STABIL KORONAR SYKDOM PROGNOSE BEHANDLING

Transkript

1 STABIL KORONAR SYKDOM PROGNOSE BEHANDLING Bjørn Arild Halvorsen, hjerteseksjonen, Sykehuset Østfold, 2013

2 Escardio.org

3 3 trinns utrednings algoritme

4 Klinisk pretest sanns hos pas med mistanke om stabil angina a Probabilities of obstructive coronary disease shown reflect the estimates for patients aged 35, 45, 55, 65, 75, and 85 years.. Genders TS et al. Eur Heart J 2011;32: Økt sannsynlighet ved: EF <50 % EKG forandringer European Heart Journal doi: /eurheartj/eht296

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10 Behandling av SCAD Optimal medisinsk behandling (OMT) ASA trombose profyl Statin plakk stabil. Antianginøs behandling Revaskulariserin g Ikke alle med SCAD har nytte av revaskularisering Risiko Symptomer tross OMT

11 Årlig mortalitet med OMT

12 Mortalitet OMT vs OMT +revask

13 AEKG - prognose Duke threadmill score (min arbeid, kjønn, ST senkning i med mer, angina under test). App. Lav arbeidskapasitet, < 5 METS Brystsmerter ved lav belastning Lavt maks BT <130 eller BT fall under belastningen Kronotrop insufficiens EKG funn: Tidlig og langvarig ST senkning i flere avledninger ST elevasjon i avledninger uten Q takk

14 Risikovurdering Iskemi utbredning Koronar anatomi

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16 Medisinsk behandling av pasienter med Stabil koronar sykdom Event prevention Lifestyle management Control of risk factors + Educate the patient Aspirin Statin Consider ACEI or ARBs ACEI = angiotensin converting enzyme inhibitors; ARB = angiotensin receptor blocker European Heart Journal doi: /eurheartj/eht296

17 Kosthold og risikofaktorer Smoking cessation Weight management Physical and sexual activity Lipid management Treatment of hypertension Treatment of diabetes Cardiac rehabilitation European Heart Journal doi: /eurheartj/eht296

18 Røykeavvenning Det mest effektive forebyggende tiltak - 36 % reduksjon i mortalitet etter hjerteinfarkt Passiv røyking har også betydning Farmakologisk og psykologisk behandling Nikotinerstatning og Bupropion (Zyban) er trygt hos pas med SCAD Vareniklid(Champix) assosiert med liten økning i CVD i en studie

19 Lipider LDL <1,8mmol/l eller >50% reduksjon om man ikke når målet. Kun statiner er dokumentert effekt på CVD Ingen spesifikke mål for TG og HDL Høy dose Atorvastatin reduserer forekomst av prosedyrerelatert hjerteinfarkt komplikasjoner ved PCI.

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21 Diabetikere HbA1C < 7.0 generelt, men individuelle mål avhenging av alder, komplikasjoner, sykdomsvarighet etc BT < 140/85 mmhg LDL < 1,8 mmol/l ACE-hemmer eller ARB til alle, nyrebeskyttende

22 Medisinsk behandling av pas med SCAD Angina relief Event prevention 1rst line Short-acting Nitrates, plus Beta-blockers or CCB-heart rate Consider CCB-DHP if low heart rate or intolerance/cotraindications Consider Beta-blockers + CCB-DHP if CCS Angina >2 Lifestyle management Control of risk factors + Educate the patient Aspirin Statin Consider ACEI or ARBs ACEI = angiotensin converting enzyme inhibitors; CABG = coronary artery bypass graft; CCB = calcium channel blockers; CCS = Canadian Cardiovascular Society; DHP = dihydropyridines; PCI = percutaneous coronary intervention. a Data for diabetics. b if intolerance, consider clopidogrel. European Heart Journal doi: /eurheartj/eht296

23 Anti-angina medisiner - mekansimer In addition to shortacting nitrates, Betablockers and Calcium Channel Blockers as first line treatment From L. Opie et al

24 Major side effects, contraindications, drug-drug interactions and precautions of anti-ischaemic drugs AV = atrioventricular; CCBs = calcium channel blockers; CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; DDI= Drug-Drug Interactions; HIV=Human Immunodeficiency Virus; PDE5 = phosphodiesterase type 5. a Very frequent or frequent; may vary according to specific drugs within the therapeutic class. batenolol, metoprolol CR, bisoprolol, carvedilol. European Heart Journal doi: /eurheartj/eht296

