Chronic CAD: Diagnosis, Treatment and Guidelines 2016 Morton J. Kern MD, MSCAI, FACC, FAHA Chief of Medicine, VA Long Beach HSC Professor of Medicine University California Irvine

Deaths attributable to cardiovascular disease (United States: 2010). Percentage breakdown of deaths attributable to cardiovascular disease (United States: 2010). Total may not add to 100 because of rounding. Coronary heart disease includes International Classification of Diseases, 10th Revision (ICD-10) codes I20 to I25; stroke, I60 to I69; heart failure, I50; high blood pressure, I10 to I15; diseases of the arteries, I70 to I78; and other, all remaining ICD-I0 I categories. *Not a true underlying cause. With any-mention deaths, heart failure accounts for 35% of cardiovascular disease deaths. Source: National Heart, Lung, and Blood Institute from National Center for Health Statistics reports and data sets. Go A et al. Circulation 2014;129:e28-e292

Deaths attributable to diseases of the heart (United States: 1900–2010). Deaths attributable to diseases of the heart (United States: 1900–2010). See Glossary (Chapter 26) for an explanation of “diseases of the heart.” Note: In the years 1900 to 1920, the International Classification of Diseases codes were 77 to 80; for 1925, 87 to 90; for 1930 to 1945, 90 to 95; for 1950 to 1960, 402 to 404 and 410 to 443; for 1965, 402 to 404 and 410 to 443; for 1970 to 1975, 390 to 398 and 404 to 429; for 1980 to 1995, 390 to 398, 402, and 404 to 429; and for 2000 to 2009, I00 to I09, I11, I13, and I20 to I51. Before 1933, data are for a death registration area and not the entire United States. In 1900, only 10 states were in the death registration area, and this increased over the years, so part of the increase in numbers of deaths is attributable to an increase in the number of states. Source: National Center for Health Statistics. Go A et al. Circulation 2014;129:e28-e292

58 yo Man, Chest pain after lunch on the way to car. Bad sushi?

CAD is a diffuse process with focal atherosclerotic material (plaque). Some plaques are obstructive but not thrombotic. Others are potentially thrombotic but not obstructive. Myocardial Infartion= Death of myocardial cells. Clinical MI = symptoms, ECG and Biomarkers

CAD as a cause of Myocardial Ischemia and Infarction Atherosclerotic Plaque Normal 16

Angiography vs. Pathology

Fibrous plaque Angiography vs CTA for CAD ACS 179 LAD Positive remodeling Soft plaque LAD Motoyama et al. JACC 2007 8

Natural History of CAD : A story of remodeling

Acute Coronary Syndrome 72 year-old Man Plaque crater, erosion Calcific nodule Thrombus

What are the Big 5 medications for CAD? BB ASA/antiplatelet agents Statins Nitrates Antihypertensive and other risk factor medications

NTG ASA Heparin GPB’s Beta blockers Statins CA blockers ACEI Ranolazine Beta blockers CA blockers ACEI NTG FIGURE 44-1 Factors influencing myocardial oxygen supply and demand. FiO2 = fraction of inspired oxygen;Hgb = hemoglobin. Braunwald’s Heart Disease, 7th Edition

Diastolic Dysfunction Ischemic Cascade Angina Δ ECG Stress ECG Systolic Dysfunction Stress Echo/MRI Diastolic Dysfunction Perfusion Abnormalities Nuclear Imaging Duration and severity of ischemia

Conditions Provoking or Exacerbating Ischemia Increased Oxygen Demand Decreased Supply Noncardiac Hyperthermia Anemia Hyperthyroidism Hypoxemia Sympathomimetic toxicity Pneumonia (e.g., cocaine use) Asthma Hypertension Chronic obstructive Anxiety pulmonary disease Arteriovenous fistulae Pulmonary hypertension Interstitial pulmonary fibrosis Obstructive sleep apnea Cardiac Sickle cell disease HCM Sympathomimetic toxicity Aortic stenosis (e.g., cocaine use) Dilated cardiomyopathy Hyperviscosity Tachycardia Polycythemia Ventricular Leukemia Supraventricular Thrombocytosis Hypergammaglobulinemia

Spectrum of CAD Presentations SIHD UA NSTEMI STEMI Definition Ischemia with activity Ischemia without necrosis Necrosis (nontransmural) Transmural necrosis Diagnosis Symptoms, ECG, Stress testing Negative Biomarkers Positive biomarkers No ECG ST-segment elevation ECG ST-segment elevation Treatment The Big 5 Invasive or conservative depending on risk Immediate reperfusion Roger VL, Go AS, Lloyd-Jones DM, et al.. Circulation. 2011;123:e18-e209. 16

