G. Gosselin, MD 2009

Dr Gilbert Gosselin,

MDCM,FRCP,FACC Cardiologue d’intervention

Institut de Cardiologie de Montréal

Chef du departement de médecine spécialisée

Centre Hospitalier Pierre-LeGardeur

INVESTIGATION, SUIVI ET TRAITEMENT

DU PATIENT ANGINEUX STABLE

RECOMMANDATIONS,

MISE A JOUR ET ROLE

DE L`ISCHEMIE

43 e CONGRES ACQ

QUEBEC , 2014

CONFLIT D’INTÉRÊTS

Cardiologue d’intervention depuis plus de 25 ans

Avec plus de 11,000 cathétérismes et 4000 interventions

Investigateur principal à l’ICM pour le projet COURAGE et le projet ISCHEMIA (co-leader national et membre du steering committee)

Intérêt académique en prévention primaire et secondaire

16/07/2014

Histoire de cas

203-1-025

♀ 64 ans

DbII, DLP+, HTA+

Angine x 3 ans

Épisode d’angine instable refroidi

MIBI ischémie modérée antérieure +

antéro-latérale

Repos

04/2001 04/2003 08/2005

Persantin

Patiente 203-1-025

DDN: 1935/03/06

Patiente 203-1-025 16/07/2014

Patiente 203-1-025 16/07/2014

Patiente 203-1-025 16/07/2014

Repos

04/2001 04/2003 08/2005

Persantin

Traitement médical optimal –PROJET COURAGE

Patiente 203-1-025

DDN: 1935/03/06

Figure 1: Diagnosis and management of patients with stable ischemic heart disease.

L’INVESTIGATION:

CONFIRMER LE DIAGNOSTIC

ET EVALUER LE PRONOSTIC

Bilan de Base

1. Histoire et examen physique pour obtenir les facteurs de

risques, l’histoire médicale et signes de maladie

cardiovasculaire.

2. Documentation des co-morbidités cardiovasculaires

(insuffisance cardiaque, maladie valvulaire, maladie cérébro-

vasculaire ou périphérique et maladie rénale)

3. Tests de routine:

- FSC - Bilan lipidique - Glucose, HbA1C - ECG

- Fonction rénale - Tests hépatiques - Tests thyroidiens

Critères de Douleurs Thoraciques

Angineuses

1. Inconfort rétro-sternal avec durée et propriétés

charactéristiques.

2. Provoquées par l’effort ou le stress.

3. Soulagées rapidement par la Nitro ou le repos.

Age

Chest Pain Criteria:

1. Sub-sternal chest discomfort with characteristic quality and duration

2. Provoked by exertion or emotional stress

3. Relieved promptly by rest or nitroglycerin

Non-anginal Chest Pain

1 of 3 Criteria

Atypical Angina

2 of 3 Criteria

Typical Angina

3 of 3 Criteria

Male Female Male Female Male Female

30 – 39 4% 2% 34% 12% 76% 26%

40 - 49 13% 3% 51% 22% 87% 55%

50 - 59 20% 7% 65% 33% 93% 73%

60 - 69 27% 14% 72% 51% 94% 86%

Cardiac Risk Factors

Modifiable Non-Modifiable

Tobacco Use/Smoking History

Dyslipidemia

Diabetes

Hypertension

Chronic Kidney Disease

Physical Inactivity

Diet

Obesity or Metabolic Syndrome

Depression

Age

Sex

Family History of Premature

Established CV Disease

Ethnic Origin

G. Gosselin, MD 2014

Diagnostics differentiels des douleurs

thoraciques

Cardiovascular Pulmonary Gatrointestinal Chest Wall Neurological Psychiatric

Aortic dissection

Congestive Heart

Failure

Pericarditis

Syndrome X

(microvascular

disease)

Pulmonary embolism

Pneumothorax

Pleuritis

Primary Pulmonary

Hypertension

Esophagitis

Esophageal Spasm

Biliary Colic:

Cholecystitis

Choledocholithiasis

Cholangitis

Peptic Ulcer Disease

Pancreatitis

Costochondritis

Fibrositis

Fibromyalgia

Rib fracture

Sternoclavicular

Arthritis

Cervical Disease

Herpes Zoster

Anxiety disorders

Hyperventilation

Panic disorder

Affective disorders (eg.

