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Coronary Artery Disease – Emphasis on Secondary Prevention After Myocardial InfarctionMichael D. Horowitz, MD, MBA, Randee Fullenwider, Pharm.D., BCACP, Jose Calderon-Abbo, MD

August 2019

Proprietary and Confidential. Do not distribute. 2

Agenda

• Anatomy and Pathology of Coronary Artery Disease (CAD)

• Risk Factors for CAD

• Presentation of CAD

- Myocardial Infarction (MI)

• Treatment of CAD

- Medications

- Intracoronary interventions

- Surgery

• Complications of CAD and MI

• Primary and Secondary Prevention of CAD

• The relationship between physical and behavioral health in CAD

• Case Study


Objectives

At the end of this activity, participants should be able to:

• Identify current practices and pharmacologic management of Coronary Artery Disease (CAD) based on Guideline Directed Medical Therapy

• Discuss the role of lipid management in primary and secondary treatment of CAD

• Discuss the role of antithrombotic therapy in the management of CAD

• Review selective mechanisms by which behavioral health influences CAD outcomes

• Discuss screening and assessment of physical and behavioral health in CAD

• Explain current management of CAD through the use of case study example

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Coronary Artery Disease – Scope of the Problem

• 1 in 3 adults in US has some form of cardiovascular disease.

• Coronary Artery Disease (CAD) accounts for the vast majority of the morbidity and mortality of cardiac disease.

• Men - CAD present in 25% age 60 to 79 years and 37% after age 80 years.

• Women - CAD present in 16% age 60 to 79 years and 23% after age 80 years.

• Over 1.5 million people have myocardial infarction (MI) per year.

• Ischemic heart disease is the leading cause of death in both men and women with over 380,000 deaths in US in 2010.

• In women, 27% of deaths are caused by ischemic heart disease (22% of deaths are caused by cancer).

• Despite recent improvements in mortality, CAD still causes substantial morbidity:

- 30% of patients never return to work after coronary revascularization procedure.

- 15-20% of patients rate their health as fair or poor despite revascularization procedure(s).

2012 ISC Guidelines: www.ahajournals.org/doi/pdf/10.1161/CIR.0b013e318277d6a0, Magnitude of the Problem, pp 10 of 118


Anatomy and Pathology of Coronary Artery Disease

• The coronary arteries arise from the ascending aorta just above the aortic valve.

• The coronary arteries provide oxygenated blood to the heart muscle (myocardium).¹

• The most common pathology involving the coronary arteries is atherosclerosis.

- Lipid-rich plaque builds up in the walls of the coronary arteries.

- The coronary plaque may gradually narrow the lumen of the artery.

- The coronary plaque may rupture with acute thrombosis of the artery.²

• Other etiologies of coronary artery disease are much less common:

- Congenital abnormalities of the coronary arteries

- Vasculitis³

¹NIH: www.ncbi.nlm.nih.gov/books/NBK537319/²CDC: www.cdc.gov/heartdisease/materials_for_patients.htm³UpToDate: www.uptodate.com/contents/coronary-heart-disease-and-myocardial-infarction-in-young-men-and-women?search=Other% 20etiologies%20of%20coronary%20artery%20disease%20are%20much%20less%20common&sectionRank=1&usage_type=default&anchor=H9&source=machineLearning&selectedTitle=2~150&display_rank=2#H9


Anatomy and Pathology of Coronary Artery Disease

Left: commons.wikimedia.org/w/index.php?curid=29738538, Public DomainRight: commons.wikimedia.org/w/index.php?curid=29140355, Public Domain

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Risk Factors for Coronary Artery Disease

Major Risk Factors for Coronary Artery Disease include:

• Elevated LDL cholesterol

• Diabetes mellitus / hyperglycemia

• Hypertension

• Smoking

• Advancing age

• Male sex

Risk Enhancers for Coronary Artery Disease include*:

• Family history of premature atherosclerotic cardiovascular disease

• Chronic kidney disease

• Chronic inflammatory conditions (rheumatoid arthritis, psoriasis, HIV/AIDS)

• History of premature menopause and/or preeclampsia

• Lipids/ Biomarkers associated with increased risk (elevated CRP, Lp(a), Apo B)*(See Appendix 4)

2018 Guidelines Blood Cholesterol: www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000625, Top 10, pg 2 of 62


Presentation of Coronary Artery Disease

The Presentation of Coronary Artery Disease includes:

• CAD may be asymptomatic

• Chronic stable angina

• Acute coronary syndrome

- ST Elevation Myocardial Infarction (STEMI)

- Non-ST Elevation Myocardial Infarction (Non-STEMI)

- Unstable angina

• Heart failure

• Cardiogenic shock

• Cardiac arrhythmias

• Sudden cardiac death

UpToDate: www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-myocarditis-in-adults?search=Coronary%20Artery% 20Disease%20Anatomy&topicRef=50&source=see_link


