Coronary Artery Disease

1
Coronary Artery Disease

• Jeffrey L. Anderson, MD
• Professor of Medicine, Univ. of Utah
• Asso. Chief of Cardiology, LDSH

2
The Heart in Health

• Heart beats
• 72/min
• 40 million/year
• gt3 billion/life-time
• Pump Function
• 100 mL/beat
• 6 liters per minute
• 360 liters per hour
• 8,640 liters (gt2,160 gallons)/day

3
The Heart and Disease

• Cardiovascular disease (CVD) the 1 cause of
  death and serious disability
• CVD responsible for 960,000 deaths/yearan
  average of 1 death every 33 sec.
• CVD claims as many as next 7 causes of death
  combined!
• Cancer 550,000 accidents 98,000, Alzheimers
  disease 45,000 AIDS 15,000
• Coronary artery disease (CAD) is the leading CVD
  cause of death 530,000 deaths/year
• 250,000 die each year without being hospitalized
  (suddenly)

4
Deaths From CVD Remain High
Deaths/100,000 Pop. (Line)
Deaths in Thousands (Bar)
600

• The total number of CVD-related deaths per year
  has remained high nearly 1 million deaths
  annually.1

1st Statin Introduced2
500
400
300
200
100
0
79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94
95 96 97 98 99 00
Year
NCEP ATP I3
NCEP ATP II4
1. Morbidity Mortality 2002 Chart Book on
Cardiovascular, Lung, and Blood Diseases. NIH
2002. 2. Med Lett Drugs Ther. 19872999101. 3.
Expert Panel. Arch Intern Med. 19881483669. 4.
Expert Panel. JAMA. 199326930153023.
5
Coronary Artery Disease an Overview

• Coronary artery disease (CAD), a common disorder,
  is characterized by progressive luminal narrowing
  of coronary arteries, typically due to
  atherosclerosis
• Because the heart is aerobic, reduction in oxygen
  supply causes important clinical consequences

6
CAD Epidemiology

• CAD is leading cause of death, disability in
  United States
• gt500,000 deaths annually
• gt5 million with symptomatic CAD
• gt5 million with subclinical CAD
• CAD frequently manifests itself in middle age
  (especially in men)
• CAD appears in women 10-15 years later (after
  menopause)

7
Coronary Anatomy

• Right (RCA) and left main coronary arteries arise
  from proximal aorta
• RCA supplies RA, RV inferior LV/septum in 85
  sinus node (SN) artery in 60
• Left anterior descending (LAD) artery supplies
  anterior LV, anterior septum (septal aa), ant-lat
  wall (diagonal aa)
• Left circumflex (LCx) supplies left LV wall
  posterior descending (PDA) artery to the inferior
  septum in 10 SN artery, 40

8
(No Transcript)
9
Coronary Physiology

• Heart is aerobic it can sustain an oxygen debt
  only briefly
• Increased O2 need met by increased coronary blood
  flow, not increased extraction
• Supply/demand imbalance (due to CAD) causes
  clinical consequences angina, MI, LV
  dysfunction, arrhythmias, sudden death
• Subendocardial zone is most vulnerable (more
  distal, lower perfusion pressure)

10
Pathogenesis of CAD

• Early, middle events Plaque develops in several
  stages endothelial injury, response to injury,
  with inflammation (macrophages, T-lymphocytes,
  smooth muscle cells), infiltration (lipids),
  expansion, calcification
• Late events Plaque erosion, ulceration,
  rupture, stimulating platelet adhesion and
  aggregation, fibrin deposition, thrombus
  formation, spasm, occlusion, myocardial
  infarction

11
Atherothrombosis a Generalized and Progressive
Process
Athero-scleroticplaque
Fattystreak
Fibrousplaque
Normal
Clinically silent
Stable angina Intermittent claudication
Increasing age ACS, acute coronary syndrome TIA,
transient ischemic attack
12
Inflammatory Mechanisms Leading to
Atherosclerotic Plaque Rupture, Thrombosis
After Libby. Circulation. 1995.
13
Plaque Rupture, Thrombosis, and Pathophysiology
of Acute Coronary Syndromes
1.5 Million per year in USA
Modified after Harrington, Duke.
14
Traditional CAD Risk Factors

• Male gender
• Age
• Family History
• Dyslipidemia
• Smoking
• Diabetes
• Hypertension
• (Renal Insufficiency)

15
Atherogenesis A Brief Incredible Journey
16
Diabetic Atherogenesis A Brief Incredible
Journey
17
Manifestations, Presentations of CAD

• Angina stable or unstable
• Myocardial infarction (MI)
• Arrhythmias
• Heart failure
• Sudden death (mechanisms VT/VF, or
  bradyarrhythmias with EM dissociation)

