coronary atherosclerosis: past, present and future · 2016-05-20 · coronary atherosclerosis:...
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Coronary Atherosclerosis:Past, Present and Future
Harisios Boudoulas, MD, Dr, Dr Hon.Professor of Medicine/Cardiovascular Medicine and Pharmacy (emeritus)
The Ohio State University, Columbus, Ohio USAHonorary Professor, Academician (an. mem.)
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Coronary Atherosclerosisin Time Past
Coronary Atherosclerosisin Time Past
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Coronary Atherosclerosis in Antiquity
• Coronary artery atheroma and calcification inEgyptian mummies 1580 BC – 525 BC
• Hippocrates 460 BC – 377 BC
• Coronary artery atheroma and calcification inEgyptian mummies 1580 BC – 525 BC
• Hippocrates 460 BC – 377 BC
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“And I will tell my soul, Soul, you have many goods laid up formany years. Take your ease, eat, drink, and be merry. But Godsaid to him, Fool! This night your soul will be required of you”
- Luke 12:19-20
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Life Expectancy from 1850 to 2000(Incidence of coronary atherosclerosis was
low when life expectancy was short)
Influenza epidemic
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Coronary Atherosclerosis in the 1950s – 1960s
• In the late fifties to mid sixties, coronaryarteriography, echocardiography, IVUS, nuclearcardiology, thrombolysis, angioplasty, stents,biomarkers of inflammation or myocardialnecrosis indices of left ventricular function werenot available for clinical use at that time.
• Electrocardiogram and chest x-ray were the hightechnology at that time.
• Only nitroglycerin, morphine and bed rest wereused for the management of coronaryatherosclerosis at the time.
• In the late fifties to mid sixties, coronaryarteriography, echocardiography, IVUS, nuclearcardiology, thrombolysis, angioplasty, stents,biomarkers of inflammation or myocardialnecrosis indices of left ventricular function werenot available for clinical use at that time.
• Electrocardiogram and chest x-ray were the hightechnology at that time.
• Only nitroglycerin, morphine and bed rest wereused for the management of coronaryatherosclerosis at the time.
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Management of AMI• Morphine
• Heparin
• Warfarin
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Selective Injection in the Right Coronary Arteryin October 30, 1958 by F. Mason Sones
Cine coronary arteriography. Modern ConceptsCardiovascular Dis 1962; 31: 735
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Chest Pain with Angiographically NormalCoronary Arteries: A New Syndrome
Myocardial lactate production in patientswith angina-like chest pain andangiographically normal coronary arteriesand left ventricle.
Boudoulas H, et al. Clin Res 1973Am J Cardiol 1974; 30: 501
Myocardial lactate production in patientswith angina-like chest pain andangiographically normal coronary arteriesand left ventricle.
Boudoulas H, et al. Clin Res 1973Am J Cardiol 1974; 30: 501
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Coronary Atherosclerosis inTime Present
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Genetic and environmental risk factors
SedentaryLife
SmokingInflammatory
Process
StressDiabetes
Hyper-tension Inhibitory
Genes
PromotorGenes
SedentaryLife Stress
FattyDiet
Other
RenalDisease
PromotorGenes
Other
Coronary Atherosclerosis
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Genetics in Coronary Atherosclerosis
• More than 55 genetic risk variants• Chromosome 9p21 locus• LDL receptor (discovery of statins)• PCSK9 mutation (monoclonal, antibodies
evolucubam, other)• Variation in ANGPTL4 (lipoprotein lipase
pathway)• Blood groups A and B are risk variants for
AMI compared to group 0 (higher vWF complex)
• More than 55 genetic risk variants• Chromosome 9p21 locus• LDL receptor (discovery of statins)• PCSK9 mutation (monoclonal, antibodies
evolucubam, other)• Variation in ANGPTL4 (lipoprotein lipase
pathway)• Blood groups A and B are risk variants for
AMI compared to group 0 (higher vWF complex)
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Coronary Atherosclerosis: Development andProgression
• Remodeling• Progression• Inflammation, neo-vessel (v-v)• Unstable plaque-rupture - thrombosis• Stabilization-regression
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Coronary Atherosclerosis: Progression and Clinical Manifestations
LipidPool
Plaque Rupture and Thrombosis
Thrombosis/Progression/
AnginaAsymptomaticStable Disease
(± Angina)
Myopathy,CHF/MR
AMI
Normal
Years
Plaquerupture
Chest Pain(Atypical)
ThrombosisOcclusion
Death/SCD
AsymptomaticStable Disease
(± Angina)AMI
Angina(Unstable)
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Prognosis is Related to Overall Disease andNot to a Specific Lesion
Coronary atherosclerosis is a systemicproblem that requires systemic treatment.