Symptoms of Coronary Artery Disease

Symptoms of Coronary Artery Disease may be very variable

• Some patients are asymptomatic

• Angina / Chest Pain

- Frequently described as ’squeezing’, ‘suffocating’, ‘heavy’ or ‘grip-like’

- May be described as ‘tightness’, ‘pressure’ or ‘discomfort’ (rather than pain)

- Not usually described as ‘sharp’ or ‘stabbing’

- Pain is substernal and may radiate to neck, jaw, epigastrium or arms

• Angina equivalent

- Dyspnea

- Mid-epigastric pain, nausea or vomiting

• Symptoms of heart failure

• Palpitations

https://www.ahajournals.org/doi/pdf/10.1161/CIR.0b013e318277d6a0

https://www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000134

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Acute Coronary Syndrome

Symptoms Indicating Increased Risk • Rest angina

- Angina occurring at rest and usually lasting greater that 20 minutes, occurring

within one week of initial presentation

• New onset angina

- Angina with onset within the preceding 2 months that causes marked

limitation of ordinary physical activity (Canadian Cardiovascular Society Grade

III or IV Angina)

• Increasing angina

- Previously diagnosed angina that has become distinctly more frequent,

longer in duration and more easily provoked by activity

2012 ACCF Guidelines: https://www.ahajournals.org/doi/pdf/10.1161/CIR.0b013e318277d6a0


Acute Myocardial Infarction

Acute Anterior ST Elevation Myocardial Infarction

ST elevation and Q waves in V2-5ST elevation in I and aVLReciprocal ST depression in lead III

litfl.com/wp-content/uploads/2018/08/ECG-Anterior-STEMI-Evolving-2.jpg


Management of Coronary Artery Disease

Goals of Management1. Prevent atherosclerosis of coronary arteries (Primary Prevention)

2. Prevent the progression of existing coronary atherosclerosis (Secondary Prevention)

3. Stabilize existing coronary plaques – prevent plaque rupture

4. Prevent or reduce myocardial ischemia

5. Prevent myocardial infarction (MI)

6. Effective management of MI – prompt revascularization

7. Prevent short term and long term complications of MI

8. Manage complications of MI

9. Reduce morbidity and mortality

10. Reduce symptoms and enhance quality of life

2012 Management IHD, www.ahajournals.org/doi/pdf/10.1161/CIR.0b013e318277d6a0, Section 4.1.1

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Management of Coronary Artery Disease – Medical Therapy

• Antiplatelet medications

– Aspirin

– Non-aspirin antiplatelet agents (P2Y12 Inhibitors)

• Lipid management

– Statins

– Ezetimibe (Zetia®)

– PCSK9 Inhibitors

• Antianginal medications

– Beta blockers

– Calcium channel blockers

– ACE inhibitors / ARBs

– Nitrates

– Ranolazine (Ranexa®)

Lexicomp: online.lexi.com/lco/action/home;jsessionid=13a2a8c54222a4566b9d1ccb6804


Antithrombotic Therapy in Coronary Artery Disease

Antiplatelet Medications

• Inhibit the function of platelets (thrombocytes)

• Commonly used antiplatelet agents

– Aspirin

– Clopidogrel (Plavix®)

– Prasugrel (Effient®)

– Ticagrelor (Brilinta®)

• Dual antiplatelet therapy (DAPT) (aspirin + a second antiplatelet drug) is used to prevent thrombus in coronary, carotid or peripheral arteries.

• DAPT is utilized after placement of arterial stents to prevent in-stent thrombosis.

• Antiplatelet therapy may be used in patients with atrial fibrillation when CHA2DS2VASc Score is 1.* (See Appendix 1)* Except in patients who have moderate-to-severe mitral stenosis or a mechanical heart valve

2019 AF Guidelines: www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000665Lexicomp: online.lexi.com/lco/action/home;jsessionid=13a2a8c54222a4566b9d1ccb6804



Anticoagulant Medications

• To prevent thrombus in coronary, carotid or peripheral arteries,

antiplatelet medications are indicated.

• In contrast, anticoagulant drugs are not used for management of

arterial disease, although they may be used for other indications.

• Two classes of anticoagulant medications available (See Appendix 2)

– Warfarin

– Non-Vitamin K Oral Anticoagulants / Direct Oral Anticoagulants

– Apixaban (Eliquis®)

– Rivaroxaban (Xarelto®)

– Edoxaban (Savaysa®)

– Dabigatran (Pradaxa®)

Lexicomp: online.lexi.com/lco/action/home;jsessionid=13a2a8c54222a4566b9d1ccb6804

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Concurrent Antiplatelet and Anticoagulant Therapy

• Some patients with coronary artery disease who are on dual antiplatelet therapy (DAPT) may also have an indication for anticoagulation therapy (such as atrial fibrillation).

• Concurrent DAPT and anticoagulation therapy increases bleeding risk.

(See Appendix 3)

• The current recommendation for management of patients who have indications for both DAPT and anticoagulation therapy is:

– Use an appropriate anticoagulation agent

– Use an appropriate non-aspirin antiplatelet agent

– Omit aspirin

• The above regimen provides adequate antithrombotic protection with less bleeding risk.

