What’s new in Cardiology - NHS Wales
Transcript of What’s new in Cardiology - NHS Wales
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What’s new in Cardiovascular medicine ?
Dr Stephen Dorman Consultant Cardiologist, Morriston Cardiac Centre
Mid & West Cardiac Network Lead
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A year in review...
• Primary & sceondary Prevention
• IHD & Coronary angioplasty
• Atrial Fibrillation
• Heart Failure & Devices
• New trends in Cardiology
• Cardiac Imaging
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Prevention is better than cure..
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Age standardised death rates from CVD – All ages UK 2010/2012
Source: BHF CVD statistics 2014
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1. Ischaemic Heart disease
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How would you treat a 50 year old lady with a cholesterol of 8 mmol/L and a systolic BP of
180mmhg ? QRISK2 = 7% 10 year MI risk therefore NO treatment under
most guidelines
Short term CVD risk scores
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Relationship between LDL cholesterol & CHD events
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Lifetime exposure to LDL
Early investment in risk factor modification
should yield cumulative lifetime benefits
Over a 15 year period a 28% lifetime
lowering of LDL resulted in a 88%
reduction in coronary heart disease
Cohen NEJM 2006
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JBS3 – “investing in your arteries”
• Personalised lifetime approach to CVD prevention
• Allows a CV risk conversation with the whole population and to empower individuals
www.jbs3risk.com
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JBS3 - A hypothetical cardiologist
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European & American lipid guidelines
“Treat to target“ vs “Fire and Forget”
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Transatlantic consensus
1. LDL is a true risk factor that causes atherosclerosis
2. Treatment should be based on overall risk assesment
3. High risk includes: Atherosclerotic CVD, Familial hypercholesterolaemia, diabetes
4. Lifestyle interventions are the basis for all treatments
5. Statins as first line therapy for LDL-C and risk reduction
6. When risk is high, treatment should be intensive. When risk is moderately high....
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•QRISK2 score
•Reduces treatment threshold from
>20% to a >10% 10 year risk of
developing CVD - Upto 4.5 million
more eligible
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NICE 2014 - Lipid modification therapy for the primary and secondary prevention of CVD
• No more fasting lipid profiles – Use Non HDL cholesterol
• For primary prevention offer Atorvasatin 20 mg to people with a >10% 10-year risk of developing CVD.
• For secondary prevention offer Atorvastatin 80 mg - Lower dose if: potential drug interactions, high risk of adverse effects, patient preference.
• If a high-intensity statin is not tolerated then treat with the maximum tolerated dose
• Measure a lipid profile at 3 months in all people who have been started on high-intensity statin treatment and aim for a greater than 40% reduction in non-HDL cholesterol
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NICE Lipid guidance 2014 – Do not Do’s
Do not offer any of the following:
• Nicotinic acid (niacin) • Omega 3 Fatty acids • Fibrates • Bile acid sequestrants
for the prevention of CVD to any of the following:
Primary or secondary prevention, CKD, Type I or II Diabetes
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Bariatric surgery & CVD
• STAMPEDE trial - The Surgical Treatment and Medications Potentially Eradicate Diabetes Effectively – NEJM 2014
• Among obese patients with uncontrolled type 2 diabetes, 3 years of intensive medical therapy plus bariatric surgery resulted in glycemic control in significantly more patients than did medical therapy alone.
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Coronary Angioplasty
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Thrombotic
events
(MACE)
Bleeding
events
Intensity of antiplatelet
+ antithrombotic therapy
Net adverse
clinical events
Thrombosis & Bleeding balance
Anti platelet & Anti thrombotic
Aspirin, Clopidogrel, Ticagrelor,
Prasugrel (po)
Cangrelor (IV)
GPIIbIIIa’s: Tirofiban, Abciximab,
Eptifibatide
UFH, LMWH, Bivalirudin
Factor Xa inhibitors.....
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New anti platelet agents
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G. Stone, TCT 2011
How long do we need dual anti platelet therapy after a
stent ?
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DAPT beyond 1 year ?
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Choose your complication.... Ischaemic or Bleeding
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How long do you need to be on dual antiplatelet therapy after angioplasty?
• Stable Angina or Acute Coronary Syndrome ?
• Type of Stent – BMS/DES/Biodegradable/Polymer free ?
• Complexity of coronary anatomy ?
• Generalised atherosclerotic burden ?
• Bleeding risk ?
• Concomitant indication for anti coagulation ?
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DAPT duration – Basic principles
• For the Stent - 6 Months
– Special stents ( Biodegradable polymer / polymer free stents ) < 1-3 months
– “Stent fest” > 6 months
• For the Artery – 12 months for ACS
• Extending DAPT beyond 12 months
– Will reduce ischaemic events but with a bleeding penalty ( NNT~NNH)
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Where is Coronary stent technology going ?
