Updates in Coronary Artery Disease Disclosure Statement of and - PowerPoint PPT Presentation

Updates in Coronary Artery Disease Disclosure Statement of and Interventional Cardiology Financial Interest Lucas S Zier, MD, MS None Assistant Clinical Professor of Medicine Division of Cardiology Zuckerberg San Francisco General Hospital University of California San Francisco Outline Outline Prevention Prevention 1. Understand the use of aspirin in the prevention of coronary artery disease 1. Understand the use of aspirin in the prevention of coronary artery disease 2. Understand the use of fish oil in the prevention of coronary artery disease 2. Understand the use of fish oil in the prevention of coronary artery disease Stable Ischemic Heart Disease Stable Ischemic Heart Disease 1. Define the role of percutaneous coronary intervention in the management 1. Define the role of percutaneous coronary intervention in the management of stable ischemic heart disease of stable ischemic heart disease 2. Review current guidelines for dual antiplatelet therapy duration following 2. Review current guidelines for dual antiplatelet duration following percutaneous coronary intervention and acute coronary syndrome percutaneous coronary intervention and acute coronary syndrome Structural Heart Disease Structural Heart Disease 1. Define the expanding role of Transcatheter Aortic Valve Replacement in 1. Define the expanding role of Transcatheter Aortic Valve Replacement in the management of aortic stenosis the management of aortic stenosis 2. Review the role of percutaneous mitral valve therapies in the clinical 2. Review the role of percutaneous mitral valve therapies in the clinical management of patients with mitral regurgitation management of patients with mitral regurgitation

Audience Response Question: Aspirin Low dose daily aspirin should be prescribed to which of the following patient(s) to reduce the risk of primary cardiovascular events: A. 66 year old man with diabetes and a strong family An ounce of prevention 58% history of coronary artery disease is worth a pound of cure B. 72 year old woman with non anginal, chronic chest 42% pain, no significant cardiovascular risk factors, and a negative stress test -Benjamin Franklin C. 46 year old man with no cardiovascular risk factors who presents to your office wanting to reduce his 0% 0% 0% lifetime risk of cardiovascular disease D. None of the above e e . v v . . . . o . . . o i . h b b d t o n a a h w i h e e t h h i n t E. All of the above w i t t a w m f f n o o a n o e l m w a n A l m o d d d N o l l o o l r r a a r e a e e y y y 6 2 6 6 7 4 Primary Prevention: Aspirin Primary Prevention: Aspirin ARRIVE Trial Gaziano JM, Brotons C, Coppolecchia R, et al., on behalf of the ARRIVE Executive Committee. Use of aspirin to reduce risk of initial vascular events in patients at moderate risk of cardiovascular disease (ARRIVE): a randomised, double-blind, placebo- controlled trial. Lancet 2018;Aug 26:

Primary Prevention: Aspirin Primary Prevention: Aspirin ARRIVE Trial ARRIVE Trial Clinical Question: Aspirin Placebo p Value What is the clinical benefit of 100 mg per day of Composite Outcome of Cardiovascular Death, 4.3% 4.5% p = 0.60 aspirin in reducing the risk of cardiovascular Myocardial Infarction, Unstable Angina, Stroke, or TIA death, myocardial infarction, unstable angina, stroke, or transient ischemic attack in patients at Gastrointestinal Bleeding 0.97% 0.43% p = 0.0007 moderate risk of cardiovascular events without diabetes? Primary Prevention: Aspirin Primary Prevention: Aspirin ASCEND Trial ASCEND Trial Clinical Question: What is the clinical benefit of 100 mg per day of aspirin in reducing the risk of vascular death, myocardial infarction, or stroke/transient ischemic attack in patients with known diabetes but no history of cardiovascular disease? The ASCEND Study Collaborative Group. Effects of Aspirin for Primary Prevention in Persons With Diabetes Mellitus. N Engl J Med 2018;379:1529-39.