2019 AHA/ACC/HRS Guidelines: www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000665


Management of Cholesterol in Coronary Artery Disease

Reduction of LDL Cholesterol

• High Intensity Statin Therapy reduces LDL Cholesterol by 50%

– Atorvastatin (Lipitor®) 40-80 mg daily

– Rosuvastatin (Crestor®) 20-40 mg daily

• Ezetimibe (Zetia®) added if LDL higher than goal on maximally tolerated statin

• PCSK9 Inhibitors added if LDL higher than goal on maximally tolerated statin and Ezetimibe

– Alirocumab (Praluent®)

– Evolocumab (Repatha®)

• PCSK9 Inhibitors have been shown to reduce the risk of adverse cardiovascular events and death in patients with cardiovascular disease.

• PCSK9 Inhibitors are administered by subcutaneous injection.

2018 Cholesterol Guidelines: https://www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000625NEJB: www.nejm.org/doi/full/10.1056/NEJMoa1801174


Cardiac Cath Lab Intervention• Diagnostic cardiac catheterization – Coronary angiography

– Demonstrates coronary artery anatomy and pathology

– Clarifies treatment options (Medical treatment vs. Intervention vs Surgery)

– Emergency catheterization for STEMI

– Urgent catheterization in Acute Coronary Syndrome of high risk clinical setting

– May be used in Chronic Stable Angina if persistent symptoms despite appropriate medical therapy or if symptoms change

– May be used to establish or confirm diagnosis if non-invasive evaluation is inconclusive

• Percutaneous coronary intervention – Intracoronary stenting

– Native coronary arteries and previous bypass grafts suitable to intervention

– Drug Eluting Stents (DES) increasingly utilized¹

– Used as initial intervention for STEMI (Ideally within 90 minutes of first symptom)²

¹UpToDate: www.uptodate.com/contents/cardiac-catheterization-techniques-normal-hemodynamics?search= Cath%20Lab&source= search_result&selectedTitle=1~150&usage_type=default&display_rank=1²UpToDate: www.uptodate.com/contents/overview-of-the-acute-management-of-st-elevation-myocardial-infarction?search=STEMI&s ource=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

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Percutaneous Coronary Artery Stenting

Subtotal occlusion of coronary artery Coronary artery after placement of stent

Images: Garrat KN, Holmes DR, Roubin GS. Early Outcome After Placement of a Metallic Intracoronary Stent: Initial Mayo Clinic Experience. Mayo Clinic Proceedings. 66:3:268-275, March 1991.


Percutaneous Coronary Artery Stenting

TAXUS™ Express2™ Paclitaxel-Eluting Coronary Artery Stent.

Paclitaxel, a mitotic inhibitor, is eluted over a period of 90 days.

Manufacturer: Boston ScientificFDA Approval: March 2004.

Left: https://en.wikipedia.org/wiki/File:PTCA_stent_NIH.gif, Public DomainRight: https://commons.wikimedia.org/wiki/File:Taxus_stent_FDA.jpg, Public Domain


Coronary Artery Bypass

• Coronary Artery Bypass (CABG)

– Approximately 400,000 CABG procedures performed in US in 2017.

– Indicated for treatment of atherosclerotic CAD with ischemia or myocardium at risk not suitable for medical therapy or percutaneous coronary intervention

- Left main coronary artery stenosis not suitable for stenting

- Multi vessel CAD, particularly involving the left anterior descending coronary artery (LAD)

- Patients with reduced left ventricular function (LV EF < 40%)

- Patients with diabetes mellitus

– CABG may be performed at same procedure with valve surgery, thoracic aortic surgery, arrhythmia surgery or other cardiac procedures

– May be performed utilizing minimally invasive techniques in some cases

– Limited incision

– Without use of cardiopulmonary bypass “Off-pump”

– Robotic CABG NEJM: www.nejm.org/doi/pdf/10.1056/NEJMra1406944, and Annals of Cardiothoracic Surgery, wwwnalscts.com/article/view/12492/12885

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Coronary Artery Bypass

A Left Internal Mammary Artery (Left Internal Thoracic Artery) bypass graft to the Left Anterior Descending Coronary Artery confers survival advantage and reduces the need for future revascularization procedures.

Annals of Thoracic Surgery: doi.org/10.1016/j.athoracsur.2015.09.100Image: Cuenca J, Bonome C. Off-Pump Coronary Artery Bypass Grafting and Other Minimally Invasive Techniques.Revista Espanola De Cardiologia. 58:1335-1348. 2005 www.ncbi.nlm.nih.gov/pubmed/16324587

The objective of Coronary Artery Bypass surgery is to achieve revascularization of all critically narrowed or occluded coronary arteries that can be grafted.

Bypasses are performed using a combination of arterial bypass grafts and venous grafts.


