cs khai pham gia - excemed · primary outcome,% 60 50 40 30 20 mortalityincreaseswithfollow-updbp
Post on 15-Oct-2020
1 Views
Preview:
TRANSCRIPT
Khai Pham Gia
Vietnam Cardiovascular Organization
Cardiovascular Hospital
Hanoi University of MedicineHanoi University of Medicine
Hanoi, Vietnam
Declared no potential conflict of interest.
Hypertension in Patients with
Coronary Artery Disease Coronary Artery Disease
Prof. Pham Gia Khai, MD. PhD. FACC. FESC
Case
• 61 yrs. F.
• HTN: 10 yrs: well controlled for 5 yrs; recent 5 yrs. Not well controlled
• DM: 5 yrs. Rx: SU + Metformin• DM: 5 yrs. Rx: SU + Metformin
• Atypical chest pain
• Dyspnea on exertion
• ECG: LV hypertrophy; cannot rule out CAD
• Cardiac Echo: LVDd: 57 mm; EF: 45%
MCQ (slide 4)
• Diagnosis of Hypertension :
• (A) Systolic ≥ 140 mmHg and
• Diastolic ≥ 90 mmHg
• (B) Systolic ≥ 140 mmHg and Choose the right answer
• Diastolic < 90 mmHg
• (C) Sporadic Hypertension on 24 hr Holter recording
• Diagnosis of Diabetes mellitus• Diagnosis of Diabetes mellitus
• (A) Fasting Blood Glucose ≥ 7 mmol/L (≥ 126 mg/L) and/or HbA1C ≥ 6.5
• (B) Fasting Blood Glucose ≥ 7 mmol/L and 2hr post-prandial Blood Glucose ≥ 7.8 mmol/L
• (C) Both (A) and (B) Choose the right answer
• Diagnosis of coronary heart disease
• (A) Chest pain relieved by Nitrates, cardiac enzymes normal
• (B) Chest pain not relieved by Nitrates, cardiac enzymes normal
• (C) Suggestive coronary angiogram, cardiac enzymes normal
• (D) Elevated cardiac enzymes, but coronary angiogram normal
• Choose the right answer
ECG
Questions ???
• Relationship between HTN and CAD
• What is the difference of CAD profile in HTN
vs normotensive patients?
• Pretest possibility of CAD? %?• Pretest possibility of CAD? %?
• Which is the best test for diagnosis of CAD in
this patients?
• Optimal strategy for CAD pts with HTN?
mo
rta
lity
risk
an
d9
5%
CI)
mo
rta
lity
risk
an
d9
5%
CI)
BP levels are directly related to ischemic heart
disease at any decade of age
256
128
64
32
256
128
64
32
Age at risk:
80–89 years
70–79 years
60–69 years
50–59 years
Age at risk:
80–89 years
70–79 years
60–69 years
50–59 years
IHD
mo
rta
lity
(flo
ati
ng
ab
solu
teri
sk
IHD
mo
rta
lity
(flo
ati
ng
ab
solu
teri
sk
16
8
4
2
1
0
16
8
4
2
1
0
90
Lewington et al. Lancet 2002;360:1903–13
50–59 years
120 140 160 180
Usual SBP (mmHg)
50–59 years
70
Usual DBP (mmHg) 80
Incidence of MI and total stroke by systolic BP
strata in the in the Framingham population
D’Agostino RW, et al. BMJ 1991; 303:385-389
Intensive Lowering BP levels increases risk of MIin patients at high or very high CV risk
primary
outcome,%
60
50
40
30
20
Mortality increases with follow-up DBP < 70 mmHgin the INVEST trial
Patientswith
primaryoutcome,n56 389 1003 596 174 33 17
Totalpatients,n 176 2239 11306 7376 1230 202 46
Meansystolicbloodpressure,mmHg
Patientswith
primaryoutcome124.3 131.7 135.1 143.7 160.2 171.6 186.0
Patientswithout
primaryoutcome127.0 129.1 131.0 138.8 154.2 169.4 187.5
Inciden
ceofprimary
100 % had coronary heart disease; treatment with beta blocker or calcium channel blocker
.
60 > 60 to 70 > 70 to 80 > 80 to 90 > 90 to 100 > 100 to 110 > 110
Diastolic Blood Pressure, mmHg
20
10
0
Messerli et al. Ann Intern Med 2006;144:884–893
confiden
ceintervals
ofeven
ts,%
Cardiovascular mortality increases with follow-up SBP
< 120 mmHg in the ONTARGET trial
30
25
20
3
2.5
2
Hazard
ratio,95%
confiden
ce
Adjusted
4.5-yearrisk
75 % had coronary heart disease at baseline treatment with ACEi and/or ARB.
