STABLE CORONARY ARTERY DİSEASE

YEDITEPE UNIVERSITY FACULTY OF MEDICINE

PHASE 4 CARDIOLOGY COURSE 2014-2015

PROF. MUZAFFER DEGERTEKIN, M.D., PhD.

MUSTAFA AYTEK SIMSEK, M.D., Attending Physician

ATHEROSCLEROTIC ATHEROSCLEROTIC CARDIOVASCULAR CARDIOVASCULAR

DIASEASEDIASEASE

Stable Ischemic Heart Disease

Acute Coronary Syndrome

ST-Segment Elevation Myocardial Infarction

Unstable Angina and Non–ST Elevation Myocardial Infarction

DEFİNİTİONDEFİNİTİON

Coronary artery diseaseCoronary artery disease::

used to describe coronary arteries affected by a pathological process.

the narrowing of the coronary arteries or blockage of coronary blood flow, usually caused by atherosclerosis.

This can cause chest pain, shortness of breath, or myocardial infarction.

NONATHEROSCLEROTİC CADNONATHEROSCLEROTİC CAD Coronary artery spasm Arteritis/vasculitis Occlusion of a coronary artery due to dissecting

aneurysm Coronary embolism Syphilitic aortitis involving the coronary ostia Cocaine induced vasospasm Vasospasm and/or thrombosis due to

hypersensitivity (Kounis syndrome) Congenital abnormalities

DEFİNİTİONDEFİNİTİON

Ischemic heart dIschemic heart disease isease ((Coronary Coronary heart diseaseheart disease or atherosclerotic or atherosclerotic heart disease)heart disease)

Cardiac disease resulting from myocardial ischemia.

Although myocardial ischemia also occurs in such conditions as aortic stenosis or anemia, the term ‘ischemic heart disease’ is generally applied only to cases of atherosclerotic origin.

DEFİNİTİONDEFİNİTİON ArteriosclerosisArteriosclerosis – a general term describing

any thickening and hardening of artery walls and loss of elasticity of medium or large arteries.

AtherosclerosisAtherosclerosis – process where fatty material is deposited along walls of arteries. This material thickens, hardens, and can eventually block the artery.

Atherosclerosis is just one type of arteriosclerosis

2013 SCAD GUIDELINE

MAGNITUDE OF THE PROBLEM

The leading cause of death The lifetime risk of developing symptomatic CAD after

age 40 (Framingham Heart Study) 49% for men 32% for women

ANGINAAngina is a type of chest discomfort

caused by poor blood flow through the coronary vessels to myocardium (≥70% reduction in luminal diameter of a major coronary artery).

ANGINA: EXERTIONALANGINA: EXERTIONALCoronary artery obstructions are not sufficient to

result in resting myocardial ischemia. However, when myocardial demand increases, ischemia results.

Angina:Variant AnginaAngina:Variant Angina

• Transient impairment of coronary blood supply by vasospasm or platelet aggregation

• Majority of patients have an atherosclerotic plaque

• Generalized arterial hypersensitivity• Long term prognosis very good

ANGINA: SILENT ISCHEMIAANGINA: SILENT ISCHEMIA Very common More episodes of silent than painful ischemia in

the same patient No pain, but ischemic ECG changes Most common in diabetics (due to neuropathy)

Difficult to diagnose Holter monitor Exercise testing As significant as chronic SAP in terms of the subsequent

risk of ACS events, as well as mortality and morbidity.

Symptoms other than angina:Breathlessness

Feeling of faintness

Anxiety

Flatulence or other dispeptic complaints

ANGINA: ANGINAL EQUIVALENT ANGINA: ANGINAL EQUIVALENT SYNDROMESYNDROME

Patient’s with exertional dyspnea rather than exertional chest pain

Caused by exercise induced left ventricular dysfunction

Shortness of breath, diaphoresis

EVALUATE ANGİNA PECTORİS

1. Location

2. Characteristics

3. Precipitating factors

4. Duration

5. Relieved

LOCATİON Usually substernal, May extend to

the left or right chest, the shoulders, the neck, jaw, arms (usually ulnar surface of

left arm), epigastrium and the upper

back) Occasionally,the radiated

pain may be more noticeable to the patient than the origin of the pain

CHARACTERİSTİCS

Deep, visceral and intense Many patients describe it as a

pressure–like, squeezing sensation

Rather than sharp or stabbing or pinprick-like pain

PRECİPİTATİNG FACTORS

Exercise, heavy meal, cold weather the emotional stress Other events that obviously

increase myocardial oxygen demand, such as rapid tacharrhytmias,

extreme elevations in blood pressure,

decrease in oxygen supply such as anemia.

DURATİON

Angina pectoris is transient lasting between 2 and 30 minutes.

Typically 2-10 minutes

The duration of the pain is minutes, not seconds, not hours

Chest pain that lasts longer than 30 min is more consistent with myocardial infarction, pain of less than 2 min is unlikely to be due to myocardial ischemia

RELİEVED BY

cessation of the precipitating event such as exercise, or

the administration of treatment such as sublingual nitroglycerine.