25 Major side effects, contraindications, drug-drug interactions and precautions of anti-ischaemic drugs CYP3A4: grapefruktjuice, erytromycin, soppmidler, AV = atrioventricular; CCBs = calcium channel blockers; CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; DDI= Drug-Drug Interactions; HIV=Human Immunodeficiency Virus; PDE5 = phosphodiesterase type 5. a Very frequent or frequent; may vary according to specific drugs within the therapeutic class. batenolol, metoprolol CR, bisoprolol, carvedilol. European Heart Journal doi: /eurheartj/eht296

26 Medisinsk behandling av pas med SCAD Angina relief Event prevention 1rst line Short-acting Nitrates, plus Beta-blockers or CCB-heart rate Consider CCB-DHP if low heart rate or intolerance/cotraindications Consider Beta-blockers + CCB-DHP if CCS Angina >2 May add or switch (1rst line for some cases) Ivabradine Long-acting nitrates Nicorandil Ranolazinea Trimetazidineb 2nd line Lifestyle management Control of risk factors + Educate the patient Aspirin Statin Consider ACEI or ARBs ACEI = angiotensin converting enzyme inhibitors; CABG = coronary artery bypass graft; CCB = calcium channel blockers; CCS = Canadian Cardiovascular Society; DHP = dihydropyridines; PCI = percutaneous coronary intervention. a Data for diabetics. b if intolerance, consider clopidogrel. European Heart Journal doi: /eurheartj/eht296

27 Langtidsvirkende nitrater Vasodilatasjon av koronare arterioler og vener. Reduesert prelaod Potensiell forverring av endotelial dysfunksjon ved langtids behandling og derfor forskjøvet til annen linje behandling 8-10 timers nitratfritt intervall for å unngå toleranse Mononitrat (Imdur, Monoket, Ismo) en eller to ganger daglig avhengig av halveringstid. Daglig nitratfritt intervall er nødvendig.

28 Ivabradin Hemmer sinusknuten, If- kanalen, selektivt. Senker hjertefrekvensen og oksygenforbruket uten at BT og inotropi påvirkes Indikasjon: angina tross betablokker eller v/intoleranse for betablokker. Beatiful-studien: SCAD med VV dysfunksjon. Redusert CV mortalitet, hospitalisering for AMI/HF Kan gis alene eller i tillegg til betablokker, mest effektiv ved hjertefrekvens > 70 pr min

29 Nye angina medisiner Nicorandil Nitrat derivat Dilaterer epikard kar IONA studien: > 5000, 14% redusert CV hendelser Sympt ikke registrert Plakk stabiliserende Trimetazidin Anti iskemisk metabolsk modulator Symptom lindrende Outcome studier mangler

30 Nye angina medisiner Ranolazine Hemmer sen Na strøm Antiiskemisk og metabolske effekter Reduserer iskemi MERLIN Økt arbeidstoleranse Diabetikere med høy HbA1C TERISSA Allopourinol Reduserer vaskulær oksydativ stress 600mg daglig Redusert iskemi og angina

31 Major side effects, contraindications, drug-drug interactions and precautions of anti-ischaemic drugs European Heart Journal doi: /eurheartj/eht296

32 Farmakologisk behandling av stabil angina pectoris ACE = angiotensin converting enzyme; SCAD = stable coronary artery disease a No demonstration of benefit on prognosis.. European Heart Journal doi: /eurheartj/eht296

33 Mikrovaskular angina ACE = angiotensin converting enzyme. European Heart Journal doi: /eurheartj/eht296

34 Medisinsk behandling av pas med SCAD Angina relief Event prevention 1rst line Short-acting Nitrates, plus Beta-blockers or CCB-heart rate Consider CCB-DHP if low heart rate or intolerance/cotraindications Consider Beta-blockers + CCB-DHP if CCS Angina >2 May add or switch (1rst line for some cases) Ivabradine Long-acting nitrates Nicorandil Ranolazinea Trimetazidineb 2nd line Lifestyle management Control of risk factors + Educate the patient Aspirin Statin Consider ACEI or ARBs ACEI = angiotensin converting enzyme inhibitors; CABG = coronary artery bypass graft; CCB = calcium channel blockers; CCS = Canadian Cardiovascular Society; + Consider Angio > PCI Stenting or CABG DHP = dihydropyridines; PCI = percutaneous coronary intervention. a Data for diabetics. b if intolerance, consider clopidogrel. European Heart Journal doi: /eurheartj/eht296

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36 Når koronar angiografi?