Heart Attack Warning Signs Chest discomfort Pressure Squeezing Fullness Pain Discomfort in other areas of the upper body Arms Jaw Neck Back Stomach Shortness of Breath Cold sweat, nausea or lightheadedness **Women have atypical presentations!! Be more wary

Current Management for Acute Coronary Syndromes high risk of in-hospital death low risk of in-hospital death, unless MI develops Treatment goal: stabilize with aspirin heparin & monitor for MI development Treatment goal: immediate restoration of coronary blood flow + Cardiac enzymes – Cardiac Enzymes High- risk features Low - risk features If no cath lab, Fibrinolytic therapy Direct PCI Scheduled PCI Manage medically

Thygesen, K. et al. Circulation 2007;116:2634-2653

Plalque Rupture Spasm, low BP Sudden Death, no CK PCI related Stent Thrombosis CABG related Thygesen, K. et al. Circulation 2007;116:2634-2653 21

7 Factors of the TIMI Risk Score for UA/NSTEMI

CAD CP algorithm

Exercise Pharmacologic 1. ECG - 2. ECHO 4. Dobutamine Echo The 5 Common Cardiac Stress Testing Modalities Exercise Pharmacologic 1. ECG - 2. ECHO 4. Dobutamine Echo 3. Nuclear 5. Adenosine Nuclear

Who needs Stress Testing? 2014 ESC/EACTS Guidelines on myocardial revascularization

Echo stress Echo stress ECG stress only Nuclear stress ECG stress only Nuclear stress

Indications for revascularization in Stable CAD or silent ischemia 2014 ESC/EACTS Guidelines on myocardial revascularization

Recommendation for CABG/PCI in Stable CAD with anatomy suitable for both procedures 2014 ESC/EACTS Guidelines on myocardial revascularization

BP control <140/90 or <130/80 DM, CR BP maintence add meds as nec to BB/ACE Lipids Add plant stanol/sterols 2g/ Lipids LDL-C <70mg/dl or high dose statin is reasonable (IIa) Lipids If LDL-C 100-70 at base, rx to <70mg/dl is reasonable

From: 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines J Am Coll Cardiol. 2014;63(25_PA):2889-2934. doi:10.1016/j.jacc.2013.11.002 ABI indicates ankle-brachial index; ASCVD, atherosclerotic cardiovascular disease; CAC, coronary artery calcium; hs-CRP, high-sensitivity C-reactive protein; LDL-C, low-density lipoprotein cholesterol; MI, myocardial infarction; and RCT, randomized controlled trial.

From: 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines J Am Coll Cardiol. 2014;63(25_PA):2889-2934. doi:10.1016/j.jacc.2013.11.002 ABI indicates ankle-brachial index; ASCVD, atherosclerotic cardiovascular disease; CAC, coronary artery calcium; hs-CRP, high-sensitivity C-reactive protein; LDL-C, low-density lipoprotein cholesterol; MI, myocardial infarction; and RCT, randomized controlled trial.

From: 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines J Am Coll Cardiol. 2014;63(25_PA):2889-2934. doi:10.1016/j.jacc.2013.11.002 ALT indicates alanine transaminase; ASCVD, atherosclerotic cardiovascular disease; CK, creatine kinase; FH, familial hypercholesterolemia; LDL-C, low-density lipoprotein cholesterol; and ULN, upper limit of normal.

From: 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines J Am Coll Cardiol. 2014;63(25_PA):2889-2934. doi:10.1016/j.jacc.2013.11.002 ABI indicates ankle-brachial index; ALT, alanine transaminase; ASCVD, atherosclerotic cardiovascular disease; CAC, coronary artery calcium; CK, creatine kinase; FH, familial hypercholesterolemia; LDL-C, low-density lipoprotein cholesterol; MI, myocardial infarction; RCT, randomized controlled trial; and ULN, upper limit of normal.

From: 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines J Am Coll Cardiol. 2014;63(25_PA):2889-2934. doi:10.1016/j.jacc.2013.11.002 ABI indicates ankle-brachial index; ALT, alanine transaminase; ASCVD, atherosclerotic cardiovascular disease; CAC, coronary artery calcium; CK, creatine kinase; FH, familial hypercholesterolemia; LDL-C, low-density lipoprotein cholesterol; MI, myocardial infarction; RCT, randomized controlled trial; and ULN, upper limit of normal.

Exercise Testing I IIa IIb III In patients entering a formal cardiac rehabilitation program after PCI, treadmill exercise testing is reasonable. Routine, periodic stress testing of asymptomatic patients after PCI without specific clinical indications should not be performed. I IIa IIb III No Benefit 37

2014 ESC/EACTS Guidelines on myocardial revascularization

Can treatment of Chronic CAD prevent sudden death?