Coronary Artery Disease in Epidemic Proportions in the Indian Subcontinent

Coronary Artery disease in an Coronary Artery disease in an epidemic proportion in India:epidemic proportion in India:Risk Factors and their Risk Factors and their managementmanagement

Dr Javed AkhtarDr Javed AkhtarConsultant CardiologistConsultant CardiologistClinical Lead, Cardiology UnitClinical Lead, Cardiology UnitBHR NHS Trust, LondonBHR NHS Trust, LondonHonorary senior LecturerHonorary senior LecturerUniversity of LondonUniversity of London

ANGINA-Chest pain distributionANGINA-Chest pain distribution

NOT ANGINA ANGINA

82,000 die every year in UK due to CAD82,000 die every year in UK due to CAD It is the leading cause of death for both men and women It is the leading cause of death for both men and women

in the U.Kin the U.K Worldwide, coronary heart disease kills more than 7 Worldwide, coronary heart disease kills more than 7

million people each yearmillion people each year Mortality in UK from CAD is decreasing significantly and a Mortality in UK from CAD is decreasing significantly and a

reduction in mortality of 40% has been achieved in a reduction in mortality of 40% has been achieved in a decade decade

Mortality from CAD is not decreasing among the south Mortality from CAD is not decreasing among the south Asians as fast as in white population Asians as fast as in white population

SOME FACTS ABOUT HEART DISEASESOME FACTS ABOUT HEART DISEASE

Atherosclerosis: When does it Atherosclerosis: When does it begin?begin?

100

80

60

40

20

0

Pre

vale

nce

of

coro

nar

yat

her

oscl

eros

is (

%)

13–19 20–29 30–39 40–49 ≥50Age (years)

17%

37%

60%

71%

85%

Tuzcu EM, et al.. Circulation. 2001;103:2705-2710.

Data from 262 heart transplant donors.Sites with intimal thickness ≥0.5 mm were defined as atherosclerotic.

Atherosclerosis TimelineAtherosclerosis TimelineFoamFoamCells Cells

FattyFattyStreak Streak

IntermediateIntermediateLesion Lesion AtheromaAtheroma

FibrousFibrousPlaquePlaque

ComplicatedComplicatedLesion/Lesion/RuptureRupture

Adapted from Pepine CJ. Am J Cardiol. 1998;82(suppl 104).

From FirstDecade

From ThirdDecade

From FourthDecade

Endothelial DysfunctionEndothelial Dysfunction

Atherosclerosis is a Chronic Inflammatory Atherosclerosis is a Chronic Inflammatory DisorderDisorder

10 Factors10 Factors That Increase the Risk of That Increase the Risk of Heart DiseaseHeart Disease and and Heart AttackHeart Attack::1) Diabetes Mellitus 1) Diabetes Mellitus 2) Tobacco Smoke2) Tobacco Smoke3) High Blood Cholesterol 3) High Blood Cholesterol 4) High Blood Pressure 4) High Blood Pressure 5) Physical Inactivity 5) Physical Inactivity 6) Obesity and Overweight 6) Obesity and Overweight 7) Stress7) Stress8) Alcohol8) Alcohol9) Diet and Nutrition 9) Diet and Nutrition 10) Age10) Age

American Heart AssociationAmerican Heart Association

Substantial Under-diagnosisSubstantial Under-diagnosis Under-TreatmentUnder-Treatment Poor Rates of BP controlPoor Rates of BP control

HypertensionHypertension

High Blood Pressure strain on the heartHigh Blood Pressure strain on the heart

High Blood PressureHigh Blood Pressure

22.7

9.5

3.3 2.45.0

2.0 3.5 2.1

45.4

21.3

12.4

6.29.9

7.3

13.9

6.3

0

10

20

30

40

50

Men2.0

Women2.2

Men3.8

Women2.6

Men2.0

Women3.7

Men4.0

Women3.0

Kannel WB. JAMA. 1996;275:1571-1576.