18
Angina Pectoris

• Syndrome of transient discomfort, usually in
  chest, caused by temporary, reversible myocardial
  ischemia
• Biochemical causes include release of adenosine,
  changes in local pH and K, stimulating
  sympathetic afferent nerves, transmitted to
  C7-T4, causing discomfort

19
Characteristics of Angina Quality

• Literally, choking discomfort rather than pain
• Crushing or pressure-like
• Squeezing or vise-like or band-like
• Strangling or constricting
• Bursting or expanding
• Heavy, weight (elephant) on chest
• Occasionally, burning
• Generally not sharp, stabbing

20
Characteristics of Angina Location

• Retrosternal (most consistently), but also may
  be
• Left precordial
• Across chest (left and right)
• Anterior neck, jaws, or arm(s) only
• Epigastric
• Usually, diffuse
• Generally, not highly localized (not finger-point)

21
Characteristics of Angina Radiation

• Left shoulder, arm (most characteristic), but
  also may be
• Right or both arms
• Shoulders, neck, jaw, teeth
• Epigastrium
• Interscapular (back)
• But, usually not below umbilicus, top of head

22
Characteristics of Angina Duration

• Typically, 2 to 5 minutes
• Generally NOT
• gt10 minutes (unless unstable angina/MI)
• Seconds (shooting)

23
Characteristics of Angina Precipitating Factors

• Exertion, emotional stress
• Meals
• Exposure to cold, wind
• Amount of exertion may vary (variable threshold
  angina)
• May be worse after arising or late in day
• Generally NOT deep breathing, change in position,
  pressure on chest wall

24
Characteristics of Angina Relieving Factors

• Rest
• Nitroglycerin
• But generally NOT antacids, NSAIDs, change in
  position, eructation

25
Angina Miscellaneous Features

• Unaffected by change in position, respiration
• At times, dyspnea, nausea, diaphoresis present
• Typically, occurs with stress, relieved with rest
• Typical angina in middle-aged men predicts CAD
  with 80-90 accuracy
• Angina in women predicts CAD in 60-65 (more
  frequently false positive or atypical)

26
Physical Examination with CAD and Angina

• Often normal, or abnormal but non-specific, when
  angina-free
• During angina
• HR, BP may increase (non-specific)
• S4 gallop most frequent finding, but subtle
• Rarely, murmur of MR, paradoxic split of S2

27
Electrocardiogram in Angina

• Resting ECG often normal or non-specific when
  angina-free
• During angina, may be normal, non-specific, or
  show ST depression
• ST depression with angina is useful
  diagnostically, prognostically
• Old MI on ECG raises suspicion that chest
  discomfort is angina

28
Grading of Angina

• Class I No angina with ordinary activity
• Class II Slight limitation due to angina
• Class III Marked limitation of activity
• Class IV Angina occurs at rest

29
Treatment of Angina

• Avoid or correct precipitating factors
• Avoid excessive stress (physical, emotional)
• Correct anemia
• Correct hypoxemia
• Treat fever
• Identify, correct hyperthyroidism
• Correct other supply/demand mismatches

30
Treatment of AnginaReduce Risk Factors

• Smoking cessation
• Hypertension control
• Diabetes control
• Weight reduction
• Lower cholesterol (LDL)
• Lower non-HDL cholesterol (LDL, VLDL, IDL)

31
Treatment of Angina

• Goals
• Prevent or reduce angina
• Prevent MI
• Aims
• Decrease myocardial oxygen demand,
• Increase oxygen supply, and/or
• Both (improve supply/demand ratio)

32
Medical Therapy of Angina Nitrates

• Reduce A/V tone, BP, ventricular volume/filling
  pressure/wall stress
• Coronary vasodilation relieve spasm, promote
  collateral flow, redistribute blood flow to
  ischemic areas
• Short-acting (sublingual or spray) nitroglycerin
  treatment of choice for immediate relief of
  angina
• Long acting (cutaneous patch or SR pills)
  complicated by AEs (headache), tolerance
• Use as second line or adjunctive therapy

33
Medical Therapy of AnginaBeta-blockers

• Many available agents (metoprolol, atenolol,
  propranolol, etc.)
• Extensively tested, clinically used
• Reduce demand by decreasing HR, BP, contractility
• Increase supply by increasing diastole,
  prolonging coronary flow
• Agents of first choice for subacute, chronic
  therapy

34
Medical Therapy of AnginaCalcium Channel
Blockers

• Include verapamil, diltiazem, amlodipine,
  nifedipine, etc.
• Coronary and arterial dilators decrease BP,
  contractility
• Verapamil, diltiazem slow HR, whereas
  short-acting nifedipine may increase HR
• Rx of choice for Prinzmetals angina second-line
  to beta-blockers for stable, unstable angina

35
Medical Therapy of AnginaCombination Therapy

• Two or three agents may be used when one alone is
  inadequate
• A Beta-blocker
• A Calcium-channel blocker
• A Long-acting Nitrate
• Isosorbide mononitrate
• Isosorbide dinitrate
• Others