112 121 126 130 133 136 140 143 149 160
15
10
5
0
1.5
1
0.5
0
Sleight et al J. Hypertens 2009;27:1360–1369
ACCORD-BPLA Trial
Intensive Lowering of BP levels did not improve CADoutcomes in the diabetic patients
CushamW, et al. N Engl J Med 2010;362:1575-85
ROADMAP: Lowest SBP and/or highest SBP reductionquartile are associated with increasedCV mortality in patients with CHD
SBP reductionLast SBP before event
* 26-MAY-2010
mmHgmmHg
Cohort of patients with pre-existing CHD (n=1104)
mortality
(%)
Olmesartan Placebo
ROADMAP: The increased mortality was only seen inpatients with pre-existing cardiovascular disease (CVD)
p = 0.02
Card
iovasularmortality
26-MA0
Incidence of MI and Strokein Hypertensive patients with CAD
stratified by Diastolic Blood Pressure levels
INVEST Trial
Messerli, et al. Ann Intern Med 2006;144:884–893
The Diagnostic dilemma of CAD in hypertensive
patients
• Chest pain is a common but also non-specific symptom inhypertensive patients both with and without CAD.
• Non invasive screening tests are not able to accurately
discriminate between hypertensive patients with and withoutassociated CAD.associated CAD.
• International guidelines are elusive on the recommended
diagnostic pathway for detection of CAD in this group ofpatients.
• Early CV risk stratification and evaluation of markers of organ
damage may improve diagnostic efficacy.
Chin D, Battistoni A, Tocci G, Passerini J, Parati G, Volpe M. Am J Hypertens. 2012 ; 25:1226-35 .
• Exercise ECG tests have a low specificity and sensitivity for
CAD determination, especially in hypertensive patients.
• This group of patients often have baseline ECG changes,
Exercise ECG
• This group of patients often have baseline ECG changes,
especially in patients with LVH.
Chin D, Battistoni A, Tocci G, Passerini J, Parati G, Volpe M. Am J Hypertens. 2012;25: 1226-35.
Exercise ECG
Weaknesses:
•
•
•
Suboptimal sensitivity.
Low sensitivity in identifying single vessel disease.
the test is not diagnostic in situations where there are• the test is not diagnostic in situations where there are
baseline ECG changes (such as evidence of leftventricular strain secondary to left ventricular
•
•
hypertrophy, left bundle branch block).
Low specificity in certain population of patients (such as
pre-menopausal women).
To increase the accuracy of the test it is necessary to
achieve 85% of the maximum heart rate.
Exercise ECG
Weaknesses:
•
•
•
Suboptimal sensitivity.
Low sensitivity in identifying single vessel disease.
the test is not diagnostic in situations where there are• the test is not diagnostic in situations where there are
baseline ECG changes (such as evidence of leftventricular strain secondary to left ventricular
•
•
hypertrophy, left bundle branch block).
Low specificity in certain population of patients (such as
pre-menopausal women).
To increase the accuracy of the test it is necessary to
achieve 85% of the maximum heart rate.
Stress echocardiography
Strengths:
• higher sensitivity and specificity than the exrecise ECG test.
• it has a higher prognostic value compared to the exercise ECG
(in fact even in the presence of a positive exercise ECG test, a
negative stress echocardiogram predicts a low risk for coronarynegative stress echocardiogram predicts a low risk for coronary
events).
•Higher sensitivity during exercise or with dobutamine, compared
to using other vasodilating agents.
•It enables assessment of other concomitant structural cardiac
abnormalities, such as valvular heart disease.
•Lack of radiation.Chin D, Battistoni A, Tocci G, Passerini J, Parati G, Volpe M. Am J
Hypertens. 2012;25: 1226-35.
Weaknesses:
• lower sensitivity in identifying one vessel disease or
moderate stenosis.
• the inability to visualise the entire left ventricle in a
single window in certain patient groups.
•the assessment of the images is operator-dependent.•the assessment of the images is operator-dependent.
• it is mainly a qualitative, rather than a quantitative
assessment.
• an inadequate acoustic window in certain patient groups
limits the sensitivity and specificity of the test (such as
Chronic obstructive pulmonary disease patients)Chin D, Battistoni A, Tocci G, Passerini J, Parati G, Volpe M. Am J Hypertens. 2012;25: 1226-35.
SPECT
Strengths:
•
l
Quantitative method, which reduces operator biasand inter-observer variability.