Cardiac Surgical Intervention for Complications of CAD

• Surgical management of complications of myocardial infarction:

– Papillary muscle rupture, with severe mitral insufficiency

– Acute ventricular septal rupture (acute ventricular septal defect)

– Acute cardiac rupture

• Surgical management of cardiogenic shock or refractory heart failure:

– Implantation of Ventricular Assist Devices

– Cardiac transplantation

Mayo Clinic: www.mayoclinic.org/tests-procedures/ventricular-assist-device/about/pac-20384529Image from: https://www.heart.org/-/media/files/affiliates/mwa/bbutzler-aha-vad.pdf?la=en&hash=AAAC180F45FFD453CF8B5FEE86C6114EDEACAEAF


Secondary Prevention of Coronary Artery DiseaseHealthy Lifestyle

• Diet

• Exercise

• Tobacco avoidance

• Optimal sleep

• Annual influenza immunization

Management of all Comorbidities

• Intensive reduction of LDL cholesterol

• Management of hypertension

• Management of diabetes

– Glycemic control / reduction of HbA1c

– SGLT2 Inhibitors

– GLP-1 Agonists

• Management of obesity

• Management of obstructive sleep apnea

2019 CVD DM Guidelines: care.diabetesjournals.org/content/42/Supplement_1/S103

2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: https://www.ahajournals.org/doi/suppl/10.1161/CIR.0000000000000678

Sodium–glucose cotransporter 2 (SGLT2) inhibitors:Canagliflozin (Invokana®)Dapagliflozin (Farxiga®)Empagliflozin (Jardiance®)Ertugliflozin (Steglatro®)

Glucagon-like peptide 1(GLP-1) receptor agonists:

Dulaglutide (Trulicity®)Exenatide (Bydureon® / Byetta®)Liraglutide (Victoza®)Semaglutide (Ozempic®)

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Management of Hypertension

2017 ACC/AHA Guidelines for Management for Hypertension

• Developed by the American College of Cardiology and the American Heart Association in collaboration with 9 other Professional Organizations

• Published in November 2017

• Guideline is 481 pages in length with 106 specific references

• The companion 28-page “Guidelines Made Simple” covers the most important points with key figures and tables

Get this document !Link:

ACC.org/GMSHBP




• Accurate measurement is essential (See Guideline Tables 8 & 9)

– Proper preparation and positioning

– Proper equipment and technique

• Increased utilization of self monitoring (See Guideline Table 10)

• Non-pharmacological interventions (Class I A Recommendation)

– Diet / Sodium reduction

– Physical activity / Exercise

– Achieve ideal body weight

• Targets of treatment

– BP < 130/80 mmHg for most patients

• Focus on cardiovascular risk reduction

2017 BP Guidelines: www.ahajournals.org/doi/pdf/10.1161/HYP.0000000000000065, Figure 4, pg 20 of 103, used for educational purpose





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• Primary pharmacological therapy for hypertension (See Guideline Table 18)

– Thiazide diuretics

– Calcium channel blockers

– Angiotensin Converting Enzyme (ACE) Inhibitors

– Angiotensin Receptor Blockers (ARB)

• Initiation of antihypertensive drug therapy with 2 first-line agents of different classes is indicated if BP reduction > 20/10 mmHg needed.

• Beta blockers are used in patients who have cardiac indications for their use (such as chronic stable angina or heart failure), but are not generally used for initial management of hypertension.

• Multiple classes of drugs available for secondary pharmacological therapy for hypertension including loop diuretics, aldosterone antagonists, beta blockers, central alpha-2 agonists and direct vasodilators. (See Guideline Table 18)



Management of Cholesterol

2018 AHA/ACC Guidelines on the Management of Cholesterol

• Developed by the American Heart Association and the American College of Cardiology in collaboration with10 other Professional Organizations

• Published in November 2018

• Guideline includes “Top 10 Take-Home Messages”

• The companion 22-page “Guidelines Made Simple” covers the most important points with key figures and tables

Get this document !Link:

ACC.org/GMSCholesterol




• In all individuals, emphasize a heart-healthy lifestyle across the life course.

• In patients with clinical ASCVD, reduce low-density lipoprotein cholesterol (LDL-C) with high-intensity statin therapy or maximally tolerated statin therapy.

• In very high-risk ASCVD, use a LDL-C threshold of 70 mg/dL to consider addition of nonstatins to statin therapy.

– Ezetimibe / PCSK9 Inhibitors

• In patients with severe primary hypercholesterolemia (LDL-C level ≥190 mg/dL) …. begin high-intensity statin therapy

ACC.org/GMSCholesterol: www.acc.org/~/media/Non-Clinical/Files-PDFs-Excel-MS-Word-etc/Guidelines/2018/Guidelines-Made-Simple-Tool-2018-Cholesterol.pdf, Top 10

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• “In patients 40 to 75 years of age with diabetes mellitus and LDL-C ≥70 mg/dL start moderate-intensity or high intensity statin therapy…”

• “In adults 40 to 75 years of age without diabetes mellitus and 10-year risk of 7.5% to 19.9% (intermediate risk), risk-enhancing factors favor initiation of statin therapy.” (See Appendix 4)

• “Assess adherence and percentage response to LDL-C–lowering medications and lifestyle changes with repeat lipid measurement 4 to 12 weeks after statin initiation or dose adjustment, repeated every 3 to 12 months as needed.”