Angina – Types:

Typical Angina:

Atypical Angina:

Noncardiac chest pain

Stable Angina: reproducible, predictable

Unstable Angina: new onset, increased freq, intensity, duration, or occurs at rest

PRE TEST PROBABILITY OF CORONARY DISEASE BY SYMPTOMS, GENDER AND AGE

CCSC ANGINA CLASSIFICATIONCCSC ANGINA CLASSIFICATION

PHYSİCAL EXAMİNATİONPHYSİCAL EXAMİNATİON May be completely normal

S3 or S4 may be heard

Mitral regurgitation

Blood pressure

Body mass index

Waist circumference

ELECTROCARDİOGRAM ELECTROCARDİOGRAM (ECG)(ECG) All patients with suspected angina should

have a resting ECG.

May be completely normal (especially between attacks of angina)

Evidence of old myocardial infarction, bundle branch block, left ventricular hypertrophy

Electrocardiogram Electrocardiogram (ECG)(ECG)• Ischemia at rest: “non-specific T and ST

changes”• changes in the T-wave or the ST segment that are “out of place”

• normally, the T-wave and the QRS complex have similar polarity

• T-wave flattening:

• T-wave inversion:

• ST-segment scooping:

•ST-segment depression:

I

III

II

AVR

AVL

AVF

Inferior Ischemia in a 42 year old male at rest

Anteriolateral ischemia in a 67 year old female while at rest

V1

V3

V2

V4

V6

V5

LABORATORY LABORATORY EXAMİNATİONEXAMİNATİON Hemoglobin Creatinine Glucose Lipids Thyroid function High sensitive CRP Homocysteine NTproBNP Troponins

CHEST X-RAYCHEST X-RAY Patients with suspected heart failure

Patients with clinical evidence of significant pulmonary disease

ECHOCARDIOGRAPHYECHOCARDIOGRAPHYUsed to assess...

Myocardial Structures

– MR, TR, AR Ventricular Function

– EF

– Wall motion abnormalities Effusions

Thrombus

Ischemia

SCREENING AND DIAGNOSISSCREENING AND DIAGNOSIS

StressStressTestTest

measures

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CoronaryCoronaryAngiographyAngiography

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coro

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Narrowing inNarrowing in

Sites of

Sites of

Electro-Electro-cardiogramcardiogram

measures

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EXERCISE STRESS TESTING EXERCISE STRESS TESTING

The most widely used

The least expensive CAD screening modality

Exercise stress Exercise stress testtest• Ischemia during exercise: ST-segment

depression• usually indicative of subendocardial ischemia

• location of ischemia does not always correspond to the leads in which it is seen

J-point.08 seconds

Quantity or depth of ST-segment depression

Baseline

Treadmille

Continued until The patient becomes fatigued Achieves 85% of the maximum predicted heart rate (approximately 220 minus the patient's age)

Terminated Signs or symptoms of severe ischemia (angina, ST-segment elevation, ST-segment depression >0.3 mV, or a fall in blood pressure of 10 mm Hg), arrhythmias, or heart block develop

Treadmille

Computer summaries can help find possible areas of ischemia – then review raw data carefully!

Determine PQ junction, J point, ST80, and estimate slope

Elevation Depression

Upsloping Horizontal Downsloping

ST SEGMENT INTERPRETATION

Magnified ischemic exercise-induced ECG pattern. Three consecutive complexes with a relatively stable baseline are selected. The PQ junction (1) and J point (2) are determined; the ST 80 (3) is determined at 80 msec after the J point. In this example, average J point displacement is 0.2 mV (2 mm) and ST 80 is 0.24 mV (2.4 mm). The average slope measurement from

the J point to ST 80 is –1.1 mV/sec.

Normal

Rapid Upsloping

Minor ST Depression

Slow Upsloping

Horizontal

Downsloping

Elevation (non Q lead)

Elevation (Q wave lead)

Duke treadmill score = duration of exercise in minutes on the Bruce protocol- (minus) 5x maximal mm ST deviation- (minus) 4x treadmill angina index

Treadmill Angina Index:0 if no angina.1 if non-limiting angina.2 if limiting angina.

High Risk = treadmill score < -1079% 4-year survivalModerate Risk = treadmill score -10 to +495% 4-year survivalLow Risk = treadmill score >+599% 4-year survival

Duke Nomogram for 2 mm depression, non-limiting chest

pain at 5 METS.