Less is more.....
•Platform – Ststeel / Co/Plt Chro
•Polymer – Permanent or resorbable
•Drug – Antiproliferative ( e.g Limus)
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FFR – Fractional Flow reserve
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Primary Angioplasty for ST elevation MI
Why Primary Angioplasty and not Lysis ?
• More effective than lysis → Mortality reduction
• Reduced Stroke
• Less re-infarction
• Home in 48 hours in uncomplicated cases
•Themes in 2014/15
•Drugs – Bivalirudin vs Heparin
•Technique – TAPAS/Total
•Bystander disease
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Primary PCI in South Wales 2009-2013
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What are the implications for Primary Care ?
• ST elevation MI patients will be leaving hospital 48h after their heart attack....
• There is not time to uptitrate all the cardiac medications in hospital
• Bisoprolol 2.5mg od → 10mg od
• Ramipril 2.5mg od → 10mg od
• New anti platelet regimes • Aspirin 75mg , Clopidogrel 75mg od , PRASUGREL 75mg od , TICAGRELOR 90mg bd
• Triple therapy & WOEST regimes
• No routine follow up of Post MI patients after first clinic visit • Secondary prevention in Primary Care / Link in to practice chronic disease nurse
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Atrial Fibrillation & Acute Coronary syndrome
• Aspirin + Clopidogrel
• Triple therapy – Warfarin, Aspirin,Clopidogrel
• Warfarin + Clopidogrel ( WOEST )
• ESC recomend lower target range INR 2-2.5
• Low dose NOAC & Aspirin & Clopidogrel
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Atrial fibrillation
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Atrial Fibrillation
www.spafacademy.org.uk
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The new oral anticoagulants
Better than Warfarin ?
3 new oral Xa/Iia inhibitors
Rivoroxaban •Factor Xa inhibitor
•ROCKET AF
•o.d dosing
Apixaban •Factor Xa inhibitor
•Aristotle
•b.d dosing
Dabigatran •Factor IIa inhibitor
•RE-LY trial
•b.d dosing
•85% Renal clearance
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Should I prescribe a NOAC ?
+VE’s
• Ease of administration
• Favourable efficacy/safety profile
• Less drug-drug interactions
• Shorter half life
-VE’s
• Cost
• Antidote
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Should I prescribe a NOAC ? Should I anticoagulate my patient
with AF?
Bleeding risk: HAS-BLED
Vs
Ischaemic risk: CHADS2VASC
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AF Ablation ? Ready for prime time
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Heart Failure
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NICE 2014: Implantable cardioverter defibrillators & Cardiac resynchropnisation therapy
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This replaces the old NICE guidelines from 2006
ICD (Implantable cardiac defibrillator)
• Post MI
• At least 4 weeks post MI + either
• LVEF <35% + NSVT + Inducible VT at EPS
or
• LVEF <30% and QRS > 120ms
CRT ( Cardiac resync therapy )
• LBBB
• NYHA III
• On Maximal medical therapy
• QRS > 120ms
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The New NICE ICD & CRT Guidelines June 2014
QRS width + LBBB NYHA class
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Key points
• Merges ischaemic and dilated cardiomyopathy together
• No mention of AF
• Broadens indications for both CRT and ICD therapy
• Simple table to aid decision making
• “Probably a reasonable compromise” Professor Martin Cowie, EP and Devices, Cardiff meeting, January 2015
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The New NICE Guidelines – June 2014
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New “blockbuster” heart failure drugs...
11.9.14 Angiotensin-neprilysin Inhibition vs Enalapril in Heart Failure
McMurray et al. nejm.org
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New trends in Cardiology...
The good, the bad and the ugly..
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The good – “TAVI”
Inoperable or High
risk for
conventional Aortic
valve replacement
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Frailty scoring in interventional cardiology ?
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The bad – “Renal Denervation”
• Renal denervation for resistant hypertension
– Promising early results
– Long term outcome data needed
– MDT approach
• SIMPLICITY HTN-3 - Large Negative RCT
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The Ugly “Beta blockers before non cardiac surgery”
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Cardiac Imaging
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New tests for diagnosis & risk stratification
NICE guidance
The exercise test should
NOT be used to diagnose
Angina
Greater emphasis on
Cardiac CT to RULE
OUT CAD in low risk
populations
Increased used of
functional testing
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Cardiac CT
•Excellent “RULE OUT”
test for significant
Coronary artery disease
•Low radiation dose
•Non invasive & safe
•Endorsed by the NICE
guidelines
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Thank you – Any questions ?
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Oral anti platelets