CAD
description
Transcript of CAD
Coronary Artery DiseaseCoronary Artery Disease
Mike Dorsch, Pharm.D.,M.S., BCPSMike Dorsch, Pharm.D.,M.S., BCPS
Chronic Disease
Symptoms
Acute Disease
CADCAD
82.6 million American adults have CVD82.6 million American adults have CVD– 16.3 million have CHD or CAD16.3 million have CHD or CAD
7.9 million have had an AMI7.9 million have had an AMI
– 7 million have had a stroke7 million have had a stroke
CHD caused 1 of 6 deaths in the US 2007CHD caused 1 of 6 deaths in the US 2007
CHD is the single largest killer of US adultsCHD is the single largest killer of US adults
Every 25 secs someone has a coronary eventEvery 25 secs someone has a coronary event
Every minute someone will die from a coronary Every minute someone will die from a coronary eventevent
AHA stats 2011
PathophysiologyPathophysiology
Atherosclerosis – chronic Atherosclerosis – chronic immunoinflammatory, fibroproliferative immunoinflammatory, fibroproliferative disease fueled by lipidsdisease fueled by lipids
Many other mechanisms proposedMany other mechanisms proposed
Risk FactorsRisk Factors
AgeAge– Men ≥ 45 or women ≥ 55Men ≥ 45 or women ≥ 55
Family history of CHDFamily history of CHD– Before 55 for male or before 65 for femaleBefore 55 for male or before 65 for female
HyperlipidemiaHyperlipidemia– LDLLDL
SmokingSmokingHypertension (≥ 140/90 or on meds)Hypertension (≥ 140/90 or on meds)Low HDL (<40)Low HDL (<40)Diabetes mellitusDiabetes mellitus
Clinical presentationClinical presentation
Angina pectoris (chest pain)Angina pectoris (chest pain)– Quality – heavy pressure, SOBQuality – heavy pressure, SOB– Location – over the sternum, left arm, jawLocation – over the sternum, left arm, jaw– Duration – 0.5-30 minutesDuration – 0.5-30 minutes– Precipitating factors – exercisePrecipitating factors – exercise– Nitroglycerin reliefNitroglycerin relief– Radiation – left shoulder, jawRadiation – left shoulder, jaw
DiagnosisDiagnosis
Related to risk factorsRelated to risk factors
ECGECG
Stress testStress test– Natural or pharmacologicNatural or pharmacologic– Nuclear stress test (imaging)Nuclear stress test (imaging)
CT angiogramCT angiogram
Angiography (cardiac catheterization)Angiography (cardiac catheterization)
DefinitionDefinition
>> 50% luminal narrowing of at least one major 50% luminal narrowing of at least one major coronary artery at previous coronary coronary artery at previous coronary angiographyangiographyhistory of previous myocardial infarction, history of previous myocardial infarction, percutaneous transluminal coronary intervention percutaneous transluminal coronary intervention or coronary artery bypass graftor coronary artery bypass graftchronic stable angina pectoris associated with a chronic stable angina pectoris associated with a positive exercise tolerance test or positive exercise tolerance test or pharmacologically induced nuclear imaging or pharmacologically induced nuclear imaging or echocardiographic changes (positive nuclear echocardiographic changes (positive nuclear imaging or echocardiographic changes required imaging or echocardiographic changes required if female)if female)
ClassificationsClassifications
Stable exertional angina (chronic)Stable exertional angina (chronic)
Unstable anginaUnstable angina
Vasospastic angina (Prinzmetal)Vasospastic angina (Prinzmetal)
Chronic stable anginaChronic stable angina
Angina that is reproduced by exertionAngina that is reproduced by exertion
Canadian Cardiovascular SocietyCanadian Cardiovascular Society– Class I – normal physical activity does not Class I – normal physical activity does not
induce anginainduce angina– Class II – slight limitations in ordinary activityClass II – slight limitations in ordinary activity– Class III – marked limitations in ordinal activityClass III – marked limitations in ordinal activity– Class IV – inability to carry on any physical Class IV – inability to carry on any physical
activity w/o discomfortactivity w/o discomfortLook in Dipiro’s tables in the IHD chapterLook in Dipiro’s tables in the IHD chapter
Chronic stable anginaChronic stable angina
TreatmentTreatment– Aggressive risk factor modification!Aggressive risk factor modification!
Chronic stable anginaChronic stable angina
Smoking cessationSmoking cessation– Reduces coronary events by 50% over 2 yrsReduces coronary events by 50% over 2 yrs– High relapse rate – encourage patientsHigh relapse rate – encourage patients– TherapiesTherapies
Group counselling, self helpGroup counselling, self help
Nicotine replacement (patches, gums, inhaler)Nicotine replacement (patches, gums, inhaler)
Bupropion SR (Zyban)Bupropion SR (Zyban)
Newer agents to comeNewer agents to come
Chronic stable anginaChronic stable angina
Treat hypertensionTreat hypertension– Decreases coronary events as well as fewer Decreases coronary events as well as fewer
strokes, less renal failure and heart failurestrokes, less renal failure and heart failure– TreatmentTreatment
Defer to HTN lecturesDefer to HTN lectures
HOPE trialHOPE trial
HOPE trialHOPE trial9,297 high-risk patients, 9,297 high-risk patients, >> 55 years old, who had evidence of vascular 55 years old, who had evidence of vascular
disease or diabetes plus one other cardiovascular risk factordisease or diabetes plus one other cardiovascular risk factor
P<0.001
HOPE Investigators. NEJM 2000;342:145-53.
