Stable Ischemic Heart

Disease

Aneesh Venkat Pakala, M.D.

Assistant Professor,

Department of Medicine,

Cardiovascular diseases section,

University of Oklahoma Health Sciences Center.

Objectives

Overview of coronary artery disease

(CAD)

Pathogenesis of atherosclerosis

Risk factors associated with CAD

Stable ischemic heart disease

Definition of CAD

Coronary artery atherosclerosis or

CAD (coronary artery disease) refers

to the presence of atherosclerotic

changes within the walls of the

coronary arteries, which causes

impairment or obstruction of normal

blood flow with resultant myocardial

ischemia.

Epidemiology of CAD

No. 1 cause of death in the US and a

major cause of morbidity.

380,000 deaths in 2010.

Over 1 million MIs per year.

30% of MI patients don’t return to work.

>13 million with coronary artery disease.

10 million with angina pectoris.

25% men over 75 years of age have

CAD.

Cost for Ischemic heart

disease

177.1 Billion dollars in 2010 for

management of ischemic heart disease.

Over 900 million a year spent in outpatient

visits.

Over 200 million a year spent for ER visits.

Over 200 million a year for prescription

drugs for ischemic heart disease.

Over 1 million PCIs and over 400,000 CABG

in 1 year.

Epidemiology continued…

In 2001, prevalence of CHD by gender

& race:

White males: 6.9%

AA males: 7.1%

Hispanic males: 7.2%

White females: 5.4%

AA females: 9.0%

Hispanic females: 6.8%

Coronary circulation:

Autoregulation

Coronary circulation: Effect

of stenosis on coronary flow.

Atherosclerosis

“Athero”: wax; sclerosis: hardening

Process in which deposits of fatty

substances, cholesterol, cellular

waste products, calcium, and other

substances build up in the inner

lining of an artery eventually leading

to plaque formation.

Atherosclerotic plaque

Clinical Manifestations of

CAD

A chronic disorder that typically cycles

in and out of clinically defined phases:

asymptomatic

Stable ischemic heart disease

Acute Coronary Syndrome:

unstable angina, NSTEMI, & STEMI

Stable ischemic heart

disease (SIHD)

Pertains to adults with known or

suspected ischemic heart disease

with stable chest discomfort (angina)

for over 2 months without worsening

frequency, severity or duration.

Definition: Stable Angina

Angina pectoris or angina is the result

of myocardial ischemia caused by an

imbalance between myocardial blood

supply and oxygen demand

STABLE as opposed to UNSTABLE

angina is when the symptoms are

reproducible after a fixed amount of

exertion.

SIHD: Aims of evaluation

Distinguish anginal chest pain due to

gradual worsening of obstructive

coronary artery disease (CAD) from

that due to atherosclerotic plaque

rupture.

Provide risk assessment in patients

with stable ischemic CAD.

Evaluation

Detailed symptom history

Focused physical examination

RISK ASSESSMENT

Evaluation/History: “chest pain”

Quality - "squeezing," "griplike," "pressurelike," "suffocating" and "heavy”; or a "discomfort" but not "pain." Angina is almost never sharp or stabbing, and usually does not change with position or respiration.

Duration - anginal episode is typically minutes in duration. Fleeting discomfort or a dull ache lasting for hours is rarely angina

Location - usually substernal, but radiation to the neck, jaw, epigastrium, or arms is not uncommon. Pain above the mandible, below the epigastrium, or localized to a small area over the left lateral chest wall is rarely anginal.

Provocation - angina is generally precipitated by exertion or emotional stress and commonly relieved by rest. Sublingual nitroglycerin also relieves angina, usually within 30 seconds to several minutes.

Major Risk Factors for CAD

Age

Gender

Family history of premature CAD

Elevated total or LDL cholesterol

Reduced HDL cholesterol

Tobacco use

Hypertension

Diabetes mellitus

Obesity

Sedentary Lifestyle

Metabolic Syndrome

Evaluation: Symptoms/Signs

Chest pain

Dyspnea

Orthopnea

PND (paroxysmal noctural dyspnea)

Dizziness

Diaphoresis

Palpitations

Syncope

Evaluation: Physical Exam

Check vital signs: temperature, BP, HR, RR

For most patients with stable angina, physical examination findings might be normal.

Other signs of atherosclerosis: carotid bruits, decreased/absent peripheral pulses,

Left heart failure: S3/S4, bibasilar rales, displaced apical impulse

Right heart failure: JVD, ascites, hepatomegaly, edema

Auscultate for aortic stenosis.

Pain produced by chest wall pressure is usually of chest wall origin.