36
Medical Therapy of Angina Aspirin

• Antiplatelet therapy with aspirin shown
  consistently to reduce subsequent MI, mortality
  in patients with angina, UA, or MI
• Aspirin should be given routinely, administered
  daily, indefinitely
• Dose 162-325 mg/d initially, then 81-162 mg/d
  maintenance dose
• Alternative if aspirin allergic or resistant
  clopidogrel (Plavix) 75 mg/d

37
Establishing a Diagnosis of CAD

• History of typical angina pectoris (?90 accurate
  in men, ?60-65 in women)
• Acute MI
• Documented prior MI (ECG, markers, imaging)
• Positive stress test
• Exercise testing
• Pharmacologic stress testing (dobutamine,
  adenosine, dipyridamole)
• Stress imaging (echo, thallium, sesta-MIBI,
  adenosine-gadolinium cardiac MRI)
• Coronary arteriography (Invasive or MSCT)

38
Unstable Angina

• Intermediate in spectrum of CAD between stable
  angina and acute MI
• A leading cause of hospitalization (750,000
  admissions per year)
• Leading diagnosis in CCUs
• Importance is frequent progression to MI, death

39
(No Transcript)
40
Acute Coronary Syndromes
No ST Elevation
ST Elevation
NSTEMI
Q-Wave AMI
Non-Q-Wave AMI
Unstable Angina
Spectrum of Acute Coronary Syndromes
Positive serum cardiac marker
Modified from ACC/AHA Guidelines for the
Management of Patients with UA and NSTEMI. JACC
200036970-1062 JACC, March 2002
41
Unstable Angina Definition

• Accelerated pattern of angina (increased
  frequency, severity, duration, or reduced
  threshold)
• Rest angina
• New onset angina (and with only mild effort)

42
Unstable Angina Pathophysiology

• In contrast to stable angina (due to increased O2
  demand), unstable angina is due to reduced O2
  supply
• Rupture of plaque, with thrombosis,
  vasoconstriction, leads to subtotal
  (infrequently, total) occlusion to coronary blood
  flow

43
Mechanisms Involved in Plaque Rupture

• The vulnerable plaque cholesterol rich, thinly
  capped
• Pro-inflammatory triggers (cytokines)
• Inflammatory cell infiltration
• Matrix degradation
• Endothelial dysfunction
• Systemic factors
• Shear stress
• Plaque geometry

44
(No Transcript)
45
Hidden Plaque and Culprit Plaque by Intravascular
Ultrasound
46
Unstable Angina History, Exam, ECG

• Symptoms similar to stable angina, but more
  severe, longer duration
• Exam, ECG more frequently abnormal

47
Variant (Prinzmetals) Angina

• Recurrent episodes of typical ischemic
  discomfort, but at rest, often early AM, more
  prolonged, requiring more nitroglycerin
• Related to profound but reversible coronary spasm
• Spasm may occur in area of plaque or
  angiographically normal artery
• ECG classically shows ST elevation (transmural
  ischemia)
• More common in Japan than US

48
Other Ischemic Syndromes

• Silent ischemia Defined by ST segment changes on
  ECG monitor (rest, exercise), stress echo, or
  stress radionuclide study, without angina
• Syndrome X (microvascular angina) Poorly
  understood. Often in younger patients, women.
  Ischemic-type pain with normal coronary angiogram
  without spasm of epicardial arteries. Some have
  positive stress tests. Increased microvascular
  (arteriolar) resistance, ?vasodilator reserve
  often present. Cardiac MRI (adenosine gadolinium)
  appears to be the best diagnostic test.

49
Therapeutic Considerations in Unstable Angina

• Bed rest, sedation (prn)
• Give aspirin, an antithrombin (low molecular
  weight heparin or unfractionated heparin),
  nitrates, beta-blockers /or calcium channel
  blockers (verapamil or diltiazem).
• Consider coronary angiography and angioplasty,
  especially if ischemia recurs at rest or with
  low-level exercise and is associated with ECG
  changes or positive markers (troponin)

50
(No Transcript)
51
Coronary Angioplasty and Stenting (PTCA, PCI)

• Balloon dilation catheter passed along wire
  through obstruction, inflated compresses plaque,
  thrombus
• gt90-95 success
• 2 acute complications (acute occlusion)
  requiring coronary artery bypass grafting (CABG).
  Reduced by stents and glycoprotein GP IIb/IIIa
  inhibitors.
• Restenosis rate 20-30 at 3-6 months. Reduced
  with new drug eluting stent (sirolimus) (to
  lt5-10).
• Preferred for 1 vessel, some 2 vessel disease

