stable angina, guidelines & racpc

West Herts Cardiology

Stable Angina, Guidelines & RACPCStable Angina, Guidelines & RACPC

Promoting Assessment & Treatment which is Structured, Systematic, Objective Evidence-based Appropriate In keeping with the patient’s wishes

Risk stratification At presentation (“pre-test”) After non-invasive assessment (“post-test”) After Coronary Angiography


Angina : NSF StandardsAngina : NSF Standards

Standard 8People with symptoms of angina or suspected angina should receive appropriate investigation and treatment to relieve their pain and reduce their risk of coronary events.

Standard 9People with angina that is increasing in frequency or severity should be referred to a cardiologist urgently or, for those at greatest risk, as an emergency.

Standard 10NHS Trusts should put in place hospital-wide systems of care so that patients with suspected or confirmed coronary heart disease receive timely and appropriate investigation and treatment to relieve their symptoms and reduce their risk of subsequent coronary events.


Arterial blood flowArterial blood flow

Blood Red cells

White cells

Platelets

Plasma (with O2 & Nutrients)

Clotting factors

Cholesterol

Toxins..

Arterial wall Endothelium

Intima

Muscular wall

Alt-F4 to close movie Space/ controls playback


Atherosclerosis TimelineAtherosclerosis TimelineFoamFoamCells Cells

FattyFattyStreak Streak

IntermediateIntermediateLesion Lesion AtheromaAtheroma

FibrousFibrousPlaquePlaque

ComplicatedComplicatedLesion / RuptureLesion / Rupture

Adapted from Pepine CJ. Am J Cardiol. 1998;82(suppl 104).

From FirstDecade

From ThirdDecade

From FourthDecade

Endothelial DysfunctionEndothelial Dysfunction


Clinical Manifestations of AtherothrombosisClinical Manifestations of Atherothrombosis

Transient ischemic attack(TIA)

Angina

Ischaemic stroke (CVA)

Acute Coronary Syndrome (ACS)Myocardial infarction (MI)

Peripheral Vascular Disease (PVD)

AAARenovascular Disease


Angina: PrognosisAngina: Prognosis

Goldman L et al Am J Cardiol 1983;51:449-52

% S

urv

ival

100

90

80

70

60

2 4 6 8 10

Years of Follow-up

Webster: 1960-5 Severe CHD

Kannel : 1949-66 Framingham Men, >50yrs, Angina

Podrid : 1981 ExECG +,Mild Angina

Webster

Kannel

Podrid


Progression of Vascular DiseaseProgression of Vascular Disease

Stable AtheromatousStable AtheromatousPlaquePlaque

Risk Factors

Asymptomatic, orAsymptomatic, or Stable Vascular Disease Stable Vascular Disease

egeg Stable AnginaStable Angina

UnstableUnstable Plaque Plaque ComplicationsComplications

• Sudden Death• ACS• Myocardial Infarction• Heart Failure

• Stroke

• etc, etc

Genetics


Stable Angina in CHDStable Angina in CHD

Narrowing of Coronary artery limits blood supply to heart muscle

If demand for blood supply cannot be met, muscle becomes ischaemic


Stable Angina: SymptomsStable Angina: Symptoms"There is a disorder of the breast with strong and peculiar symptoms considerable for the kind of danger belonging to it. The seat of it and the sense of strangling and anxiety with which it is attended may make it not improperly called angina pectoris.

They who are afflicted with it are seized while they are walking with a painful and most disagreeable sensation in the breast ... But the moment they stand still all this uneasiness vanishes.

If the pain continues, patients suddenly fall down and perish almost immediately.”

William Heberden London Medical Transactions 1772


Effects of Myocardial IschaemiaEffects of Myocardial Ischaemia

Myocardial Ischaemia

Angina ArrhythmiaBreathlessness

Sudden Death

Most Myocardial ischaemia is painless (“Silent”) ….

TransientLV Dysfunction

ProgressiveLV dysfunction


Causes of Myocardial IschaemiaCauses of Myocardial IschaemiaReduced

Oxygen SupplyIncreased

Oxygen Demand

Coronary AtheroThrombosis gradual, progressive sudden, ± occlusive

Other causes of Coronary flow active spasm lack of vasodilatation

Cold Anaemia Carbon Monoxide High Altitude

Increased Heart Rate Exercise, stress Smoking

Increased LV stress LVH, Hypertension Aortic Stenosis, HCM

Cold Food Hyperthyroidism

: Effects of cigarette smoking


Evaluation and DiagnosisEvaluation and Diagnosis

In patients presenting with chest pain detailed symptom history focused physical examination directed risk-factor assessment

Estimate the probability of significant CHD if intermediate or high: refer to RACPC

Objective assessment (eg ExECG) is for: Diagnosis of myocardial ischaemia Assessment of severity & pathophysiology Assessment of prognosis


Rapid Access Chest Pain ClinicsRapid Access Chest Pain Clinics

“One-stop” assessment of stable patients

Recent (<6 months) onset of exertional chest pain, intermediate-high risk of angina

Known CHD which was stable (eg after PTCA or CABG) now symptomatic again

< 2 week wait to clinic


Classification of Chest PainClassification of Chest PainEstimating the Probability of CHD from History of Chest Pain Precipitated by exercise Brief duration (<15 minutes) Relieved promptly by rest or GTN Central chest location Radiates to Jaw, Throat, or L Arm Absence of other causes for pain

CHDIf only ONE criterion + = Non Anginal pain : < 30%If only criteria 4-6 +,or any TWO + = Chest Pain ? Cause : 30-70%If only criteria 1-3 +,or any FOUR + = Typical Angina : > 70%

Diamond GA, Forester JS. NEJM 1979;300:1350-8 Patterson RE, et al JACC 1989;13:1653-65