Differential Diagnosis of Chest

Pain

Non-Ischemic CV

aortic dissection

pericarditis

Pulmonary

pulmonary embolus

pneumothorax

pneumonia

pleuritis

Chest Wall

costochondritis

fibrositis

rib fracture

sternoclavicular

arthritis

herpes zoster

Gastrointestinal

Esophageal

esophagitis

spasm

reflux

Biliary

colic

cholecystitis

cholangitis

Peptic ulcer

Pancreatitis

Psychiatric

Anxiety disorder

Hyperventilation

panic disorder

primary anxiety

Affective disorders

depression

Diagnosis

CBC (check hemoglobin)

BMP (check glucose, electrolytes, Cr)

Fasting lipid panel

Resting ECG.

Chest x-ray in patients with signs or symptoms of CHF.

Diagnosis: 12 Lead Resting

ECG

Should be recorded in all patients with

symptoms suggestive of angina

pectoris

Normal in 50% of patients with stable

angina

A normal ECG does not exclude

severe CAD

Class 1 (Level of Evidence: B). A

resting ECG is recommended in

patients without an obvious,

noncardiac cause of chest pain.

Electrocardiogram.

Diagnosis: Stress Test

Exercise stress EKG

Exercise or pharmacologic stress with Echocardiogram

Exercise or pharmacologic stress with Myocardial perfusion

imaging.

Exercise stress is the test of

choice if patient can

exercise.

Stress testing: Exercise EKG

Stress testing: Stress imaging.

Stress Imaging

Myocardial Perfusion

Imaging

Stress echocardiography

Able to exercise.

Class1 (Level of Evidence: A). Standard exercise

ECG testing is recommended for patients with an

intermediate pretest probability of IHD who have an

interpretable ECG and at least moderate physical

functioning or no disabling comorbidity.

Class 1 (Level of Evidence: B) Exercise stress with

nuclear MPI or echocardiography is recommended for

patients with an intermediate to high pretest probability

of IHD who have an uninterpretable ECG and at least

moderate physical functioning or no disabling

comorbidity .

Stress testing in suspected

SIHD.

Able to exercise.

Class III (Level of Evidence: C). Pharmacological

stress with nuclear MPI, echocardiography, or CMR is

not recommended for patients who have an

interpretable ECG and at least moderate physical

functioning or no disabling comorbidity.

Class III (Level of Evidence: C). Exercise stress with

nuclear MPI is not recommended as an initial test in

low-risk patients who have an interpretable ECG and

at least moderate physical functioning or no disabling

comorbidity.

Stress testing in suspected

SIHD.

Stress testing in suspected

SIHD.

Unable to exercise.

Class I : Pharmacological stress with

nuclear MPI or echocardiography is

recommended for patients with an

intermediate to high pretest probability of

IHD who are incapable of at least

moderate physical functioning or have

disabling comorbidity.

Stress testing in suspected

SIHD.

Unable to exercise.

Class III: Standard exercise ECG testing

is not recommended for patients who

have an uninterpretable ECG or are

incapable of at least moderate physical

functioning or have disabling comorbidity.

(Level of Evidence: C).

Resting imaging to detect

cardiac structure and function

Class 1(Level of Evidence: B).

Assessment of resting LV systolic and

diastolic ventricular function and

evaluation for abnormalities of

myocardium, heart valves, or pericardium

are recommended with the use of

Doppler echocardiography in patients

with known or suspected IHD and a prior

MI, pathological Q waves, symptoms or

signs suggestive of heart failure, complex

ventricular arrhythmias, or an

undiagnosed heart murmur.

Class III (Level of Evidence: C) Echocardiography,

radionuclide imaging, CMR, and cardiac CT are not

recommended for routine assessment of LV function

in patients with a normal ECG, no history of MI, no

symptoms or signs suggestive of heart failure, and no

complex ventricular arrhythmias.

Class III (Level of Evidence: C) Routine reassessment

(1 year) of LV function with technologies such as

echocardiography radionuclide imaging, CMR, or

cardiac CT is not recommended in patients with no

change in clinical status and for whom no change in

therapy is contemplated.

Resting imaging to detect

cardiac structure and function

Diagnosis: Angiography

Depending on stress test results can

either consider medical therapy or

consider sending patient for a

coronary angiography.

Coronary Angiography

Coronary angiography

continued…

To assess risk after non invasive

testing is done:

Class I (Level of Evidence C).

