L’angine©2005 PPS® Relationship Between LDL-C and Event Rates in TNT and Other Statin Trials 30...
Transcript of L’angine©2005 PPS® Relationship Between LDL-C and Event Rates in TNT and Other Statin Trials 30...
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Michel Samson m.d. Cardiologue CHUL du CHUQ Québec
L’angine
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Quels sont les critères d’angine de notre patient???
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Diagnostic de l’angine
• 1. rétro-sternale et de type viscérale (pesanteur, brûlement, serrement)?
• 2. provoquée par l’effort ou l’émotion intense?
• 3. soulagée par repos ou la TNT ?
La douleur est…
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La douleur…
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Diagnostic de l’angine • Angor Typique = 3/3
• Angor atypique = 2/3
• Douleur thoracique = 1/3 d’étiologie indéterminée
(DTEI)
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Prévalence de MCAS selon type de patients
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Classe fonctionnelle « Canadian Cardiovascular Society »
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Évaluation: Recherche de causes secondaires et facteurs de risque: examen physique FSC TSH Bilan lipidique Biologie générale
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VRAI ou FAUX… chronologiquement… …la douleur cardiaque apparaît en même temps que les changements ECG
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Cascade ischémique
MVO2
Temps Effort
métabolique
Dysfonction systolique
Dysfonction diastolique
Changement ECG
Angor
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Protocole de Bruce
Stade Vitesse mph
Pente %
Dépense Mets
1 1,7 10 4.8
2 2.5 12 6.8
3 3.4 14 10
4 4.2 16 13
5 5.0 18 16
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Dépense énergétique
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Application clinique du test d’effort
• Diagnostic de la maladie • Pronostic de la maladie • Évaluation post-infarctus
• Évaluation de FA, arythmies • … de claudication • … du traitement • Prescription d’exercice
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Lequel n’est pas un critère de sévérité au Tapis roulant?
• Une épreuve cliniquement positive. • Un sous-décalage ST prolongé. • Une baisse de TA. • Une durée de moins de 6 minutes
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Critères de sévérités au Tapis roulant
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Comparaison Repos - Effort
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Scintigraphie myocardique
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• L’utilisation comme 1er test chez un jeune homme de 35 ans.
• Comme 1er test chez un patient avec BBG
La meilleure indication d’un Thallium ou MIBI est…
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Scintigraphie myocardique: agents
99
99
Captés par le myocarde en proportion de la perfusion
Lancet;354:661-66
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• Le tapis non-interprétable
• Le tapis non-valable
• le patient avec probabilité moyenne
• Clarifier la signification physiologique d’une lésion connue
• Localiser l’ischémie
Indication de la scintigraphie myocardique - diagnostic -
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Claudication intermittente La grand-maman et sa marchette… Fréquence cardiaque visée non-
atteinte
Indication de la scintigraphie myocardique: Le tapis non-valable:
Stimulation pharmacologique: Persantin IV ou Adénosine
1- Perfusion des artères normales (endothélium sain) relativement aux artères sténosées.
2- Vol coronarien chez 10-20%
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Scintigraphie myocardique de notre patient
Repos
Effort
Ischémie légère territoire antérieur
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Coronarographie • 1. Angor non-contrôlé
• 2. Critères de sévérité à l’évaluation non- invasive……..
……..suspicion de 3 vx ou Tronc commun
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Coronarographie – exemple: coronaire droite 80%
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Nommer maintenant quelques médicaments
pouvant modifier le pronostic???
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Objectifs de traitement - angine -
Réduire les symptômes
Éviter les événements coronariens et prolonger la vie
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Éviter les événements coronariens et prolonger la vie
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Bénéfice absolu de l ’ASA selon le niveau de risque de base.
CHEST 1998; 114: 470S -488S Circulation 2000;101:1206-18
200-1000
78 55
20
NNT Acute MI . 41
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AAS vs clopidogrel
Réduction
du risque
relatif
AAS Antiplatelet Trialists’
Collaboration
25 %
Clopidogrel CAPRIE
33 %
+8.7%
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©2005 PPS®
Relationship Between LDL-C and Event Rates in TNT and Other Statin Trials
30
25
20
15
10
5
00 70 90 110 130 150 170 190 210
LDL-C (mg/dL)
TNT (atorvastatin 80 mg/d)
TNT (atorvastatin 10 mg/d)HPS
CARE
LIPIDLIPID
CAREHPSEv
ent
(%)
StatinPlacebo
4S
4S
TNT=Treating to New Targets; HPS=Heart Protection Study; CARE=Cholesterol and Recurrent Events Trial; LIPID=Long-term Intervention with Pravastatin in Ischaemic Disease; 4S=Scandinavian Simvastatin Survival Study.
LaRosa JC et al. N Engl J Med. 2005;352:1425-1435.
