8/5/2013 F EATURES OF THIS T ALK � It’s a debut O UTPATIENT M ANAGEMENT OF � Covers a broad array of topics � Greatest attention to common challenges in decision CAD- A P RIMARY C ARE making P ERSPECTIVE � All recommendations supported by the following Guideline: AHA Guideline for the Diagnosis and Michael G. Shlipak, MD, MPH Management of Patients with Stable Ischemic Heart Professor of Medicine, Biostatistics, and Disease (Circulation, 2012) Epidemiology � Class 1 indication: we should do this Chief, General Internal Medicine � Class 2 indication: it’s reasonable to do this August 5 , 2013 P RETEST PROBABILITY OF CORONARY HEART DISEASE Q UESTION #1 IN PATIENTS WITH CHEST PAIN ACCORDING TO AGE , GENDER , AND SYMPTOMS YOUR PATIENT IS A 62 YO MAN WITH HISTORY OF CONTROLLED HYPERTENSION , MILD OVERWEIGHT ( BMI 29), AND UNTREATED LDL Age Nonanginal Chest Atypical angina Typical angina OF 137 MG / DL . HE REPORTS TO YOU THAT FOR ABOUT 2 MONTHS Pain HE HAS EXPERIENCED LEFT - SIDED CHEST TIGHTNESS AFTER Men Women Men Women Men Women WORKING UP 2 FLIGHTS OF STAIRS . IT IS RELIEVED BY REST AND 30-39 4 2 34 12 76 26 IS NOT PROGRESSING NOTICEABLY . THE SYMPTOMS HAVE NOT 40-49 13 3 51 22 87 55 OCCURRED AT ANY OTHER TIMES . WHAT IS THE PROBABILITY 50-59 20 7 65 31 93 73 THAT THE PATIENT ’ S SYMPTOMS ARE CAUSED BY CAD ? 60-69 27 14 72 51 94 86 52% <50% a) AHA definitions: low risk ~10% or less 60% b) high risk ~90% or higher 25% intermediate risk- anything in between 80% c) 13% 10% >90% d) Diamond GA et al., N Engl J Med 1979 % % % % Weiner DA et al., N Engl J Med 1979 0 0 0 0 5 6 8 9 < > 1
8/5/2013 N ON I NVASIVE T ESTING FOR D IAGNOSIS O F Q UESTION #2: Y OUR PATIENT IS CAPABLE OF I SCHEMIC H EART D ISEASE WALKING AND HAS A NORMAL RESTING ECG. W HICH OF THE FOLLOWING TESTS SHOULD AHA recommendation is to limit testing to YOU ORDER NEXT ? intermediate risk patients � If patient can exercise and has normal resting ECG, Exercise only stress test a) 44% then exercise only stress test Exercise with perfusion imaging b) � If abnormal ECG, then exercise/imaging or exercise Exercise echo c) echo 26% Coronary angiography d) � If patient cannot exercise, then pharmacologic None of the above e) stress with imaging/echo 14% 14% 2% . . o . . . . . . . . h . . y h c o b l i a n t e g w i n e o e s a h e e i c y t s s r f c i i e a r o c r r x n e e E e x o n x r E E o o N C W HY DO WE ONLY TEST PATIENTS WITH Q UESTION #3: W HICH OF THE FOLLOWING IS INTERMEDIATE PROBABILITY OF CAD? NOT CONSIDERED PART OF OPTIMAL MEDICAL � Exercise only: THERAPY FOR A PATIENT WITH ANGINAL � LR+ = 3.0 SYMPTOMS ? � LR- = 0.42 (Gianrossi R. et al. Circulation, 1989) ACE inhibitors (ARBs) a) � Exercise echo: 80% Aspirin � LR+ = 3.7 b) � LR- = 0.19 Beta blockers c) (Fleischmann KE. et al. JAMA 1998) Statins d) � Exercise imaging: � LR+ = 2.4 � LR- = 0.20 15% (Fleischmann KE. et al. JAMA 1998) 4% 2% - + - + - + (0.65) (0.97) (0.02) (0.28) (0.25) (0.77) ACE inhibitors... Aspirin Statins Beta blockers 0.1 0.5 0.9 2
8/5/2013 A SPIRIN B ETA B LOCKERS � All patients with CAD should use 81-162mg of � Improved survival in patients with prior MI aspirin (class 1) � If patient has prior MI, BB is class 1 � Clopidigrel (plavix) should be offered to patients � If MI >3 years ago, BB is class 2A who cannot tolerate aspirin (class 1) � Best choice for angina symptoms � Aspirin + clopidigrel for severe patients is reasonable (class 2B) S TATINS ( MORE ON THIS TOPIC LATER ) ACE I NHIBITORS � LDL target <100 mg/dL - class 1 � Not clearly indicated in patients with angina because no effect on symptoms � LDL target <70 mg/dL - class 2A � Considered a “reasonable choice” (2A) � ACE inhibitors (Class I) must be used for patients with: � Reduced ejection fraction � CKD with albuminuria 3
