investigation, suivi et traitement du patient …...with stable cad, as compared with optimal...
TRANSCRIPT
G. Gosselin, MD 2009
Dr Gilbert Gosselin,
MDCM,FRCP,FACC Cardiologue d’intervention
Institut de Cardiologie de Montréal
Chef du departement de médecine spécialisée
Centre Hospitalier Pierre-LeGardeur
INVESTIGATION, SUIVI ET TRAITEMENT
DU PATIENT ANGINEUX STABLE
RECOMMANDATIONS,
MISE A JOUR ET ROLE
DE L`ISCHEMIE
43 e CONGRES ACQ
QUEBEC , 2014
CONFLIT D’INTÉRÊTS
Cardiologue d’intervention depuis plus de 25 ans
Avec plus de 11,000 cathétérismes et 4000 interventions
Investigateur principal à l’ICM pour le projet COURAGE et le projet ISCHEMIA (co-leader national et membre du steering committee)
Intérêt académique en prévention primaire et secondaire
16/07/2014
Histoire de cas
203-1-025
♀ 64 ans
DbII, DLP+, HTA+
Angine x 3 ans
Épisode d’angine instable refroidi
MIBI ischémie modérée antérieure +
antéro-latérale
Repos
04/2001 04/2003 08/2005
Persantin
Patiente 203-1-025
DDN: 1935/03/06
Patiente 203-1-025 16/07/2014
Patiente 203-1-025 16/07/2014
Patiente 203-1-025 16/07/2014
Repos
04/2001 04/2003 08/2005
Persantin
Traitement médical optimal –PROJET COURAGE
Patiente 203-1-025
DDN: 1935/03/06
Figure 1: Diagnosis and management of patients with stable ischemic heart disease.
L’INVESTIGATION:
CONFIRMER LE DIAGNOSTIC
ET EVALUER LE PRONOSTIC
Bilan de Base
1. Histoire et examen physique pour obtenir les facteurs de
risques, l’histoire médicale et signes de maladie
cardiovasculaire.
2. Documentation des co-morbidités cardiovasculaires
(insuffisance cardiaque, maladie valvulaire, maladie cérébro-
vasculaire ou périphérique et maladie rénale)
3. Tests de routine:
- FSC - Bilan lipidique - Glucose, HbA1C - ECG
- Fonction rénale - Tests hépatiques - Tests thyroidiens
Critères de Douleurs Thoraciques
Angineuses
1. Inconfort rétro-sternal avec durée et propriétés
charactéristiques.
2. Provoquées par l’effort ou le stress.
3. Soulagées rapidement par la Nitro ou le repos.
Age
Chest Pain Criteria:
1. Sub-sternal chest discomfort with characteristic quality and duration
2. Provoked by exertion or emotional stress
3. Relieved promptly by rest or nitroglycerin
Non-anginal Chest Pain
1 of 3 Criteria
Atypical Angina
2 of 3 Criteria
Typical Angina
3 of 3 Criteria
Male Female Male Female Male Female
30 – 39 4% 2% 34% 12% 76% 26%
40 - 49 13% 3% 51% 22% 87% 55%
50 - 59 20% 7% 65% 33% 93% 73%
60 - 69 27% 14% 72% 51% 94% 86%
Cardiac Risk Factors
Modifiable Non-Modifiable
Tobacco Use/Smoking History
Dyslipidemia
Diabetes
Hypertension
Chronic Kidney Disease
Physical Inactivity
Diet
Obesity or Metabolic Syndrome
Depression
Age
Sex
Family History of Premature
Established CV Disease
Ethnic Origin
G. Gosselin, MD 2014
Diagnostics differentiels des douleurs
thoraciques
Cardiovascular Pulmonary Gatrointestinal Chest Wall Neurological Psychiatric
Aortic dissection
Congestive Heart
Failure
Pericarditis
Syndrome X
(microvascular
disease)
Pulmonary embolism
Pneumothorax
Pleuritis
Primary Pulmonary
Hypertension
Esophagitis
Esophageal Spasm
Biliary Colic:
Cholecystitis
Choledocholithiasis
Cholangitis
Peptic Ulcer Disease
Pancreatitis
Costochondritis
Fibrositis
Fibromyalgia
Rib fracture
Sternoclavicular
Arthritis
Cervical Disease
Herpes Zoster
Anxiety disorders
Hyperventilation
Panic disorder
Affective disorders (eg.