NormotensiveHypertensive

Coronarydisease Stroke

Peripheral arterydisease

Cardiacfailure

HypertensionHypertensionA Risk Factor for Cardiovascular A Risk Factor for Cardiovascular DiseaseDisease

Risk ratio:

Biennial age-

adjusted rate per

1000 subjects

Relative risk of stroke mortality30

5

10

15

20

0

25

n=347,978 men without previous MI

<120 130–139 160–179 ≥210120–129 140–159 180–209

<80 85–89 100–109 ≥120

80–84 90–99 110–119

DBP (mmHg) SBP (mmHg)

1.761.441.002.54

4.00

6.31

12.57

2.331.681.00

3.78

6.57

10.70

24.34

Increasing BP is closely associated Increasing BP is closely associated with increasing risk of death from with increasing risk of death from strokestroke

DBP SBP

Neaton JD, et al. 1995RAS07000047

n=347,978 men without previous MICHD: coronary heart disease

Relative risk of CHD mortality8

2

4

0

6

<120 130–139 160–179 ≥210

120–129 140–159 180–209

<80 85–89 100–109 ≥120

80–84 90–99 110–119

SBP (mmHg) DBP (mmHg)

1.661.281.00

2.45

3.42

5.26

6.40

1.481.211.00

1.842.56

3.45

5.17

Increasing BP is closely associated with Increasing BP is closely associated with increasing risk of death from coronary heart increasing risk of death from coronary heart

diseasedisease

Neaton JD, et al. 1995

DBPSBP

RAS07000047

Adjusted relative risk

Increasing BP is closely associated Increasing BP is closely associated with increasing risk of end stage with increasing risk of end stage renal diseaserenal disease

*p<0.001; ESRD due to any cause in 332,544 men screened for MRFIT§Men with optimal BP was the reference category

<120§

80

<130 85

130 139 85 89

BP (mmHg) ≥210 120

140 159 90 99

160 179100 109

180 209110 119

0

5

10

15

20

2522.1

1.0 1.2

11.2

6.03.11.9

*

*

**

*

Klag MJ, et al. N Engl J Med 1996RAS07000047

{{

Impact of High-Normal BP on CV RiskImpact of High-Normal BP on CV Risk

Optimal BP: <120/80 mm Hg; normal BP: 120-129/80-84 mm Hg; high-normal BP: 130-139/85-89 mm Hg.

Vasan RS et al. N Engl J Med. 2001;345:1291-1297.

Cumulative incidence of CV events

(%)

16

12

108642

0

14

Optimal BP

Normal BP

12

10

8

6

4

2

0

0 2 4 6 8 10 12Years

Optimal BP

Normal BP

High-normal BPWomen

Men

Cumulative incidence of CV events

(%)

High-normal BP

Implications of Small Reductions in DBPImplications of Small Reductions in DBPfor Primary Preventionfor Primary Prevention

CHD, coronary heart disease.Cook NR et al. Arch Intern Med. 1995;155:701-709.

-21-16

-6

-46

-38

-15

-50

-40

-30

-20

-10

07.5 mm Hg 5-6 mm Hg 2 mm Hg

CHDStroke

Risk reduction

(%)

DBP reduction

Benefits of Tight BP and Tight Glucose Control Benefits of Tight BP and Tight Glucose Control UKPDSUKPDS

-50

-40

-30

-20

-10

0

Tight glucose controlTight BP control

Microvascularendpoints

*

StrokeAny diabetes-

related endpointDiabetes-related

deaths

*

**

*P<0.02, tight BP control (achieved BP 144/82 mm Hg) vs.. less tight control (achieved BP 154/87 mm Hg).†P<0.03, intensive glucose control (achieved HbA1c 7.0%) vs. less intensive control (achieved HbA1c 7.9%).UKPDS Group. BMJ. 1998;317:703-713.UKPDS Group. Lancet. 1998;352:837-853.

