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Smita Negi MD, FACC
Atherosclerosis & Stable Ischemic Heart Disease
Diagnosis, Treatment and Guidelines
Pretest Questions
• Board Review Question 1
56-year-old male Mr. SIHD with DSL and HTN and family history of CAD, remote history of smoking presents with chest pain symptoms ongoing for over 2 years, predictably brought on with exertion and relieved by rest. What findings in the plaque indicate stability?
1-Upregulation of matrix metalloproteinase
2-Predominance of macrophages
3-Fibrous cap > 130 microns
4-Neoangiogenesis
5- All of the above
6-None of the above
• Board Review Question 2
Mr. SIHD is well educated and does a lot of internet
research. He asks you “ Doc, what will be the first
sign of reduced blood supply to my heart muscles” ?
You reply-
1-T wave inversions on ECG with exercise
2-Chest pain with Creatinine Kinase of 600
3-Wall motion abnormalities on stress echo
4-Perfusion defect on nuclear stress test
5-All of the above at the same time
• Board Review Question 3
Mr SIHD is in your clinic and reports exertional chest
pain symptom. He reports good ET and goes to gym
every other day but has to cut back on his sessions
due to CP.
Current meds- HCTZ, Lisinopril, baby ASA
Vitals BP=134/72, PR-85/min
1-Coronary Angiogram
2-Dobutamine stress echo
3-Regadenosine Nuclear Stress test
4-Exercise ECG stress test
5-CMRI
6-Reassurance and RTC as needed.
• Board Review Question 4
You are in clinic and are called to the Stress
department by supervising tech.
Mr. SIHD was scheduled for an exercise ECG stress
test. He ran on treadmill for 2 minutes but started
complaining of knee pain. His HR is at 60% of
MPHR. No changes on ECG. BP is at 142/98. He
states he cannot go any further.
1-Continue with the test
2-CMRI
3-Schedule coronary angiogram
4-Regadenosine Nuclear stress test
5-This is a test negative for ischemia. Reassurance
and D/C from clinic
• Board Review Question
Mr. SIHD undergoes Pharmacological Nuclear
Stress test. Continues with exertional CP.
Vitals stable, on metoprolol, asa, Lipitor, Lisinopril.
1-CT Angiogram
2-Coronary Angiogram
3-Reassurance
4-Isosorbide mononitrate
5-Diltiazem
• Board Review Question
Mr. SIHD now s/p pharmacologic nuclear stress
test-negative for inducible ischemia. ASA, acei, bb,
long acting nitrate, statin. Despite max therapy,
continues with exertional CP.
Bp=102/72, hr-65/min, ECG-unchanged
1-Add HCTZ
2-Dobutamine stress echo
3-CT Angiogram
4-Coronary Angiogram
5-Reassurance and RTC in 1 year
• Board Review Question 5
Mr. SIHD undergoes LHC and PCI with 3.0 DES to
his proximal right coronary artery. He is started on
ASA and P2Y12 inhibitor. Since his PCI, much
improved.
Comes back to clinic in 6 weeks and wants to
undergo hernia repair surgery next month (2
months).
1-Hold ASA and P2Y12.
2-ASA and P2Y12 for 36 months.
3-ASA and P2Y12 for 6 months.
4-ASA and P2Y12 for 12 months.
5-ASA and P2Y12 lifelong
• Board Review Question 6
Mr. SIHD presents to clinic now 1 year later. He has
been sent for a preop clearance for his hernia sx by
your surgery colleague. He is now on ASA, Plavix,
metoprolol, Lisinopril and statin. Feels great, goes to
gym every other day (>120min/week) back to his
regular sessions.
BP-120/66, HR-64, ECG-unchanged
1-Pharmacologic Stress test.
2-Coronary CTA
3-Proceed with surgery.
4-Ranexa
5-Coronary Angiogram
Objective
• Atherosclerosis
– Pathogenesis
– Clinical presentation
• Stable ischemic heart disease
– Clinical presentation
– Diagnostics
– Treatment options
Deaths attributable to cardiovascular disease
Go A et al. Circulation 2014;129:e28-e292
Risk factors
Non modifiable• Age
• Gender
• Genetic
Modifiable• Hyperlipidemia
• Smoking
• Arterial hypertension
• Physical inactivity
• Diabetes mellitus
• Obesity
• Stable plaque • Unstable “vulnerable” plaque
seven types of vulnerable plaques
70%
Diagnostic criteria for vulnerable plaque
Major criteria.
