clinical Likelihood of Disease

Testing for CAD

Does the patient have coronary artery stenoses?

- Evidence of ischemia

Severe Symptoms

HIGH

or symptoms

1. Optimal Medical Therapy

2. Assessment of Risk (mortality)

- Extent of ischemia

- Coronary anatomy

STEP 3

Invasive Angiography

& Revascularization

STEP 2

YES

European Heart Journal 2013 - doi:10.1093/eurheartj/eht296

All CAD Patients need Optimal Medical Management, NOT all Patients need Revascularization

Event prevention

• Lifestyle management

• Control of risk factors

Educate patient

Angina relief

1st line

Short-acting nitrates plus

• ββββ-blockers or CCB heart rate

• Consider CCB-DHP if low HR orintolerance/contraindications

• Consider ββββ-blockers + CCB-DHP

May add orswitch (1st time

for some cases)

• Aspirin†

• Stains

• Consider ACEi or ARBs

• Consider ββββ-blockers + CCB-DHPif CCS angina >2

2nd line

• Ivabradine

• Long-actingnitrates

• Nicorandil

• Ranolazine*

• Trimetazidine*

Consider angio→→→→PCI-stenting or

CABG

*Data for diabetics †If intolerance consider clopidogrel

ESC Guidelines 2013European Heart Journal 2013 - doi:10.1093/eurheartj/eht296

Control well global CV Risk

Factors is the key for the

Treatment of CAD

per

100

pers

ons

35

30

45

40

24%

33%

44%

Framingham Heart Study

Risk of acute myocardial infarction associated

with exposure to multiple risk factors

50

5year

CV

Drisk

per

Reference group: female aged 50 years, TC=4 mmol/L, HDL=1.6 mmol/L, non smoker, no diabetes, at SBP levels of 110,

120, 130, 140, 150, 160, 170 & 180 mmHg

Derived from Anderson et al. Am Heart J 1991;121-293-8

20

Referencegroup

TC=7mmol/L

& smoker male

25

10

15

5

0

& diabetes 60 yrs& HDL=1mmol/L

3%

<1%

6%

12%

18%

24%

Use of the IMPACT mortality model to explain the fall

in CHD deaths in England & Wales 1981–2000

Bridging science and health policy in cardiovascular disease: focus on lipid managementA Report from a Session held during the 7th International Symposium on Multiple Risk Factors

in CV Diseases: Prevention and Intervention – Health Policy, in Venice, Italy, on 25 October,2008

Derived from Atherosclerosis Supplements 10 (2009) 3–21

10%

Reduction

10%

Reduction

in Total-C+45%

Reduction=

Benefit of global CVRF control

Emberson et al. Eur Heart J. 2004;25:484-491

in BP in Total-C+ Reduction

in CVD

=

Predicted Reduction in Major CVD (%)

Treatment

Based on lipids

(statin)

Treatment

Based on BP

Treatment Based on

Overall Absolute Risk

(ASA, lipids, BP)

-6 -6

-9 -8

-12-10

-15

-10

-5

0

Benefit of global CVRF control

Adapted from Emberson et al. Eur Heart J. 2004;25:484-491

Predicted Reduction in Major CVD (%)

-17

-28

-12

-37-40

-35

-30

-25

-20

-15

Top 10%

Top 20%

Top 30%

Treatment thresholds

MCQ (slide 44)Stratification of risk factorsStratification of risk factors

(A) No

(B) YesChoose the right answer

Risk factors as has been proved

BP – Cholesterol – Age – Smoking – DM – GenderEBP – Cholesterol – Age – Smoking – DM – GenderE

(A) Ranking No

(B) Ranking Yes

Choose the right answer

Pretest as established by ESC 2013

Chest pain (Present-Atypical-Absent) – Age – Gender

(A) Meaning Yes

(B) Meaning No

Treatment of HTN in Patients with

CAD

Pharmacological Treatment of

Hypertension in the Management

of Ischemic Heart Disease

Hypertension. 2015;65:000-000. DOI: 10.1161/HYP.0000000000000018

Revascularization Strategy for

Stable Ischemic Heart Disease

Patients with Multivessel Disease

and Hypertension

CABG vs PCI ?CABG vs PCI ?

+ Optimal Medical Treatment

Not all SCAD patients benefit from revascularization

Not all SCAD patients benefit from revascularization

Indications for Revascularization in patients

with stable angina or silent ischaemia

European Heart Journal

doi:10.1093/eurheartj/ehu278

Recommendation for the type of revascularization

(CABG or PCI) inpatients with SCAD with suitable

coronary anatomy for both procedures and low

predicted surgical mortality

European Heart Journal

doi:10.1093/eurheartj/ehu278

MCQ (slide 53)

• Risk stratification for appropriate approach in

diagnosis and treatment

• (A) Should be done

• (B) Optional because of patient and local

infrastructure

• Choose the appropriate answer• Choose the appropriate answer

• Treatment of HTN and accompanying diseases

• (A) Treat HTN first

• (B) Treat HTN and accompanying diseases

• (C) The approach to diagnosis and treatment should

be adapted to individual basis

What did we do with our patient

• Stress ECG: not preferred (LV hypertrophy)

• Echo stress: > 15% Myocardium ischemic

• Risk stratification: high risk

• Optimal Medical Rx:

� DAPT (aspirin + clopidogrel)

� Statin

� ACEi

� Betablocker

� Insulin + Metformine

• Coronary Angiography and Intervention

Cor. angiogram

Post PCI (total revascularization)

Many Thanks