52
Tools Toys for Managing Coronary Plaques
(TOYS-R-US)

• Compress it Balloons
• Tack it Stents (wire cylinder)
• Cut it Directional Atherectomy
• Drill it Rotablator
• Vaporize it Laser
• Remove it TEC Catheter
• Suck it out Angiojet

53
Coronary Stenting

• Coronary stenting has succeeded balloon
  angioplasty as the dominant approach to PCI
• In 2004, about 80 of procedures estimated to use
  stenting
• Restenosis occurs in 20 within 3-6 months, may
  be redilated and irradiated (brachytherapy)
• Coated stents (e.g., sirolimus, tacrolimus),
  available beginning in 2003, have ??restenosis to
  5-10 but ?late thrombosis
• Prolonged clopidogrel (3-12 mo) indicated

54
Ischemic Complications of PCI
White HD. AM J Cardiol. 1997 80(4A) 2B-10B.
55
Surgical Therapy CABG

• Often preferred for multivessel (2-3) disease
• Saphenous veins commonly used
• Arterial grafts more durable, used whenever
  possible
• Internal thoracic (mammary) artery graft often
  used for LAD
• Radial artery also may be used as a conduit
• Better durability than PCI (b/o restenosis with
  need for redo procedures). Same survival (BARI).
  Better outcomes in diabetics.

56
Coronary Artery Disease Acute Myocardial
Infarction (AMI)

• Definition Myocardial necrosis resulting from
  impairment of coronary blood supply
• Irreversibility of MI (necrosis) contrasts with
  reversibility of stable and unstable angina
  (ischemia)

57
Pathogenesis of Acute MI

• Plaque fissuring
• Intraluminal thrombus formation
• Platelet adhesion, aggregation
• Formation of fibrin net
• Occlusive platelet and fibrin-rich, red blood
  cell containing clot
• Intraplaque hemorrhage, thrombus
• Coronary artery spasm

58
Acute MI Coronary Occlusion
DeWood, NEJM, 1980
59
Acute MI History

• Discomfort qualitatively similar to that of
  angina, but more severe
• Duration of discomfort prolonged30 min to
  several hours
• Pain unrelated to exertion, unrelieved by rest or
  nitroglycerin
• Dyspnea, weakness, dizziness, sense of impending
  doom often present
• gt20 of MIs atypical (unrecognized) or silent

60
Acute MI Diagnosis

• No clinical gold standard
• History, ECG, cardiac markers the diagnostic
  triad
• ECG
• Sensitivity 50-80 (if first MI)
• Classic ST elevation evolving to Q-waves in 1/3
  (STEMI)
• Others (2/3) have ST depression or T-wave
  inversion or non-specific changes (NSTEMI)

61
Serum Markers of Acute MI
Marker Time Appears Time Elevated ?6 hr ?12 hr Speci-ficity Comment
Tn I 2-6 h 5-10 d ?75 90-100 ?98 Test of choice
Tn T 2-6 h 5-14 d ?80 95-100 ?95 Excellent except RF
CK-MB 3-6 h 2-4 d ?65 ?95 ?95 CP with ? Tn
MB2 Isoform 2-6 h 1-2 d ?95 98-100 ?95 Tech. difficult
Myo-globin 1-2 h lt1 d ?85 ?90 ?80 Rapid, sensitive, non-spec.
62
MI Categories by ECG

• ST elevation vs. Non-ST elevation MI
• A distinction on ED evaluation at admission
• ST elevation implies transmural ischemia, larger
  area of infarction, usually evolves into Q-wave
  MI treat with reperfusion Rx
• ST depression associated with subendocardial
  ischemia/infarction treat with antithrombotics,
  angiographic evaluation

63
Acute Coronary Syndromes
No ST Elevation
ST Elevation
NSTEMI
Q-Wave AMI
Non-Q-Wave AMI
Unstable Angina
Spectrum of Acute Coronary Syndromes
Positive serum cardiac marker
Modified from ACC/AHA Guidelines for the
Management of Patients with UA and NSTEMI. JACC
200036970-1062 JACC, March 2002
64
MI Categories by ECG

• Q-wave vs. Non Q-wave MI
• A distinction at hospital discharge
• Q-wave MI associated with more necrosis, higher
  short-term mortality
• Non Q-wave MI associated with more recurrent
  angina, MI, sudden death
• Long-term (gt1-2 year) mortality equal

65
Acute ST Elevation Anterior MI
?
66
Acute Infero-Posterior MI
?
67
ST Depression Precordial Leads
68
ST Depression
69
Evolving Acute Antero-lateral MI
70
Evolving Anteroseptal MI
71
Evolved Inferior MI
72
Acute MI Physical Examination

• May be normal
• S4 gallop most common finding (uncomplicated MI)
• Focus on assessing cardiac function
• Low BP, poor perfusion (low cardiac output)
• S3 gallop indicates LV failure
• Pulmonary rales indicates congestive heart
  failure
• Pericardial friction rub (pericarditis)
• Holosystolic murmur of MR or VSD