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Coronary Atherosclerosis: Progression and Clinical Manifestations
LipidPool
Plaque Rupture and Thrombosis
Thrombosis/Progression/
AnginaAsymptomaticStable Disease
(± Angina)
Myopathy,CHF/MR
AMI
Normal
Years
Plaquerupture
Chest Pain(Atypical)
ThrombosisOcclusion
Death/SCD
AsymptomaticStable Disease
(± Angina)AMI
Angina(Unstable)
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Coronary Atherosclerosis: Therapy for the Plaque
To Prevent
Progression
Rupture
Thrombosis
Infarction
Death
D/CSmoking ↓ LDL-C Anti-
plateletβ-
Blocker ACEI
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
To Prevent
Progression
Rupture
Thrombosis
Infarction
Death
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+• Moderate exercise; Mediterranean diet• Ezetamibe• New drugs, Evolocumab• The role of vitamin D• Other
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Coronary Atherosclerosis: Clinical Significance ofLeft Ventricular (LV) Function
• LV systolic function is a stronger prognostic indicatorcompared to number of diseased vessels.
• Coronary bypass surgery and/or β-blockade therapyincreased survival only in patients with abnormal leftventricular systolic function. Boudoulas, O’Neil,Weissler, et al. Circulation 1981, Am J Cardiol 1981,Circulation 1982.
• CASS (Coronary Artery Surgery Study).Circulation 1983
• LV systolic function is a stronger prognostic indicatorcompared to number of diseased vessels.
• Coronary bypass surgery and/or β-blockade therapyincreased survival only in patients with abnormal leftventricular systolic function. Boudoulas, O’Neil,Weissler, et al. Circulation 1981, Am J Cardiol 1981,Circulation 1982.
• CASS (Coronary Artery Surgery Study).Circulation 1983
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Coronary Atherosclerosis: Therapy to Preserve /Improve LV Function
Goal
Stabilize PlaquePrevent Rupture,Thrombosis, MI
↓ Infract size
ImproveFunction
Therapyfor plaque
β-Blocker ACEI
Revascul-arization Cell
+ +
+
+
+
+
+
?
+
+
Thrombo-lysis
Goal
Stabilize PlaquePrevent Rupture,Thrombosis, MI
↓ Infract size
ImproveFunction
+
+
+
+
+
+
?
+
+
+
+
+
+
• Triggers of MI• Preconditioning, Postconditioning?
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Cell Based Therapy / Biomaterial• Intracoronary
injection
• Direct injection– Epicardial (Surgery)– Endocardial
(Percutaneous)
• Intracoronaryinjection
• Direct injection– Epicardial (Surgery)– Endocardial
(Percutaneous)
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Coronary Atherosclerosis: Medical Therapy vs.Revascularization for the Individual Patient
PharmacologicAgents
Bypass
Stent
The Superior PhysicianHe is skeptical toward the data of his ownprofession, welcomes discoveries which upset hisprevious hypothesis, and still animated by humansympathy and understanding.
- Alfred North Whitehead, Dialogues (Lucien Press) 1954
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Coronary Atherosclerosis:Medical Therapy vs. Revascularization
• Medical management improves symptoms, increases survival and inmost instances is not inferior to revascularization.
• As medical therapy is getting better, revascularization looks betteras well (“free ride”) since all patients with coronary atherosclerosisare on optimal medical management.
• Medical therapy for most patients with chronic stable angina shouldbe the initial approach.