depression)
Somatiform disorders
Thought disorders
(ie:fixed delusions)
Conditions provocant ou
exacerbant l’ischemie (1)
Increased Oxygen Demand Decreased Oxygen Supply
Noncardiac Noncardiac
Hyper/hypothermia Anemia
Hyperthyroidism Hypoxemia/high altitude
Sympathomimetic toxicity Pneumonia
(eg. cocaine use) Asthma
Hypertension Chronic obstructive pulmonary disease
Anxiety Pulmonary hypertension
High Cardiac Output States Interstitial pulmonary fibrosis
(eg Arteriovenous fistulae) Obstructive sleep apnea
Sickle cell disease
Sympathomimetic toxicity (eg. cocaine use,
pheochromocytoma)
Hyperviscosity (Polycythemia, Leukemia,
Thrombocytosis, Hypergammaglobulinemia)
Conditions provocant ou
exacerbant l’ischemia (2)
Increased Oxygen Demand Decreased Oxygen Supply
Cardiac Cardiac
Left Ventricular Hypertrophy Aortic stenosis
Aortic stenosis Hypertrophic cardiomyopathy
Hypertrophic cardiomyopathy Obstructive coronary artery disease
Dilated cardiomyopathy Microvascular disease
Tachycardia (ventricular, Coronary Spasm
supraventricular)
Technology Sensitivity Specificity
Exercise Treadmill 0.68 (0.23-1.0) 0.77 (0.17-1.0)
Attenuation Corrected SPECT 0.86 (0.81-0.91) 0.82 (0.75-0.89)
Gated SPECT 0.84 (0.79-0.88) 0.78 (0.71-0.85)
Traditional SPECT 0.86 (0.84-0.88) 0.71 (0.67-0.76)
Contrast Stress Echocardiography
(wall motion) 0.84 (0.79-0.90) 0.80 (0.73-0.87)
Exercise or Pharmacologic Stress Echocardiography 0.79 (0.77-0.82) 0.84 (0-.82-0.86)
Cardiac Computed Tomographic Angiography 0.96 (0.94-0.98) 0.82 (0.73-0.90)
Positron Emission Tomography 0.90 (0.88-0.92) 0.88 (0.85-0.91)
Cardiac MRI (perfusion) 0.91 (0.88-0.94) 0.81 (0.75-0.87)
Criteres de haut risques
associes avec > 3% risques annuels de deces ou IM
Exercise Treadmill
≥ 2mm of ST-segment depression at low (< 5 metabolic
equivalents, METS) workload or persisting into recovery
Exercise-induced ST-segment elevation
Exercise-induced VT/VF
failure to increase systolic blood pressure to > 120 mm Hg
or sustained decrease > 10 mm Hg during exercise
Myocardial Perfusion Imaging
Severe resting LV dysfunction (LVEF < 35%) not readily
explained by non-coronary causes
Resting perfusion abnormalities ≥10% of the myocardium in
patients without prior history or evidence of MI
Severe stress-induced LV dysfunction (peak exercise LVEF
<45% or drop in LVEF with stress ≥10%)
Stress-induced perfusion abnormalities encumbering ≥10%
myocardium or stress segmental scores indicating multiple
vascular territories with abnormalities
Stress-induced LV dilation
Increased lung uptake
Criteres de haut risques
associes avec > 3% risques annuels de deces ou IM
Criteres de haut risques
associes avec > 3% risques annuels de deces ou IM
Stress Echocardiography
Inducible wall motion abnormality involving >2
segments or 2 coronary beds
Wall motion abnormality developing at low dose of
dobutamine (< 10 micrograms/kg/min) or at a low
heart rate (<120 beats/min)
Coronary Computed Tomographic Angiography
Multivessel obstructive CAD or left main stenosis on
CCTA
Criteres de haut risques
associes avec > 3% risques annuels de deces ou IM
Facteurs pronostiques fondamentaux pour
evaluer la maladie coronarienne stable
RECOMMANDATIONS
EVALUATION ANATOMIQUE DES
CORONAIRES CHEZ LES PATIENTS AVEC
CRITERES DE HAUT-RISQUE
CHEZ LES PATIENTS AVEC SYMPTOMES
REFRACTAIRES,UNE CORONAROGRAPHIE
EST INDIQUEE POUR EVALUER LA
POSSIBILTE DE REVASCULARISATION
INITIER LE TRAITEMENT MEDICAL
Buts de la thérapie
1. Améliorer les symptômes
2. Améliorer la qualité de vie
3. Diminuer les risques d’infarctus
4. Diminuer les risques de mortalité
Recommandations MCAS Prise en charge - Angor stable
Treatment with aspirin 75 to 162 mg daily should be continued
indefinitely in the absence of contraindications in patients with
SIHD.
