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Transcript of © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (1): ITC1-1. * For Best Viewing:...
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (1): ITC1-1.
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© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (1): ITC1-1.
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© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (1): ITC1-1.
in the clinic
Stable Ischemic Heart Disease
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (1): ITC1-1.
Why is it important to differentiate SIHD from unstable angina? Stable angina
Typically brought on by exertion or emotion
Unstable angina
More random and unpredictable, occurring without trigger
Rest angina: Occurring at rest and lasting >20 minutes
New-onset severe angina: Severe onset ≤2 months of initial presentation
Increasing angina: Previously diagnosed, crescendo pattern
Manage low-risk unstable angina the same as SIHD
Manage intermediate- or high-risk unstable angina more aggressively
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (1): ITC1-1.
What other diseases might be confused with stable ischemic heart disease?
Nonischemic CV: aortic dissection, pericarditis
Pulmonary: embolus, pneumothorax, pneumonia, pleuritis
Esophageal: esophagitis, spasm, reflux
Biliary: colic, cholecystitis, choledocholithiasis, cholangitis
Peptic ulcer
Pancreatitis
Chest wall: costochondrosis, fibrositis, rib fracture, sternoclavicular arthritis, herpes zoster (before the rash)
Psychiatric: anxiety/ affective/ somatoform/ thought disorders
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (1): ITC1-1.
Why is it important to estimate the probability of disease separately from the mortality risk? If <5% probability of CAD: look for other causes of pain
Predictors of CAD Patient age, sex, and type of angina Smoking history, hyperlipidemia, diabetes
Clinical Classification of Chest Pain Typical angina (definite)
Substernal chest discomfort: characteristic quality, duration
Provoked by stress; relieved by rest or nitroglycerin
Atypical angina (probable) Meets 2 of the above characteristics
Noncardiac chest pain Meets ≤1 of typical angina characteristics
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (1): ITC1-1.
How should information from the physical exam be used to evaluate people with SIHD? May reveal related conditions (HF, valvular heart disease)
Signs suggesting CAD (only present during chest pain) S3 or S4 gallop, mitral regurgitant murmur, bibasilar rales,
paradoxically split S2, or chest wall heave
Signs of CHD Jugular venous pulsation, S3 gallop, mitral regurgitation
murmur, displaced apical impulse, pulmonary crackles, diminished breath sounds, dullness to percussion, abdomino-jugular reflux, hepatomegaly, lower extremity edema
Signs of noncoronary atherosclerotic vascular disease
Carotid bruit, diminished / absent pedal pulses, abdominal aneurysms
Xanthelasma and xanthomas: hyperlipidemias
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (1): ITC1-1.
What other preliminary tests should be used to evaluate people with suspected SIHD?
Electrocardiogram
All patients: resting ECG
Chest X-ray
If no obvious noncardiac cause of angina
Echocardiography (rest)
If patient has signs or symptoms suggesting HF or cardiac valvular lesions
If ECG findings show a pathologic Q-wave
If ECG findings show complex ventricular arrhythmias
Not recommended for most patients with SIHD
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (1): ITC1-1.
Which diagnostic test should follow the preliminary assessment?
Standard exercise ECG
If exercise ECG can’t be interpreted / performed:
If due to left bundle branch block: Pharmacologic stress test with imaging (radionuclide perfusion of myocardium / ECHO)
If due to other abnormalities: Exercise stress test with imaging (radionuclide perfusion of myocardium / ECHO)
If patient can’t exercise: Pharmacologic stress test with imaging (radionuclide perfusion of myocardium / ECHO)
Coronary artery calcium for assessment: uncertain
Low coronary artery calcium score identifies people w/o CAD
High score is less reliable in ruling in CAD
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (1): ITC1-1.
Predicts mortality risk based on ECG once the diagnosis is established
If ≥ +5: estimated cardiac mortality rate ≤ 1%/y, usually no further risk assessment required
If < +5 and ≥ -10: use stress imaging or coronary angiography to stratify into low-risk and high-risk groups
If < -10: annual mortality ≥ 3%, consider for revascularization
Duke Treadmill Score
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (1): ITC1-1.
When should clinicians refer patients with suspected ischemic heart disease to specialists?
Consult a cardiologist when…
Diagnosis uncertain after noninvasive testing
Noninvasive testing is contraindicated
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (1): ITC1-1.
When should coronary angiography be used as the initial test to evaluate people with suspected ischemic heart disease?
Patients have survived sudden cardiac death or a life-threatening ventricular arrhythmia
Some employers require before allowing return to work
Regardless of the results from noninvasive testing
Pilots, firefighters, police force
Patients have a high likelihood of severe CAD
Coronary artery spasm strongly suspected
Some patients with HF
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (1): ITC1-1.