1.8 2.9 3.4 3.9 4.5 5.0 5.5 2.4
( Mmol/L )
-Lipides-
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HOPE: Primary Outcome Reductions in MI, Stroke, or Cardiovascular Death
0.20
0.15
0.10
0.05
0 0 500 1000 1500
22% Reduction in Events P=.0001
Days of Follow-up
% o
f Pat
ient
s R
each
ing
Endp
oint
s Placebo
Ramipril - Altace
Autres études avec IECA: EUROPA avec perindopril – Coversyl PEACE avec trandolapril - Mavik
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AAS vs clopidogrel
Réduction
du risque
relatif
AAS Antiplatelet Trialists’
Collaboration
25 %
Clopidogrel CAPRIE
33 %
+8.7%
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Risk of a major cardiovascular event reduced
130 0
5
10
15
20
25
30
170 160 150 140
% risk reduction
Optimal SBP reduction in the HOT Study
Achieved DBP mm Hg
0 5
10 15 20
25 30
105 100 95 90 85 80
% risk reduction
Optimal DBP reduction in the HOT Study
Achieved SBP mm Hg
138.5 / 82.6
22% 30%
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Arrêt du tabac…amélioration du pronostic
JAMA 2003; 290: 86 36% de la mortalité totale
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Alors… Prolonger la vie
et éviter les événements coronariens
• Anti-plaquettaires • Statines • IECA, • Tx HTA, • Arrêt cigarette…
signifie
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Réduire les symptômes
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MÉCANISMES DU PHÉNOMENE ISCHÉMIQUE
Le plus souvent: Augmentation Demande O² En présence de: Sténose fixe et / ou Augmentation Tonus coronaire
OFFRE DEMANDE
Résistance coronarienne Pression de perfusion Durée diastole Libération O²
Pré-charge Post-charge Contractilité Fréquence cardiaque
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Contrôler l’angine…
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Trucs et Astuces – ß-bloqueurs
• Chez patients avec: – angine d’effort reproductible – HTA – Insuffisance cardiaque (Coreg, Lopressor,
Monocor)
• Viser fréquence + 60 / min. surtout si encore symptomatique • Asthme = véritable contre-indication • MPOC non-réversible, DM sans hypoglycémie, bradycardie, claudication CI
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Trucs et Astuces - BCC • Chez patients avec:
– angine à seuil variable ou repos – HTA
• Ne pas utiliser forme à courte action d’Adalat • Norvasc, Plendil, Adalat-XL = bonne association avec ß-bloqueurs
• Plendil et surtout Norvasc = sécure si insuffisance cardiaque • Isoptin et Cardizem si FA , TSV ou tendance à tachycardie
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Trucs et Astuces - Nitrates • Angine infréquente: TNT prn seulement = adéquat • Angine stable à seuil variable • Angine stable et TA normale
• Discuter de la « stigmatisation de la maladie » avec TNT S/L
• Utiliser avant efforts prédisposants
• Vacances thérapeutiques... > 10-12 h.
• À ne pas prendre debout (surtout chez patients âgés)
• Optimiser hydratation
• Possible œdème périphérique en association avec forte dose bloquants calciques
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ASSOCIATION MÉDICAMENTEUSE
• Double thérapie utile mais triple = ???
• TNT + ß-bloqueur = effet secondaire de l'un vs l'autre si composante effort > repos
• TNT + bloquant calcique: si forte composante de repos ou mixte. Pas de dyhydropyridines (nifé., félo, amlo, nicar.)
• ATTN angine réfractaire demande évaluation poussée
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Y-a-t-il un traitement meilleur qu’un autre?
Il n’existe pour l’instant AUCUNE évidence qu’une classe d’anti-angineux soit meilleure qu’une autre en terme symptomatique…
Il n’existe pour l’instant AUCUNE évidence claire que le traitement
avec TNT, BB, ou BCC change le pronostic du patient angineux…
Eur Heart J Supplements 2001; 3: O8-O11 JAMA 2004; 292: 2217-2226
SAUF: une petite et courte étude avec aténolol (ASIST) et une autre avec amlodipine (PREVENT) qui ont montré une différence sur les événements combinés sans changement sur la mortalité. Par ailleurs, l’étude CAMELOT avec l‘amlodipine chez des coronariens a montré une diminution des hospitalisations ou interventions pour angine sans changer les autres paramètres.
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Vrai ou Faux???
L’angioplastie diminue la survenue des infarctus.
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Traitement interventionnel
Angioplastie…
Pontages aorto-coronariens…
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• Sténose du tronc commun gauche
• MCAS de 3 vx et FE abaissée: 3 études / 3
• MCAS 3 vx et FE normale: 2 études / 3
• MCAS 2 vx incluant IVA proximale: 1 étude / 3
Pontages vs Traitement médical
Études CASS, VA, Européenne
Meilleure survie démontrée avec Pontages si:
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Atorvastatin versus Revascularization Treatment study AVERT
N Engl J Med 1999;341:70-6
36%
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Angioplastie vs Tx médical RITA-2 à 7 ans
Moins d’angine avec Angioplastie
MAIS aucune différence
infarctus et / ou décès
J Am Coll Cardio 2003; 42: 1161
Angioplastie surtout si symptômes réfractaires ou inacceptables au patient
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Pontages vs Angioplastie Problèmes: chaque étude utilise une technique d’angioplastie « passée date »
biais de sélection important opérateur et centre dépendant pour le pontage et angioplastie
La méta-analyse de 2003 montre pour le PAC: un avantage de survie à 5 et 8ans.(9 études) moins de d’angine moins de revascularisation
J Am Coll Cardio 2003; 41: 1293 L’étude la plus récente ARTS II avec des tuteurs médicamentés montre une survie identique à un an.
ACC 2005, www.theheart.org
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Pontages vs Angioplastie
lésions nombreuses ou complexes, tronc commun, occlusions totales, mauvaise fonction VG DM II
On favorise le pontage si:
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Quels traitements lui appliquerez-vous?
En conclusion: retournons à notre patient…
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De retour à notre patient…
• Angor typique de bas grade • Pas de critères de mauvais pronostic au tapis et au MIBI • Tx médical équivalent au Tx interventionnel face au pronostic
• Excellente évolution jusqu’à présent…
• Un tx médical est effectué: ASA, Monocor, Lipitor