depression)

Somatiform disorders

Thought disorders

(ie:fixed delusions)

Conditions provocant ou

exacerbant l’ischemie (1)

Increased Oxygen Demand Decreased Oxygen Supply

Noncardiac Noncardiac

Hyper/hypothermia Anemia

Hyperthyroidism Hypoxemia/high altitude

Sympathomimetic toxicity Pneumonia

(eg. cocaine use) Asthma

Hypertension Chronic obstructive pulmonary disease

Anxiety Pulmonary hypertension

High Cardiac Output States Interstitial pulmonary fibrosis

(eg Arteriovenous fistulae) Obstructive sleep apnea

Sickle cell disease

Sympathomimetic toxicity (eg. cocaine use,

pheochromocytoma)

Hyperviscosity (Polycythemia, Leukemia,

Thrombocytosis, Hypergammaglobulinemia)

Conditions provocant ou

exacerbant l’ischemia (2)

Increased Oxygen Demand Decreased Oxygen Supply

Cardiac Cardiac

Left Ventricular Hypertrophy Aortic stenosis

Aortic stenosis Hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy Obstructive coronary artery disease

Dilated cardiomyopathy Microvascular disease

Tachycardia (ventricular, Coronary Spasm

supraventricular)

Technology Sensitivity Specificity

Exercise Treadmill 0.68 (0.23-1.0) 0.77 (0.17-1.0)

Attenuation Corrected SPECT 0.86 (0.81-0.91) 0.82 (0.75-0.89)

Gated SPECT 0.84 (0.79-0.88) 0.78 (0.71-0.85)

Traditional SPECT 0.86 (0.84-0.88) 0.71 (0.67-0.76)

Contrast Stress Echocardiography

(wall motion) 0.84 (0.79-0.90) 0.80 (0.73-0.87)

Exercise or Pharmacologic Stress Echocardiography 0.79 (0.77-0.82) 0.84 (0-.82-0.86)

Cardiac Computed Tomographic Angiography 0.96 (0.94-0.98) 0.82 (0.73-0.90)

Positron Emission Tomography 0.90 (0.88-0.92) 0.88 (0.85-0.91)

Cardiac MRI (perfusion) 0.91 (0.88-0.94) 0.81 (0.75-0.87)

Criteres de haut risques

associes avec > 3% risques annuels de deces ou IM

Exercise Treadmill

≥ 2mm of ST-segment depression at low (< 5 metabolic

equivalents, METS) workload or persisting into recovery

Exercise-induced ST-segment elevation

Exercise-induced VT/VF

failure to increase systolic blood pressure to > 120 mm Hg

or sustained decrease > 10 mm Hg during exercise

Myocardial Perfusion Imaging

Severe resting LV dysfunction (LVEF < 35%) not readily

explained by non-coronary causes

Resting perfusion abnormalities ≥10% of the myocardium in

patients without prior history or evidence of MI

Severe stress-induced LV dysfunction (peak exercise LVEF

<45% or drop in LVEF with stress ≥10%)

Stress-induced perfusion abnormalities encumbering ≥10%

myocardium or stress segmental scores indicating multiple

vascular territories with abnormalities

Stress-induced LV dilation

Increased lung uptake

Criteres de haut risques

associes avec > 3% risques annuels de deces ou IM

Criteres de haut risques

associes avec > 3% risques annuels de deces ou IM

Stress Echocardiography

Inducible wall motion abnormality involving >2

segments or 2 coronary beds

Wall motion abnormality developing at low dose of

dobutamine (< 10 micrograms/kg/min) or at a low

heart rate (<120 beats/min)

Coronary Computed Tomographic Angiography

Multivessel obstructive CAD or left main stenosis on

CCTA

Criteres de haut risques

associes avec > 3% risques annuels de deces ou IM

Facteurs pronostiques fondamentaux pour

evaluer la maladie coronarienne stable

RECOMMANDATIONS

EVALUATION ANATOMIQUE DES

CORONAIRES CHEZ LES PATIENTS AVEC

CRITERES DE HAUT-RISQUE

CHEZ LES PATIENTS AVEC SYMPTOMES

REFRACTAIRES,UNE CORONAROGRAPHIE

EST INDIQUEE POUR EVALUER LA

POSSIBILTE DE REVASCULARISATION

INITIER LE TRAITEMENT MEDICAL

Buts de la thérapie

1. Améliorer les symptômes

2. Améliorer la qualité de vie

3. Diminuer les risques d’infarctus

4. Diminuer les risques de mortalité

Recommandations MCAS Prise en charge - Angor stable

Treatment with aspirin 75 to 162 mg daily should be continued

indefinitely in the absence of contraindications in patients with

SIHD.