37 Global strategi for intervensjon i SCAD pasienter med iskemi Significant CAD + Ischemia (>10% myocardium) + OMT Revascularization possible Revascularization not possible Failure Refractory angina Stem cell therapy? Spinal cord stimulation? External counterpulsation? Chronic pain syndrome management? Drug therapy? CABG hybrid PCI CABG = coronary artery bypass graft; CAD= coronary artery disease; LAD = left anterior descending; LV = left ventricular; OMT = optimal medical treatment; PCI = percutaneous coronary intervention. European Heart Journal doi: /eurheartj/eht296

38 PCI eller CABG

39 Peri-procedural antiplatelet strategies in SCAD patients DATP = Dual antiplatelet therapy; SCAD = stable coronary artery disease.. European Heart Journal doi: /eurheartj/eht296

40 PCI or CABG surgery in SCAD with left main coronary artery involvement Left main coronary artery with relevant stenosisa ±1 vessel disease Ostium/mid shaft High surgical riskb PCI Distal bifurcation ±2 or 3 vessel disease Syntax score 32 Heart Team Discussion Syntax score 33 Low surgical riskb CABG CABG = coronary artery bypass graft; LAD = left anterior descending; PCI = percutaneous coronary intervention. a >50% stenosis and proof of ischaemia, >90% stenosis in two angiographic views, or FFR bcabg is the preferred option in most patients unless patients co-morbidities or specificities deserve discussion by the heart team. According to local practice (time constraints, workload) direct transfer to CABG may be allowed in these low risk patients, when formal discussion in a multidisciplinary team is not required (adapted from ESC/EACTS Guidelines on Myocardial Revascularization 2010). European Heart Journal doi: /eurheartj/eht296

41 Syntax skår

42 Follow-up of revascularized stable coronary artery disease patients (1) ACS = acute coronary syndrome; BMS = bare metal stents; CABG = coronary artery bypass graft surgery; DAPT = dual antiplatelet therapy; DES = drug eluting stents; ECG = electrocardiogram; LM = left main; MPS = myocardial perfusion scintigraphy; MRI = magnetic resonance imaging; PCI = percutaneous coronary intervention; SAPT = single antiplatelet therapy. European Heart Journal doi: /eurheartj/eht296

43 Follow-up of revascularized stable coronary artery disease patients (2) ACS = acute coronary syndrome; BMS = bare metal stents; CABG = coronary artery bypass graft surgery; DAPT = dual antiplatelet therapy; DES = drug eluting stents; ECG = electrocardiogram; LM = left main; MPS = myocardial perfusion scintigraphy; MRI = magnetic resonance imaging; PCI = percutaneous coronary intervention; SAPT = single antiplatelet therapy. European Heart Journal doi: /eurheartj/eht296

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47 Diagnostikk av mistenkt SCAD Ingen hjerteutredning Invasiv angiografi

48 Mistenkt stabil koronarsykdom Pretest sannsynlighet for koronarsykdom Ikke-invasiv testing for å stille diagnosen Klinikk, hvile EKG, ekkokardiografi Stress imaging foretrukket framfor AEKG CT hjerte ved lav intermediær sanns og passende pas Lokal ekspertise og pasientforhold avgjør hvilken test Risikovurdering (mortalitet) OMT ved PTP >85% eller pos ikke-invasiv test Invasiv angiografi for revaskularisering ved høy

49 Pharmacological treatments in SCAD patients (1) ACE = angiotensin converting enzyme; SCAD = stable coronary artery disease a No demonstration of benefit on prognosis.. European Heart Journal doi: /eurheartj/eht296

50 Use of fractional flow reserve/intravascular ultra sound/optical coherence tomography in SCAD FFR = fractional flow reserve; IVUS = intravascular ultrasound; OCT = optical coherence tomography; SCAD = stable coronary artery disease. European Heart Journal doi: /eurheartj/eht296

51 Revascularization vs OMT: the 7 more recent randomized trials TIME MASS II JSAP FAME-2 Recruitment (years) Study size (n) Mean age (years) Angina CCS Stress ischaemia (% of patients) Prior MI (% of patients) II-IV II-III 0 0-III 0-II 0-II I-IV 69 NA 100 NA NA NA Mean LVEF (%) NA 65 16% with EF<0.50 Yes Yes Yes Yes Yes Yes No Yes No No No Yes PCI PCI or CABG PCI PCI Death Death/MI/ Urgent revascular. Angiographic selection No Mandatory documented ischaemia Revascularization Primary Endpoint (PEP) No SWISSI II PCI or CABG PCI or CABG PCI Angina Death/MI/ refractory angina Death/MI/ revascular. COURAGE Death/MI BARI-2D Death/ACS No at 1 year Revascularization Yes Yes at 5 years Yes No No Yes Yes better on PEP CABG = coronary artery bypass graft; CCS = Canadian Cardiovascular Society; LVEF = left ventricular ejection fraction; (CABG) MI = myocardial infarction; PCI = percutaneous coronary intervention. European Heart Journal doi: /eurheartj/eht296

52 Revascularization of SCAD patients on OMT (Adapted from the ESC/EACTS 2010 Guidelines) European Heart Journal doi: /eurheartj/eht296