8/5/2013 C ASE C ONTINUED R ISK P REDICTION IN CAD � Your patient worries that something bad might � Primary prevention: happen with his heart. He asks you to assess the � Patients without CAD or CVD likelihood of him having a heart attack or dying from � Framingham risk score his heart disease. How do you determine risk in the � Secondary prevention: secondary prevention setting? � Patients who have CAD � No risk score for ambulatory patients with established CAD � Framingham risk score does not work R ISK F ACTORS FOR A DVERSE O UTCOMES C ARDIAC -S PECIFIC R ISK FACTORS IN IN P ATIENTS WITH CAD P ATIENTS WITH CAD Exercise capacity 1. � Feared adverse outcomes in CAD patients: Number and size of MIs 2. � Recurrent MI Reduced ejection fraction � Heart failure 3. BNP/NT-pro-BNP � Sudden death 4. � Framingham risk factors are still important: Troponin T 5. •Blood pressure control •Smoking cessation •Weight loss •Diabetes control •Lipid management •Encourage exercise � Although important, cardiac status matters more for prognosis than metabolic risk factors Kragelund C. N Engl J Med, 2005 Omland T. N Engl J Med, 2009 4
8/5/2013 T REATMENT OF A NGINAL S YMPTOMS F OLLOW U P IN CAD P ATIENTS R ANKING ANTI -I SCHEMIC A GENTS ( PER AHA GUIDELINES ) BBs- top choice 1. Routine CCBs or long acting nitrites (if BB intolerant) 2. � Assess anginal symptoms and physical function Use combinations if necessary 3. � Assess signs of heart failure or arrythmia NTG (sl or spray) for immediate relief 4. � Risk factor management Ranolozine as lesser alternative (class 2A) 5. � Lifestyle Situational � If heart failure signs or repeat MI � echo � If new or worsening angina � exercise testing C ASE S TUDY F OLLOW U P I NTERVENTIONS IN S TABLE A NGINA � Your patient is still frustrated by the concept of � Interventions should be limited to patients who fail medical management and concerned that his optimal medical therapy symptoms indicate an impending heart attack. He � Currently, 85% of all percutaneous coronary asks you “why can’t I just get a stent and fix this intervention (PCI) procedures are elective in problem?” patients with stable angina � The COURAGE trial demonstrated that PCI does This seems logical- why not proceed to PCI? not improve outcomes 5
8/5/2013 COURAGE O UTCOMES COURAGE T RIAL � Conducted to compare OMT with and without PCI in 2,287 patients with stable angina � Funded by the US VA R&D/Canadian Institutes of Health Research � Outcome: � All-cause mortality � Non-fatal MI � Average follow-up: 4.6 years Boden et al. NEJM 2007 Boden et al. NEJM 2007 COURAGE R ESULTS C ASE S TUDY F OLLOW U P � Your patient insists on talking with a specialist � Adverse event rates: � You refer to a cardiologist � 19.0% in PCI group � The patient returns to your office 8 weeks later for a � 18.5% in OMT group follow-up visit… � HR PCI vs. no PCI: � Composite death/MI/stroke: 1.05, 0.87-1.27 …after having received a stent. � Hospitalization for ACS: 1.07, 0.84-1.37 � Myocardial Infarction: 1.13, 0.89-1.43 � PCI doesn’t reduce risk of death, MI, or other CV What happened? events when added to OMT in patients with stable angina Boden et al. NEJM 2007 6
8/5/2013 C ARDIOLOGISTS ’ U SE OF PCI FOR S TABLE CAD � Design : focus groups of cardiologists in N. Cal � Research Question : Why do cardiologists ignore What are cardiologists COURAGE results? � Reasons given for performing PCI in stable angina: thinking? � Belief in the benefits of treating ischemia � Belief in the open artery hypothesis � Potential regret (psychological and legal) for not intervening if a cardiac event could be averted � Alleviation of patient anxiety � “Oculostenotic reflex” � Belief that referring PCP expects a procedure Lin et al. Arch Intern Med. 2007 Q UESTION 4 C ONCLUSIONS � We need to fully implement OMT ( β -blocker, statin, Y OUR PATIENT RETURNS FOR FOLLOW UP . H E HAS BEEN TAKING aspirin) first, before referring to cardiologists 20 MG SIMVASTATIN . LDL IS 110 MG , HDL 25 MG . W HICH IS THE � We need to resist the urge to “fix” patients’ angina BEST NEXT STEP ? by stenting 56% � We need to educate patients that stents do not ↑ simvastatin a) prevent adverse outcomes Change to pravastatin b) � We need to be clear about our expectations prior to Change to atorvastatin c) 29% referring patients to cardiologists Add gemfibrozil d) Add niacin e) 8% 6% 0% . . n . . . . . . . i v r z i c a o a t o i r a r n p b o d o f i t m d t A e e g e g n g n a d a h h d C A C 7
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