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Guidelines Applied to Guidelines Applied to Practice (GAP)Practice (GAP)

American College of Cardiology, American College of Cardiology, Puerto Rico ChapterPuerto Rico Chapter

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INTRODUCTIONINTRODUCTIONSan Juan : Hotel Intercontinental, Feb. 6, 2007 - Jorge Ortega Gil, MD San Juan : Hotel Intercontinental, Feb. 6, 2007 - Jorge Ortega Gil, MD MayagMayagüüez : Casa del Médico, Feb. 7, 2007 – Marcos Velázquez, MDez : Casa del Médico, Feb. 7, 2007 – Marcos Velázquez, MD

Ponce : Casa del Médico, Feb. 8, 2007 – José Gómez Rivera, MDPonce : Casa del Médico, Feb. 8, 2007 – José Gómez Rivera, MD

Guidelines Applied in Practice Guidelines Applied in Practice (GAP)(GAP)

Chronic Coronary Chronic Coronary SyndromesSyndromes

(Chronic Stable Angina)(Chronic Stable Angina)

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Ischemic Heart Disease in the United StatesThe Magnitude of the Health Problem

Despite the well documented recent decline in Despite the well documented recent decline in cardiovascular mortality, IHD remains the leading cause of cardiovascular mortality, IHD remains the leading cause of deathdeath

The initial clinical presentation is about the same for both The initial clinical presentation is about the same for both chronic and acute coronary syndromes (50% each)chronic and acute coronary syndromes (50% each)

About 1.5 million myocardial infarctions occur each year, About 1.5 million myocardial infarctions occur each year, one third to one half are fatalone third to one half are fatal 200,000 have silent infarctions200,000 have silent infarctions

16 million people have symptomatic CAD16 million people have symptomatic CAD Approximately 2.5 % of totally asymptomatic middle-aged Approximately 2.5 % of totally asymptomatic middle-aged

men have silent myocardial ischemiamen have silent myocardial ischemia One million each PCI and CABG are performed each yearOne million each PCI and CABG are performed each year Annual cost in 2004 was about $368 billionAnnual cost in 2004 was about $368 billion

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The ACC/AHA Guideline ClassificationsThe ACC/AHA Guideline Classifications

Class I:Class I: Evidence and / or agreement that treatment is Evidence and / or agreement that treatment is effectiveeffective

Class IIa:Class IIa: Weight of evidence favors use Weight of evidence favors useClass IIb:Class IIb: Usefulness less well established Usefulness less well establishedClass III:Class III: Evidence and/ or agreement that treatment is Evidence and/ or agreement that treatment is

not effectivenot effective

Level of evidenceLevel of evidence: : A (high rank)A (high rank) – Based on large randomized trials – Based on large randomized trialsB (Intermediate rankB (Intermediate rank)) Based on smaller trials or Based on smaller trials or careful analysescareful analysesC (low rank)C (low rank) – Based on expert consensus – Based on expert consensus

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Pathophysiology & Pathophysiology & Clinical PresentationsClinical Presentations

Chronic Coronary SyndromesChronic Coronary Syndromes(Chronic Stable Angina)(Chronic Stable Angina)

GAPGAP

San Juan : Hotel Intercontinental, Feb. 6, 2007 - Jorge Ortega Gil, MD San Juan : Hotel Intercontinental, Feb. 6, 2007 - Jorge Ortega Gil, MD MayagMayagüüez : Casa del Médico, Feb. 7, 2007 – Marcos Velázquez, MDez : Casa del Médico, Feb. 7, 2007 – Marcos Velázquez, MD

Ponce : Casa del Médico, Feb. 8, 2007 – José Gómez Rivera, MDPonce : Casa del Médico, Feb. 8, 2007 – José Gómez Rivera, MD

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Ischemic Heart Disease - OverviewIschemic Heart Disease - Overview

Atherosclerosis

Atherothrombosis

Pathophysiology

Clinical Presentations

Silent ischemia

Stable angina Acute Coronary Syndromes

ParametersAnatomy: Atheroma / Atherothrombosis

Subjective: Angina

Objective: EKG T wave ST seg changes

Chemistry: Cardiac serum biomarkers:

CPK, CK-MB, Troponins

Epicardial & Microvascular Spam

Prevalence & severity of stenosis

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Events During AtherogenesisEvents During Atherogenesis

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P x r

2hWall Stress =

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ISCHEMIC CASCADEISCHEMIC CASCADE

Predictable sequence of Predictable sequence of pathophysiologic events post pathophysiologic events post

myocardial supply/demand imbalancemyocardial supply/demand imbalance

•Biochemical metabolic actions

•Flow Maldistribution

•Hypoperfusion

•(Rales)

Angina / SI

• Compliance

• Contractility

• EF

• LVEDP

•(S4)Nuclear

Echo

EKG

TIM

E F

RO

M O

NS

ET

OF

ISC

HE

MIA

± 45 sec.