Treatment with clopidogrel is reasonable when aspirin is
contraindicated in patients with SIHD .
I IIa IIb III
I IIa IIb III
Thérapie Anti-plaquettaire
Traitement chronique
du patient angineux
81 mg d’aspirine quotidiennement
75 mg de clopidogrel si intolérant à l’ASA
Aucune indication pour la double thérapie sauf si
dilatation avec stent
Statine en accordance avec les lignes directrices
(SCC vs. ACC-AHA…)
IECA si patient présente HTA, DbII, FE < 40%,
insuffisance rénale
Beta blockers should be prescribed as initial therapy for relief of
symptoms in patients with SIHD.
Calcium channel blockers or long-acting nitrates should be
prescribed for relief of symptoms when beta blockers are
contraindicated or cause unacceptable side effects in patients with
SIHD.
Calcium channel blockers or long-acting nitrates, in combination
with beta blockers, should be prescribed for relief of symptoms
when initial treatment with beta blockers is unsuccessful in patients
with SIHD.
I IIa IIb III
Médication anti-Ischémique
I IIa IIb III
I IIa IIb III
Beta-blocker therapy should be started and continued for 3 years in all
patients with normal LV function after MI or ACS.
Beta-blocker therapy should be used in all patients with LV systolic
dysfunction (EF ≤40%) with heart failure or prior MI, unless
contraindicated. (Use should be limited to carvedilol, metoprolol
succinate, or bisoprolol, which have been shown to reduce risk of
death.)
Beta blockers may be considered as chronic therapy for all other
patients with coronary or other vascular disease.
I IIa IIb III
I IIa IIb III
I IIa IIb III
Thérapie Bêta-Bloqueurs
ACE inhibitors should be prescribed in all patients with SIHD
who also have hypertension, diabetes mellitus, LVEF 40% or
less, or CKD, unless contraindicated.
ARBs are recommended for patients with SIHD who have
hypertension, diabetes mellitus, LV systolic dysfunction, or
CKD and have indications for, but are intolerant of, ACE
inhibitors.
I IIa IIb III
Antagonistes récepteurs Rénine-Angiotensine-Aldosterone
I IIa IIb III
Treatment with an ACE inhibitor is reasonable in patients with
both SIHD and other vascular disease.
It is reasonable to use ARBs in other patients who are ACE
inhibitor intolerant.
Antagonistes récepteurs
Rénine-Angiotensine-Aldosterone (cont.)
I IIa IIb III
I IIa IIb III
ARA si intolérant aux IECA
Bloqueurs chez les patients angineux avec FE < 40%
indéfiniment
Bloqueurs en première ligne pour soulager les
symptômes (viser pouls ≤ 55-60/bpm)
Si intolérance ou contre-indications, utiliser les
antagonistes du calcium et les dérivés nitrés
Éviter les antagonistes du calcium non-dihydropyridine
avec les b-bloqueurs re risques de Bloc AV, bradycardie
Traitement chronique
du patient angineux
Recommandations MCAS Angor stable
Éviter:
- la thérapie par chélation
- Allopurinol
- Magnesium
- Co-enzyme Q10
- Suxia Jiuxin Wan, Shenshao
- Testostérone
Traitement chronique
du patient angineux (suite)
EVALUATION DU BESOIN DE
REVASCULARISATION
G. Gosselin, MD 2009
G. Gosselin, MD 2009
G. Gosselin, MD 2009
G. Gosselin, MD 2009
The First Coronary Angioplasty
for Stable CAD; 1977
First coronary angioplasty lesion (circles) two days before (A),
immediately after (B), and one month after (C) balloon dilation
16/07/2014
ETUDES RANDOMISES DE SRATEGIES DE
REVASCULARISATION VS TRAITEMENT MEDICAL
OPTIMAL DE LA MCAS STABLE
BARI 2D
COURAGE
16/07/2014
Published on-line 3/27/07
Print version 4/12/07
Aim of the COURAGE Trial
To determine whether the addition of PCI
to optimal medical therapy, when used as
an initial management strategy, reduces
the risk of death or nonfatal MI in patients
with stable CAD, as compared with
optimal medical therapy alone.
