Stabil koronária betegség diagnózisa

és kezelése. Rizikó felmérés.

Dr. Bárczi György
SE Városmajori
Szív- és Érgyógyászati Klinika

2018.06.04.
Stabil versus unstable plaque
 Clinical presentation of CAD

Asymptomatic Chronic Heart Angina Acute Arrhythmia,

(silent Failure Pectoris Coronary Sudden
ischaemia) Syndrome Cardiac Death

Stable CAD

NSTE-ACS Guidelines
Short-Term Risk of Death or Nonfatal MI in
Patients With UA/NSTEMI
 Patients with stable known or suspected
coronary artery disease (SCAD)
• Those who have stable angina or equivalent
• Previously symptomatic known CAD known

• Symptoms first time judged to be in chronic stable condition

• Symptoms first time , but low risk ACS
• Asymptomatic pts. with abnormal test(s).

Stable to unstable continuum without a clear boundary!

 Magnitude of the Problem

• 1 in 3 adults in the US has some forms of CV disease.

• The survival rate of patients with IHD has been stadily
improving.
• SCAD annual mortality: 1.2-2.4%
• Olmsted County and Framingham: reported annual rates of
MI in patients with Angina 3.0-3.5%.
• Annual incidence of Nitrate Angina:
Diagnózis
• History:
– Focus on CV risk, other manifestations of CV disease and abnormal bleeding
• Clinical classification of Chest pain:

• Physical examination:
- Differencial diagnosis
- Concomitant diseases
- Evidence of CV diseases
• Differential Diagnosis:
– Non ischemic cardiovascular
– Pulmonary
– Gastrointestinal
– Chest wall
– Psychiatric
• Conditions provoking or exacerbating ischemia
 Pre-test probability (PTP)

• Influenced by the prevalence of the disease in the population

studied as well as clinical features (CV risk factors).
• Major determinants:
age, gender, nature of symptoms.

CV risk factors:DM, Smoking, Hyperlipidaemia

 PTP and non invasive diagnostic testing

~85%

•No test with low PTP < 15% - safe to assume no obstructive CAD

•No test with high PTP > 85% - obstructive CAD

 Initial diagnostic management of patients with
suspected SCAD

3
Ischaemic cascade
 Exercise ECG
• Diagnosis of CAD: Sensitivity:
– Sensitivity 45-50%
– Specificity 85-90%
PPT 15-65% and EF> 50% - I/B
• Patients on treatment to evaluate control of
symptoms and ischaemia – IIa/C
• (Adding cardiopulmonary exercise testing may
improve sensitivity significantly./ ΔVO2/Δwork rate slope/)
Use of exercise or pharmacologic stress testing in
combination with imaging
 Use of exercise or pharmacologic stress testing in
combination with imaging

• Pharmacological test is prefered when there

is already a resting wall motion abnormality.
• Contrast/tissue doppler imaging/strain rate
imaging may improve diagnostic performance.
• PET is superior to SPECT imaging for detection
of SCAD.
• Hyprid techniques: SPECT/CT, PET/CT, PET/MR
- future.
 Invasive coronary angiography (ICA) for
diagnosis
• Early:
– Clinical profile suggesting a high event risk
– LVEF < 50% + typical angina
– High PTP (>85%)
– Special professions as eg. pilots.

• Late: after stress/imaging testing

 Imaging summary
- Indications of different imaging tests for the diagnosis of
obstructive coronary artery disease and for the
assessment of prognosis in subjects without known coronary
artery disease -
 Detection of high risk patients
(annual mortality > 3%)
They will benefit from revasculariozation beyond the
amelioration of symptoms

(1) Risk stratification by clinical evaluation

(2) Risk stratification by ventricular function

(3) Risk stratification by response to stress testing

(4) Risk stratification by coronary anatomy.

 Ad 1. Risk stratification by clinical evaluation

• ECG (Q wave, LBBB, etc.)

• CV risk factors: DM, Hypertension, current
smoking, eleveted cholesterol
• Age
• Chronic kidney disease
• PAD
• Heart failure, known prior MI
 Risk stratification by ventricular function

• CoronaryArterySurgeryStudy Registry:
12 year survival (MVD):
EF> 50% - 49%
EF < 35% - 21% (p< 0.0001)
 Ad. 3. Risk stratification by response to stress
testing

Duke treadmill score:

 Ad 4. Risk stratification by
coronary anatomy.

CASS Registry
• LM

• Proximal LAD

• MVD
 Re-assesment in patients with
SCAD
• FU visits are recommended in the first year in
every 4-6 moths (GP!) – I/C
• Annual ECG – I/C
• Exercise/imaging test if recurrent or new
symptoms – I/C
Treatment

Before-after
 Lifestyle management
• Stop smoking
• BMI< 25 kg/m2
• Exercise training > 3 times a week for 30
min/session
• LDL-C < 1.8 mmol/l
• BP: < 140/90 mmHg
• HbA1C < 7.0%
• Avoid HRT
Medical management of patients with stable
coronary artery disease.
Global strategy of intervention in stable coronary artery
disease in patients with demonstrated ischaemia.
OMT v. OMT+revascularization
CABG versus PCI
 CABG versus PCI by SYNTAX score
Cumulative incidence of MACE in patients with 3-vessel CAD based on SYNTAX score
at 3-year follow-up in the SYNTAX trial treated with either CABG (blue) or PCI (gold).
 Vital Importance of Involvment by an
Informed Patient:
I/C
• Outcomes-risks-costs.
• Patients should be encoureged to seek
additional information from other sources.
• Medical versus PCI
• PCI versus CABG
• „opening a partially blocked artery will
prevent a heart attack and prolong life..”
 Conclusion
• Diagnosis:
– Clinical evaluation + PTP – at least ½ Dg.
– High risk SCAD pts. – early ICA
• Treatment:
– High risk (annual mortality rate > 3%)
- OMT+revascularization
– Low risk – Heart team+ patient decision