myocardial oxygen consumption introduction: physiology...myocardial oxygen consumption factors mvo 2...
TRANSCRIPT
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Myocardial oxygen consumptionINTRODUCTION: physiology
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Cath12
months later
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Glycocalyx
Endothelial cells
RBC
Basic level: inflammation, hyperglycemia and other risk factors damage vascular lining
DOI: 10.1016/j.chest.2018.03.003
Vascular Endothelial Glycocalyx
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Supply: epicardial vessel
Atherosclerosis (epicardial)
Or small vessel (diabetes, hypertension, other)
Demand
HEART RATE
Blood pressure
LV volume
Contractility
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By the guidelines
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Robert Chilton DO, FACOI, FACC, FAHA
Professor of Medicine
University of Texas Health Science Center
San Antonio, Texas
Director of Cath Lab
Director clinical proteomics center2019 review
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1. Patient presents with history of negative stress test but clinical suspicion of CAD: cath II B
2. Patient has intermediate risk unable to do non invasive testing cath II B
3. FFR from FAME I and II is superior to angiographic visual assessment
4. IV infusion of EDTA now is Class II B (recent trial found to reduce CV events)
5. Enhanced external counter pulsation (EECP) for relief of refractory angina II B
• Contraindicated in decompensated HF, PAD or severe aortic regurgitation
6. Heart team approach for revascularization in diabetes / complex patients
7. Left mains heart team pci/CABG
8. CABG with LIMA if DM / complex mv dx first class 1 survival benefit not pci
• FREEDOM trial in DM primary EP in all sections better
• Death, non fatal MI/stroke p<0.005
• 5 year rates
• PCI-26.6%
• CABG-18.7% Primary endpoint events
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Revascularization to Improve Survival Compared
With Medical Therapy
Appropriate Use Criteria 2017Unprotected left main=UPLM
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Revascularization to Improve Survival Compared
With Medical Therapy Unprotected left main=UPLM
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1. Patient has class 1 indication for CABG
2. Patient has equal indication for PCI or CABG without LM or proximal LAD
3. Patient should have global risk reduction and managed medically
4. Patient has a class II A indication for PCI
5. Patient has class II B for CABG
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1. Patient has class 1 indication for CABG
2. Patient has equal indication for PCI or CABG without LM
or proximal LAD both class 1
3. Patient should have global risk reduction and managed
medically
4. Patient has a class II A indication for PCI
5. Patient has class II A for CABG
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No class 1 for LAD disease
To IMPROVE SURVIVAL
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1. 0.5%
2. 1%
3. 2%
4. >3% or more annually
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0
2
4
6
8
10
1 vessel
dx2 vessel
dx3 vessel
dx 3VDx +
prox 95%
LAD)
1.4 2.44.2
8.2
Percent mortality per year
Adapted from al Patel et al
J Am Coll Cardiol. 1996;27:964–1047
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Landmark Trials
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Randomized trial involving 2287 patients who had
objective evidence of myocardial ischemia
and significant coronary artery disease
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Diabetes and multivessel coronary
artery disease to undergo either PCI with drug-eluting
stents or CABG
Primary outcome measure was a composite of
death from any cause, nonfatal
myocardial infarction, or nonfatal stroke
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FFR VS. ANGIOGRAPHY FOR MULTIVESSEL EVALUATION
FAME
2 YEAR FOLLOW-UP
PCI performed on
indicated lesionsRandomized
PCI performed on
indicated lesions
only if FFR ≤0.80
Composite of death,
MI and repeat revasc.
(MACE) at 1 year
Primary Endpoint
Individual rates of death, MI,
and repeat revasc., MACE,
and functional status at 2 years
Key Secondary Endpoints
FFR-Guided
Angio-Guided
730 days
4.5%
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No class 3
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No trial has suggested a survival advantage of PCI
PCI for symptom relief……..
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Closing slide: translational biology
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MYOCARDIAL OXYGEN CONSUMPTION
FACTORS MVO2
• HEART RATE
• MOST IMPORTANT
•
•
•
•
•
= P x R/2h
LaPlace’s Law
h
σR
Pressure
Wall
Thickness
=Wall TensionP=Pressure
R=Radius
h=Wall thickness
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•
•
•
•
Nitric oxide is life
Acta Physiol 2009, 196, 193–222
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NIRS-IVUS
8 months before
30 y/o/ Hispanic
type 2 DM male
A1c 8.5
Obese
HDL low
High triglycerides
Biopsy proven
NASH
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Post test
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1. Patient has class 1 indication for CABG
2. Patient has equal indication for PCI or CABG without LM or proximal LAD
3. Patient should have global risk reduction and managed medically
4. Patient has a class II A indication for PCI
5. Patient has class II B for CABG
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1. Patient has class 1 indication for CABG
2. Patient has equal indication for PCI or CABG without LM
or proximal LAD both class 1
3. Patient should have global risk reduction and managed
medically
4. Patient has a class II A indication for PCI
5. Patient has class II A for CABG
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1. 0.5%
2. 1%
3. 2%
4. >3% or more
annually
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Thank you