1. Dr Jayachandran Thejus

2.  Coronary artery disease-  Block in coronary artery due to plaque or thrombus  Leads to myocardial ischemia manifested as chest discomfort  Two types-  Plaque- stable angina  Thrombus- acute coronary syndrome

3.  Stable angina-  Obstructive plaque  Blood flow enough at rest  Blood flow is inadequate when heart muscle needs extra blood as during exercise or emotional stress  Angina on exertion or emotion

4.  Stable angina means exertional chest discomfort due to a fixed stenosis in a coronary artery.

5. How to diagnose whether a person with chest discomfort has coronary artery disease or not?  Assess the probability  Typical nature of pain  Age  Male sex  Risk factors  Low probability- no tests  Intermediate probability- TMT or alternate tests  High probability- coronary angiography

6.  Intermediate probability- which test to choose?  Treadmill exercise test or TMT

9.  TMT is not possible  Pt cannot exercise  LBBB, WPW, pacemaker, resting ST depression, digitalis  SPECT  CT angiography

10. SPECT  Radioactive technitium is injected IV at stress and at rest  Radioactivity from various areas of the heart is measured.  Perfusion defect during stress indicates ischemic myocardium.  Can be done with adenosine IV in patients who cannot exercise

11. CT coronary angiography  Negative predictive value is high.  Positive predictive value is low.  Useful to rule out CAD in low risk patients.  If positive, does not mean that stenosis is present. ICA is needed.

12.  Invasive coronary angiography-  Intermediate probability- Stress test positive  High probability  Typical angina  RWMA by echo  Low EF by echo

13.  Patient presents with chest pain.  You evaluate the patient and find the probability of having CAD.  Low probability- follow-up.  Intermediate probability- TMT. If positive- angiography.  High probability- angiography

14.  Angiography-  No plaques- no treatment  Non-obstructive coronary plaques- medical management  Obstructive coronary plaques-  Small vessel- Medical management  Large vessel- PCI or CABG

15.  Coronary stenosis-  Single vessel- PCI  Multivessel- SYNTAX score  <22- PCI  22 to 32- PCI or CABG  >/= 33-CABG  Left main-  Ostial or mid- PCI  Distal- CABG

16. Lifestyle modification  Smoking cessation  Most effective lifestyle change  Nicotine gum and bupropion can be given  Diet  Decrease saturated fatty acids  Increase PUFA- fish  Increase fruit and vegetable intake  Decrease total energy intake to keep BMI < 25

17.  Regular physical activity  Aerobic activity like walking is preferred  Intensity depends on cardiac status  Sexual activity  PDE5 inhibitor has interaction with nitrates  Weight reduction  Sleep apnoea evaluation

18.  LDL  Reduce by > 50%  BP  Keep < 140/90 mm Hg

19.  Pharmacological treatment-  To improve long term prognosis  Aspirin  Statin  To relieve angina  S/L nitrate SOS  If angina is frequent- b B or Ca CB or both  Is still no relief- long acting nitrate or other drugs

20.  Pharmacological treatment-  To improve long term prognosis  Aspirin  Statin  To relieve angina  S/L nitrate SOS  If angina is frequent- b B or Ca CB or both  Is still no relief- long acting nitrate or other drugs  Aspirin 75 to 150 mg/day.  If intolerant, clopidogrel.  Do not add aspirin to clopidogrel.

21.  Pharmacological treatment-  To improve long term prognosis  Aspirin  Statin  To relieve angina  S/L nitrate SOS  If angina is frequent- b B or Ca CB or both  Is still no relief- long acting nitrate or other drugs  Statin always needs to be added.  LDL has to be reduced by more than 50% of basline value.

22.  Pharmacological treatment-  To improve long term prognosis  Aspirin  Statin  To relieve angina  S/L nitrate SOS  If angina is frequent- b B or Ca CB or both  Is still no relief- long acting nitrate or other drugs  ACEI to improve prognosis in  HT  DM  CKD  EF 40% or less

23.  Pharmacological treatment-  To improve long term prognosis  Aspirin  Statin  To relieve angina  S/L nitrate SOS  If angina is frequent- b B or Ca CB or both  Is still no relief- long acting nitrate or other drugs Sublingual nitrate SOS  5 mg ISDN  0.5 mg NTG

24.  Pharmacological treatment-  To improve long term prognosis  Aspirin  Statin  To relieve angina  S/L nitrate SOS  If angina is frequent- b B or Ca CB or both  Is still no relief- long acting nitrate or other drugs  Beta-blocker  Any cardioselective beta-blocker  Do not combine with non-DHP Ca CB  Include to improve prognosis in post MI and HF.

25.  Pharmacological treatment-  To improve long term prognosis  Aspirin  Statin  To relieve angina  S/L nitrate SOS  If angina is frequent- b B or Ca CB or both  Is still no relief- long acting nitrate or other drugs  CaCB  Non-DHP  Verapamil  Diltiazem  DHP  Long acting nifedipine  Amlodipine

26.  Pharmacological treatment-  To improve long term prognosis  Aspirin  Statin  To relieve angina  S/L nitrate SOS  If angina is frequent- b B or Ca CB or both  Is still no relief- long acting nitrate or other drugs  Long acting nitrate  If frequent angina  10 mg ISDN TDS or 30 – 60 mg ISMN bid or controlled release NTG 2.6 or 6.4 mg bid  Try to avoid CaCB or alpha blocker

27.  Pharmacological treatment-  To improve long term prognosis  Aspirin  Statin  To relieve angina  S/L nitrate SOS  If angina is frequent- b B or Ca CB or both  Is still no relief- long acting nitrate or other drugs  Ranolazine  500 to 1000 mg bid  Most trial data among alternative drugs  No effect on BP or heart rate

28.  Pharmacological treatment-  To improve long term prognosis  Aspirin  Statin  To relieve angina  S/L nitrate SOS  If angina is frequent- b B or Ca CB or both  Is still no relief- long acting nitrate or other drugs  Ivabradine  5 to 7.5 mg bid  If rate is uncontrolled even after b B optimum dose

29.  Pharmacological treatment-  To improve long term prognosis  Aspirin  Statin  To relieve angina  S/L nitrate SOS  If angina is frequent- b B or Ca CB or both  Is still no relief- long acting nitrate or other drugs  Nicorandil  5 to 10 mg bid

30.  Pharmacological treatment-  To improve long term prognosis  Aspirin  Statin  To relieve angina  S/L nitrate SOS  If angina is frequent- b B or Ca CB or both  Is still no relief- long acting nitrate or other drugs  Trimetazidine  35 mg bid

31.  Pharmacological treatment-  To improve long term prognosis  Aspirin  Statin  To relieve angina  S/L nitrate SOS  If angina is frequent- b B or Ca CB or both  Is still no relief- long acting nitrate or other drugs  EECP  Spinal cord stimulation  Chelation

34. You can download the slide set at heartpearls.com