1. Myocardial Ischemia: Concepts in Management Topics in Clinical Medicine February 14, 2007

2. Familiar Concepts Determinants of myocardial ischemia Making the diagnosis – clinical and laboratory investigation Prognosis should determine treatment

3. Historical Notes Errors in judgment must occur in the practice of an art which consists largely in balancing probabilities. Sir William Osler, 1882 The capacity to make effective use of today’s diagnostic…technology depends in large measure on the accuracy with which the physician can perceive the dangers to the patient at that particular moment…The ability to forecast with reasonable accuracy is one of the most important things a doctor can do. Walsh McDermott, 1982

4. Prognosis in Chronic Ischemic Heart Disease Severity Time in Years Death TRANSITIONTRANSITION ZONEZONE STEMI NSTEMI UAP SCA A B C

5. Familiar Concepts Determinants of myocardial ischemia Determinants of myocardial oxygen supply  Oxygen-carrying capacity  Coronary flow Determinants of myocardial oxygen demand  Heart rate  Wall tension (~ systolic pressure)  Contractility

6. Familiar Concepts Determinants of myocardial ischemia Making the diagnosis – clinical and laboratory investigation –Typical angina (definite) Substernal discomfort, quality, duration Provoked by exertion or emotion Relieved by rest or TNG –Atypical angina (probable) – 2 of above –Non-specific chest pain – 1 or none

7. Pretest Likelihood of CAD AgeMenWomenMenWomenMenWomen 30-394234127626 40-4913351228755 50-5920765319373 60-69271472519486 Non-Specific Atypical Typical

8. Pretest Likelihood of CAD at Catheterization AgeMenWomenMenWomenMenWomen 30-394234127626 40-4913351228755 50-5920765319373 60-69271472519486 Non-Specific Atypical Typical

9. Familiar Concepts Determinants of myocardial ischemia Making the diagnosis – clinical and laboratory investigation Prognosis should determine treatment Duke Treadmill Score Time in minutes = - 5 x mm ST depression = 0 = none - 4 x angina index 1 = angina, not limiting 2 = limiting angina Total score = ScoreRisk GroupAnnual Mortality > 5Low0.25% -10 to +4Intermediate1.25% < -11High5.25%

10. Why do we treat angina? Prevent Death Prevent MI Reduce Symptoms ASA and Anti-anginal Therapy Beta-blocker and Blood Pressure Cigarette Smoking and Cholesterol Diet and Diabetes Education and Exercise

11. New Concepts Unusual presentations Acute treatment in myocardial infarction – how and where to open the artery Secondary prevention after myocardial infarction Women

12. MI - Secondary Prevention BP control (<140/90; <130/80 if diabetes or renal failure; pre-hypertension) Lipids – LDL 500, use fibrate** or niacin first, then treat LDL; ** watch for myopathy – keep statin dose low Beta-blocker Anti-platelet therapy – ASA 75-162 (325 x 1 month if stent); clopidogrel 75 mg/d ACEi; ARB, esp if intolerant Aldosterone blockade if EF <40%, DM, CHF

13. Smoking Cessation Diet - <7% saturated fat, <200 mg cholesterol, stanol/sterol, viscous fiber, fish Physical Activity – 30 min 7/wk Weight management – waist circumference Diabetes control – HbA1c < 7 MI - Secondary Prevention

15. How to Keep Up Online – e.g., Harrison’s Online Guidelines – specialty societies – www.americanheart.orgwww.americanheart.org

16. Class I Benefit>>Risk Treatment SHOULD be performed/admin istered Class IIa Benefit>>Risk Additional studies with focused objectives needed IT IS REASONABLE to administer Class IIb Benefit  Risk Additional studies with broad objectives needed; IT IS NOT UNREASONABLE to administer treatment Class III Risk  Benefit No additional studies needed Procedure/Treatment should NOT be performed/administered SINCE IT IS NOT HELPFUL AND MAY BE HARMFUL Level A Multiple (3-5) population risk strata evaluated* Consistency of direction and magnitude of effect Recommendation that procedure or treatment is useful/effective Sufficient evidence from multiple randomized trials or meta-analyses Recommendation in favor of treatment or procedure being useful/effective Some conflicting evidence from multiple randomized trials or meta-analyses Recommendation's usefulness/efficacy less well established Greater conflicting evidence from multiple randomized trials or meta- analyses Recommendation that procedure or treatment not useful/effective and may be harmful Sufficient evidence from multiple randomized trials or meta-analyses Level B Limited (2- 3)population risk strata evaluated* Recommendation that procedure or treatment is useful/effective Limited evidence from single randomized trial or non-randomized studies Recommendation in favor of treatment or procedure being useful/effective Some conflicting evidence from single randomized trial or non- randomized studies Recommendation’s usefulness/efficacy less well established Greater conflicting evidence from single randomized trial or non- randomized studies Recommendation that procedure or treatment not useful.effective and may be harmful Limited evidence from single randomized trial or non-randomized studies Level C Very Limited (1-2) population risk strata evaluated* Recommendation that procedure or treatment is useful/effective Only expert opinion, case studies, or standard-of- care Recommendation in favor of treatment or procedure being useful/ effective Only diverging expert opinion, case studies, or standard-of-care Recommendation’s usefulness/efficacy less well established Only diverging expert opinion, case studies, or standard-of-care Recommendation that procedure or treatment not useful/effective and may be harmful Only expert opinion, case studies, or standard-of-care Estimate of Certainty (Precision) of Treatment Effect Classification of Recommendations and Levels of Evidence Size of Treatment Effect