CLINICAL BOTTOM LINE: Diagnosis… Predictors of CAD
Age, sex, type of chest pain Smoking history, hyperlipidemia, diabetes mellitus
Physical exam Identify cardiac disease other than CAD Identify comorbid diseases exacerbating angina
Diagnostic tests Resting ECG and chest x-ray Exercise ECG: CAD probability, mortality risk Coronary angiography: specific, limited subset of patients
Consult cardiologist if: Diagnosis uncertain after noninvasive testing Noninvasive testing contraindicated
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (1): ITC1-1.
What are the goals of treatment?
Minimize likelihood of death & maximize health and function
Reduce premature CV death
Prevent complications that impair functional well-being
Strategies for achieving treatment goals
Patient education
Lifestyle modification
Medical therapy
Revascularization (coronary artery bypass grafting or PCI)
Use guideline-directed medical therapy — whether or not revascularization occurs
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (1): ITC1-1.
What is the role of patient education?
Reduce risk factors Improve medication adherence Improve patient satisfaction
Should include:
Review of individual prognosis and important risk factors
Ways to reduce these risk factors
Benefits + side effects of medications and how to administer
Address limitations on physical activity
When to seek medical help
MI signs, symptoms; when to use aspirin, nitroglycerin
What to do in an emergency
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (1): ITC1-1.
Which risk factors should be modified?
Smoking
Recommend smoking cessation and develop cessation plan
Physical activity
If angina chronic + stable: moderate aerobic activity ≥5 d/wk
If high risk of cardiac complications: medically supervised program helps establish safe exercise regimen
Dietary modification
Diet low in saturated fat, cholesterol, trans-fatty acids, and sodium and rich in fresh fruits, vegetables, whole grains
Omega-3 fatty acids, plant stanols/sterols, fiber: reduce risk
If alcohol is part of the diet, consumption should be moderate
Lipid management
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (1): ITC1-1.
Which medical therapies can prevent myocardial infarction or death?
Antiplatelet therapy
Annual influenza vaccine
ACE inhibitors
Angiotensin-receptor antagonists
Beta-blocker therapy
Vitamins and mineral supplements aren’t recommended for preventing CAD events
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (1): ITC1-1.
Which medical therapies relieve symptoms?
Short-acting nitrates
β-blocker Therapy
Calcium-channel blockers and long-acting nitrates
Ranolazine
Alternative therapies for refractory angina in SIHD
Spinal cord stimulation
Enhanced external counterpulsation
Transmyocardial revascularization
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (1): ITC1-1.
Which patients with SIHD are candidates for revascularization with either CABG or a PCI?
To improve survival if mortality risk is high
Left main or complex CAD
>50% stenosis in left main coronary artery
>70% in 3 major coronary arteries
>70% in proximal left anterior descending artery + 1 other major coronary artery
Survivors of sudden cardiac death (presumed ischemia-mediated ventricular tachycardia from >70% stenosis in major coronary artery)
To relieve symptoms if they persist despite therapy
For stenosis likely to affect survival: same recommendations
Other patients with >70% stenosis in ≥1 coronary arteries
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (1): ITC1-1.
Are there special considerations for women, older adults, or patients with diabetes mellitus, CKD, or other conditions? Women
More atypical chest pain + angina-equivalent symptoms
Tend to be treated less aggressively (bc different presentation and testing compared to men?)
Older adults Diagnosis and stress testing harder due to physiologic
changes of aging, coexisting conditions
Receive less evidence-based care (bc pharmacotherapy more difficult? bc of increased CABG morbidity, mortality?)
Diabetes mellitus
Greater risk of SIHD + magnified effects of other risk factors
Chronic kidney disease
Greater risk of SIHD + poor outcomes after AMI interventions
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (1): ITC1-1.
How should patients with treated ischemic heart disease be followed?
Each visit: obtain detailed information on angina
Decreased level of physical activity since the last visit?
Has angina increased in frequency or become more severe?
Are risk factors modified and IHD knowledge improved?
Any new comorbid illnesses?
Has severity or treatment of comorbid illnesses worsened angina?
Assess adherence to therapy and AEs
Encourage smoking cessation, exercise, balanced diet
Use lab evaluation to monitor modifiable risk factors
ECHO / radionuclide imaging / stress test: new symptoms
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (1): ITC1-1.
What do professional organizations recommend with regard to prevention, screening, diagnosis and treatment of SIHD?
Use 2012 clinical guideline for diagnosis and management of SIHD
From the ACP, ACC Foundation, AHA, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (1): ITC1-1.
CLINICAL BOTTOM LINE: Treatment… Minimize likelihood of death & maximize health and function
Use guideline-directed medical therapy
Reduce risk factors with lifestyle modifications and medical Rx
Patient education ensures Understanding of underlying disease process Understanding of warning signs and symptoms of MI Informed decisions about treatment options
Consider revascularization if mortality risk is high or symptoms persist despite guideline-directed medical therapy