Coronary arteriography is

recommended for patients with

SIHD whose clinical characteristics

and results of noninvasive testing

indicate a high likelihood of

severe IHD and when the benefits

are deemed to exceed risk

Coronary angiography

Class III:

Coronary angiography for risk assessment is not recommended in

patients with SIHD who elect not to undergo revascularization or who

are not candidates for revascularization because of comorbidities

or individual preferences (306,366). (Level of Evidence: B)

Coronary angiography is not recommended to further assess risk in

patients with SIHD who have preserved LV function (EF 50%) and

low-risk criteria on noninvasive testing (306,366). (Level of

Evidence: B)

Coronary angiography is not recommended to assess risk in patient

who are at low risk according to clinical criteria and who have not

undergone noninvasive risk testing. (Level of Evidence: C)

Coronary angiography is not recommended to assess risk in

asymptomatic patients with no evidence of ischemia on noninvasive

testing. (Level of Evidence: C)

Coronary angiography with

known SIHD

Risk assessment

High risk features:

Low EF <35%

High risk Duke treadmill score.

High risk stress imaging features.

High risk stress echocardiographic

features.

CLASS I (Level of Evidence: C)

Choices about diagnostic and

therapeutic options should be made

through a process of shared decision

making involving the patient and

provider, with the provider explaining

information about risks, benefits, and

costs to the patient.

Patient information

Chronic Stable Angina

Treatment Objectives

Reduce the risk of mortality and morbid events

Reduce symptoms

Medical therapy first!!!

Treatment

Class I:

Introduction to self-monitoring skills (Level of

Evidence: C);

Information on how to recognize worsening

cardiovascular symptoms and take appropriate

action. (Level of Evidence: C)

Educated about the following lifestyle elements:

maintenance of a BMI of 18.5 to 24.9 kg/m2, and

waist circumference less than 40 inches in men and

less than 35 inches in women; lipid management; BP

control; smoking cessation and avoidance of

exposure to secondhand smoke(Level of Evidence:

C)

Treatment

Risk factor modification:

Class I:

Lifestyle modifications, including daily physical

activity and weight management, are strongly

recommended for all patients with SIHD. (Level of

Evidence: B)

Dietary therapy for all patients should include

reduced intake of saturated fats (to 7% of total

calories), trans fatty acids (to 1% of total calories),

and cholesterol (to 200 mg/d). (Level of Evidence:

B)

Treatment

Smoking cessation:

Class 1. Smoking cessation and avoidance of

exposure to environmental tobacco smoke at work

and home should be encouraged for all patients with

SIHD. Follow-up, referral to special programs, and

pharmacotherapy are recommended, as is a stepwise

strategy for smoking cessation (Ask, Advise, Assess,

Assist, Arrange, Avoid). (Level of Evidence: B)

Antiplatelet Agents

Aspirin

Aspirin 81mg daily should be used routinely in all

patients with acute and chronic ischemic heart

disease with or without manifest symptoms in the

absence of contraindications

in >3,000 patients with stable angina, aspirin

reduced the risk of adverse cardiovascular

events by 33%

in patients with unstable angina, aspirin

decreases the short and long-term risk of

fatal and nonfatal MI

Statins

Treatment: Medical therapy to relieve symptoms

Class I:

Beta blockers should be prescribed as initial therapy for relief

of symptoms in patients with SIHD (Level of Evidence: B)

Calcium channel blockers or long-acting nitrates should be

prescribed for relief of symptoms when beta blockers are

contraindicated or cause unacceptable side effects in patients

with SIHD (Level of Evidence: B)

Calcium channel blockers or long-acting nitrates, in combination

with beta blockers, should be prescribed for relief of symptoms

when initial treatment with beta blockers is unsuccessful in

patients with SIHD. (Level of Evidence: B)

Sublingual nitroglycerin or nitroglycerin spray is

recommended for immediate relief of angina in patients with

SIHD (Level of Evidence: B)

Elimination of anginal chest pain

Return to normal activities

Functional capacity of CCS class I

angina

Good patient compliance - minimal

side effects of therapy, cost-effective

Definition of Successful

Therapy

Medical therapy vs

Revascularization

Revascularization

Revascularization :

PCI (percutaneous coronary intervention)

CABG (coronary artery bypass grafting)

Indications:

High grade coronary lesions (Left main,

multivessel disease involving prox LAD)

High risk stress test features.

Severe symptoms despite medical therapy.

Follow up

Class I:

Patients with SIHD should receive periodic follow-up, at least

annually, that includes all of the following (Level of Evidence:

C):

a. Assessment of symptoms and clinical function;

b. Surveillance for complications of SIHD, including heart

failure and arrhythmias;

c. Monitoring of cardiac risk factors; and

d. Assessment of the adequacy of and adherence to

recommended lifestyle changes and medical therapy.

Assessment of LVEF and segmental wall motion by

echocardiography or radionuclide imaging is recommended in

patients with new or worsening heart failure or evidence of

intervening MI by history or ECG. (Level of Evidence: C)

Questions Thank you!