Myocardial Ischemia Redefined: Optimal Care in CAD

1
Myocardial Ischemia RedefinedOptimal Care in
CAD
2
Learning objectives

• To improve patient management through a better
  understanding of

• Pathophysiology of myocardial ischemia
• Efficacy and safety of behavioral and
  pharmacologic approaches to minimize recurring
  ischemic episodes
• Clinical trials investigating multiple treatment
  targets
• Current clinical guidelines

3
Curriculum overview

• Epidemiology and prevalence of myocardial
  ischemia
• Magnitude of the problem
• Challenges in selected populations
• Issues in contemporary clinical practice
• Scientific review
• Clinical trial update
• New guidelines in myocardial ischemia management
• Risk stratification

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Chronic ischemic heart disease Overview

• Highly prevalent
• 6.5-16.5 million in the US
• Multifactorial etiology
• CAD, hypertension, hypertrophic cardiomyopathy,
  valvular heart disease
• High socioeconomic burden
• Depression
• ?Quality of life
• High costs of care

Gibbons RJ et al. www.acc.org.
5
Repeat revascularization is common post-PCI/CABG
N 18,240 who underwent elective PCI or CABG
46
50
40
30
30
Patients()
20
10
0
Recurrentangina
2nd revascularization
Kempf J et al. Presented at ESC. 2007.
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Angina increases cost of care
US managed care enrollees, n 140,001 with
asymptomatic CAD, n 23,535 with angina Dx
Average yearly cost/patient 11,530
(asymptomatic CAD) vs 22,004 (angina)
ED visits
Hospitalizations
ED visits
Prior to diagnosis
Following diagnosis
Kempf J et al. Presented at Scientific Forum on
Quality of Care and Outcomes Res in CV Disease.
2006.
And Rx nitrates and/or ß-blockers and/or CCBs
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Challenges in selected populations
Pathophysiology and implications of ischemic
heart disease in women
Women
Ischemic heart disease
Diabetes
Elderly
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WISE Landmark study in women
Prospective cohort study conducted at 4 US sites

• Goals
• Improve diagnostic testing for ischemic heart
  disease in women
• Study pathophysiologic mechanisms for ischemia in
  the absence of epicardial coronary artery
  stenoses
• Evaluate the influence of menopausal status and
  reproductive hormone levels on diagnostic testing
  results

Womens Ischemia Syndrome Evaluation
Bairey Merz CN et al. J Am Coll Cardiol.
1999331453-61.
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WISE Persistent chest pain in women predicts
future CV events

n 673 WISE participants with chest pain at
baseline
1
0.9
Without CAD HR 1.89 (1.063.39)P 0.03
Event-freesurvival ()
0.8
0.7
With CAD HR 1.17 (0.761.80)P 0.49
0.6
0
1
2
3
4
5
6
Years from PChP diagnosis (at one year)
Neither
PChPNo CAD
No PChPCAD
Both
PChP persistent chest pain
Johnson BD et al. Eur Heart J. 2006271408-15.
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WISE Persistent chest pain associated with
diminished QOL
No obstructive CAD No obstructive CAD Obstructive CAD Obstructive CAD
No PChP PChP No PChP PChP
Angina symptoms
Typical presentation () 30 33 32 40
Intensity (range 1-5) 2.3 2.6 2.6 2.6
Daily frequency () 30 49 34 39
Psychological symptoms
Perceived QOL 7.3 6.6 7.1 6.6
Depression 8.8 12.2 9.3 12.9
Anxiety 18.0 20.1 17.7 20.1
Adjusted P 0.04 Range 1 - 10 (best) ?score
?trait
Johnson BD et al. Eur Heart J. 2006271408-15.
Bairey Merz CN et al. J Am Coll Cardiol.
1999331453-61.
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WISE CAD imposes an economic burden
N 883 women with angiographic CAD
80
70



60

50
Cumulative observed direct costs (, thousands)
40

30
20
10
0
2
3
4
5
1
Follow-up (years)
Nonobstructive CAD
1 vessel CAD
2 vessel CAD
3 vessel CAD
P lt 0.0001 nonobstructive vs 1-3 vessel CAD
Shaw LJ et al. Circulation. 2006114894-904.
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Contemporary clinical practice of ischemic heart
disease
Opportunity for early detection, risk
stratification, and medical therapy
Healthy population
Revas revascularization
Adapted from Timmis AD et al. Heart.
200793786-91.