• Revascularization: persistent symptoms - large area of myocardiumat risk
• The greater the severity of ischemia, extent of disease and LVdysfunction the greater the benefit on survival from revascularizationover medical therapy.
• Medical management improves symptoms, increases survival and inmost instances is not inferior to revascularization.
• As medical therapy is getting better, revascularization looks betteras well (“free ride”) since all patients with coronary atherosclerosisare on optimal medical management.
• Medical therapy for most patients with chronic stable angina shouldbe the initial approach.
• Revascularization: persistent symptoms - large area of myocardiumat risk
• The greater the severity of ischemia, extent of disease and LVdysfunction the greater the benefit on survival from revascularizationover medical therapy.
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Coronary Atherosclerosis: PCI versus CABGAvailable Information Should be Applied to the Individual Patient
• Left main or equivalent
• 3 VD with EF < 50%or large area of ischemia
• 3 VD (prox. LAD), normal EFespecially in diabetics
• 2 VD (prox. LAD), EF < 50%or large area of ischemia
• Proximal LAD
Consider CABG Consider PCI
• Proximal LAD
• 1-2 VD (no prox. LAD), LVdysfunction or large area of ischemia
• 2-3 VD (prox. LAD),normal LV, no diabetes
• Symptom control
• Restenosis, large area of ischemia
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Operating Room Catheterization Lab
Hybrid Cardiovascular Operating Room
Vanderbilt University, First Adult OR/Lab in USA
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Coronary Atherosclerosis: Available Information Should be Applied to theIndividual Patient
PharmacologicAgents
BypassStent
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Coronary Atherosclerosis in Time Future
Quo Vadis
Coronary Atherosclerosis in Time Future
Quo Vadis
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Halfway Technology and Cost ofMedicine
–
–
MedicalCost
–
–No Therapy
MedicalCost
HalfwayTechnology
Prevention/Cure
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Translational research
René Magritte. La Clairvoyance, 1936
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Certain Infections Diseases
–
–
• Rheumatic fever
• Syphilis
• Tuberculosis
• Peptic ulcer
• Other
Frequency
Mortality from CardiovascularDisease
UnitedStates
USA
BritianUSA
Finland
Northwestern Europe,Australia, Canada, New
Zealand, USA–
–Time
• Rheumatic fever
• Syphilis
• Tuberculosis
• Peptic ulcer
• Other
Frequency
Japan
“Time present and time pastAre both perhaps present in time future,
And time future contained in time past.”- T. S. Eliot, Four Quartets
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Genome Atlas• Coronary atherosclerosis• Other
Immunology - Inflammation
• Developing medicines that mimic thenatural successes of the human genome
• Pharmacogenetics/Pharmacogenomics• Other
Vaccines for prevention:• Atherosclerosis• Other
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Epigenetics
Epigenetics link genetics and environment throughmodification of gene expression
GeneEnvironment A Disease
Environment B No Disease
Pathologic effects of tobacco(cigarette smoke/secondhand smoke)
Environment A Disease
Environment B No Disease
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Coronary Atherosclerosis: Early treatment mayprevent the clinical manifestations of the disease
↓ LDL-C (Statin), Other
LDL-C< 45 mg/dl (Statin)
No therapy
Frequency ofclinical
manifestationsof coronary
atherosclerosis
Birth 20 40 60 80
Age (years)
LDL-C< 45 mg/dl (Statin)
Statin + PCSK9i
Vaccine, Other
0 –
Frequency ofclinical
manifestationsof coronary
atherosclerosis
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Coronary Atherosclerosis in Time Past, Time Presentand Time Future
Dev
elop
men
ts PharmacologicAgents
Prevention/Cure
1950 2010Time
Dev
elop
men
ts
BypassStent
PharmacologicAgents
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Microbiome and Chronic Disease
• Antibiotics and obesity• Diabetes• Coronary atherosclerosis• Other
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Mild to Moderate Coronary ArteryStenosis is Responsible for Most of the
Myocardial Infarctions
• Little WC, et al. Circulation. 1988
• Abrose JA, et al. J Am Coll Cardiol. 1988
• Little WC, et al. Circulation. 1988
• Abrose JA, et al. J Am Coll Cardiol. 1988
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Davies. Pathology
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Optical Coherence Tomography
Tanaka, et al. Eur Heart J 2009; 30: 1348-1355
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Thermographic catheter
Stefanadis, Ch.