HOPE trialHOPE trial
MI/Stroke/MI/Stroke/CV DeathCV Death
CV DeathCV Death MIMI StrokeStroke TotalTotalMortalityMortality
22% Risk Reduction22% Risk Reductionp<0.001p<0.001
25% Risk Reduction25% Risk Reductionp<0.001p<0.001
20% Risk Reduction20% Risk Reductionp=<0.001p=<0.001
31% Risk Reduction31% Risk Reductionp=<0.001p=<0.001
16% Risk 16% Risk ReductionReductionp=0.006p=0.006
Non CV DeathNon CV Death
0% Risk Reduction0% Risk Reductionp=0.78p=0.78
HOPE Investigators. NEJM 2000;342:145-53.
Chronic stable anginaChronic stable angina
HypercholesterolemiaHypercholesterolemia– Reducing LDL reduces events (primary or Reducing LDL reduces events (primary or
secondary prevention)secondary prevention)– TreatmentTreatment
Defer to Lipid lecturesDefer to Lipid lectures
StatinsStatins
Goal LDL <100 or <70Goal LDL <100 or <70
Scandinavian Simvastatin Survival Scandinavian Simvastatin Survival Study (4S)Study (4S)
Years since randomizationYears since randomization
% S
urv
ivin
g%
Su
rviv
ing
30% risk reduction
p = 0.0003
The Lancet, Vol 344, November 19, 1994The Lancet, Vol 344, November 19, 1994
4,444 patients with CAD4,444 patients with CAD
Scandinavian Simvastatin Survival Scandinavian Simvastatin Survival Study (4S)Study (4S)
11.5%11.5%
8.2%8.2%
Chronic stable anginaChronic stable angina
ObesityObesity– BMI >32 kg/mBMI >32 kg/m22 is associated with increase is associated with increase
mortalitymortality– TreatmentTreatment
Dietary modificationDietary modification
Exercise programExercise program
Pharmacologic therapyPharmacologic therapy– Newer agents coming to marketNewer agents coming to market
Chronic stable anginaChronic stable angina
Control diabetesControl diabetes– DM is a CAD equivalentDM is a CAD equivalent– TreatmentTreatment
Refer to DM lecturesRefer to DM lectures
ACEi, statinACEi, statin
Newer agents coming to marketNewer agents coming to market
Chronic stable anginaChronic stable angina
Antiplatelet therapyAntiplatelet therapy– ASA 81-325mg dailyASA 81-325mg daily
Antithrombotic TrialistsAntithrombotic Trialists’’ Collaboration Collaboration
Antithrombotic Trialists’ Collaboration. BMJ 2002; 324: 71–86.
*Vascular events = myocardial infarction, stroke or vascular death
Category % Odds Reduction
Acute myocardial infarction
Acute stroke
Prior myocardial infarction
Prior stroke/transient ischemic attack
Other high riskCoronary artery disease
(e.g. unstable angina, heart failure)Peripheral arterial disease
(e.g. intermittent claudication)High risk of embolism (e.g. atrial fibrillation)Other (e.g. diabetes mellitus)All trials
1.00.50.0 1.5 2.0Control betterAntiplatelet better
Vasospastic angina (Prinzmetal)Vasospastic angina (Prinzmetal)
Vasospasm that occurs at the site of a Vasospasm that occurs at the site of a coronary arterycoronary artery
Vasospastic angina (Prinzmetal)Vasospastic angina (Prinzmetal)
Clinical presentationClinical presentation– Spontaneous and occurs at rest, with no Spontaneous and occurs at rest, with no
clear association with exertionclear association with exertion– Pain often cyclical (ie, same time of day), Pain often cyclical (ie, same time of day),
usually midnight to early a.m.usually midnight to early a.m.– Pain is similar to angina of effort but may be Pain is similar to angina of effort but may be
longer in durationlonger in duration– Pain may resolve spontaneously or with SL Pain may resolve spontaneously or with SL
nitroglycerinnitroglycerin
Vasospastic angina (Prinzmetal)Vasospastic angina (Prinzmetal)
DiagnosisDiagnosis– Same as chronic stable anginaSame as chronic stable angina– Can give ergonovine, acetylcholine, or Can give ergonovine, acetylcholine, or
methacholine to provoke vasospasmmethacholine to provoke vasospasm
Vasospastic angina (Prinzmetal)Vasospastic angina (Prinzmetal)
TreatmentTreatment– NitratesNitrates– Calcium channel blockersCalcium channel blockers
QuestionsQuestions