Active inflammation (monocytes/macrophages and sometimes T-
cell infiltration)
Thin cap with large lipid core
Endothelial denudation with superficial plaque aggregation
Fissured plaque
Luminal stenosis > 90%
Minor criteria
Superficial calcified nodule
Intra plaque haemorrhage
Endothelial dysfunction
Outward (positive) remodelling
Vulnerable
Blood
Vulnerable
Myocardium
Vulnerable
Plaque
Vulnerable Patient
Coronary artery disease
•MI
•Angina
Cerebrovascular disease
•Stroke
•TIA
Peripheral artery disease
•AAA
•abdominal angina
•renal artery disease
•Intermittent claudication
•Rest pain, cold pulseless leg
Lower the incidence of CVD related deaths
Identification in vivo
Prevention of rupture
Non invasive methods Invasive methods
Computed tomography (CT)
Magnetic resonance (MRI)
Intravascular ultrasound (IVUS)
Optical coherence tomography (OCT)
Near infrared spctroscopy (NIRS)
Biomarkers
The Quest for the Vulnerable Plaque
179ACS
LAD
Angiography vs CTA for CAD
Motoyama et al. JACC 2007
Fibrous plaque
Positive remodelingSoft plaque
Angiography vs. Pathology
Natural History of CAD : Remodeling
IVUS
EEMLumen
MLA
Plaque burden
NIRS chemogram
NIRS and IVUS
Yellow = high probability of lipids
IVUS cross-section
External elastic membrane
Lumen diameter / areaLipid core burden index(LCBI)
STABLE ISCHEMIC HEART
DISEASE
• Characterised by transient myocardial ischemia
• Most commonly caused by obstruction of the
coronary arteries by atheromatous plaque
Stable ischemic heart disease
Physiology of coronary circulation
• Coronary blood flow is phasic with maximal flow in diastole.
• 75% of the oxygen delivered by coronary arteries isextracted by LV → limited oxygen extraction reservein coronary circulation.
• At 85% lumen diameter at maximum exercise, vasodilator reserve is exhausted → inadequate pressure distal to the stenosis → rest or exertional myocardial ischemia
Perfusion
Abnormalities
Systolic Dysfunction
Δ ECG
Angina
Diastolic Dysfunction
Duration and severity of ischemia
Nuclear Imaging
Stress Echo/MRI
Stress ECG
Ischemic Cascade
Spectrum of CAD Presentations
DefinitionIschemia
with activity
Ischemia without
necrosis
Necrosis
(nontransmural)Transmural necrosis
Diagnosis
Symptoms,
ECG,
Stress
testing
Negative Biomarkers Positive biomarkers
No ECG ST-segment elevationECG ST-segment
elevation
Treatment The Big 5 Invasive or conservative depending on riskImmediate
reperfusion
SIHD UA NSTEMI STEMI
Roger VL, Go AS, Lloyd-Jones DM, et al.. Circulation. 2011;123:e18-e209.
Classification of SIHD
• Chronic stable angina pectoris
Fixed
• Variant angina pectoris
(Vasospastic/Prinzemetal’s)
Dynamic/Spasm
• Asymptomatic myocardial ischemia
Diabetics
Radiation
Conditions Provoking or Exacerbating IschemiaIncreased Oxygen Demand Decreased Supply
NoncardiacHyperthermia AnemiaHyperthyroidism HypoxemiaSympathomimetic toxicity (e.g., cocaine use) AsthmaHypertension Chronic obstructiveAnxiety pulmonary diseaseArteriovenous fistulae Pulmonary hypertension
Interstitial pulmonary fibrosisObstructive sleep apnea
Cardiac Sickle cell diseaseHCM Sympathomimetic toxicityAortic stenosis (e.g., cocaine use)Dilated cardiomyopathy HyperviscosityTachycardia
Grading of angina pectoris
Work up for SIHD
• History- typical symptoms
• Laboratory evaluation
– dyslipidemia, hyperglycemia, renal disease etc.
• Resting ecg
• ECHO
• Stress testing
• CT angiography
EuroIntervention 2015;10:1024-1094 published online ahead of print September 2014
2014 ESC/EACTS Guidelines on myocardial revascularization
Who needs Stress Testing?
Mr. SIHD
Exercise Pharmacologic
1. ECG -
2. ECHO 4. Dobutamine Echo
3. Nuclear 5. Adenosine Nuclear
The 5 Common Cardiac Stress Testing Modalities
CAD CP algorithm
Evaluation
What are the Big 5 medications for
CAD?
1. Beta blockers
2. ASA/antiplatelet agents
3. Statins
4. Nitrates
5. Antihypertensive and other risk
factor medications
Braunwald’s Heart Disease, 7th Edition
Beta blockers
CA blockers
ACEI
NTG
NTG
ASA
Heparin
GPB’s
Statins
Ranolazine
Indications for revascularization in Stable CAD or
silent ischemia
EuroIntervention 2015;10:1024-1094 published online ahead of print September 2014
2014 ESC/EACTS Guidelines on myocardial revascularization
Atleast 2 antianginals
SYNTAX
CABG or PCI ? in Stable CAD
EuroIntervention 2015;10:1024-1094 published online ahead of print September 2014
2014 ESC/EACTS Guidelines on myocardial revascularization
EuroIntervention 2015;10:1024-1094 published online ahead of print September 2014
2014 ESC/EACTS Guidelines on myocardial revascularization
Thygesen, K. et al. Circulation 2007;116:2634-2653
Plalque Rupture
Spasm, low BP
Sudden Death, no CK
PCI related
Stent Thrombosis
CABG related
THANK YOU FOR
YOUR ATTENTION !