arthur “cliff” a. bayani ii, md cardiology fellow slmc
TRANSCRIPT
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SILENT ISCHEMIASTABLE CAD
ARTHUR “Cliff” A. BAYANI II, MDCardiology FellowSLMC
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Objectives
To present a case of a patient with silent ischemia.
To present management regarding silent ischemia.
SILENT ISCHEMIA Journal of the American College of Cardiology Vol.59,No. 5, 2012© 2012 by the American College of Cardiology Foundation Published by Elsevier Inc. doi:10.1016/j.jacc.2011.07.050
EFFECTIVENESS OF PCI IN PATIENTS WITH SILENT MYOCARDIAL ISCHEMIAJournal of the American Cardiology 2012; 109;954-959
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Patient Profile
72
Female
HTN
Diabetic
No Family History CAD
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Patient Profile
Relatively Good Functional Capacity
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Patient Profile
No Chest Pain
No Palpitations
No DOB
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Inducible Ischemia on Treadmill Stress Test
Stage 3 Mets 5
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ECG
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CXRAY
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Diagnostic Angiograpy:
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Clinical Summary
72 years old Female Hypertensive Diabetic Denies chest pain,
dyspnea, palipations, easy fatigability etc.
Inducible ischemia on stress test.
CAD OF LAD
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ISSUES:
What to do?
What would you do?
What Benefit?
Indication for therapy?
Guidelines?
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Silent Ischemia
IntroductionAsymptomatic ST-segment depression during ambulatory electrocardiogram monitoring occurs more often than symptomatic ST-segment depression in patients with coronary artery disease.
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Silent Ischemia
Introductionsilent ischemia may persist despite current-era treatment and might still identify patients with increased risk of CV events.
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Silent ischemia
1970s, asymptomatic ST segment depression during ambulatory ECG monitoring > symptomatic ST segment depression in patients with CAD.
1980s and 1990s, silent ischemia was associated with adverse events
Review of clinical significance is warranted
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Definition, Diagnosis, and Mechanism
May be detected in patients:
1.) no symptoms during an exercise or pharmaceutical stress test but do have transient ST-segment changes,
2.) perfusion defects, 3.)or reversible regional wall motion
abnormalities.
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Definition, Diagnosis and Mechanism
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Definition, Diagnosis and Mechanism
The combination of an increasing demand and an altered supply secondary to abnormal microvascular and endothelial response is a possible explanation for the mechanism of silent ischemia.
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Prevalence
Nearly one-half of patients with stable CAD are shown to have transient ST-segment depressions.
One-half of patients admitted with UA
Have risk factors for CAD : 15% with mild-to-moderate hypertension who had no signs nor symptoms of CAD, 12% of NIDDM. Half of these patients were found to have perfusion defects during thallium scintigraphy.
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Prevalence
Even healthy patients without risk factors for CAD have been shown to have silent ischemia.
24% of apparently healthy individuals either had an abnormal stress test or perfusion study.
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Prognosis of Patients with Silent Ischemia
Patients with stable CAD In patients with
medically managed CAD, the likelihood of death or myocardial infarction during the 7 years of follow up was similar between patients with asymptomatic ST segment depression with exercise.
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Prognosis of Patients with Silent Ischemia
Healthy Subjects
Zellweger et al. 3,664 consecutive asymptomatic patients without known CAD who had undergone myocardial perfusion imaging.
> 7.5% ischemic myocardium, increased risk of CV events.
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Medical Therapy and RevascularizationThe ACIP trial
(Asymptomatic Cardiac Ischemia Pilot Study)
618 Participants were randomized to medical therapy vs. revascularization.
Conclusion: ACIP demonstrated increased suppression of ischemic episodes and decreased CV outcomes in PCI group
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SWISS INTERVENTIONAL STUDY ON SILENT ISCHEMIA II 201 PATIENTS
3 MONTHS AFTER ACUTE MI
PCI DECREASED LONG TERM EFFECT OF CARDIAC EVENTS
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Effectiveness of PCI in Patient with Silent Ischemia(Post Hoc Analysis of the Courage Trial) 2280
Major Cardiac events: 12 % PCI + OMT vs. OMT alone
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THANKYOU