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Effect of Fixed Stenosis on Myocardial Blood Flow

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Progression of coronary plaque over time Clinical FindingsProgression of coronary plaque over time Clinical Findings

Acute Coronary SyndromesSudden Cardiac Death

Acute silent occlusive process

Angina pectoris

Thrombogenicrisk factors

Atherogenic risk factors

Endothelial dysfunction

20 years 60 yearsAge

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IHD – Clinical SpectrumIHD – Clinical SpectrumChronicChronic

Stable AnginaStable Angina Silent IschemiaSilent Ischemia Mixed AnginaMixed Angina Microvascular Angina Microvascular Angina

(Syndrome X)(Syndrome X) Stunned & HibernatingStunned & Hibernating

Acute Acute Unstable AnginaUnstable Angina Acute Myocardial Acute Myocardial

Infarction (NSTEMI, Infarction (NSTEMI, STEMI)STEMI)

Sudden Cardiac DeathSudden Cardiac DeathPrinzmetal AnginaPrinzmetal Angina

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ANGINA PECTORISANGINA PECTORIS Location:Location: Usually Substernal, Jaw & Epigastrium Usually Substernal, Jaw & Epigastrium QualityQuality: Sensation of Pain / Discomfort, Oppression, : Sensation of Pain / Discomfort, Oppression,

Pressure, Burning, Tightness, Crushing or Squeezing. Can Pressure, Burning, Tightness, Crushing or Squeezing. Can Resemble Ïndigestion”Resemble Ïndigestion”

RadiationRadiation:: Radiates To Left Or Right Arm Or Shoulder, Jaw Radiates To Left Or Right Arm Or Shoulder, Jaw or Epigastrium.or Epigastrium.

Assocatie Symptoms:Assocatie Symptoms:.. Dyspnea, Diaphoresis, Weakness, Dyspnea, Diaphoresis, Weakness, Nausea, Vomiting, and/or Feeling of Anxiety Or Impending Nausea, Vomiting, and/or Feeling of Anxiety Or Impending DoomDoom

Duration:Duration: 2 Min. – 30 Min. - To Several Hours 2 Min. – 30 Min. - To Several Hours - Relieved By TNG In 1-10 Min or Rest- Relieved By TNG In 1-10 Min or Rest Related To:Related To: Exercise, Cold, Meals, Emotion, Coitus. Rest. Exercise, Cold, Meals, Emotion, Coitus. Rest.DIFFERENTIAL DIAGNOSIS OF CHEST PAINDIFFERENTIAL DIAGNOSIS OF CHEST PAIN Cardiovascular: Pericarditis, Aortic Valve Disease, Aortic Cardiovascular: Pericarditis, Aortic Valve Disease, Aortic

Dissection, Pulmonary Embolism, Mitral Valve ProlapseDissection, Pulmonary Embolism, Mitral Valve Prolapse Gastrointestinal: Esophageal, Biliary, Peptic ulcer, Gastrointestinal: Esophageal, Biliary, Peptic ulcer,

PancreatitisPancreatitis Pulmonary: Pneumothorax, Pneumonia, PleuritisPulmonary: Pneumothorax, Pneumonia, Pleuritis Chest Wall: Costochondritis, Rib fracture, Herpes zosterChest Wall: Costochondritis, Rib fracture, Herpes zoster Psychological: Anxiety disordersPsychological: Anxiety disorders

ClassClass Activity Activity evokingevoking

anginaangina

Limits Limits to to normalnormal

activityactivity

II ProlongProlonged ed exertionexertion

NoneNone

IIII Walking Walking > 2 > 2 blocksblocks

SlightSlight

IIIIII Walking Walking < 2 < 2 blocksblocks

MarkedMarked

IVIV Minimal Minimal or restor rest

SevereSevere

Canadian Cardiovascular Society Classification ( CCSC)

Typical angina (define) : Typical angina (define) : Substernal chest discomfort with a characteristic quality Substernal chest discomfort with a characteristic quality and duration that is Provoked by exertion or emotional stress andand duration that is Provoked by exertion or emotional stress and

Relieved by rest or nitroglycerinRelieved by rest or nitroglycerinAtypical angina ( probable): Atypical angina ( probable): Meets 2 of the above characteristics Meets 2 of the above characteristicsNoncardiac chest pain :Noncardiac chest pain : Meets one or none of the typical angina characteristics Meets one or none of the typical angina characteristics