New nuclear techniques such as the “gated” SPECT,
enable a contemporary functional and perfusionalassessment of the myocardium, hence increasing theassessment of the myocardium, hence increasing thespecificity of the diagnosis of coronaropathy.
Weaknesses:
l
l
Poor spatial resolution ( approx. 1cm).
The need to use radioactive material limits the use
of this diagnostic technique as a regular “screening”test in hypertensive patients.
Chin D, Battistoni A, Tocci G, Passerini J, Parati G, Volpe M. Am J
Hypertens. 2012;25: 1226-35.
Coronary angiography
remains theremains the
“Gold Standard” ???
Coronary angiography in HT
- In patients without known CAD undergoing elective
invasive angiography the diagnostic yield is relatively low
- This is particularly true for HT with LVH.
- CV risk profiling in HT is of clinical value
Patel MR et al ,
NEJM 2010
The majority of patients with Hypertension
have other coronary risk factorsFramingham Study
Kannel, Am J Hypertens, 2000; 13: 3S-10S
INTERHEART Study
Risk of acute myocardial infarction associated with
exposure to multiple risk factors
Yusuf S, et al. Lancet 2004;364:937–52
CV risk charts
Estimation of ten-year risk of fatal cardiovascular disease in Europe: the SCORE project. Eur Heart J 24:987Z 1003.
Clinical Likelihood of Disease (pretest) (ESC 2013)
This risk is modified if
- ECG indicates abnormalities
- LV EF < 50%
- Visualization of coronary stenoses
< 15%
Nothing
STEP 1
15-85%> 85%
3 Step Algorithm for Diagnosis CAD (ESC 2013 Guidelines)
Determine the Clinical Likelihood of Disease
Testing for CAD
Does the patient have coronary artery stenoses?
- Evidence of ischemia
Severe Symptoms
HIGH
or symptoms
1. Optimal Medical Therapy
2. Assessment of Risk (mortality)
- Extent of ischemia
- Coronary anatomy
STEP 3
Invasive Angiography
& Revascularization
STEP 2
YES
Can it apply for
Hypertensive
Patient?
LOW
CHD RISK
Risk score
INTERMEDIATE HIGH
NON LVHLVH• Consider clustering
of major CV risk factors
and anginal typical
Exercise ECG
High thresholdpositive test
low thresholdpositive test
CORONARY ANGIOGRAPHY
Identify the most appropriate
imaging technique on the
basis of different criteria,
such as :
-Gender
-Patient structure
-Baseline ECG changes
Stress
echocardiographyCoronary CT
Cardiac
RadionuclideImaging
Cardiac MRI
POSITIVE TEST
and anginal typical
symptoms.
•Positive Calcium score
•Carotid artery
atherosclerosis by US
Early and accurate CV risk stratification
in hypertensive patients
Early identification of patients at high risk
of developing coronary heart diseaseof developing coronary heart disease
Helps to target early therapeutic interventions
to prevent coronary morbidity and mortality
Diagnostic flow chart of CAD in hypertensive patients
FRS/SCORE
Target organ damage
HIGH
RISK
LOW
RISK
INTERMEDIATE
RISK
NonLVH Non
LVHLVH
Stress
echoCCT CMRRNI EXERCISE EKG
High
threshold
positive test
Low threshold
positive test
Positive test
CORONARY ANGIOGRAPHY
- Visualization of coronary stenoses
< 15%
Nothing
STEP 1
15-85%> 85%
3 Step Algorithm for SCAD (ESC Guidelines 2103)
Determine the Clinical Likelihood of Disease
Testing for CAD
Does the patient have coronary artery stenoses?
