evolving concepts in defining optimal strategies for management of ihd

Evolving Concepts in Defining Optimal

Strategies for Management of IHD

Dr. Kyaw Soe Win

Department of Cardiovascular Medicine9-Mar-15

Myanmar Medical Conference Taungyi

Angina and IHD

ANGINA is pain or discomfort in the chest

caused by inadequate blood flow through the

coronary blood vessels, is a consequence of

myocardial O2 demand exceeding supply.

It is the principle symptom of ischemic heart

disease (IHD); This is sometimes called

myocardial ischaemia

Types of Angina

Chronic stable angina also called classic, typical, or effort angina

Unstable anginaalso called preinfarction or crescendo angina

Vasospastic anginaalso called Prinzmetal’s or variant angina

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Typical Progression of Coronary Atherosclerosis.

4Abrams,NEJM,2005;352:2524-2533

Stable angina: the most common

(90%) is chest pain caused by a temporary

inadequacy of blood flow to the myocardium

• Usually lasts 1-15 minutes, and is provoked

by exercise, stress, extreme cold or heat,

heavy meals, alcohol, or smoking.

Rx: is promptly relieved by rest or

nitroglycerin (a vasodilator).

• The underlying cause is usually narrowing

of the coronary arteries by atheroma - the

narrowing of blood vessels by deposits of

fatty or fibrous material

Unstable angina

lies between stable angina and MI.

The pathology is similar to that involved in MI: a

platelet-fibrin thrombus associated with a raptured

atherosclerotic plaque, but without complete

occlusion of the blood vessel.

1. chest pains occur with increased frequency

2. precipitated by progressively less effort.

3. The symptoms are NOT relieved by rest or

nitroglycerin.

4. requires hospital admission and more aggressive

therapy to prevent death and progression to MI.

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Aims of drug treatment for stable

Angina

Relieve symptoms

Minimize the frequency, duration and

intensity of attacks.

Improve the patient’s functional capacity with

as few side effects as possible

Stop and regression of the disease process

Prevent or delay the worst possible outcome,

MI & death

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To reduce the cardiac workload and

metabolic demand

To increase the perfusion of the heart

muscle

To prevent myocardial infarction

Therapeutic goals

To reduce the cardiac workload and metabolic demand

To increase the perfusion of the heart muscle

To prevent myocardial infarction

Ca2+ antagonists, β-adrenoreceptor antagonists,

Ivabradine, Trimetazidine, Ranolazine

Lipid lowering drugs, particularly statins, can be given if

elevated plasma cholesterol levels are detected

Antiplatelet drugs, especially low-dose (75mg) aspirin to

reduce the possibility of thrombosis.

Therapeutic goals

Nitrates, Nicorandil, PCI, CABG

Treatment of Chronic Stable Angina

MedicalRevascularization

PCI CABG

Does Revascularization improve

Prognosis in Stable IHD ie;

Reduction of and MI and death?

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Prognosis in Stable IHD ie;

Reduction of and MI and death ?

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symptom ?

No

Yes

Optimal Medical Therapy for Stable

Coronary Artery Disease.

39

1.Non-pharmacologic therapy

2.Vasculoprotective therapy

3.Anti-anginal therapy

40

1.Lifestyle Modification

1. Regular aerobic activity

2. Weight reduction and maintainence

3. Diet

4. Tobacco abstinence and avoidance

of passive smoke

2.Optimize non cardiac comorbidities

Non Pharmacologic Therapy

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The Vasculoprotective Regimen for Stable Angina.

Abrams J. N Engl J Med 2005;352:2524-2533.

43

Antianginal Drugs

Nitrates : sublingual, transcutaneous, oral

Beta Blockers

Calcium Channel Blockers

Nicorandil

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NEWER ANTIANGINAL DRUGS

Metabolic modulators, eg, ranolazine,

trimetazidine

Direct bradycardic agents, eg, ivabradine

Potassium channel activators, eg, nicorandil

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European guidelines onthe management of

stable coronary artery disease

Key points&

new position for Ivabradine and Trimetazidine

Montalescot G, Sechtem U, Achenbach S, et al. 2013 ESC guidelines on the management of stable coronary artery disease: The Task Force on the management of stable coronary artery

disease of the European Society of Cardiology. Eur Heart J. 2013;34(38):2949-3003.

Medical management of SCAD patients

“We recommend the old drugs as first line treatment because they are cheap, effective and available everywhere.”

“We have roughly the same level of evidence for all of the second line drugs and we recommend that physicians also choose according to what is available in their country.”

Chairmen opinion:*

Angina relief Event prevention

• β-blockers and/or CCB

IvabradineLong-acting nitratesNicorandilRanolazineTrimetazidine

• Lifestyle management• Control of risk factors

• Aspirin (if intolerance, consider clopidogrel)

• Statins• Consider ACE inhibitors or ARBs

+ consider angio → PCI-stenting or CABG

Short-acting nitrates, plus

1st line

2nd line

Montalescot G, Sechtem U, Achenbach S, et al. 2013 ESC guidelines on the management of stable coronary artery disease: the task force on the management of stable coronary artery


*New ESC Guidelines published on stable coronary artery disease. Eur Heart J. 2013;34:2927-2930.