Risk reduction

(%)

†

†

LVH is a major risk factor for CVDLVH is a major risk factor for CVD1-6 fold 1-6 fold higher risk for higher risk for anginaangina2-5 fold 2-5 fold higher risk for higher risk for MIMI6-17 fold 6-17 fold higher risk for higher risk for heart failureheart failure3-10 fold 3-10 fold higher risk for higher risk for strokestroke

Risk associated with LVH Risk associated with LVH secondary to Hypertensionsecondary to Hypertension

DrugsDrugs1. ACE-inhibitor/ARBs1. ACE-inhibitor/ARBs2. Calcium Channel Blocker: Amlodipine/Felodipine2. Calcium Channel Blocker: Amlodipine/Felodipine3. Diuretic: Bendroflumethiazide3. Diuretic: Bendroflumethiazide4. . Spironolactone4. . Spironolactone5. Beta-blocker5. Beta-blocker

Non-Pharmacological Non-Pharmacological interventions:interventions:1. Reduction in body weight1. Reduction in body weight2. Regular exercise2. Regular exercise3. Reduction in salt intake3. Reduction in salt intake4. Regular life style4. Regular life style

Management of Management of HypertensionHypertension

Poor compliancePoor compliance Ineffective drugsIneffective drugs Occasional missed dosesOccasional missed doses Asymptomatic conditionAsymptomatic condition Lifestyle factors Lifestyle factors Drug side-effectsDrug side-effects Need for additional agentsNeed for additional agents Key Reason for poor BP control is use of Key Reason for poor BP control is use of

MonotherapyMonotherapy Majority of patients require two or more drugsMajority of patients require two or more drugs

Why do so many patients fail to Why do so many patients fail to achieve BP goal?achieve BP goal?

Average no. of antihypertensive medications1 2 3 4

Multiple antihypertensive agents are Multiple antihypertensive agents are needed to reach BP goalneeded to reach BP goal

Trial (SBP achieved)

Adapted from Bakris et al. Am J Med 2004;116(5A):30S–8 Dahlöf et al. Lancet 2005;366:895–906

ASCOT-BPLA (136.9 mmHg)ALLHAT (138 mmHg)

IDNT (138 mmHg)

RENAAL (141 mmHg)

UKPDS (144 mmHg)

ABCD (132 mmHg)

MDRD (132 mmHg)

HOT (138 mmHg)

AASK (128 mmHg)

RAS07000047

The single most important aspect of The single most important aspect of treating a patient with Hypertension is to treating a patient with Hypertension is to achieve Optimal Blood Pressure and achieve Optimal Blood Pressure and treating the other risk factors treating the other risk factors simultaneouslysimultaneously


Life Style AdviceLife Style Advice Reduce Body weight (Maintain BMI 20-25 Reduce Body weight (Maintain BMI 20-25

Kg/m2)Kg/m2) Reduce dietary Sodium Intake toReduce dietary Sodium Intake to <100 mmol/day or 6 G of Nacl or 2.4 G <100 mmol/day or 6 G of Nacl or 2.4 G

of Na/dayof Na/day Regular Aerobic Exercise(brisk walking 30 Regular Aerobic Exercise(brisk walking 30

mt/day , most of the days)mt/day , most of the days) Limit Alcohol consumptionLimit Alcohol consumption Quit SmokingQuit Smoking Reduce dietary intake of saturated fat and Reduce dietary intake of saturated fat and

increase Vegetables and Fruit portionsincrease Vegetables and Fruit portions


Wrong Dietary HabitsWrong Dietary Habits

Certain Facts about South AsiansCertain Facts about South Asians

DietDiet high in fat and low in fruits & vegetables high in fat and low in fruits & vegetables


Simply a cultural difference?Simply a cultural difference?

200g Margarine 2 Kilos Ghee!

Stress related Heart diseaseStress related Heart disease

Lack of ExerciseLack of Exercise

Genes and environment in type 2 Genes and environment in type 2 diabetes and atherosclerosisdiabetes and atherosclerosis

Women

>80 cm = Increased risk

Men

>88 cm = Increased risk

Lean MEJ et al. Lancet; 1998; 351:853-6

Waist circumference as a measure Waist circumference as a measure of body fat distributionof body fat distribution

cm

Waist CircumferenceWaist CircumferenceWaist CircumferenceWaist Circumference

A VITAL SIGN!!!A VITAL SIGN!!!

