8/5/2019 Q UESTION #2: Y OUR PATIENT IS CAPABLE P RETEST PROBABILITY - PowerPoint PPT Presentation

8/5/2019 D ISCLOSURES  I am on the Scientific Advisory Boards with stock option compensation for the following O UTPATIENT M ANAGEMENT companies: OF CAD- A P RIMARY C ARE  TAI Diagnostics  Cricket Health, Inc. P ERSPECTIVE Michael G. Shlipak, MD, MPH Scientific Director , Kidney Health Research Collaborative Professor of Medicine, Epidemiology & Biostatistics University of California, San Francisco Associate Chief of Medicine for Research Development San Francisco VA Medical Center August 5, 2019 Q UESTION #1 F EATURES OF THIS T ALK Y OUR PATIENT IS A 62 YO MAN WITH HISTORY OF CONTROLLED HYPERTENSION , MILD OVERWEIGHT (BMI 29),  Covers a broad array of topics AND UNTREATED LDL OF 137 MG / D L. H E REPORTS TO YOU THAT FOR ABOUT 2 MONTHS HE HAS EXPERIENCED LEFT -  Greatest attention to common challenges in decision SIDED CHEST TIGHTNESS AFTER WORKING UP 2 FLIGHTS OF making STAIRS . I T IS RELIEVED BY REST AND IS NOT PROGRESSING  All recommendations supported by the following NOTICEABLY . T HE SYMPTOMS HAVE NOT OCCURRED AT ANY Guideline: AHA Guideline for the Diagnosis and OTHER TIMES . W HAT IS THE PROBABILITY THAT THE Management of Patients with Stable Ischemic PATIENT ’ S SYMPTOMS ARE CAUSED BY CAD? Heart Disease (Circulation, 2012) 39% A. <50%  Class 1 indication: we should do this  Class 2 indication: it’s reasonable to do this B. 60% 26% 25% C. 80% D. >90% 10% % % % % 0 0 0 0 5 6 8 9 < >

8/5/2019 Q UESTION #2: Y OUR PATIENT IS CAPABLE P RETEST PROBABILITY OF CORONARY HEART DISEASE IN PATIENTS WITH CHEST PAIN OF WALKING AND HAS A NORMAL RESTING ACCORDING TO AGE , GENDER , AND SYMPTOMS ECG. W HICH OF THE FOLLOWING TESTS SHOULD YOU ORDER NEXT ? Age Nonanginal Chest Atypical angina Typical angina 38% Pain A. Exercise only stress test Men Women Men Women Men Women B. Exercise with perfusion imaging 30-39 4 2 34 12 76 26 24% C. Exercise echo 40-49 13 3 51 22 87 55 14% 14% D. Coronary angiography 50-59 20 7 65 31 93 73 9% E. None of the above 60-69 27 14 72 51 94 86 AHA definitions: low risk ~10% or less Exercise only stress test Exercise echo None of the above Coronary angiography Exercise with perfusion... high risk ~90% or higher intermediate risk- anything in between Diamond GA et al., N Engl J Med 1979 Weiner DA et al., N Engl J Med 1979 W HY DO WE ONLY TEST PATIENTS WITH N ON I NVASIVE T ESTING FOR D IAGNOSIS O F INTERMEDIATE PROBABILITY OF CAD? I SCHEMIC H EART D ISEASE  Exercise only: AHA recommendation is to limit testing to  LR+ = 3.0 intermediate risk patients  LR- = 0.42 (Gianrossi R. et al. Circulation, 1989)  If patient can exercise and has normal resting  Exercise echo: ECG, then exercise only stress test  LR+ = 3.7  If abnormal ECG, then exercise/imaging or  LR- = 0.19 exercise echo (Fleischmann KE. et al. JAMA 1998)  Exercise imaging:  If patient cannot exercise, then pharmacologic  LR+ = 2.4 stress with imaging/echo  LR- = 0.20 (Fleischmann KE. et al. JAMA 1998) - + - + + - (0.65) (0.97) (0.02) (0.28) (0.77) (0.25) 0.1 0.5 0.9

8/5/2019 PROMISE T RIAL T RIAL D ESIGN  10,000 participants in North America Is coronary CT angio the best  193 sites  NIH-funded tests for evaluation of  Randomization: intermediate risk patients with  CTA- coronary computed tomographic angiography chest pain?  Functional Testing- (one of the 3 options)  Exercise EGG  Nuclear stress Douglas P.S. et al N Engl J Med, 2015  Stress echo  Composite: death, MI, UA hospital procedure complication  Median follow-up 25 months Q UESTION 3 P ATIENT C HARACTERISTICS A MONG THESE INTERMEDIATE RISK PATIENTS , WHAT  Age : 60±8 PERCENTAGE WOULD YOU GUESS HAD THE PRIMARY  Women : 53% OUTCOME ( DEATH OR MI) WITHIN 2 YEARS ?  Mean : 2.4 risk factors A. <5%  Typical angina: 17% 41% B. 5-10%  Atypical angina: 78% 37% C. 10-20%  Non-anginal symptoms: 10% D. >20%  Individual predicted CAD risk: mean 0.53 14% 7% % % % % 0 5 0 0 < 1 2 2 5 - 0 - > 1