Survival Free of Death from Any Cause
and Myocardial Infarction
Number at Risk
Medical Therapy 1138 1017 959 834 638 408 192 30
PCI 1149 1013 952 833 637 417 200 35
Years 0 1 2 3 4 5 6
0.0
0.5
0.6
0.7
0.8
0.9
1.0
PCI + OMT
Optimal Medical Therapy (OMT)
Hazard ratio: 1.05
95% CI (0.87-1.27)
P = 0.62
7
LES CRITIQUES DE COURAGE
1) LA NON QUANTIFICATION DE L`ISCHEMIE
2) LA CONNAISSANCE DE L`ANATOMIE
CORONARIENNE
3) LA REVASCULARISATION NON OPTIMALE
(PEU DE DES…)
QUE DOIT ON RETENIR DE COURAGE
1) le traitement medical est justifié dans la
MCAS stable
2) la revascularisation peut etre faite lors de l`echec
du traitement medical
3) l`ischemie semble etre le marqueur critique et
semble predire le pronostic
FAME
Tonino et al. N Engl J Med 2009;360:213-24.
• 1005 patients with multivessel CAD underwent FFR-guided (<0.80) vs. angiography-
guided PCI
• Primary endpoint: death, MI, repeat revascularization at 1 year
16/07/2014
FAME: Death, MI, Repeat Revascularization
Tonino et al. N Engl J Med 2009;360:213-24.
P = 0.02
JACC 2012
G. Gosselin, MD 2009
Complete Revascularization
Ischemic:
PCI- revascularization of all vessels >2.25 mm that have been
demonstrated to result in ischemia by non-invasive imaging or
FFR
CABG- grafting of all areas of significant ischemia based on
preoperative testing or FFR of intermediate lesions at diagnostic
catheterization, as well as making every effort to revascularize
areas subtended by occluded coronaries unless the myocardium
is demonstrated to be non-viable
Ischemia on
stress image
in the
distribution of
the stenosis
+
-
% Stenosis on
Cath
≥50%
FFR Requirement (≥2.25
mm artery)
No PCI
<50%(if PCI is
considered) Required
PCI <0.80
>0.80 No PCI
<80% (if PCI is
considered) Required
PCI
>0.80 No PCI
≥80% Consider
Imaging
Stress
Test
PCI
<0.80
PCI based on anatomic feasibility and clinical considerations
PCI
>0.80 No PCI
<0.80
16/07/2014 136
Cath in Patients Randomized to CON Strategy
■ Cath will be reserved for patients with refractory angina, acute coronary syndrome, acute
ischemic heart failure or resuscitated cardiac arrest
No Yes
Hospitalization for ACS1?
Refractory symptoms? 2
No Yes
NOT consistent with CON strategy
NOT Adherent to Protocol
Consistent with CON strategy
Adherent to Protocol
Cath in CON Patient
1ACS=acute coronary syndrome, includes resuscitated cardiac arrest and hospitalization for acute ischemic heart failure
2According to trial definition
Determination of acute ischemic event and refractory symptoms
will be confirmed centrally
FOLLOW-UP CLINIQUE ADEQUAT
ECG DE REPOS ANNUEL OU SI
CHANGEMENT DE SYMPTOMES
PATIENTS DEVRAIENT ETRE REFERRES A UN
PROGRAMME DE REHABILITATION
CARDIAQUE
PATIENTS DEVRAIENT ACCUMULER 150 MIN
D`EXERCICE PAR SEMAINE
PATIENTS NON CONTROLES PAR THERAPIE
MEDICALE DEVRAIENT ETRE REEVALUES
PAS D`INDICATION D`EE OU MIBI DE
ROUTINE
RECOMMANDATIONS
UN JOUR… LES MEDICAMENTS REMPLACERONT LA
DILATATION…
L’INTERVENTION PERCUTANEE
REMPLACERA LA CHIRURGIE…
ET LES CHIRURGIENS VOUDRONT
DILATER…
MERCI DE VOTRE ATTENTION
16/07/2014