SMOKINGSMOKING

SmokeSmoke more than others more than others


>4,000 chemicals inside a cigarette>4,000 chemicals inside a cigarette

The two most harmful chemicals are:The two most harmful chemicals are: Nicotine and carbon monoxideNicotine and carbon monoxide

Nicotine:Nicotine: causes addiction, speeds up the causes addiction, speeds up the heart, raises blood pressure, and constricts heart, raises blood pressure, and constricts the arteriesthe arteries

Carbon monoxide: Carbon monoxide: robs the heart of robs the heart of oxygen, and when combined with nicotine oxygen, and when combined with nicotine it increases blood clotting and cloggingit increases blood clotting and clogging

Harmful Chemicals in Harmful Chemicals in Cigarettes:Cigarettes:

People who smoke:People who smoke:

High risk for IHDHigh risk for IHD High Blood pressureHigh Blood pressure Heart attacksHeart attacks COPD/Chronic bronchitisCOPD/Chronic bronchitis Lung CancerLung Cancer and other adverse effects and other adverse effects

SmokingSmoking

10 Million People smoke in England10 Million People smoke in England 120,000 deaths in UK are Smoking related120,000 deaths in UK are Smoking related 50% of Smokers will die prematurely50% of Smokers will die prematurely 1 in 2 of those who die , die before they reach middle 1 in 2 of those who die , die before they reach middle

age.age. 20% of CHD related deaths in men and 17% in 20% of CHD related deaths in men and 17% in

women are attributed to Smokingwomen are attributed to Smoking

Smoking: Some Smoking: Some factsfacts

Smoking 3-6 Cigs/day Smoking 3-6 Cigs/day doubles the doubles the chance of having Heart attackchance of having Heart attack

Smokers are > twice likely to Smokers are > twice likely to have have fatal heart attack than non-fatal heart attack than non-SmokersSmokers

Within 5 years of giving up Within 5 years of giving up smokingsmoking risk is reduced almost to risk is reduced almost to that of non-smoker that of non-smoker

Smoking: Some Smoking: Some factsfacts

Non-Smoker’s LungsNon-Smoker’s Lungs

Smoker’s LungsSmoker’s Lungs

HyperlipidaeHyperlipidaemiamia

Apart from lowering Total Cholesterol, LDL and Apart from lowering Total Cholesterol, LDL and Triglycerides, and Triglycerides, and

slight increase in HDL, they also have following functions:slight increase in HDL, they also have following functions:

1.1. Fall in C-reactive proteinFall in C-reactive protein

2.2. Statins bind to the lymphocyte function-associated Statins bind to the lymphocyte function-associated antigen-1(LFA-1) therefore antigen-1(LFA-1) therefore potent anti-inflammatory potent anti-inflammatory effectseffects

3.3. Statins improve endothelial function by Statins improve endothelial function by increasing nitric increasing nitric oxide, a vasodilator and decreases the production of oxide, a vasodilator and decreases the production of endothelin-1, a potent vasoconstrictorendothelin-1, a potent vasoconstrictor

4.4. Statins Statins increase the number and activity of circulating increase the number and activity of circulating progenitor cellsprogenitor cells in patients with stable coronary artery in patients with stable coronary artery disease which may disease which may promote the growth of collateral promote the growth of collateral circulation circulation

Do Statins do more than lower lipids?Do Statins do more than lower lipids?

Correlation between percent reduction of LDL Correlation between percent reduction of LDL cholesterol and percent reduction of cholesterol and percent reduction of CAD mortalityCAD mortality

WOSCOPS

CARE

4S

LIPID

?