ACC.org/GMSCholesterol: www.acc.org/~/media/Non-Clinical/Files-PDFs-Excel-MS-Word-etc/Guidelines/2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol A Report: https://www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000625




ACC.org/GMSCholesterol: www.acc.org/~/media/Non-Clinical/Files-PDFs-Excel-MS-Word-etc/Guidelines/2018/Guidelines-Made-Simple-Tool-2018-Cholesterol.pdf, used for educational purpose


Behavioral Health & Coronary Artery Disease

• Patients with behavioral health problems are at increased risk of cardiovascular disease.

• In patients with cardiovascular disease, behavioral health problems are predictors of increased morbidity and mortality and poor quality of life.

• The risk of depression is increased 3-fold in patients with cardiovascular disease.

• Prevalence of depression is 30% in patients with myocardial infarction, unstable angina, CHF, CVA and in those who have undergone percutaneous coronary intervention, CABG and valve surgery.

• Depression is associated with 2-2.5 x increased risk of mortality in patients with cardiovascular disease.

• Patients with PTSD, anxiety and social isolation are at increased risk of poor cardiovascular outcomes.

Mavrides N 2015; Jackson S 1969; Lichtman JH 2008, 2014; Cohen BE 2015; Batelaan NM 2016

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Valtorta NK 2016; Lichtman JH 2008; Cohen BE 2014; Valmontes 2009; Mavrides 2015

Behavioral • Poor adherence • Lifestyle (smoking, SUD’s, physical

activity, diet)• Socio-economic downward drift • Poor functional status

Biological • Inflammation (IL-1, IL-6, CRP,

adhesion molecules, fibrinogen, NFKB)

• Reduced heart rate variability and arrythmogenesis

• Thrombogenesis• Impaired vascular function • Shared risk: Diabetes & Hypertension• Social isolation • Drug side effects & drug interactions

Mechanism of Interactions Between Biological and Behavioral Factors



• Assessment

– Psychosocial issues

– Risk of depression

– Socioeconomic issues, access to care and healthcare disparities

– Social isolation

• Screening (See Appendix 5)

– Depression (PHQ-2 or PHQ-9)

– Anxiety (GAD-7)

– Psychological trauma

• Initiate treatment (See Appendix 5)

– Refer to Behavioral Health Professional (moderate to severe cases)

– Assess suicidality

NCBI: www.ncbi.nlm.nih.gov/pubmed/18824640

Behavioral Health Plan of Care



Lichtman JH 2008; Correll C 2015; Mavrides 2015

Treatment of Behavioral Health Issues (See Appendix 5)

• Antidepressants

- SSRI / SNRI

- Other antidepressant medications

• Cognitive Behavioral Therapy (CBT)

• Physical activity

- Cardiac rehabilitation

- Physical therapy

• Smoking cessation

• Case management / care coordination

• Clinical practice guidelines

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Case Study

Mr. Art Burn is a 69 year old man with history of myocardial infarction 17 years ago. He subsequently developed chronic stable angina which does not interfere with his normal activities including full-time employment and golf.

Comorbidities include dyslipidemia, hypertension and diabetes mellitus (type 2).

Member is adherent to prescribed medications which include aspirin, atorvastatin 20 mg daily, lisinopril, metoprolol, metformin and empagliflozin (Jardiance®).

At the time of last evaluation by his Cardiologist, Member reported that he was doing well. BMI was 23 kg/m2. BP 130/76 mmHg. EKG sinus rhythm with no indication of ischemia. Evidence of old myocardial infarction was unchanged from previous EKGs. Echocardiogram showed preserved left ventricular function with EF of approximately 50%.

Mr. Burn has an existing relationship with a Case Manager from when he had herniorrhaphy several years ago.

Mr. Art Burn now calls to report that within the past 2 weeks he has developed bothersome chest discomfort. Initially symptoms only occurred with walking but now it is happening at rest. Pain is occurring with increased frequency and each episode lasts longer. Associated symptoms include a feeling of indigestion and mild dyspnea.

Mr. Burn is anxious and has a sense of impending doom.

He wants to know what he should do.


Case Study Question #1

Based on Mr. Burn’s history and current symptoms, all of the following statements are true EXCEPT:

A. Mr. Burn has symptoms suggestive of Acute Coronary Syndrome.

B. Mr. Burn should call his Primary Care office to schedule a stress test.

C. Mr. Burns should report his symptoms to his cardiologist immediately. If the office is closed he should speak to the Cardiologist on call.

D. If Mr. Burn is unable to speak with a Cardiologist promptly, he should have someone take him to an Emergency Room now or he should call 911.

