• Goal: Prevention of recurrent events• Life style changes – exercise, smoking, weight• Hypertension• Diabetes• Aspirin• ACE/ARB• Influenza vaccine• LIPID LOWERING - CONTROVERSIAL

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Ref: Electronic Publication. Braunwald’s Heart Disease

• Benefits in most trials did not start for 3-5 years

• TNT – excluded patients above the age of 75

• High dose statins may be associated with more myopathy: CKD, old age, Frailty, Multisystem disease, Drug interactions

• ? Use the lowest effective dose.

TREATING TO NEW TARGETSN ENGL J MED 2005; 352: 1425

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NITROGLYCERIN

BETA

BLOCKER

CALCIUM

CHANNEL

BLOCKER

IMPROVE SUPPLY

++ - +

LOWER DEMAND

++ ++++ ++

ACUTE BENEFIT +++ ++ ++

CHRONIC BENEFIT

+/- +++++ ++

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• Mechanism: NO contributor, vasodilate• Physiology: Reduce preload, afterload,

Dilate collaterals, counteract spasm• Action: Rapid onset• Administration: iv, sl, buccal, topical, (PO)• Limitations

– Tachyphylaxis rapidly develops– Hypotension, tachycardia

• MAINSTAY FOR ALL PATIENTS WITH ANGINA

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• Postural hypotension– Rapid absorption with Isosorbide dinitrate – Interaction with alpha blockers (BPH in men)– Bradycardia– Volume depletion

• Approaches– Isosorbide mononitrate– Topical nitrates

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• Mechanism: Competitive inhibition at beta 1 and beta 2 receptors

• Physiology: Reduce demand through slower heart rate, lower BP, and reduced contractility

• Action: Variable onset, usually slow

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• Pitfalls in Elderly– Titrate to resting heart rate – sick sinus syndrome

• ? Role of pacemaker for therapy

– Inadequate doses to achieve reduced contractility– Short actions of drugs – metoprolol, atenolol –

multiple dosing.– CNS penetration – lipophilic

• Favor nadolol, atenolol

• Only anti-anginal with evidence for prolonging life in patients post MI

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• Mechanism: Vascular Smooth muscle relaxation and reduced contractility

• Physiology:– Demand reduced by reducing BP, contractility,

and heart rate (for some)– Supply improved by blocking spasm

• Action: Duration longer, rapid onset

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• Limitations in elderly– Dihydropyridines induce reflex tachycardia– Contraindicated in low EF patients post MI– Edema formation (venous insufficiency)– Sick sinus syndrome – non dihydropyridines,

combinations with beta blockers– Constipation – Postural hypotension

• Role: “triple therapy”

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• Dose: 500 mg bid increasing to 1000 mg bid• Added to existing antianginals• Contraindications:

– • With pre-existing QT prolongation– • With hepatic impairment (Child-Pugh Classes A

[mild], B [moderate] or C [severe])– • On QT prolonging drugs– • On potent and moderately potent CYP3A

inhibitors, including diltiazem

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• Piperazine derivative• Anti-ischemic effect

without effect on heart rate or blood pressure

• Inhibits late Ina (slowly inactivating component of sodium

current) = reduce intracellular calcium and sodium overload

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• Randomized, 3-group parallel, double-blind, placebo-controlled trial of 823 eligible adults.

• Patients received twice-daily placebo or 750 mg or 1000 mg of ranolazine

• Treadmill exercise 12 hours (trough) and 4 hours (peak) after dosing was assessed after 2, 6 (trough only), and 12 weeks of treatment.

• Trough exercise duration increased by 115.6 seconds … vs 91.7 seconds in the placebo group (P = .01).

• The increases did not depend on changes in blood pressure, heart rate, or background antianginal therapy and persisted throughout 12 weeks.

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JAMA. 2004;291:309-316

• 6560 patients over 442 sites (17 countries) 2004-2006

• ACS, TIMI > 3• Placebo v IV then po

ranolazine (1000 mg bid)

• Endpoint: Occurrence of Death, MI, Recurrent Ischemia Result: No Difference

• Median follow: 348 days

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• Side effects more common– Dizziness– Constipation, Nausea, dyspepsia, abdominal

pain– Asthenia– Headache

• QT prolongation due to drug interactions

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ABNORMAL CORONARY CIRCULATION• Proximal LAD: 99 %

stenosis, site of prior stent.– ·Mid LAD: 80 % stenosis.

– ·D1: 80 % stenosis. – ·D2: 99 % stenosis.

• ·Mid circumflex: 40 % stenosis.

• ·Mid RCA: 99 % stenosis.– ·Distal RCA: 60 % stenosis.– RPDA: 90 % stenosis.

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• All therapy requires lifestyle changes and drugs for secondary prevention of ischemic events

• Revascularization– Surgical (1968)– Percutaneous (1978)

• PCI v. Surgery

• Medical v. Intervention

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• Lesion angioplasty POBA

• Atherectomy and occluded vessels

• Adjunctive Platelet Therapies

• Stenting – BMS, DES– Bare Metal– Drug Eluting

• Efficacy: Equivalent to surgical intervention in short term relief

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• Indications– Symptomatic – refractory to medical therapy– Prognostic

• Left main stenosis > 50%• Three vessel disease +/- impaired LV function• Two vessel disease with LAD involvement

• Risks – Mortality 1-2%, increased by gender, emergency surgery, LV function, reoperation

• Advances – Off Pump, Limited access, Arterial Conduits

• Comparisons – anti-anginal effect long term 85%

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Lee, S. J. et al. JAMA 2006;295:801-808

Copyright restrictions may apply.

• Switzerland• Patients over 75• Chronic stable

angina• 148 optimized Med• 153 invasive• Similar outcomes

for symptoms, QOL, Death or Nonfatal Infarction

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COURAGE

N Engl J Med 2007;356:1503-16.

Chronic Stable Angina

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Average age 6185% Male86% White

• Vitamin E• Garlic• Gingko Biloba• Salmon oil• Red Algae• Chelation Therapy

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• Decision: PCI of LAD

• Readmitted emergently with severe pain and palpitations – RCA ischemia and atrial fibrillation

• Converted to NSR, RCA revascularized

• Referred for cardiac rehab – completely asymptomatic

• 2 years later – recurrent angina then ACS – new RCA lesion.

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Conclusions:

Angina 2012

• Angina pectoris is a classic syndrome of ischemia•Evaluation depends on a history – 95% specific; In the elderly it often has reduced sensitivity•Clinical assessment focuses on stability and high risk cases•Therapy always involves secondary prevention, but not all is proven for elderly patients•Drug therapy can be effective with caution.•Interventional therapies work well. They do NOT always offer survival benefit.•Drug therapy should be mastered for those in whom intervention carries risks

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