%

red

uct

ion

LD

L c

ho

lest

ero

l

% reduction CAD mortality

- 60%

0

- 30%

0 - 70%- 35%

AFCAPS

Secondary prevention

Primary prevention

Post-CABG

LIPID-Rx

4S-Pl

CARE-Rx

%

red

uct

ion

C

AD

m

orb

idit

y

LDL cholesterol mg/dl

WOS-Rx

WOS-Pl

AFCAPS-RX-RX

AFCAPS-Pl

50 70 90 110 130 150 170 190 210

5

0

10

15

20

25

4S-RxLIPID-Pl

CARE-Pl

Secondary CAD prevention

Primary CAD prevention

Correlation between absolute reduction of LDL cholesterol and percent reduction of CAD morbidity

TNT: Atorva 80 mg

TNT: Atorva 10 mg

Low HDL-C Levels Increase CHD Risk Even When Low HDL-C Levels Increase CHD Risk Even When Total-C Is NormalTotal-C Is Normal (Framingham)(Framingham)

Risk of CHD by HDL-C and Total-C levels; aged 48–83 yCastelli WP et al. JAMA 1986;256:2835–2838

02468

101214

< 1 1-1.2 1.2-1.5 1.5< 5.0

6.0-6.55.0-6.0

6.5

HDL-C (mmol/L) Tota

l-C (m

mol

/L)

14

-y in

cid

en

ce

rate

s (%

) fo

r C

HD

11.24

11.91

12.50

11.91

6.56

4.67

9.05

5.53

4.85

4.153.77

2.782.06

3.83

10.7

6.6

MIRACL: Addressed a Research GapMIRACL: Addressed a Research Gap

Schwartz GG et al. Am J Cardiol 1998;81:578–581.

Acute coronaryevent

MIRACL

4S

AFCAPS / TexCAPS/WOSCOPS

CARE/LIPID

4 moNo history of CAD Unstable CAD

Randomization:24–96 h

3 mo

t=0

6 mo

Randomization:CARE - 3–20 moLIPID - 3–36 mo

Randomization:>6 mo

Stable CAD

Primary prevention Secondary prevention

The prevention of coronary and stroke events with Atorvastatin The prevention of coronary and stroke events with Atorvastatin in:in:

Hypertensive patient with at least 3 CV risk factors,Hypertensive patient with at least 3 CV risk factors, who have average or lower-than average cholesterol who have average or lower-than average cholesterol

concentrationsconcentrations

Possible CV risk factors:Possible CV risk factors: LVHLVH Type II diabetesType II diabetes PVDPVD H/o Stroke/TIA H/o Stroke/TIA Male >55 years oldMale >55 years old Micro-albuminuria or Proteinuria Micro-albuminuria or Proteinuria Smoking Smoking premature family history of CHDpremature family history of CHD

A multicentre randomised placebo-controlled trialA multicentre randomised placebo-controlled trial Planned follow-up was 5 years, but trial was stopped after Planned follow-up was 5 years, but trial was stopped after

median 3.3 years after significant benefit with Atorvastatin median 3.3 years after significant benefit with Atorvastatin emergedemerged

ASCOT-LLAASCOT-LLA

Sever PS et al. Lancet 2003; 361: 1149-1158

R R

R

+

R = Randomised

atorvastatinatorvastatin placeboplacebo placeboplacebo atorvastatinatorvastatinopen lipid-loweringopen lipid-lowering

ASCOT patientsASCOT patients

TC 6.5 mmol/LTC 6.5 mmol/L TC >6.5 mmol/LTC >6.5 mmol/L TC 6.5 mmol/LTC 6.5 mmol/LTC >6.5 mmol/LTC >6.5 mmol/L

-blocker ± diuretic-blocker ± diuretic CCB ± ACEICCB ± ACEI

open lipid-loweringopen lipid-lowering open lipid-loweringopen lipid-lowering

2,250atorvastatin

2,250atorvastatin

2,250 placebo2,250

placebo2,250

placebo2,250

placebo2,250

atorvastatin2,250

atorvastatin8,000

open lipid-lowering8,000

open lipid-lowering

18,000 patients18,000 patients

5,000TC 6.5 mmol/L

5,000TC 6.5 mmol/L

4,000TC >6.5 mmol/L

4,000TC >6.5 mmol/L

5,000TC 6.5 mmol/L

5,000TC 6.5 mmol/L

4,000TC >6.5 mmol/L

4,000TC >6.5 mmol/L

9,000-blocker ± diuretic

9,000-blocker ± diuretic

9,000CB ± ACEI

9,000CB ± ACEI

500open lipid-lowering




Study designStudy design

Adapted from Sever PS et al. for the ASCOT Investigators. J Hypertens 2001; 19: 1139-1147