73
Acute MI Complications Arrhythmias

• Mechanisms
• Slowed conduction, increased dispersion of
  recovery (favoring reentry)
• Ischemic myocardial irritability abnormal
  automaticity
• Increased sympathetic tone, catecholamines
  disparity in refractory periods, increased
  automaticity, reduced VF threshold,
  tachyarrhythmias
• Increased parasympathetic tone depressed
  automaticity, bradyarrhythmias
• LVD, LAE triggering stretch receptors/channels

74
Acute MI Complications Arrhythmias

• Tachyarrhythmias
• Ventricular PVCs (80-90) VT/VF (10-20)
  primary VF?5
• Supraventricular PACs, SVT, atrial flutter
  (1-2), atrial fibrillation (10-15)
• Bradyarrhythmias Sinus bradycardia, sinus
  arrest, 1/2/3 degree AV nodal block
• Conduction disturbances RBBB, LBBB, LAFB, LPFH,
  bifascicular block (often with large MI, poor
  prognosis) infranodal (distal) AV block

75
Ventricular Tachycardia
76
Ventricular Fibrillation
77
Atrial Fibrillation
78
Right Bundle Branch Block
79
Left Bundle Branch Block
80
MI Complications Heart Failure, Mechanical
Complications

• Heart Failure To some degree in up to ½ of
  STEMI. Relates to loss of contracting muscle
  (infarction plus stunning)
• Mechanical Complications
• Cardiogenic shock Occurs in ?5, usually fatal
  (gt70) gt40 loss of LV
• Rupture of LV free wall Usually immediately
  fatal
• Rupture of IVS (acute VSD) High early mortality
  (urgent surgical repair)
• Rupture of papillary muscle with severe MR high
  early mortality (urgent surgical repair)
• Papillary muscle dysfunction Variable MR, risk

81
MI Complications Thrombosis and Thromboembolism

• Systemic arterial emboli
• Source is mural thrombus, especially with large
  MIs involving apex. (Mural thrombus in 40
  anterior MI, 10 inferior MIs).
• Some embolize.
• Pulmonary embolus
• Consequence of venous stasis in lower extremities
  with large MI, CHF, immobility

82
MI Complications Miscellaneous

• Pericarditis
• Early Indicates transmural extension of MI
• Late Autoimmune etiology (Dresslers syndrome)
• RV Infarction
• 10-15 of inferior MIs very prox. RCA occlusion
• ST elevation in V4R, RS3
• Hypotension, low CO, ?death rate
• Aggressive Rx with fluids, pressors, pacing prn
• Infarct Extension, Expansion
• Recurrent chest pain, often with heart failure

83
Acute Inferior MI with Right Ventricular
Infarction (right precordial ST-elevation)
84
In-Hospital Mortality after MIby Functional
(Killip) Class

• Killip I No Heart Failure 5
• Killip II Moderate HF 10-20
• Killip III Severe HF 35-45
• Killip IV Cardiogenic Shock 70-95

85
In-Hospital Mortality by Era

• Pre-CCU era ? 30
• Early CCU era (1970s) ? 20
• Later CCU era (1980s) ? 15
• Reperfusion era (1990-) ? 5-10

86
Prognosis with Acute MI

• Half of deaths occur pre-hospital
• In-hospital mortality ?10
• First year mortality, ?5-10

87
STEMI General Approach

• MONA (MS, O2, NTG, ASA) BB, ACE-I, statin
• Reperfusion therapy (if lt12h or ongoing chest
  pain, STE)
• Primary PCI if experience, lt1-2 h to lab
• Pretreat w/ heparin (or LMWH), ASA, GPIIb/IIIa
• Or, Lytic Rx (TNKase, reteplase, tPA)
• With heparin (60U/kg, 12U/kg/h), ASA
• ?Alternative, enoxaparin

88
Care Pathways in Acute Coronary Syndromes

• Pathway 1 STE-MI Reperfusion Rx IV
  thrombolysis or primary angioplasty
• Pathway 2 Definite UA/Non-STE-MI (ECG and/or
  markers abnl) Heparin, antiplatelet (GP
  inhibitor, ASA, clopidogrel), early cath
• Pathway 3 Probable UA (ECG/markers nl) Heparin,
  ASA, serial ECGs/troponins
• Pathway 4 Possible UA (CP atypical) Observation
  unit further risk stratify

89
MI Therapies

• General measures (rest, oxygen, morphine)
• Reperfusion Rx thrombolytic or P-PCI
• Aspirin and heparin
• Nitrates (as needed for HF, BP, angina)
• Beta-blockers (unless contraindicated)
• Angiotensin converting enzyme (ACE) inhibitors
  (most, especially with HF)
• Lipid lowering (statin in most)

