Management of Chronic Stable Angina

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Management of Chronic Stable Angina

• AIMGP Seminar Series
• Mirek Otremba 2007

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References

• ACC/AHA Guideline on Chronic Stable Angina
• Circ. 1999 992829-2848
• Update JACC 2003 41159-68
• 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

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Objectives

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

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Case Presentations

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

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Patient No. 1

• 63 F
• Smoker
• Obese
• Exertional angina (CCS Class 2)

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Patient No. 2

• 52 M
• Type II DM
• Exertional angina (CCS 3)
• Non-invasive testing shows large anterior
  perfusion defect which is reversible

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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

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Overview of Treatment

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

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Just a ReminderRegarding 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

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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

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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)

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Prevention of MI and Death in CAD

• ß blockers (Class I)
• Better evidence (Level A) in patients with
  previous MI. Level B with patients without MI

Bisoprolol 2.5mg10mg once
daily
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Prevention of MI and Death in CAD

• Lipid lowering therapy with Statin (Class I)
• LDL target lt 2.0 mmol/L
• LDL target lt 1.8 mmol/L in very high risk
  patients? (ATP III/NCEP)
• Less evidence for HDL/TG therapy (Class IIa)

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Prevention of MI and Death in CAD

• ACE Inhibitors (Class I)
• HOPE trial Ramipril
• EUROPA Perindopril
• PEACE Trandolapril (-ve study)

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Pharmacotherapy to Reduce Symptoms

• Calcium antagonists (Class I)
• ß Blockers (Class I)
• Nitrates (Class I)
• All prolong duration of exercise before onset of
  angina and ST segment changes
• All decrease frequency of angina

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Pharmacotherapy to Reduce Symptoms

• Calcium antagonists (Class I)
• Long acting CCBs NOT short acting ones which are
  felt to increase adverse cardiac events
• Use in combination or alone

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Pharmacotherapy to Reduce Symptoms

• Long acting nitrates (Class I)
• Short acting nitrates for relief of acute
  episodes

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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

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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

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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

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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?

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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

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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

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Back to the cases...Patient 3
73 M Hx prior MI Known Gr. 2 LV Inferior
reversible defect on Sestamibi Presenting with
ongoing anginal symptoms despite ß blockers,
CCBs, Nitrates

• Relieve Symptoms
• Single vessel disease suspected
• Ongoing symptoms despite optimal medical
  management --gt 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

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Summary for the Tx of CAD