Management of Chronic Stable Angina

1. Management of Chronic Stable Angina AIMGP Seminar Series Mirek Otremba 2007

2. References • ACC/AHA Guideline on Chronic Stable Angina • Circ. 1999; 99:2829-2848 • Update JACC 2003; 41:159-68 • www.acc.org • CCS Consensus on Chronic Ischemic Heart Disease • Can J Cardiol 2000; Vol 16 no. 12: 1515-1535 • Chronic Stable Angina • NEJM 2005; 352: 2524-33 • Noninvasive tests in patients with stable CAD • NEJM 2001; 344: 1840-45

3. Objectives • Treatment options for chronic angina • Understand which treatments • prevent MI and death • reduce symptoms • Review the indications for revascularization (PCI or CABG)

4. Case Presentations • How would you further investigate and/or manage the following patients? • Take a few minutes for discussion

5. Patient No. 1 • 63 F • Smoker • Obese • Exertional angina (CCS Class 2)

6. Patient No. 2 • 52 M • Type II DM • Exertional angina (CCS 3) • Non-invasive testing shows large anterior perfusion defect which is reversible

7. Patient No. 3 • 73 M • Hx prior MI • Known Gr. 2 LV • Inferior reversible defect on Sestamibi • Presenting with ongoing anginal symptoms despite beta blockers, calcium channel blockers, Nitrates

8. Overview of Treatment • The treatment of angina has 2 purposes • Prevent MI and death (prolong life) • Reduce symptoms (improve quality of life)

9. Just a Reminder…Regarding Recommendations • Class 1 - Conditions for which there is evidence and/or general agreement that a given treatment is useful • Class 2 - Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness of a treatment

10. Reminder - Recommendations • Class 2a - Weight of evidence/opinion is in favor of usefulness • Class 2b - Usefulness is less well established by evidence/opinion • Class 3 - Conditions for which there is evidence/opinion that the treatment is ineffective and/or harmful

11. Prevention of MI and Death in CAD • Antiplatelet agents • ASA 81-150mg daily (Class I) • Clopidogrel 75mg daily (Class IIa): when ASA contraindicated • ASA + Clopidogrel for patients post PCI or ACS for at least 12 months (Class I)

12. Prevention of MI and Death in CAD • β blockers (Class I) • Better evidence (Level A) in patients with previous MI. Level B with patients without MI Bisoprolol 2.5mg–10mg once daily

13. Prevention of MI and Death in CAD • Lipid lowering therapy with Statin (Class I) • LDL target < 2.0 mmol/L • LDL target < 1.8 mmol/L in very high risk patients? (ATP III/NCEP) • Less evidence for HDL/TG therapy (Class IIa)

14. Prevention of MI and Death in CAD • ACE Inhibitors (Class I) • HOPE trial – Ramipril • EUROPA – Perindopril • PEACE – Trandolapril (-ve study)

15. Pharmacotherapy to Reduce Symptoms • Calcium antagonists (Class I) • β Blockers (Class I) • Nitrates (Class I) • All prolong duration of exercise before onset of angina and ST segment changes • All decrease frequency of angina

16. Pharmacotherapy to Reduce Symptoms • Calcium antagonists (Class I) • Long acting CCB’s NOT short acting ones which are felt to increase adverse cardiac events • Use in combination or alone

17. Pharmacotherapy to Reduce Symptoms • Long acting nitrates (Class I) • Short acting nitrates for relief of acute episodes

18. Goal of therapy • For most patients the goal of treatment is to be completely free of angina • A return to normal activities and functional capacity • Aim for CCS class I angina or better • Address other modifiable risk factors such as cholesterol, smoking, HTN, DM, and exercise, weight

19. Revascularization - CABG • Medical Treatment vs CABG • CABG has survival benefit when there is • Left main stenosis • 3,2, or 1 vessel disease that includes proximal LAD • 3 vessel disease (without prox. LAD), with poor LV function • CABG better in relieving symptoms

20. Revascularization - PCI • Medical Treatment vs PCI • Equivalent in terms of survival benefit • PCI - less angina (better quality of life) • PCI vs CABG • Where CABG not indicated for survival benefits: • Equivalent except: • CABG is better in pt with DM • PCI is better when CABG too high risk • PCI pts have more angina and repeat procedures

21. Follow-up and Monitoring • Follow up every 4 to 12 months • Repeat stress testing if significant change in clinical status • Questions to ask at follow up • Deceased level of activity? • Increase in angina symptoms or prn nitrate use? • Is pt tolerating therapy? • Other modifiable risk factors?

22. Back to the cases...Patient 1 • 63 F • Smoker • Obese • Exertional angina (CCS Class 2) • Stress test shows small apical reversible defect • Relieve Angina Symptoms • start with Metoprolol and titrate to achieve HR 55-60; prescribe and counsel re NTG spray use • titrate BB and consider addition of longer acting NTG or CCB is symptoms persist despite BB • Prevent MI and Death • give ECASA 325 mg po od • Consider Statin and ACE-In • check and treat lipids, blood sugar, counsel re: smoking, weight reduction, stress modification • given the small single territory defect on non-invasive testing no need to investigate with angiogram

23. Back to the cases...Patient 2 • 52 M • Type II DM • Exertional angina (CCS 3) • Non-invasive testing shows large reversible anterior perfusion defect • Relieve Symptoms: as in Patient #1 • Prevent MI and Death • ASA, Statin, and ACE-In • Treat DM, check lipids • Pt may have proximal LAD lesion and requires further evaluation with angiogram

24. 73 M • Hx prior MI • Known Gr. 2 LV • Inferior reversible defect on Sestamibi • Presenting with ongoing anginal symptoms despite βblockers, CCBs, Nitrates Back to the cases...Patient 3 • Relieve Symptoms • Single vessel disease suspected • Ongoing symptoms despite optimal medical management --> needs angiogram • May require revascularization for symptom relief • Prevent MI and death • ASA, Statin • BB (history of MI) • ACE (Gr 2 LV) • RF modification as appropriate

25. Summary for the Tx of CAD