90
Examples of Evidence-Based Medicine (Clinical
Trials) at Work to Advance Treatment of Acute
Coronary SyndromesNon STE-ACS Advances
91
ADM IRAL and CADILLAC
Stone et al. Circ 2000 102 II-664, Barragan et
al Circ 2000 102 II-662
6 Month Mortality
? 55
? 14
NEJM 2001 3441895
NEJM 2002 346957
92
ACC/AHA Guideline2002 UpdateRecommendations
for Antithrombotic Therapy
High Risk or Definite ACSWith Cath and PCI
Likely/Definite ACS
Possible ACS
Aspirin
Class IIa Enoxaparin preferred over IV UFH
Braunwald E, et al. J Am Coll Cardiol
200036970-1062. www.acc.org 3/15/2002.
93
Potential Advantages of Low Molecular Weight
Heparins

• Inhibit thrombin generation (anti factor-Xa
  activity) as well as thrombin activity
  (anti-IIa)
• ? Binding to plasma proteins, endothelial cells
  (?bioavailability) c/w UFH
• Dose-independent clearance, longer half-life
• Predictable, sustained anticoagulation with fixed
  dose (wgt. adj.) once or twice daily subcutaneous
  injections
• Monitoring of PTT not required

Mix of pentasaccharide lengths (lt,gt18 U), hence
anti-Xa/IIa possibly clinical effects, vary
among LMWHs
94
Circulation 1999 1001602
95
Synergy Death and MI at 30 Days
1.1
HR 0.96 (0.87-1.06)
96
(No Transcript)
97
(No Transcript)
98
(No Transcript)
99
(No Transcript)
100
(No Transcript)
101
(No Transcript)
102
(No Transcript)
103
In-hospital mortality by timing of GP IIb-IIIa
inhibitor therapy and/or early cath
Data on file, Duke Clinical Research Institute,
Durham, NC.
104
NSTE ACS Treatment Goals/Benchmarks

• Upstream GPI use in 75 of patients with
  high-risk NSTE ACS patients
• Catheterization during hospitalization in 90 of
  high-risk NSTE ACS patients
• Catheterization within 48 hours in 75 of
  high-risk NSTE ACS patients.

105
CAPRIE Clopidogrel vs Aspirin for Secondary
Prevention ofMI, Stroke, or Vascular Death
Placebo1
16
25
Aspirin1,2
Event Rate per Year
8.7
Clopidogrel2
12
RelativeRiskReduction
7.7
Cumulative Event Rate -
5.83
8
5.33
4
p 0.045
0
0
3
6
9
12
15
18
21
24
27
30
33
36
Time from Randomization (mo)
ITT analysis.1Antiplatelet Trialists
Collaboration. BMJ. 1994 30881106. 2CAPRIE
Steering Committee, Lancet. 199634813291339.
106
Yusuf, NEJM, 2001
107
HOPE Trial Ramipril after ACSPrimary Results
in 9297 with CAD or Equivalent
D/MI/CVA. RR0.78 (0.70-0.86)
NEJM 2000 342145
108
PROVE-IT Aggressive vs. Moderate Lipid Lowering
after ACS
Median LDL-C (Q2, Q3) 95 (79, 113) 62 (50, 79)
120
100
Pravastatin 40mg
18?
80
LDL-C (mg/dL)
60
Atorvastatin 80mg
48 ?
40
Plt0.001
20
Rand.
30 days
4 mos.
8 mos.
16 mos.
Final
Cannon. NEJM 2004
109
PROVE-IT Primary Results (All-Cause Death or
Major CV Events)
Pravastatin 40mg 537/2063 (26.3)
30
25
20
with Event
Atorvastatin 80mg 464/2099 (22.4)
15
10
16 RRR at 2 years (p 0.005)
5
0
Months of Follow-up
110
Updated Recommendations to ATP III Algorithm for
LDL Rx

• For High-Risk (CHD/Equiv LDL goal lt100)
• LDL goal of lt70 mg/dL is an option
• If baseline LDLgt100, drug/TLC is indicated
• If LDLlt100, drug Rx to LDL lt70 is an option
• For mod high risk (2 RF 10-20 10y risk)
• LDL goal of lt100 mg/dL is a therapeutic option
  (currently lt130)
• If baseline LDL 100-129, drug Rx to achieve
  LDLlt100 is a treatment option.
• Choose Rx to achieve ?30-40 LDL lowering
• Guidelines for lower risk patients unchanged

Circulation 2004 110227
111
STE-MI Strategiesand Recent Research Advances
112
Benefits of Intracoronary Streptokinase in Acute
STE-MI

• ?Pain (? morphine) (plt0.001)
• ?Heart failure (?Killip class) (plt0.01)
• ?ST segments (plt0.01)
• ?Q waves (plt0.01)
• ?Ejection fraction (4 v -3, plt0.01)
• ?Infarct size (plt0.05)