E. Mr. Burn will likely have prompt cardiac catheterization.

Answer: B. Mr. Burn should call his Primary Care office to schedule a stress test.



Mr. Burn followed the recommendation of Case Manger and called his Cardiologist who advised that he immediately go to the Emergency Room.

Emergency Cardiac Catheterization demonstrated a new critical lesion in the proximal left anterior descending (LAD) coronary artery. An drug-eluting stent (DES) was placed in this artery without complications. There was no other critical coronary disease except for the chronically occluded vessel (which occurred at the time of previous MI,17 years ago). There was minimal elevation of Troponin and left ventricular function was preserved.

At the time of post-discharge call, appropriate actions includes the following:

A. Confirm that Member understands his discharge instructions.

B. Confirm that Member has an appointment to see his Cardiologist for follow-up.

C. Confirm that Member has filled all of his new prescriptions, that he understands how to take all of his medications and that he has an adequate supply of previous medications.

D. Inquire if Member is having any current symptoms, including cardiac symptoms and catheterization-site bleeding, and and ensure that he understand what should be reported to his Cardiologist.

E. All of the above are appropriate at this time.

Answer: E. All of the above are appropriate at this time.

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On follow up call 2 weeks later, medication reconciliation is performed. Mr. Burn advises that he is on all of the same medications that he was on previously. In addition, several new medications have been added. Which of the following statements regarding medications is guideline-supported in this situation:

A. Clopidogrel (Plavix®) has been added. The Cardiologist explained that this will be continued for at least one year since Member has a new drug-eluting stent (DES).

B. Aspirin will be continued.

C. Atorvastatin dosage has been increased to 80 mg daily (High Intensity Statin Therapy). The Cardiologist explained that the therapeutic goal is to lower the LDL Cholesterol level to < 70 mg/dL. If this cannot be achieved within 6 to 12 weeks, then Ezetimibe (Zetia®) will be added.

D. The current HbA1c is 6.8%. Metformin and empagliflozin (Jardiance®) will be continued unchanged for now. Cardiologist has referred Member to an Endocrinologist to determine if there may be a role for addition of a GLP-1 Agonists for possible additional cardiovascular benefit.

E. All of the above statements are supported by current treatment guidelines.

Answer: E. All of the above statements are supported by current treatment guidelines.


Case Study Question #4On follow up call 1 month after intracoronary stenting, Mr. Burn admits that he has been feeling “a little down”.

On further inquiry by the Case Manager, Mr. Burn says that he is not sleeping well most nights and he feels tired. He has a poor appetite.

Mr. Burn said that he lives alone. His adult children and grandchildren all live several hours away. The Cardiologist has advised Member that he can return to work and he can resume golfing. Mr. Burn says that he will go back to work next week but he “has no interest in golf at this time”.

On further questioning, Mr. Burn says that he had an episode of depression approximately 10 years ago subsequent to the death of his spouse. He said that he was treated with an antidepressant for one year with very good response.

All of the following are correct EXCEPT:

A. The incidence of depression in patients undergoing intracoronary stenting is approximately 30%.

B. Depression increases risk of morbidity and mortality in patients with CAD.

C. Use PHQ-9 (or other available PHQ Assessment) to screen for depression.

D. Case Manager should encourage Member to ask his PCP about antidepressant medication therapy.

E. Patients with drug-eluting stents (DES) cannot take SSRI antidepressants for one year.

Answer E. Patients with drug-eluting stents (DES) cannot take SSRI antidepressants for one year.


Quick Guide

Quick Guide Posted on Nexus: nexus-sp.optum.com/Atlas/Document.html?TT46058

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Q & A


Appendix


Appendix 1 – Assessing Stroke Risk in Atrial Fibrillation

CHA2DS2VASc Score*

* Used to assess risk of stroke in patients with atrial fibrillation except with moderate-to-severe mitral stenosis or a mechanical heart valve Sex category: male = 0 points / female = 1 pointThe maximal possible score is 9 since the two age categories are mutually exclusive.

AHA: www.ahajournals.org/doi/pdf/10.1161/STROKEAHA.118.021453

Condition Score if present

C Congestive Heart Failure 1

H Hypertension 1

A2 Age 75 years or older 2

D Diabetes mellitus 1

S2 Prior stroke, TIA or thromboembolism 2

V Vascular disease 1

A Age 65 -74 1

Sc Sex category - Female 1

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Appendix 2 – Anticoagulation Therapy

Warfarin Anticoagulation

• Available since 1954

• Currently, the most widely used anticoagulant medication

• Brands in US are Coumadin® and Jantoven®

• Mechanism is inhibition of action of Vitamin K in synthesis of 4 coagulation

factors by the liver (Factors II, VII, IX, X)

• The degree of anticoagulation is determined by the Prothrombin Time (PT)

which is generally reported as the International Normalized Ratio (INR)

• Many factors influence stability of anticoagulation with warfarin including diet,

other medications, activity and genetics

2019 AF Guidelines: www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000665. Lexicomp: online.lexi.com/lco/action/home;jsessionid=13a2a8c54222a4566b9d1ccb6804



