Myocardial Ischemia Redefined:Optimal Care in CAD

Learning objectives

To improve patient management through a better understanding of:

• Pathophysiology of myocardial ischemia

• Efficacy and safety of behavioral and pharmacologic approaches to minimize recurring ischemic episodes

• Clinical trials investigating multiple treatment targets

• Current clinical guidelines

Curriculum overview

• Epidemiology and prevalence of myocardial ischemia– Magnitude of the problem– Challenges in selected populations

• Issues in contemporary clinical practice

• Scientific review

• Clinical trial update

• New guidelines in myocardial ischemia management

• Risk stratification

Chronic ischemic heart disease: Overview

• Highly prevalent– 6.5-16.5 million in the US

• Multifactorial etiology– CAD, hypertension, hypertrophic cardiomyopathy, valvular heart

disease

• High socioeconomic burden– Depression– ↓Quality of life– High costs of care

Gibbons RJ et al. www.acc.org.

Repeat revascularization is common post-PCI/CABG

Kempf J et al. Presented at ESC. 2007.

N = 18,240 who underwent elective PCI or CABG

46

30

0

10

20

Patients(%)

Recurrentangina

2nd revascularization

30

40

50

Angina increases cost of care

0

10

20

30

40

50

Patients (%)

Asymptomatic CAD Angina

Prior to diagnosis Following diagnosis

ED visits HospitalizationsED visits

Kempf J et al. Presented at Scientific Forum on Quality of Care and Outcomes Res in CV Disease. 2006.

US managed care enrollees, n = 140,001 with asymptomatic CAD, n = 23,535 with angina Dx*

Average yearly cost/patient

$11,530 (asymptomatic CAD)

vs $22,004 (angina)

*And Rx nitrates and/or β-blockers and/or CCBs

Challenges in selected populations: Pathophysiology and implications of ischemic heart disease in women

Women

Elderly Diabetes

Ischemic heart

disease

WISE: Landmark study in women

Goals:

• Improve diagnostic testing for ischemic heart disease in women

• Study pathophysiologic mechanisms for ischemia in the absence of epicardial coronary artery stenoses

• Evaluate the influence of menopausal status and reproductive hormone levels on diagnostic testing results

Bairey Merz CN et al. J Am Coll Cardiol. 1999;33:1453-61.Women’s Ischemia Syndrome Evaluation

Prospective cohort study conducted at 4 US sites

WISE: Persistent chest pain in women predicts future CV events

Johnson BD et al. Eur Heart J. 2006;27:1408-15.

With CADHR 1.17 (0.76–1.80)P = 0.49

Without CADHR 1.89 (1.06–3.39)P = 0.03

Event-freesurvival

(%)

Years from PChP diagnosis (at one year)

0.7

0.6

1

0.9

0.8

0 1 2 3 4 5 6

Neither PChPNo CAD

No PChPCAD

Both

n = 673 WISE participants with chest pain at baseline

PChP = persistent chest pain

WISE: Persistent chest pain associated with diminished QOL

No obstructive CAD Obstructive CAD

No PChP PChPNo

PChP PChP

Angina symptoms

Typical presentation (%) 30 33 32 40

Intensity (range 1-5) 2.3 2.6* 2.6 2.6

Daily frequency (%) 30 49* 34 39*

Psychological symptoms

Perceived QOL† 7.3 6.6* 7.1 6.6

Depression‡ 8.8 12.2* 9.3 12.9*

Anxiety‡ 18.0 20.1* 17.7 20.1

*Adjusted P ≤ 0.04†Range: 1 - 10 (best); ‡score = trait

Johnson BD et al. Eur Heart J. 2006;27:1408-15. Bairey Merz CN et al. J Am Coll Cardiol. 1999;33:1453-61.

*

** * *

WISE: CAD imposes an economic burden

Shaw LJ et al. Circulation. 2006;114:894-904.

N = 883 women with angiographic CAD

80

70

60

50

40

30

20

10

0

Cumulative observed

direct costs ($, thousands)

Nonobstructive CAD

2 3 4 5

1 vessel CAD 2 vessel CAD 3 vessel CAD

Follow-up (years)

1

*P < 0.0001 nonobstructive vs 1-3 vessel CAD

Contemporary clinical practice of ischemic heart disease

Adapted from Timmis AD et al. Heart. 2007;93:786-91.

Angiogram

Cardiologist referral

Treatment(Angina, risk factors)

Risk stratification(Stress test, CT angio)

Presentation to PCP

Incident angina

Visible

Submerged

Revas

Healthy population

Opportunity for early detection, risk stratification, and medical therapy

Revas = revascularization