Anderson et al, NEJM 1983 3081312
113
Reductions in Vascular Mortality after SK /or ASA
51
40
33
23
21
ISIS-2. Lancet 1988. 17,187 pts w/ suspected MI
(lt24 h)
114
(No Transcript)
115
AMI Mortality by Early Coronary Perfusion Grade
8.8
7
3.7
Anderson. Am J Cardiol, 1991
116
GUSTO-I 20 ?TIMI Grade 3 Flow Yields 1
?Mortality
60
54
50
t-PA
6.3
40
32
TIMI Grade 3 Flow
30
20
SK
7.4
10
0
t-PA
SK
5
8
7
6
The GUSTO Angiographic Investigators. N Engl J
Med. 19933291615-1622.
117
Thrombolytic Therapy Update 2005

• Newer, mutant tPAs (reteplase rPA,
  tenecteplase TNK-tPA) are more convenient (1-2
  boluses), may reduce bleeding (wgt-adjusted,
  fibrin-selective TNK-tPA), but dont improve
  survival or reduce intracranial hemorrhage risk
  compared with native tPA

118
Combination Fibrinolytic and Advanced
Antithrombotic Therapies for STEMI
119
Rationale for Combination Therapy of STEMI
Combination Therapy Lytic, antiplatelet,
antithrombin
Reduces Reinfarction
? Thrombus
? Stenosis ? Minimum Diameter
? Myocardial Blush ? ST Resolution
? Epicardial Flow
? Myocardial Flow
Facilitates PCI
Gibson et al. J Am Coll Cardiol.
199525582-589. Gibson et al. Circulation.
20011032550-2554.
120
Comparison of Adjunctive Therapy to Thrombolysis
(TNKase) in STE-AMI ASSENT 3
20
18
Heparin
15.4
16
14
Enoxaparin
11.4
12
11.1
Abciximab
Probability ()
10
8
6
4
P0.0001
2
0
0
Days to Death or Reinfarction or Refractory
Ischemia
Lancet 2001 358605
121
ASSENT 3 Primary Efficacy and Safety Endpoint of
Death, Reinfarction or Refractory Ischemia, ICH
or Major Bleeding in Patients gt 75 Years of Age
30 day Risk
P0.001
Abciximab
Enoxaparin
Lancet 2001 358605
122
(No Transcript)
123
(No Transcript)
124
(No Transcript)
125
(No Transcript)
126
Thrombolytic Combination Therapies Status 2005

• Too much bleeding occurs with routine GP IIb/IIIa
  inhibition plus a thrombolytic and heparin or
  LMWH (i.e., in elderly).
• Clopidogrel appealing alternative as a potent
  antiplatelet adjunct therapy.
• Enoxaparin promising as an alternative to
  heparin, deserves further study

127
Primary Angioplasty and Stenting Based Therapies
for STEMI
128
(No Transcript)
129
(No Transcript)
130
Primary PCI vs. Fibrinolytic Therapy DANAMI-2
Primary Endpoint at 30 Days
Referral hospitals, N1,129 patients
NNT17
20
Fibrinolysis
14.2
Log rank p0.002
Cumulative event rate ()
10
8.5
PCI
0
0
5
10
15
20
25
30
Days
NEJM 2003 349733
Primary end point Death or reinfarction or
stroke. 96 transferred lt 2 h median, 67 min.
Only 2 of lytic pts got rescue PCI
131
Interventional Cardiology Outcomes with
Drug-Eluting Stents
Event DES BMS RR (CI)
Angio Restenosis 8.9 29.3 0.18 (0.06-0.40)
MACE 7.8 16.4 0.42 (0.37-0.53)
MI 2.7 2.9 0.92 (0.65-1.25)
Death 0.9 0.9 1.11 (0.61-2.06
Lancet 2004 364583. N11 trials, 5,103 pts.
BMSbare metal stents. Other advances Distal
protection devices PFO/ASD closure devices
132
Ischemic Complications of PCI
White HD. AM J Cardiol. 1997 80(4A) 2B-10B.
133
CRUSADE Registry In-Hospital Events by Upstream
vs. In-Lab GPI Use(PCI lt48 hrs GP IIb/IIIa
n5,833)
In-lab Only GP IIb/IIIa (n3,642)
Adjusted OR 0.83 (95 CI 0.631.09)
6
5
Upstream GP IIb/IIIa (n2,191)
5.02
4
4.15
3
Adjusted OR 0.95 (95 CI 0.601.15)
2
1.65
1
1.32
0
Death
Death/MI
CRUSADE Registry. Peterson. ACC. 2003.
134
Treatment Trends for Reperfusion-Eligible
AMIs 1990 to 2000

• AMI pts eligible for fibrinolytics fell
• 36 to 27
• Eligible given reperfusion stayed constant
• 69 to 70
• In reperfusion-eligible, lytic use?, PCI?
• 59 to 48 12 to 24
• In fibrinolytic-treated pts, time to Rx fell
• 62 to 38 minutes