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CAD - Clinical SpectrumCAD - Clinical Spectrum Chronic ischemic heart diseaseChronic ischemic heart disease Ischemia precipitated by increased myocardial oxygen Ischemia precipitated by increased myocardial oxygen

demand in the setting of a fixed, not vulnerable atherosclerotic demand in the setting of a fixed, not vulnerable atherosclerotic lesion. It is called lesion. It is called Stable AnginaStable Angina when the clinical when the clinical characteristics (Angina attacks) do not change in frequency, characteristics (Angina attacks) do not change in frequency, duration, precipitating causes, or easy with the angina is duration, precipitating causes, or easy with the angina is relieved, for at least 60 days.relieved, for at least 60 days.

--Silent Ischemia, -Mixed Angina -Syndome X Silent Ischemia, -Mixed Angina -Syndome X -Stunning & Hibernating.-Stunning & Hibernating.

Acute Coronary Syndromes (ACS)Acute Coronary Syndromes (ACS) Ischemia or infarction are caused from a primary reduction in Ischemia or infarction are caused from a primary reduction in

coronary flow, precipitated by plaque disruption and coronary flow, precipitated by plaque disruption and subsequent thrombus formation:subsequent thrombus formation:

Unstable Angina, NSTEMI, STEMIUnstable Angina, NSTEMI, STEMI Prinzmetal AnginaPrinzmetal Angina

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Is the objective Is the objective evidence-ST evidence-ST segment shifts- of segment shifts- of myocardial myocardial ischemia which is ischemia which is not associated with not associated with angina or angina angina or angina equivalents.equivalents.

Silent Ischemia

ST seg. depression

Iceberg’s sign

Angina

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Mixed AnginaMixed Angina Exertional Angina Plus Angina at Rest or Cold-Exertional Angina Plus Angina at Rest or Cold-

induced Angina or Emotion-Induced Angina.induced Angina or Emotion-Induced Angina. Angina at Variable Thresholds of Exercise.Angina at Variable Thresholds of Exercise.

ClassicAngina

Prinzmetal Angina

Transient ST seg depression

Transient ST seg elevation

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Pathophysiology: Dynamic small vessel constriction (vasospasm)

(positive stress testing)

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Prolonged bouts of chest pain at Prolonged bouts of chest pain at rest with EKG ST seg. elevation.rest with EKG ST seg. elevation.

PRINZMETAL OR VARIANT ANGINA

A = Marked transitory ST Elevation during a bout of severe chest pain B = Thirty min. after A (Normal EKG)

Pathophysiology: profound spasm of one of the three major epicardial coronary arteries.

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Post-ischemic LV Dysfunction Impaired LV contractility despite the presence of viable myocytes

Acute phenomenon – The LV dysfunction is due to short periods of coronary occlusion, and persists for minutes, hours or even days after blood flow has been restored. This process is reversible spontaneously.

Chronic phenomenon – The LV dysfunction is the result of months or years of chronic ischemia. This process requires revascularization ( PCI, CABG) in order to restore contractility.

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Chronic Coronary Syndromes Chronic Coronary Syndromes TreatmentTreatment

PharmacologicPharmacologic AntithromboticsAntithrombotics Beta-BlockersBeta-Blockers ACE-InhibitorsACE-Inhibitors Lipid-Lowering Agents (+stantins)Lipid-Lowering Agents (+stantins) Aggressive Risk Factors ModificationsAggressive Risk Factors Modifications Influenza VaccineInfluenza Vaccine

RevascularizationRevascularization Mechanical: PCI, CABGMechanical: PCI, CABG

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Treatment of Chronic Ischemic Heart Disease I. Medical

A) Antianginal and Anti-ischemic therapy - Blockers; Calcium antagonists;Nitroglycerin and Nitrates

B) Pharmacotherapy to prevent Myocardial Infarction and Death Antiplatelet / Antithrombotic agents

Lipid – Lowering agents Angiotensin – converting enzymes inhibition (ACE-I)– Blockers

C) Risk Factor Modification Smoking cessation; Blood pressure control

D) Influenza Vaccine

II. Mechanical Revascularization A) Percutaneous coronary intervenntion (PCI): Conventional Angioplasty (PTCA) Stents implantation: Bare metal & drug - eluting stentsB) Surgical - Coronary artery bypass graft (CABG)

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Guidelines Applied to Guidelines Applied to Practice (GAP)Practice (GAP)

American College of Cardiology, American College of Cardiology, Puerto Rico ChapterPuerto Rico Chapter

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Holter * EBCT *MRI

LVG /