CCB = Calcium channel blockerACEI = ACE inhibitorTC = Total cholesterol

Primary endpoint: Cumulative Primary endpoint: Cumulative incidence of non-fatal MI & fatal CHDincidence of non-fatal MI & fatal CHD

36% Relative Risk Reduction

Atorvastatin 10 mg Number of events 100

Placebo Number of events 154

HR=0.64 (0.50-0.83)P=0.0005

0

1

2

3

4

0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5

Time (years)

Pro

po

rtio

n o

f p

atie

nts

%

Adapted from Sever PS et al. Lancet 2003; 361: 1149-1158

Cumulative incidence for fatal & Cumulative incidence for fatal & non-fatal strokenon-fatal stroke

0

1

2

3

0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5

Years

Pro

po

rtio

n o

f p

ati

en

ts (

%)

27% Relative Risk Reduction

HR=0.73 (0.56-0.96)P=0.0236

Atorvastatin 10 mg Number of events 89

Placebo Number of events 121


Effect of atorvastatin & placebo on Effect of atorvastatin & placebo on study endpointsstudy endpoints


Hazard Ratio (95% CI)

0.64 (0.50-0.83)

0.79 (0.69-0.90)

0.71 (0.59-0.86)

0.62 (0.47-0.81)

0.87 (0.71-1.06)

0.90 (0.66-1.23)

0.73 (0.56-0.96)

1.13 (0.73-1.78)

0.82 (0.40-1.66)

0.87 (0.49-1.57)

0.59 (0.38-0.90)

1.02 (0.66-1.57)

1.15 (0.91-1.44)

1.29 (0.76-2.19)

Primary Endpoints

Non-fatal MI (incl silent) + fatal CHD

Secondary Endpoints

Total CV events and procedures

Total coronary events

Non-fatal MI (excl silent) + fatal CHD

All-cause mortality

Cardiovascular mortality

Fatal and non-fatal stroke

Fatal and non-fatal heart failure

Tertiary Endpoints

Silent MI

Unstable angina

Chronic stable angina

Peripheral arterial disease

Development of diabetes mellitus

Development of renal impairment

0.5 1.0 1.5

Atorvastatin better Placebo better

Risk Ratio P value

0.0005

0.0005

0.0005

0.0005

0.1649

0.5066

0.0236

0.5794

0.5813

0.6447

0.0135

0.9254

0.2493

0.3513Area of squares is proportional to the amount of statistical information

Significant risk reductions inSignificant risk reductions in

Non-fatal MI (inc. silent MI) & fatal CHD Non-fatal MI (inc. silent MI) & fatal CHD (-36%, P=0.0005) (-36%, P=0.0005) [Primary endpoint][Primary endpoint]

Total cardiovascular events and procedures Total cardiovascular events and procedures (-21%, (-21%, P=0.0005)P=0.0005)

Total coronary events Total coronary events (-29%, P=0.0005)(-29%, P=0.0005)

Fatal and non-fatal stroke Fatal and non-fatal stroke (-27%, P=0.0236)(-27%, P=0.0236)

These reductions in major CV events are large given the short follow-up time These reductions in major CV events are large given the short follow-up time (median 3.3 years, after 5 year study was stopped early)(median 3.3 years, after 5 year study was stopped early)

These endpoints were met despite patients having average or lower These endpoints were met despite patients having average or lower than average baseline cholesterol levelsthan average baseline cholesterol levels

SummarySummaryPrimary endpoint :Treatment with atorvastatin 10 mg/day (vs placebo) in hypertensive patients with multiple risk factors is associated with:


In hypertensive patients with multiple In hypertensive patients with multiple risk factors at modest risk of CHD, with risk factors at modest risk of CHD, with average or lower than average cholesterol average or lower than average cholesterol concentrations, atorvastatin is associated concentrations, atorvastatin is associated with significant risk reductions in major with significant risk reductions in major CV events including strokeCV events including stroke

ConclusionConclusion


Diabetes:Diabetes: Is it coronary Is it coronary equivalent?equivalent?