Rogers, JACC 2000
135
Selecting the Best Reperfusion Strategy in STEMI
Its All a Matter of Time

• Giugliano, Braunwald. Circ 2003 1082828
• When PCI is not available or when the delay is
  anticipated to be gt90 min, fibrinolytic therapy
  should be considered in patients who can be
  treated within 2-3 hr of symptom onset and who
  are not at high risk for ICH.
• This may be followed by PCI to achieve maximal
  sustained patency of the infarct artery.
• Even better outcomes might be obtained if
  patients undergo early PCI (stenting). (CAPTIM,
  SIAM-III)

136
Time to Rx and Mortality in STEMI after
Prehospital Fibrinolysis or P-PCI A CAPTIM
Substudy. Steg, Circ 03 1082851
Interaction p0.04
137
Current Trends with Primary PCI

• Medically facilitated PCI
• Pretreatment with GP IIb/IIIa inhibitor
• Pre-PCI clopidogrel (ADP receptor antag.)
• Continue clopidogrel for 6-12 months after PCI
• Enoxaparin replaces heparin for med Rx
• Coated Stents to reduce restenosis
• After elective PCI
• After urgent or emergent PCI for ACS

138
RAVEL Results
MACE Free
TVR
Restenosis
Plt0.0001
Plt0.001
Plt0.001
Angiographic Restenosis ()
Target Vessel Revascularization ()
MACE Free Survival ()
Bare Stent
Sirolimus Coated
Bare Stent
Sirolimus Coated
Sirolimus Coated
Bare Stent
139
Medical Therapy after Acute Coronary Syndrome
How Far to Go?

• Long-term Medical Therapy Options
• BB, ASA, smoking cessation
• Above plus a statin if LDLgt130, begun as an outpt
  after 3-6 months of diet, exercise
• Above plus inpatient statin if LDLgt130
• Above plus inpatient statin if LDLgt100
• Above plus inpatient statin regardless of LDL
• Above plus an ACEI, clopidogrel

140
Does Evidence-Based Therapy of CAD Work?
141
CRUSADE A National Registry of gt100,000Process
vs. Outcome
5.9
5.0
4.6
3.6
Lappe et al. Ann Intern Med Oct 2004
142
Secondary Prevention after ACS

• Antiplatelet
• --Aspirin, 75-162 mg/d indefinitely
• --Clopidogrel, 75 mg/d. gt3-12 mo after stent,
• and in high-risk patients
• Lipid lowering
• --Statin regardless of LDL (to target lt70mg/dL
  or 30-40 reduction from baseline)
• Beta-blocker (unless contraindicated)
• ACEI (unless contraindicated)
• NTG (for PRN use)
• Smoking cessation
• Control of diabetes, HTN diet, exercise

143
IHC Discharge Medication Program Improvement in
Prescription Rates in Cardiac Patients
Lappe et al. Ann Intern Med Oct 2004
144
Improvements in 1-Year Outcomes with a Discharge
Medication Program
Reduction
Lappe et al. Ann Intern Med 2004 141446. All
plt0.001-002
145
Deaths From CVD Remain High
Deaths/100,000 Pop. (Line)
Deaths in Thousands (Bar)
600

• The total number of CVD-related deaths per year
  has remained high nearly 1 million deaths
  annually.1

1st Statin Introduced2
500
400
300
200
100
0
79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94
95 96 97 98 99 00
Year
NCEP ATP I3
NCEP ATP II4
1. Morbidity Mortality 2002 Chart Book on
Cardiovascular, Lung, and Blood Diseases. NIH
2002. 2. Med Lett Drugs Ther. 19872999101. 3.
Expert Panel. Arch Intern Med. 19881483669. 4.
Expert Panel. JAMA. 199326930153023.
146
Regenerative Cell Therapy after Myocardial
Infarction

• Research Hope for Better
• Future Outcomes

147
Landmark Late Breaking Clinical Trial 2004

• BOOST A Randomized-Controlled Clinical Trial of
  Intracoronary Autologous Bone Marrow Cell
  Transplantation Post Myocardial Infarction
• K C Wollert, Helmut Drexler
• Hannover, Germany

Lancet, July 2004
148
BOOST Results
Measure Control (30) BMC Transfer (30)
LCA 23 23
RCA 7 7
Max CK ?2800 ?2900
EF base 51.3 50.0
EF 6 mo 52.0 56.7
? EF 0.7 6.7 (p0.0026)
In recent TOP-CARE Study, MI size reduction of
20 directly shown (CMR Gad-Viability)
(Circulation 2003)
149
(No Transcript)
150
(No Transcript)
151
(No Transcript)
152
(No Transcript)
153
Thank you ! Any Questions?