STRESS ELECTROCARDIOGRAPHIC STRESS ELECTROCARDIOGRAPHIC INDICATORS OF SEVERE CORONARY INDICATORS OF SEVERE CORONARY DISEASE OR POOR PROGNOSIS DISEASE OR POOR PROGNOSIS

Downsloping ST-segment depression ≥3 mV Involvement of five or more leads with ST-

segment depression Early ST-segment depression (<5 METS) Prolonged ST-segment depression late into

recovery Failure to complete stage II of Bruce protocol Failure to obtain HR >120/min (off negative

chronotropic drugs) Exertional hypotension

MYOCARDIAL PERFUSION MYOCARDIAL PERFUSION IMAGING (THALLIUM SCAN)IMAGING (THALLIUM SCAN)

Used to assess... Ischemia (diagnosis and prognosis of CAD)

Ventricular Function

– Ejection Fraction Myocardial Viability

– Reversible vs non-reversible

Diagnosis/prognosis for CADDiagnosis/prognosis for CAD when when Non-diagnostic EST Abnormal resting ECG Negative EST with continued chest pain Intermediate probability of disease

Defined CADDefined CAD• Post infarct risk stratification• Risk stratification to determine need

for revascularization ( viability study )

STRESS STRESS ECHOECHOCARDİOGRAPHYCARDİOGRAPHY Ischemia may cause wall motion

abnormalities, no rise of fall in LVEF Sensitivity/specificity same as nuclear testing May be better in women

MANAGEMENTMANAGEMENT Lifestyle modificiations

Medical Treatment

Invasive Procedures

Prevention

LİFESTYLE MODİFİCİATİONSLİFESTYLE MODİFİCİATİONS Diet & salt restriction

Weight reduction

Smoking

Physical activity

Avoid precipitating factors (walking into a wind or uphill, cold weather, large meals)

MEDİCAL MEDİCAL TREATMENTTREATMENT

Aspirin

ACE inhibitors

Beta-blockers

Calcium channel blockers

Nitrates

Statins

TREATMENT ALGORITHMTREATMENT ALGORITHM

NITRATESNITRATES

Increase in intracellular cyclic guanosine monophosphate (cGMP) levels and cause smooth muscle relaxation

Venous vasodilation/pre-load reduction Arterial dilation/after-load reduction Coronary arterial vasodilation Prevention of coronary vasoconstriction Enhancement of coronary collateral flow Antiplatelet and antithrombotic effects

NITRATESNITRATES

Side EffectsHeadacheFlushingHypotension and syncope (take first dose

sitting)Palpitations Tolerance (to reduce tolerance, smaller doses

with less frequent dosing building in a nitrate-free interval of 8-12 hours and avoidance of long-acting formulations unless a prolonged nitrate-free interval is provided)

StatinsStatins Reduces the risk of atherosclerotic

cardiovascular complications in both primary and secondary prevention settings.

Block cholesterol synthesis in the liver by inhibiting the enzyme 3-hydroxy-3-methyl-glutaryl coenzyme A reductase.

Atorvastatin, rosuvastatin, simvastatin, pravastatin, fluvastatin...

Not only lower cholesterol levels but also antiinflammatory and antithrombotic effects (pleiotropic effects)

LİPİD LOWERİNG DRUGSLİPİD LOWERİNG DRUGS Fibrates

Reduce TG and to a lesser extent cholesterol and LDL. Nicotinic acid

Reduce TG and to a lesser extent cholesterol and LDL. increases HDL Side effects (flushing)

Bile acid sequestrants Anion exchange resins binds with cholesterol-containing bile acids in the intestine,

and promoting the conversion of cholesterol to bile acids in the liver.

BETA-BLOCKERSBETA-BLOCKERS

Metoprolol, bisoprolol, propranolol, atenolol Decrease myocardial oxygen consumption Blunt exercise response, block the action of

catecholamines in increasing heart rate, blood pressure, and cardiac contractility

Try to avoid drugs with intrinsic sympathomimetic activity

First line therapy in all patients with angina if possible

BETA BLOCKERS BETA BLOCKERS

Side EffectsBronchospasm Diminished exercise capacity and

fatigue Negative inotropy Sexual dysfunction Bradyarrhythmia Masking of hypoglycemia Increased claudication Hair loss

CALCIUM CHANNEL BLOCKERSCALCIUM CHANNEL BLOCKERS

Verapamil, diltiazem, nifedipine, nicardipine, amlodipine, felodipine

Arterial dilation/afterload reduction Coronary arterial vasodilation Prevention of coronary vasoconstriction Enhancement of coronary collateral flow Improved subendocardial perfusion Slowing of heart rate with diltiazem, verapamil

CALCIUM CHANNEL BLOCKERS CALCIUM CHANNEL BLOCKERS

Side Effects Palpitations Headache Ankle edema Gingival hyperplasia Constipation

INVASİVE TREATMENT INVASİVE TREATMENT PERCUTANEOUS CORONARY INTERVENTION (PCI)

Indications for Angioplasty (+/- stenting)

                                                                                                                               

                 

CORONARY ARTERY BYPASS GRAFT (CABG)

Indications Left main disease > 50 %

Proximal 3 vessel disease

Multivessel disease with left ventricular dysfunction

Better in diabetics

Lifestyle limiting angina unresponsive to medical therapy and/or PCI