Medical management of SCAD patients

Chairmen opinion:*

Angina relief Event prevention

• β-blockers and/or CCB

IvabradineLong-acting nitratesNicorandilRanolazineTrimetazidine

• Lifestyle management• Control of risk factors

• Aspirin (if intolerance, consider clopidogrel)

• Statins• Consider ACE inhibitors or ARBs

+ consider angio → PCI-stenting or CABG

Short-acting nitrates, plus

1st line

2nd line

About revascularization, chairmen hopes that “guidelines will shift physicians’ practice so that they consider optimal medical treatment as their first course of action in stable CAD patients”.



*New ESC Guidelines published on stable coronary artery disease. Eur Heart J. 2013;34:2927-2930.

• Women Women more frequently have CAD with stable angina and no obstructive

coronary disease.

Women are more likely to have complications from revascularization.

• Diabetic patients Need different risk factor management.

• Older patients High-risk group with higher mortality and higher rates of myocardial infarction.

Usually undertreated, receiving less drugs.

Difficult diagnosis due to atypical symptoms.

Higher risk of complications during and after coronary revascularization.

• Comorbidities/intolerance Depending on comorbidities/tolerance, it is indicated to use second-line therapies

as first-line treatment in selected patients.

Specific patient profiles



Therapy to prevent MI and death

Aspirin

Low-dose aspirin is the drug of choice in most cases and clopidogrel

may be considered for some patients.

Statin

Target LDL-C: <1.8 mmol/L and/or >50% reduction if the target level

cannot be reached.

Renin-angiotensin-aldosterone system blockers

ACE inhibitors are recommended for the treatment of patients with

SCAD, especially with coexisting hypertension, LVEF ≤40%, diabetes,

or chronic kidney disease, unless contra-indicated.

ARBs are recommended as an alternative therapy for patients with

SCAD when ACE inhibition is indicated but not tolerated.



“Adding ivabradine 7.5 mg twice daily to atenolol therapy gave better control of heart rate and

anginal symptoms.”

“In 1507 patients with prior angina enrolled in the Morbidity-Mortality Evaluation of the If Inhibitor

Ivabradine in Patients With Coronary Artery Disease and Left Ventricular Dysfunction

(BEAUTIFUL) trial, ivabradine reduced the composite primary end point of CV death,

hospitalization with MI and HF, and reduced hospitalization for MI. The effect was

predominant in patients with a heart rate 70 bpm.”

“Ivabradine is thus an effective anti-anginal agent, alone or in combination with β-blockers.”

New ESC guidelines and Ivabradine



New ESC guidelines and Trimetazidine

“Trimetazidine is an anti-ischemic metabolic modulator, with similar anti-

anginal efficacy to propranolol in doses of 20 mg thrice daily.”

“Trimetazidine (35 mg twice daily) added to β-blockade (atenolol)

improved effort-induced myocardial ischemia, as reviewed by the EMA in

June 2012.”

In diabetic persons, Trimetazidine improved HbA1c and glycemia, while

increasing forearm glucose uptake.”



Conclusion

ESC Guidelines highlighted two aims for the pharmacological management

of stable CAD patients: obtain relief of symptoms and prevent cardiovascular

events.

CAD patients should all receive aspirin and a statin, plus an ACE inhibitor

in case of comorbidities.

-blockers or CCBs should be prescribed as first-line treatment to reduce

angina.

Ivabradine and Trimetazidine (as well as long-acting nitrates, nicorandil and

ranolazine) are recommended second-line, in combination with first-line

treatment, in patients remaining symptomatic.

Physicians should consider optimal medical treatment before

revascularization procedures.



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Lifestyle modification and management of non-

cardiac comorbidities is important.

It needs to be understood that coronary artery

disease is a chronic condition, which is

manageable but not curable.

Conclusions

Vasculoprotective therapy is important

including antiplatelet agents such as aspirin

and clopidogrel, statins, and ACEI

Antianginal drugs should be prescribed to

relieve symptoms. Beta blockers should be

used unless contraindicated or not tolerated.

Under most circumstances, optimal medical

therapy is primary approach and

revascularization should be considered as

needed or for special coronary anatomy.

Conclusions

What is the role of revascularization

in unstable IHD ie; Acute Coronary

Syndrome?

9-Mar-15

Thank you

9-Mar-15

evolving concepts in defining optimal strategies for management of ihd

Healthcare

coronary blood vessels

ihd angina

coronary arteries

acute coronary syndromes

narrowing of blood vessels

vulnerable plaque

inadequate blood flow

myocardial ischemia