Treatment with clopidogrel is reasonable when aspirin is

contraindicated in patients with SIHD .

I IIa IIb III

I IIa IIb III

Thérapie Anti-plaquettaire

Traitement chronique

du patient angineux

81 mg d’aspirine quotidiennement

75 mg de clopidogrel si intolérant à l’ASA

Aucune indication pour la double thérapie sauf si

dilatation avec stent

Statine en accordance avec les lignes directrices

(SCC vs. ACC-AHA…)

IECA si patient présente HTA, DbII, FE < 40%,

insuffisance rénale

Beta blockers should be prescribed as initial therapy for relief of

symptoms in patients with SIHD.

Calcium channel blockers or long-acting nitrates should be

prescribed for relief of symptoms when beta blockers are

contraindicated or cause unacceptable side effects in patients with

SIHD.

Calcium channel blockers or long-acting nitrates, in combination

with beta blockers, should be prescribed for relief of symptoms

when initial treatment with beta blockers is unsuccessful in patients

with SIHD.

I IIa IIb III

Médication anti-Ischémique

I IIa IIb III

I IIa IIb III

Beta-blocker therapy should be started and continued for 3 years in all

patients with normal LV function after MI or ACS.

Beta-blocker therapy should be used in all patients with LV systolic

dysfunction (EF ≤40%) with heart failure or prior MI, unless

contraindicated. (Use should be limited to carvedilol, metoprolol

succinate, or bisoprolol, which have been shown to reduce risk of

death.)

Beta blockers may be considered as chronic therapy for all other

patients with coronary or other vascular disease.

I IIa IIb III

I IIa IIb III

I IIa IIb III

Thérapie Bêta-Bloqueurs

ACE inhibitors should be prescribed in all patients with SIHD

who also have hypertension, diabetes mellitus, LVEF 40% or

less, or CKD, unless contraindicated.

ARBs are recommended for patients with SIHD who have

hypertension, diabetes mellitus, LV systolic dysfunction, or

CKD and have indications for, but are intolerant of, ACE

inhibitors.

I IIa IIb III

Antagonistes récepteurs Rénine-Angiotensine-Aldosterone

I IIa IIb III

Treatment with an ACE inhibitor is reasonable in patients with

both SIHD and other vascular disease.

It is reasonable to use ARBs in other patients who are ACE

inhibitor intolerant.

Antagonistes récepteurs

Rénine-Angiotensine-Aldosterone (cont.)

I IIa IIb III

I IIa IIb III

ARA si intolérant aux IECA

Bloqueurs chez les patients angineux avec FE < 40%

indéfiniment

Bloqueurs en première ligne pour soulager les

symptômes (viser pouls ≤ 55-60/bpm)

Si intolérance ou contre-indications, utiliser les

antagonistes du calcium et les dérivés nitrés

Éviter les antagonistes du calcium non-dihydropyridine

avec les b-bloqueurs re risques de Bloc AV, bradycardie

Traitement chronique

du patient angineux

Recommandations MCAS Angor stable

Éviter:

- la thérapie par chélation

- Allopurinol

- Magnesium

- Co-enzyme Q10

- Suxia Jiuxin Wan, Shenshao

- Testostérone

Traitement chronique

du patient angineux (suite)

EVALUATION DU BESOIN DE

REVASCULARISATION

G. Gosselin, MD 2009

G. Gosselin, MD 2009

G. Gosselin, MD 2009

G. Gosselin, MD 2009

The First Coronary Angioplasty

for Stable CAD; 1977

First coronary angioplasty lesion (circles) two days before (A),

immediately after (B), and one month after (C) balloon dilation

16/07/2014

ETUDES RANDOMISES DE SRATEGIES DE

REVASCULARISATION VS TRAITEMENT MEDICAL

OPTIMAL DE LA MCAS STABLE

BARI 2D

COURAGE

16/07/2014

Published on-line 3/27/07

Print version 4/12/07

Aim of the COURAGE Trial

To determine whether the addition of PCI

to optimal medical therapy, when used as

an initial management strategy, reduces

the risk of death or nonfatal MI in patients

with stable CAD, as compared with

optimal medical therapy alone.