- Evidence of ischemia
Severe Symptoms
HIGH
or symptoms
1. Optimal Medical Therapy
2. Assessment of Risk (mortality)
- Extent of ischemia
- Coronary anatomy
STEP 3
Invasive Angiography
& Revascularization
STEP 2
YES
European Heart Journal 2013 - doi:10.1093/eurheartj/eht296
All CAD Patients need Optimal Medical Management, NOT all Patients need Revascularization
Event prevention
• Lifestyle management
• Control of risk factors
Educate patient
Angina relief
1st line
Short-acting nitrates plus
• ββββ-blockers or CCB heart rate
• Consider CCB-DHP if low HR orintolerance/contraindications
• Consider ββββ-blockers + CCB-DHP
May add orswitch (1st time
for some cases)
• Aspirin†
• Stains
• Consider ACEi or ARBs
• Consider ββββ-blockers + CCB-DHPif CCS angina >2
2nd line
• Ivabradine
• Long-actingnitrates
• Nicorandil
• Ranolazine*
• Trimetazidine*
Consider angio→→→→PCI-stenting or
CABG
*Data for diabetics †If intolerance consider clopidogrel
ESC Guidelines 2013European Heart Journal 2013 - doi:10.1093/eurheartj/eht296
Control well global CV Risk
Factors is the key for the
Treatment of CAD
per
100
pers
ons
35
30
45
40
24%
33%
44%
Framingham Heart Study
Risk of acute myocardial infarction associated
with exposure to multiple risk factors
50
5year
CV
Drisk
per
Reference group: female aged 50 years, TC=4 mmol/L, HDL=1.6 mmol/L, non smoker, no diabetes, at SBP levels of 110,
120, 130, 140, 150, 160, 170 & 180 mmHg
Derived from Anderson et al. Am Heart J 1991;121-293-8
20
Referencegroup
TC=7mmol/L
& smoker male
25
10
15
5
0
& diabetes 60 yrs& HDL=1mmol/L
3%
<1%
6%
12%
18%
24%
Use of the IMPACT mortality model to explain the fall
in CHD deaths in England & Wales 1981–2000
Bridging science and health policy in cardiovascular disease: focus on lipid managementA Report from a Session held during the 7th International Symposium on Multiple Risk Factors
in CV Diseases: Prevention and Intervention – Health Policy, in Venice, Italy, on 25 October,2008
Derived from Atherosclerosis Supplements 10 (2009) 3–21
10%
Reduction
10%
Reduction
in Total-C+45%
Reduction=
Benefit of global CVRF control
Emberson et al. Eur Heart J. 2004;25:484-491
in BP in Total-C+ Reduction
in CVD
=
Predicted Reduction in Major CVD (%)
Treatment
Based on lipids
(statin)
Treatment
Based on BP
Treatment Based on
Overall Absolute Risk
(ASA, lipids, BP)
-6 -6
-9 -8
-12-10
-15
-10
-5
0
Benefit of global CVRF control
Adapted from Emberson et al. Eur Heart J. 2004;25:484-491
Predicted Reduction in Major CVD (%)
-17
-28
-12
-37-40
-35
-30
-25
-20
-15
Top 10%
Top 20%
Top 30%
Treatment thresholds
MCQ (slide 44)Stratification of risk factorsStratification of risk factors
(A) No
(B) YesChoose the right answer
Risk factors as has been proved
BP – Cholesterol – Age – Smoking – DM – GenderEBP – Cholesterol – Age – Smoking – DM – GenderE
(A) Ranking No
(B) Ranking Yes
Choose the right answer
Pretest as established by ESC 2013
Chest pain (Present-Atypical-Absent) – Age – Gender
(A) Meaning Yes
(B) Meaning No
Treatment of HTN in Patients with
CAD
Pharmacological Treatment of
Hypertension in the Management
of Ischemic Heart Disease
Hypertension. 2015;65:000-000. DOI: 10.1161/HYP.0000000000000018
Revascularization Strategy for
Stable Ischemic Heart Disease
Patients with Multivessel Disease
and Hypertension
CABG vs PCI ?CABG vs PCI ?
+ Optimal Medical Treatment
Not all SCAD patients benefit from revascularization
Not all SCAD patients benefit from revascularization
Indications for Revascularization in patients
with stable angina or silent ischaemia
European Heart Journal
doi:10.1093/eurheartj/ehu278
Recommendation for the type of revascularization
(CABG or PCI) inpatients with SCAD with suitable
coronary anatomy for both procedures and low
predicted surgical mortality
European Heart Journal
doi:10.1093/eurheartj/ehu278
MCQ (slide 53)
• Risk stratification for appropriate approach in
diagnosis and treatment
• (A) Should be done
• (B) Optional because of patient and local
infrastructure
• Choose the appropriate answer• Choose the appropriate answer
• Treatment of HTN and accompanying diseases
• (A) Treat HTN first
• (B) Treat HTN and accompanying diseases
• (C) The approach to diagnosis and treatment should
be adapted to individual basis
What did we do with our patient
• Stress ECG: not preferred (LV hypertrophy)
• Echo stress: > 15% Myocardium ischemic
• Risk stratification: high risk
• Optimal Medical Rx:
� DAPT (aspirin + clopidogrel)
� Statin
� ACEi
� Betablocker
� Insulin + Metformine
• Coronary Angiography and Intervention
Cor. angiogram
Post PCI (total revascularization)
Many Thanks
top related