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0.35 –
0.3 –
0.25 –
0.2 –
0.15 –
0.1 –
0.05 –
0.0 –
∆TºC
Plaque Temperature in Acute Coronary Syndromes (ACS)and Stable Angina (SA)
0.35 –
0.3 –
0.25 –
0.2 –
0.15 –
0.1 –
0.05 –
0.0 –
ACS SA
∆TºC
Stefanadis et al. Atherosclerosis 2006.
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Opening of the Coronary Artery Stenosis RelievesSymptoms
• Gruentzig AR, Angioplasty 1977
• Sigwart U, Stents 1987
• Stefanadis Ch, Covered stents 1996
• Serruys PW, Heparin coated stents 1998
• Gruentzig AR, Angioplasty 1977
• Sigwart U, Stents 1987
• Stefanadis Ch, Covered stents 1996
• Serruys PW, Heparin coated stents 1998
Antiplatelet Therapy
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Atherosclerotic plaques as Defined by Coronary Arteriographyand Intravascular Ultrasound
ACCSAP 2009
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Progression of Coronary Atherosclerosis
Ischemia (angina, acutecoronary syndromes)
Years
Ischemia (angina, acutecoronary syndromes)
• β-Blockers• Calcium blockers• Coronary bypass surgery
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“Since we did not find any thrombi without fissuresor any fissures without thrombi we are forced toconclude that there was a causal associationbetween these two findings in the cases weexamined.”
Constantinides P. Am Soc Exp Pathol. Chicago, April 16, 1964Atheroscl Res 1966; 6: 1-7
Pathologists View of Thrombosis in AcuteMyocardial Infarction
“Since we did not find any thrombi without fissuresor any fissures without thrombi we are forced toconclude that there was a causal associationbetween these two findings in the cases weexamined.”
Constantinides P. Am Soc Exp Pathol. Chicago, April 16, 1964Atheroscl Res 1966; 6: 1-7
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Coronary Thrombosis in AMIDetermined by Coronary Arteriography
Dewood, et al. N Engl J Med. 1980
• ACE inhibitors• β-Blockers• Thrombolysis• Biomarkers• Rehabilitation
• CCU• PCI• ICD
• ACE inhibitors• β-Blockers• Thrombolysis• Biomarkers• Rehabilitation
• CCU• PCI• ICD
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Screening of Ruptured Plaque byIntravascular Ultrasound
Ge, Erbel, Boudoulas, et al. Heart 1999; 81: 621-627
Fibrous cap
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The Shortcomings of Diagnosing CoronaryAtherosclerosis Based on Stress -Induced Ischemia
Stress ECG
Stress NuclearStress Echo
“We had the experiencebut missed the meaning.”
- T.S. Eliot
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Multislice CT
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Information Available Related to CoronaryAtherosclerosis in the Late Fifties - Early Sixties
• Angina pectorisHeberden W. Royal College of Physicians 1768
• Coronary artery occlusion produces myocardial infarctionHerrick JB. Association of American Physicians, Chicago 1912
JAMA 1912; 54: 2015
Nitroglycerin
• Angina pectorisHeberden W. Royal College of Physicians 1768
• Coronary artery occlusion produces myocardial infarctionHerrick JB. Association of American Physicians, Chicago 1912
JAMA 1912; 54: 2015
Nitroglycerin
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Regression of Coronary Artery Disease as a Result ofIntensive Lipid-Lowering Therapy in Men with High levels
of Apolipoprotein B
Brown, G, et al. N Engl J Med 1990; 323: 1289-98.
The Role of Statins
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PRESENTPAST
Therapy of Peptic Uncer: Past and PresentTherapy of Coronary Atherosclerosis: Present and Future
FUTURE(Prevention, Cure)
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Imaging of the Entire Cardiovascular System / Molecular Imaging
MRI PET/MRI