NOACs / DOACs- I

• Non-Vitamin K Oral Anticoagulants / Direct Oral Anticoagulants

• Mechanism is direct inhibition of action of a specific coagulation factor

• Factor Xa inhibitors

– Apixaban (Eliquis®)

– Rivaroxaban (Xarelto®)

– Endoxaban (Savaysa®)

• Factor II inhibitors (Direct Thrombin Inhibitor = DTIs)

– Dabigatran (Pradaxa®)

• Look for the letters Xa in the name to identify NOACs / DOACs

• NOACs / DOACs are much more expensive than warfarin2019 AF Guidelines: www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000665. Lexicomp: online.lexi.com/lco/action/home;jsessionid=13a2a8c54222a4566b9d1ccb6804



NOACs / DOACs- II

• Equal to or better than warfarin in prevention of stroke in most patient with atrial fibrillation (but not all)

• Advantages of NOACs / DOACS

– Fixed dosage for most patients (poor renal function is key exception)

– Rapid onset of action (1-4 hours to maximal effect)

– No routine laboratory monitoring

– Few drug interactions (exceptions are some antifungal and antiviral agents )

– No dietary interactions / restrictions

• Bleeding with NOACs / DOACS

– Bleeding risk is favorable compared to warfarin – but bleeding still a risk

– Specific reversal agents for Dabigatran and for the Factor Xa inhibitors

– Prothrombin Complex Concentrate (4F-PCC / aPCC) may also be used

2019 AF Guidelines: www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000665. Lexicomp: online.lexi.com/lco/action/home;jsessionid=13a2a8c54222a4566b9d1ccb6804

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Appendix 3 – Assessing the Risk of Bleeding

HAS-BLED Risk Score for Assessing Bleeding Risk with Antithrombotic Therapy

H - Hypertension (>160 mmHg)

A - Abnormal renal function (Cr > 2.26 mg/dl)

A - Abnormal hepatic function

S - Prior stroke–

B - Prior major bleeding

L – Labile INR (<60% time in range)

E – Elderly (age > 65)

D – Drugs predisposing to bleeding (Antiplatelet agents / NSAIDs)

D – Drugs (Prior drug or alcohol use)Score of 3 or greater indicates increased risk of bleeding

The maximal possible score is 9

2019 AHA/ACC/HRS Guidelines: www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000665


Appendix 4 – Risk Enhancing Factors for CAD2018 AHA/ACC Guidelines on the Management of Cholesterol

2018 Cholesterol Guidelines: https://www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000625


Appendix 5 – Behavioral Health in CAD

Algorithm for Management of Behavioral Health Problems

Lichtman JH et al Circulation. 2008;118:1768-75

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PHQ-2 (Patient Health Questionnaire - 2 Item)

• Over the past 2 weeks, how often have you been bothered by any of the following problems?

(1) Little interest or pleasure in doing things

(2) Feeling down, depressed, or hopeless

• If the answer is “yes” to either of the 2 questions, then refer for more comprehensive clinical evaluation by a professional qualified in the diagnosis and management of depression or screen with PHQ-9.

Kroenke, K., Spitzer, R. L., & Williams, J. B. (2003). The Patient Health Questionnaire-2: validity of a two-item depression screener. Medical care, 1284-1292. www.phqscreeners.com/select-screener/36



Kroenke K, Spitzer RL. The PHQ-9: A new depression diagnostic and severity measure. Psychiatric Annals. 2002;32:509-515Phizer: https://www.phqscreeners.com/select-screener/36, used for educational purpose.

Interpretation of Severity of Depression: <10 Mild 10-19 Moderate >20 Severe*

* The interpretation presented is adapted for patients with CAD


Thank You

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References

1. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease. www.ahajournals.org/doi/pdf/10.1161/CIR.0b013e318277d6a0 Published December 2012, Accessed April 14, 2019.

2. 2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease. www.ahajournals.org/doi/pdf/10.1161/CIR.00000000 00000095 Published November 2014, Accessed April 14, 2019.

3. 2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes. www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000134 Published December 2014, Accessed April 25, 2019.

4. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. www.onlinejacc.org/content/ early/2017/11/04/j.jacc.2017.11.006 https://www.ahajournals.org/doi/pdf/10.1161/HYP.0000000000000065Published November 2017, Accessed April 28, 2019.

5. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults – Guidelines Made Simple. https://www.acc.org/~/media/Non-Clinical/Files-PDFs-Excel-MS-Word-etc/Guidelines/2017/ Guidelines_Made_Simple_2017_HBP.pdf, ACC.org/GMSHBP, Published November 2017, Accessed April 28, 2019.


References

6. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults – Guidelines Made Simple. https://www.acc.org/~/media/Non-Clinical/Files-PDFs-Excel-MS-Word-etc/Guidelines/2017/ Guidelines_Made_Simple_2017_HBP.pdf, ACC.org/GMSHBP, Published November 2017, Accessed April 28, 2019.

7. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol. www.onlinejacc.org/content/early/2018/11/02/ j.jacc.2018.11.003, Published November 2018,Accessed May 18, 2019.

8. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol – Guidelines Made Simple. www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000625,ACC.org/GMS Cholesterol, Published November 2017, Accessed May 18, 2019.

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10. Aldea, Gabriel & Bakaeen, Faisal, The Society of Thoracic Surgeons Clinical Practice Guidelines on Arterial Conduits for Coronary Artery Bypass Grafting, www.annalsthoracicsurgery.org/article/S0003-4975(15)01608-2/fulltext, The Annals of cardiothoracic Surgery, February 2016, Accessed July 19, 2019.

11. Alexander, John & Smith, Peter, Coronary Artery Bypass Grafting, NEJM, www.nejm.org/doi/pdf/10.1056/ NEJMra1406944, May 19, 2016, Accessed July 29, 2019.


References

12. Azar Rabih, Coronary heart disease and myocardial infarction in young men and women, www.uptodate.com/contents/coronary-heart-disease-and-myocardial-infarction-in-young-men-and-women#H9, May 23, 2019, Accessed July 19, 2019.

13. Alexander, John & Smith, Peter, Coronary Artery Bypass Grafting, NEJM, www.nejm.org/doi/pdf/10.1056/ NEJMra1406944, May 19, 2016, Accessed July 29, 2019.

14. Azar Rabih, Coronary heart disease and myocardial infarction in young men and women, www.uptodate.com/contents/coronary-heart-disease-and-myocardial-infarction-in-young-men-and-women#H9, May 23, 2019, Accessed July 19, 2019.

15. CDC, Division for Heart Disease & Stroke Prevention, Heart Disease Fact Sheet, www.cdc.gov/dhdsp/data_ statistics/fact_sheets/fs_heart_disease.htm, August 27, 2017, Accessed July 19, 2019.

16. Cao, Christopher, & Indraratna Praveen, A systematic review on robotic coronary artery bypass graft surgery, www.annalscts.com/article/view/12492/12885, November 2016, Accessed July 19, 2019.

17. Cooper, Leslie, Clinical manifestations and diagnosis of myocarditis in adults, www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-myocarditis-in-adults, Updated February 14, 2019, Accessed July 19, 2019.

18. Cuenca J, Bonome C. Off-Pump Coronary Artery Bypass Grafting and Other Minimally Invasive Techniques.

19. Revista Espanola De Cardiologia, www.ncbi.nlm.nih.gov/pubmed/16324587 2005, Accessed July 29, 2019.

20. Kern, Morton, Cardiac catheterization techniques: Normal hemodynamics, www.uptodate.com/contents/cardiac-catheterization-techniques-normal-hemodynamics, November 20, 2017, Accessed July 19, 2019.

21. Lexicomp: online.lexi.com/lco/action/home;jsessionid=13a2a8c54222a4566b9d1ccb6804, Accessed July 29, 2019.

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References

22. Lichman JH et al Circulation., Depression and coronary heart disease, www.ncbi.nlm.nih.gov/ pubmed/18824640, 2008; 118:1768-75, Accessed July 22, 2019.

23. Mahler, Simon, Angina pectoris: Chest pain caused by coronary artery obstruction, www.uptodate.com/contents/ angina-pectoris-chest-pain-caused-by-coronary-artery-obstruction?search= %20angina&source=search_result &selectedTitle=1~150&usage_type=default&display_rank=1, Updated March 6, 2019, Accessed July 19, 2019.

24. Mayo Clinic, VAD, www.mayoclinic.org/tests-procedures/ventricular-assist-device/about/pac-20384529, June 11, 2019, Accessed July 22, 2019.

25. Reeder, Guy & Kennedy Harold, Overview of the acute management of ST-elevation myocardial infarction, www.uptodate.com/contents/overview-of-the-acute-management-of-st-elevation-myocardial-infarction, January 28, 2019, Accessed July 29, 2019.

26. Schwartz, Gregory & Steg Gabriel, et al, NEJM, Alirocumab and Cardiovascular Outcomes after Acute Coronary Syndrome, www.nejm.org/doi/full/10.1056/NEJMoa1801174, November 29, 2018, Accessed July 19, 2019.

27. Standards of Medical Care in Diabetes – 2019 Section 10:Cardiovascular Disease and Risk Management. http://care.diabetesjournals.org/content/42/Supplement_1/S103, Published January 2019, Accessed June 10, 2019.

28. The Society of Thoracic Surgeons Clinical Practice Guidelines on Arterial Conduits for Coronary Artery Bypass Grafting. doi.org/10.1016/j.athoracsur.2015.09.100, Published February 2016, Accessed April 25, 2019.

29. White, Hunter & Borgee, Judith, Anatomy, Abdomen and Pelvis, Aorta, NCBI, www.ncbi.nlm.nih.gov/ books/NBK537319/, February 2, 2019, Accessed July 19, 2019

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