8/5/2019 CT A NGIO IS NO B ETTER THAN S UMMARY F UNCTIONAL T ESTING  A lot of testing with very low yield  “Intermediate risk” is actually low risk  “…reflects an excellent prognosis for patients with similar, new-onset, stable chest pain in real- world settings.” Incidence of death or MI was only 1%/year in each group Q UESTION #4 A SPIRIN Based on his symptoms of typical angina, you  All patients with CAD should use 81-162mg of inform your patient that he has CAD. You explain aspirin (class 1) the proven value of “optimal medical therapy”  Clopidigrel (plavix) should be offered to patients Which of the following is not considered part of who cannot tolerate aspirin (class 1) optimal medical therapy for a patient with  Aspirin + clopidigrel for severe patients is anginal symptoms? 68% reasonable (class 2B) A. ACE inhibitors (ARBs) B. Aspirin C. Beta blockers 20% D. Statins 13% 0% ) s n s s B i r n r e i R p i k t c a A s o t ( A S l s b r o a t t i e b i B h n i E C A

8/5/2019 B ETA B LOCKERS S TATINS ( MORE ON THIS TOPIC LATER )  Improved survival in patients with prior MI  LDL target <100 mg/dL - class 1  If patient has prior MI, BB is class 1  LDL target <70 mg/dL - class 2A  If MI >3 years ago, BB is class 2A  “No evidence to suggest LDL targets of 70 vs.  Best choice for angina symptoms 100mg/dL in patients with ASCVD” ACE I NHIBITORS C ASE C ONTINUED  Not clearly indicated in patients with angina  Your patient worries that something bad might because no effect on symptoms happen with his heart. He asks you to assess the likelihood of him having a heart attack or dying  Considered a “reasonable choice” (2A) from his heart disease. How do you determine  ACE inhibitors (Class I) must be used for risk in the secondary prevention setting? patients with:  Reduced ejection fraction  CKD with albuminuria

8/5/2019 R ISK F ACTORS FOR A DVERSE R ISK P REDICTION IN CAD O UTCOMES IN P ATIENTS WITH CAD  Primary prevention:  Feared adverse outcomes in CAD patients:  Patients without CAD or CVD  Recurrent MI  CVD risk calculator  Heart failure  Sudden death  Secondary prevention:  Traditional CVD risk factors are still important:  Patients who have CAD  No risk score for ambulatory patients with • Blood pressure control • Smoking cessation • Weight loss established CAD • Diabetes control • Lipid management • Encourage exercise  CVD risk calculators do not work  Although important, cardiac status matters more for prognosis than metabolic risk factors C ARDIAC -S PECIFIC R ISK FACTORS IN TREATMENT OF ANGINAL SYMPTOMS P ATIENTS WITH CAD RANKING ANTI-ISCHEMIC AGENTS (PER AHA GUIDELINES) Exercise capacity BBs- top choice 1. 1. Number and size of MIs CCBs or long acting nitrates (if BB intolerant) 2. 2. Reduced ejection fraction Use combinations if necessary 3. 3. HF symptoms NTG (sl or spray) for immediate relief 4. 4. BNP/NT-pro-BNP Ranolozine as lesser alternative (class 2A) 5. 5. High sensitivity troponins 6.

8/5/2019 F OLLOW U P IN CAD P ATIENTS C ASE S TUDY F OLLOW U P  Your patient is still frustrated by the concept of Routine medical management and concerned that his  Assess anginal symptoms and physical function symptoms indicate an impending heart attack. He asks you “why can’t I just get a stent and fix  Assess signs of heart failure or arrythmia this problem?”  Risk factor management  Lifestyle This seems logical- why not proceed to PCI? Situational  If heart failure signs or repeat MI  echo  If new or worsening angina  exercise testing or coronary angiography COURAGE TRIAL I NTERVENTIONS IN S TABLE A NGINA  Conducted to compare OMT with and without  Interventions should be limited to patients who PCI in 2,287 patients with stable angina fail optimal medical therapy  Funded by the US VA R&D/Canadian Institutes  Currently, 85% of all percutaneous coronary of Health Research intervention (PCI) procedures are elective in patients with stable angina  Outcome:  The COURAGE trial demonstrated that PCI does  All-cause mortality not improve outcomes  Non-fatal MI  Initial trial: mean of 4.6 years Boden et al. NEJM 2007  Extended follow-up: 12 years Sedlis et al. NEJM 2015

8/5/2019 COURAGE O UTCOMES C ASE S TUDY F OLLOW U P  Your patient insists on talking with a specialist  You refer to a cardiologist  The patient returns to your office 8 weeks later for a follow-up visit… Sedlis et al. NEJM 2015 …after having received a stent. What happened? CARDIOLOGISTS’ USE OF PCI FOR STABLE CAD  Design : focus groups of cardiologists in N. Cal  Research Question : Why do cardiologists What are cardiologists ignore COURAGE results?  Reasons given for performing PCI in stable thinking? angina:  Belief in the benefits of treating ischemia and in the open artery hypothesis  Potential regret (psychological and legal) for not intervening if a cardiac event could be averted  Alleviation of patient anxiety  Belief that referring PCP expects a procedure Lin et al. Arch Intern Med. 2007