Survival Free of Death from Any Cause

and Myocardial Infarction

Number at Risk

Medical Therapy 1138 1017 959 834 638 408 192 30

PCI 1149 1013 952 833 637 417 200 35

Years 0 1 2 3 4 5 6

0.0

0.5

0.6

0.7

0.8

0.9

1.0

PCI + OMT

Optimal Medical Therapy (OMT)

Hazard ratio: 1.05

95% CI (0.87-1.27)

P = 0.62

7

LES CRITIQUES DE COURAGE

1) LA NON QUANTIFICATION DE L`ISCHEMIE

2) LA CONNAISSANCE DE L`ANATOMIE

CORONARIENNE

3) LA REVASCULARISATION NON OPTIMALE

(PEU DE DES…)

QUE DOIT ON RETENIR DE COURAGE

1) le traitement medical est justifié dans la

MCAS stable

2) la revascularisation peut etre faite lors de l`echec

du traitement medical

3) l`ischemie semble etre le marqueur critique et

semble predire le pronostic

FAME

Tonino et al. N Engl J Med 2009;360:213-24.

• 1005 patients with multivessel CAD underwent FFR-guided (<0.80) vs. angiography-

guided PCI

• Primary endpoint: death, MI, repeat revascularization at 1 year

16/07/2014

FAME: Death, MI, Repeat Revascularization

Tonino et al. N Engl J Med 2009;360:213-24.

P = 0.02

JACC 2012

G. Gosselin, MD 2009

Complete Revascularization

Ischemic:

PCI- revascularization of all vessels >2.25 mm that have been

demonstrated to result in ischemia by non-invasive imaging or

FFR

CABG- grafting of all areas of significant ischemia based on

preoperative testing or FFR of intermediate lesions at diagnostic

catheterization, as well as making every effort to revascularize

areas subtended by occluded coronaries unless the myocardium

is demonstrated to be non-viable

Ischemia on

stress image

in the

distribution of

the stenosis

+

-

% Stenosis on

Cath

≥50%

FFR Requirement (≥2.25

mm artery)

No PCI

<50%(if PCI is

considered) Required

PCI <0.80

>0.80 No PCI

<80% (if PCI is

considered) Required

PCI

>0.80 No PCI

≥80% Consider

Imaging

Stress

Test

PCI

<0.80

PCI based on anatomic feasibility and clinical considerations

PCI

>0.80 No PCI

<0.80

16/07/2014 136

Cath in Patients Randomized to CON Strategy

■ Cath will be reserved for patients with refractory angina, acute coronary syndrome, acute

ischemic heart failure or resuscitated cardiac arrest

No Yes

Hospitalization for ACS1?

Refractory symptoms? 2

No Yes

NOT consistent with CON strategy

NOT Adherent to Protocol

Consistent with CON strategy

Adherent to Protocol

Cath in CON Patient

1ACS=acute coronary syndrome, includes resuscitated cardiac arrest and hospitalization for acute ischemic heart failure

2According to trial definition

Determination of acute ischemic event and refractory symptoms

will be confirmed centrally

FOLLOW-UP CLINIQUE ADEQUAT

ECG DE REPOS ANNUEL OU SI

CHANGEMENT DE SYMPTOMES

PATIENTS DEVRAIENT ETRE REFERRES A UN

PROGRAMME DE REHABILITATION

CARDIAQUE

PATIENTS DEVRAIENT ACCUMULER 150 MIN

D`EXERCICE PAR SEMAINE

PATIENTS NON CONTROLES PAR THERAPIE

MEDICALE DEVRAIENT ETRE REEVALUES

PAS D`INDICATION D`EE OU MIBI DE

ROUTINE

RECOMMANDATIONS

UN JOUR… LES MEDICAMENTS REMPLACERONT LA

DILATATION…

L’INTERVENTION PERCUTANEE

REMPLACERA LA CHIRURGIE…

ET LES CHIRURGIENS VOUDRONT

DILATER…

MERCI DE VOTRE ATTENTION

16/07/2014