Chronic CAD:
Diagnosis, Treatment and
Guidelines 2016
Morton J. Kern MD, MSCAI, FACC, FAHA
Chief of Medicine, VA Long Beach HSC
Professor of Medicine
University California Irvine
Deaths attributable to cardiovascular disease
(United States: 2010).
Go A et al. Circulation 2014;129:e28-e292
Deaths attributable to diseases of the heart
(United States: 1900–2010).
Go A et al. Circulation 2014;129:e28-e292
58 yo Man,
Chest pain
after lunch
on the way to
car.
Bad sushi?
CAD is a diffuse process with
focal atherosclerotic material
(plaque).
Some plaques are obstructive
but not thrombotic.
Others are potentially
thrombotic but not
obstructive.
Myocardial Infartion=
Death of myocardial cells.
Clinical MI = symptoms, ECG
and Biomarkers
CAD as a cause of Myocardial Ischemia and Infarction
Normal
Atherosclerotic Plaque
Angiography vs. Pathology
Angiography vs CTA for CAD
ACS
179
Fibrous plaque
Positive remodeling
Soft plaque
LAD
Motoyama et al. JACC 2007
Natural History of CAD : A story of remodeling
•Acute Coronary Syndrome
•72 year-old Man
•Plaque crater, erosion
•Calcific nodule
•Thrombus
What are the Big 5 medications for
CAD?
1.
2.
3.
4.
5.
BB
ASA/antiplatelet agents
Statins
Nitrates
Antihypertensive and other risk
factor medications
NTG
ASA
Heparin
GPB’s
Statins
Beta blockers
CA blockers
ACEI
NTG
Ranolazine
Braunwald’s Heart Disease, 7th Edition
Ischemic Cascade
Angina
Δ ECG
Stress ECG
Systolic Dysfunction
Stress Echo/MRI
Diastolic Dysfunction
Perfusion
Abnormalities
Nuclear Imaging
Duration and severity of ischemia
Conditions Provoking or Exacerbating Ischemia
Increased Oxygen Demand
Decreased Supply
Noncardiac
Hyperthermia
Hyperthyroidism
Sympathomimetic toxicity
(e.g., cocaine use) Asthma
Hypertension
Anxiety
Arteriovenous fistulae
Cardiac
HCM
Aortic stenosis
Dilated cardiomyopathy
Tachycardia
Ventricular
Supraventricular
Anemia
Hypoxemia
Pneumonia
Chronic obstructive
pulmonary disease
Pulmonary hypertension
Interstitial pulmonary fibrosis
Obstructive sleep apnea
Sickle cell disease
Sympathomimetic toxicity
(e.g., cocaine use)
Hyperviscosity
Polycythemia
Leukemia
Thrombocytosis
Hypergammaglobulinemia
Spectrum of CAD Presentations
SIHD
Definition
Diagnosis
Treatment
Ischemia
with activity
UA
Ischemia without
necrosis
NSTEMI
STEMI
Necrosis
(nontransmural)
Transmural necrosis
Symptoms, Negative Biomarkers
ECG,
Stress
testing
No ECG ST-segment elevation
The Big 5
Positive biomarkers
Invasive or conservative depending on risk
ECG ST-segment
elevation
Immediate
reperfusion
Roger VL, Go AS, Lloyd-Jones DM, et al.. Circulation. 2011;123:e18-e209.
Proportion of Veteran VHA outpatients aged 65+ with at least one
instance of cardiovascular conditions, FY10
30%
25%
20%
15%
10%
5%
0%
WV
MV
Heart Attack Warning Signs
•
•
•
•
•
Chest discomfort
– Pressure
– Squeezing
– Fullness
– Pain
Discomfort in other areas of the upper body
– Arms
– Jaw
– Neck
– Back
– Stomach
Shortness of Breath
Cold sweat, nausea or lightheadedness
**Women have atypical presentations!! Be more wary
Current Management for Acute Coronary
Syndromes
high risk of in-hospital
death
Treatment goal:
immediate restoration of
coronary blood flow
If no cath
lab,
Fibrinolyti
c
therapy
Direct
PCI
low risk of
in-hospital death, unless MI develops
Treatment goal: stabilize with aspirin
heparin & monitor for MI development
+ Cardiac enzymes
– Cardiac Enzymes
Highrisk
features
Low risk
features
Scheduled
PCI
Manage
medically
Thygesen, K. et al. Circulation 2007;116:2634-2653
Plalque Rupture
Spasm, low BP
Sudden Death, no CK
PCI related
Stent Thrombosis
CABG related
Thygesen, K. et al. Circulation 2007;116:2634-2653
7 Factors of the TIMI Risk Score for UA/NSTEMI
CAD CP algorithm
The 5 Common Cardiac Stress Testing Modalities
Exercise
1. ECG
2. ECHO
3. Nuclear
Pharmacologic
4. Dobutamine Echo
5. Adenosine Nuclear
Who needs Stress Testing?
EuroIntervention 2015;10:1024-1094 published online ahead of print September 2014
2014 ESC/EACTS Guidelines on myocardial revascularization
Proportion of stress test type
out of all stress tests conducted in MEN
Veteran VHA outpatients
(N=157,140)
Proportion of stress test type
out of all stress tests conducted
in WOMEN Veteran VHA
outpatients (N=7,198)
5.56% Echo stress
4.16% Echo stress
40.93%
46.72
%
ECG stress only
47.72
%
ECG stress only
54.92%
Nuclear stress
Echo Stress Test
Nuclear Stress Test
VETERANS HEALTH ADMINISTRATION
Nuclear stress
Non-Imaging Stress Test
28
Indications for revascularization in Stable CAD or
silent ischemia
EuroIntervention 2015;10:1024-1094 published online ahead of print September 2014
2014 ESC/EACTS Guidelines on myocardial revascularization
Recommendation for CABG/PCI in Stable CAD with
anatomy suitable for both procedures
EuroIntervention 2015;10:1024-1094 published online ahead of print September 2014
2014 ESC/EACTS Guidelines on myocardial revascularization
BP control
BP maintence
Lipids
Lipids
Lipids
<140/90 or <130/80 DM, CR
add meds as nec to BB/ACE
Add plant stanol/sterols 2g/
LDL-C <70mg/dl or high dose
statin is reasonable (IIa)
If LDL-C 100-70 at base, rx to
<70mg/dl is reasonable
From: 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic
Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines
J Am Coll Cardiol. 2014;63(25_PA):2889-2934. doi:10.1016/j.jacc.2013.11.002
From: 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic
Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines
J Am Coll Cardiol. 2014;63(25_PA):2889-2934. doi:10.1016/j.jacc.2013.11.002
From: 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic
Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines
J Am Coll Cardiol. 2014;63(25_PA):2889-2934. doi:10.1016/j.jacc.2013.11.002
From: 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic
Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines
J Am Coll Cardiol. 2014;63(25_PA):2889-2934. doi:10.1016/j.jacc.2013.11.002
From: 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic
Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines
J Am Coll Cardiol. 2014;63(25_PA):2889-2934. doi:10.1016/j.jacc.2013.11.002
Exercise Testing
I IIa IIb III
In patients entering a formal cardiac
rehabilitation program after PCI, treadmill
exercise testing is reasonable.
I IIa IIb III
Routine, periodic stress testing of asymptomatic
patients after PCI without specific clinical
indications should not be performed.
No Benefit
EuroIntervention 2015;10:1024-1094 published online ahead of print September 2014
2014 ESC/EACTS Guidelines on myocardial revascularization
Can treatment of
Chronic CAD
prevent sudden
death?