Global projections for the diabetes Global projections for the diabetes epidemic 1995-2010epidemic 1995-2010

Risk factors for developing Diabetes:Risk factors for developing Diabetes: ObesityObesity Lack of ExerciseLack of Exercise sedentary life stylesedentary life style Waist girth increaseWaist girth increase Family history of diabetesFamily history of diabetes increasing ageincreasing age

DiabetesDiabetes

Diabetes - a Major CHD Risk Factor

“ … all persons with diabetes could be treated as if they had prior coronary heart disease.”

1. Haffner SM et al N Engl J Med 1998; 339: 229-234

So WHO is at risk ?

Inci

den

ce o

f M

I af

ter

7 ye

ar f

ollo

w-u

p

NormalPopulation

Prior M I(no diabetes)

Type 2 Diabetes

(without M I)

Type 2 Diabetes (prior M I)

0

10

20

30

40

50

WOMENWOMENMENMEN

Survival Post-MI in Diabetic and Non-diabetic Survival Post-MI in Diabetic and Non-diabetic Men and Women: Men and Women: Minnesota Heart SurveyMinnesota Heart Survey

Adapted from Sprafka JM et al. Diabetes Care 1991;14:537-543.

100

80

60

40

0

Surv

ival (%

)

Months Post-MI

No diabetes

n=228

n=1628

Months Post-MI

Surv

ival (%

)

0 20 40 60

Diabetes

100

80

60

40

080 0 20 40 60 80

Diabetes

No diabetes

n=156

n=568

In people with diabetes:1. Heart disease twice as often as people without diabetes. 2. CVS complications occur at an earlier age and result in

premature death.3. Diabetics are 2-4 times more likely to suffer strokes if had a stroke, 2-4 times as likely to have a recurrence.

In people with diabetes:1. Heart disease twice as often as people without diabetes. 2. CVS complications occur at an earlier age and result in

premature death.3. Diabetics are 2-4 times more likely to suffer strokes if had a stroke, 2-4 times as likely to have a recurrence.

Diabetes and CVDDiabetes and CVD

Insulin ResistanceInsulin Resistance

This profile could be

BADNEWS

… as they may be at serious risk of CHD due to their low HDL

for patients with the Metabolic Syndrome and/or type 2 diabetes

See Slide 28 for Prescribing Information

The RIGHT drug for the RIGHT patient

Insulin resistance is linked to a range Insulin resistance is linked to a range of CVDof CVDrisk factorsrisk factors

Insulin resistance

Dyslipidaemia

Microalbuminuria

CVD

Vascular inflammation

Hypertension

Atherosclerosis

Endothelial dysfunction

Adapted from McFarlane SI, et al. J Clin Endocrinol Metab 2001;86:713–718.

Proportion of patients with cardiovascular disease Proportion of patients with cardiovascular disease increases with duration of type 2 diabetesincreases with duration of type 2 diabetes

Years T2DMYears T2DM<=2<=2<=2<=2 3-53-53-53-5 6-96-96-96-9 10-1410-1410-1410-14 15+15+15+15+

15%15%15%15%

21%21%21%21%24%24%24%24%

29%29%29%29%

48%48%48%48%

Harris,S et al. CDA 2003; Type 2 Diabetes and Associated Complications in Primary Care in Canada: The Impact of Duration of Disease on Morbidity LoadHarris,S et al. CDA 2003; Type 2 Diabetes and Associated Complications in Primary Care in Canada: The Impact of Duration of Disease on Morbidity Load..

Investigations in Investigations in suspected coronary suspected coronary artery diseaseartery disease

Investigating suspected coronary artery Investigating suspected coronary artery diseasediseaseBlood tests: Blood tests: FBC, U&E, FBS, Fasting lipids, GTTFBC, U&E, FBS, Fasting lipids, GTTCXRCXRECGECGEchocardiographyEchocardiographyNon-invasive tests:Non-invasive tests:1. Treadmill ECG stress test1. Treadmill ECG stress test2. Myocardial perfusion Imaging2. Myocardial perfusion Imaging3. Stress Echocardiography3. Stress Echocardiography4. CMR stress test4. CMR stress test5. Calcium scoring and CT coronary angiography5. Calcium scoring and CT coronary angiographyCoronary angiographyCoronary angiographyAny other test for co-morbiditiesAny other test for co-morbidities