Primary Prevention: Aspirin Primary Prevention: Aspirin ASCEND Trial ASCEND Trial Aspirin Placebo p Value NNH: 1111 NNT: 1000 Composite Outcome of Cardiovascular Death, 8.5% 9.6% p = 0.01 Myocardial Infarction, Stroke, or TIA Aspirin resulted in a 1.1% Aspirin resulted in a 0.9% absolute risk reduction in absolute increase in major major adverse bleeding cardiovascular events Major Bleeding 4.1% 3.2% p = 0.003 Primary Prevention: Aspirin Primary Prevention: Aspirin ASCEND Trial What about cancer?... Aspirin Placebo p Value Gastrointestinal Cancer 2.0% 2.0% p = 1 All Cancer 11.6% 11.5% p = 0.98

Primary Prevention: Aspirin Primary Prevention: Aspirin Summary Aspirin and All Cause Mortality in 14 Primary Preventions Trials An aspirin a day… Should not routinely be prescribed to patients without prior cardiovascular events due to a lack of clinical benefit and/or increased risk of bleeding that offsets the reduction in cardiovascular events Primary Prevention: Aspirin Summary Secondary Prevention: Fish Oil 2019 ACC/AHA Guidelines Arnett, Donna K., et al. "2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease." Journal of the American College of Cardiology (2019): 26029.

Secondary Prevention: Fish Oil Audience Response Question: Fish Oil REDUCE-IT Trial A 72 year old woman presents to your office for a follow up appointment. She has a history of diabetes, hypertension, hyperlipidemia and recently had a STEMI treated with PCI to her mid LAD. She is on appropriate guideline directed medical therapy for CAD including a statin. She wants to further reduce her risk of future cardiovascular events and asks whether she should take fish oil. The most appropriate advice is: 58% A. It is reasonable to take any over the counter fish oil supplement at 2 grams per day to reduce her risk of future cardiovascular events B. There is no data supporting the use of fish oil for 22% secondary prevention of cardiovascular events 11% 8% C. Pharmaceutical grade DHA derived from fish oil will reduce her risk of cardiovascular events . . . . . . D. Pharmaceutical grade EPA derived from fish oil will a i . E . t D e r e k o e p d d a a t p a u r r o g g t s l a l a reduce her risk of cardiovascular events e a l t c c b a i t i a d t u u n o e e o c n c a Bhatt DL, Steg G, Miller M, et al., on behalf of the REDUCE-IT Investigators. Cardiovascular Risk Reduction With Icosapent s a a s m m e i e r r r r a a s e h Ethyl for Hypertriglyceridemia. N Engl J Med 2019;380:11-22. i h t h P P I T Secondary Prevention: Fish Oil Secondary Prevention: Fish Oil REDUCE-IT Trial REDUCE-IT Trial Clinical Question: Icosapent Ethyl Placebo p Value What is the clinical benefit of icosapent ethyl in reducing the risk of cardiovascular death, non Composite Outcome of Cardiovascular 17.2% 22% p < 0.0001 fatal myocardial infarction, nonfatal stroke, Death, Non Fatal Myocardial Infarction, Nonfatal Stroke, Coronary coronary revascularization, or unstable angina in Revascularization, or Unstable Angina patients with established cardiovascular disease or diabetes and one additional risk factor already Adverse Bleeding Events 2.7% 2.1% p = 0.06 receiving a stable dose of a statin?

Secondary Prevention: Fish Oil Secondary Prevention: Fish Oil REDUCE-IT Trial REDUCE-IT Trial No Benefit in Reducing Cardiovascular Events Secondary Prevention: Fish Oil Summary Icosapent ethyl… Consider prescribing this medication to patients with a history of cardiovascular disease or diabetes with additional risk factors Stable Ischemic who are already receiving ACC/AHA Heart Disease guideline directed lipid lowering therapy and want to further reduce their cardiovascular risk

Audience Response Question: CAD Outline Prevention Percutaneous coronary intervention in combination with 1. Understand the use of aspirin in the prevention of coronary artery disease medical therapy has been shown to have the following 2. Understand the use of fish oil in the prevention of coronary artery disease clinical benefits in the management of stable ischemic heart disease compared to medical therapy alone: Stable Ischemic Heart Disease 1. Define the role of percutaneous coronary intervention in the management 41% A. Reduction in the risk of death, myocardial of stable ischemic heart disease infarction and urgent revascularization 2. Review current guidelines for dual antiplatelet duration following 27% percutaneous coronary intervention and acute coronary syndrome B. Reduction in the frequency and severity of angina 16% 16% C. Statements 1 and 2 are both correct Structural Heart Disease D. None of the above statements are correct 1. Define the expanding role of Transcatheter Aortic Valve Replacement in the management of aortic stenosis . . 2. Review the role of percutaneous mitral valve therapies in the clinical . . . . . . . . . o f e e . u t k r a q a t s e s i 2 r r e management of patients with mitral regurgitation e f d v e n o h t h a b t a n 1 i n e n i s n t h o n t i o e t i m f c t o u c u e e d d t n e a R e t o R S N Stable Ischemic Heart Disease: Prognosis Stable Ischemic Heart Disease The problem with coronary revascularization…