EchocardiographyEchocardiography

Normal Normal chocardiographychocardiography

Antero-septal MIAntero-septal MI

Anterior MIAnterior MI

Treadmill Test (Exercise ECG teat)Treadmill Test (Exercise ECG teat)

Stress Thallium TestStress Thallium Test

Severe coronary artery Severe coronary artery disease disease

Lt Main coronary Lt Main coronary stenosisstenosis

LMCA stenosis RAO caudal.avi.mp4

A = Aspirin and Antianginal therapy A = Aspirin and Antianginal therapy B = Beta-blocker and Blood pressure B = Beta-blocker and Blood pressure C = Cigarette smoking and Cholesterol C = Cigarette smoking and Cholesterol D = Diet and Diabetes D = Diet and Diabetes E = Education and Exercise E = Education and Exercise

Initial TreatmentInitial Treatment

1/00

80medslides.com

significant left main disease (>60%)significant left main disease (>60%)

3-vessel disease with LVEF< 50%)3-vessel disease with LVEF< 50%)

Left Main equivalentLeft Main equivalent

2-vessel disease with significant 2-vessel disease with significant proximal LAD disease (>70%) and proximal LAD disease (>70%) and either either LVEF < 50%) or demonstrable ischemia on LVEF < 50%) or demonstrable ischemia on noninvasive testingnoninvasive testing

Revascularization for Chronic Stable Revascularization for Chronic Stable AnginaAnginacoronary artery bypass surgery - coronary artery bypass surgery - Class IClass I

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in patients with prior PCI, in patients with prior PCI, CABG or PCI with a large area CABG or PCI with a large area of viable myocardium and/or of viable myocardium and/or high-risk criteria on high-risk criteria on noninvasive testingnoninvasive testing

Failed Medical therapyFailed Medical therapy

Revascularization for Chronic Stable Revascularization for Chronic Stable AnginaAnginaPCI or CABG - Class IPCI or CABG - Class I

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Severe coronary artery Severe coronary artery disease disease

PCI to LADPCI to LAD

Severe LAD stenosis before Severe LAD stenosis before D1D1

Case 1Case 1

PCI and ACSPCI and ACS50 yr old man, ST dep anterior leads, trop +ve

Coronary Artery Bypass GraftCoronary Artery Bypass Graft

Daily exercise for 30 MinsDaily exercise for 30 Mins

ExerciseExercise

ExerciseExercise

Be aware of health issuesBe aware of health issues Body weightBody weight Regular exerciseRegular exercise Dietary habits: More vegetable and less meat, less Dietary habits: More vegetable and less meat, less

oil/butter/Ghee oil/butter/Ghee About risk factors for CHDAbout risk factors for CHD BP check up at regular intervalsBP check up at regular intervals Strict control of HypertensionStrict control of Hypertension Strict control of diabetesStrict control of diabetes >40 years, have at least ETT if possible even without any >40 years, have at least ETT if possible even without any

anginaangina Strict control of dyslipidaemia(HDL, LDL, Total Cholesterol, Strict control of dyslipidaemia(HDL, LDL, Total Cholesterol,

Triglycerides level)Triglycerides level) If coronary artery disease be under follow-up of a properly If coronary artery disease be under follow-up of a properly

trained cardiologisttrained cardiologist If you are advised PCI/CABG, discuss with the cardiologist If you are advised PCI/CABG, discuss with the cardiologist

pros and cons of the procedure and if it is going to increase pros and cons of the procedure and if it is going to increase your survival (it is not against Qaza-o-Kadr)your survival (it is not against Qaza-o-Kadr)

Take-Home MessageTake-Home Message

ThanksThanks

Dr Javed AkhtarDr Javed Akhtar

Coronary Artery Disease in Epidemic Proportions in the Indian Subcontinent

Education

Transcript of Coronary Artery Disease in Epidemic Proportions in the Indian Subcontinent