Pre-test probability of CHD: Duke ScorePre-test probability of CHD: Duke Score

By combining

Classification of Chest Pain

CHD risk factors (including ECG)

a more accurate prediction of the (pre-test) probability of significant CHD can be generated

Structured, systematic, objective assessment

Easy to use on web, PC or PDA

Pryor DB et al Ann Int Med 1993;118:81-90



Precipitated by exercise 0 0=N, 1=Y

Brief duration (2-15min) 1 0=N, 1=Y

Relieved promptly by rest or GTN 0 0=N, 1=Y

Retrosternal 0 0=N, 1=Y

Radiating to jaw, neck or L arm 1 0=N, 1=Y

Absence of other cause 1 0=N, 1=Y

Chest Pain Classified as:

Age 55Sex 0 0=M, 1=F

Smoking 1 0=N, 1=Y

Total Cholesterol 7 mmol/l

Diabetes 1 0=N, 1=Y

Previous MI 0 0=N, 1=Y

ECG: Q waves 0 0=N, 1=Y

ECG: ST changes at rest 1 0=N, 1=Y

Probability of significant CHD 88%(>75% stenosis of at least 1 major coronary artery)

Chest Pain ? Cause

Classification of Chest Pain: Enter Chest Pain features

Clinical Risk Assessment: Enter Clinical features


Probability of CHD

50%

Multiple risk factors

Probability of CHD increased to 88%



Precipitated by exercise 0 0=N, 1=Y

Brief duration (2-15min) 1 0=N, 1=Y

Relieved promptly by rest or GTN 0 0=N, 1=Y

Retrosternal 0 0=N, 1=Y

Radiating to jaw, neck or L arm 1 0=N, 1=Y

Absence of other cause 1 0=N, 1=Y

Chest Pain Classified as:

Age 55Sex 1 0=M, 1=F

Smoking 0 0=N, 1=Y

Total Cholesterol 7 mmol/l

Diabetes 0 0=N, 1=Y

Previous MI 0 0=N, 1=Y

ECG: Q waves 0 0=N, 1=Y

ECG: ST changes at rest 0 0=N, 1=Y

Probability of significant CHD 15%(>75% stenosis of at least 1 major coronary artery)

Chest Pain ? Cause

Classification of Chest Pain: Enter Chest Pain features

Clinical Risk Assessment: Enter Clinical features


Probability of CHD

50%

Few risk factors

Probability of CHD decreased to 15%



Demonstration of web-based RACPC referral form automatic risk assessment

www.westhertshospitals.nhs.uk/whcRisk calculators → RACPC Referral


Rapid Access Chest Pain ClinicsRapid Access Chest Pain Clinics

Not every patient with chest pain is suitable

Acute MI / Unstable Angina: CCU

Stable Angina with mod-high prob of CHD

Chest Pain ? Cause with mod prob of CHD

Atypical Pain with low prob of CHD: ?? OP

ACS / MI, Heart Failure, Valve Disease, Palpitations

Anaemia, AF, Digoxin, LVH++, LBBB, can’t walk


Evidence-based Management of AnginaEvidence-based Management of Angina

Careful assessment ? Underlying cause ? Risk factors : Smoking, Lipids, BP, DM ? Prognosis : Exercise ECG

Treatment Stop smoking, lose weight, healthy diet Aspirin, + Statin and ACEI as appropriate for 2y prevention Blocker if possible (else Verapamil or Diltiazem) Nicorandil or Nitrate, using GTN prophylactically

Consider Angiography Revascularisation


Effects of Treatment of Stable AnginaTreatment Angina

control Improved Prognosis

Prevention of MI Nitrates Yes No

Blockers Yes Yes

Ca++ blockers

Dihydropyridines: short acting Poor No (prognosis )

: long acting Yes ?

Diltiazem, Verapamil Yes ? No

Aspirin No Yes

Statin ?Yes Yes

ACEI ?Yes Yes

PTCA Yes ?

CABG Yes Yes


Stable Angina GuidelinesStable Angina Guidelines

Gibbons et al JACC 1999;7:2092–197


Stable Angina Guidelines – Assessment 1Stable Angina Guidelines – Assessment 1


Stable Angina Guidelines – Assessment 2Stable Angina Guidelines – Assessment 2


Stable Angina Guidelines - TreatmentStable Angina Guidelines - Treatment


Prognostic Markers in Exercise TestingPrognostic Markers in Exercise Testing

The Duke Treadmill Score = exercise time in minutes on Bruce Protocol minus 5 x the ST-segment deviation

during or after exercise (mm) 4 x the angina index

0 if there is no angina 1 if angina occurs, and 2 if angina is the reason for stopping the test

works well for both inpatients and outpatients, and equally well for men and women

Mark DB et al NEJM 1991;325:849-53Shaw LJ et al Circulation 1998;98:1622-30


Duke Treadmill ScoreDuke Treadmill Score

Survival According to Risk Groups

4 -Year Annual

Risk Group (Score) Total Survival Mortality

Low ( +5) 62% 99% 0.25%

Moderate (-10 to +4) 34% 95% 1.25%

High (< -10) 4% 79% 5.00%



Use of Duke Treadmill ScoreUse of Duke Treadmill Score

Predicted average RecommendedRisk score annual mortality treatment

low <1% per year Medical therapy

intermediate 1% to 3% Cardiac Catheterization? Stress imaging

high-risk >3% per year Cardiac Catheterization

* <5% pt with low-risk treadmill score will be identified as high risk after imaging* those with known LV dysfunction should have cardiac catheterization



Coronary Revascularisation: 1Coronary Revascularisation: 1

Limiting Angina despite Medical treatment

Recent MIor Unstable Angina

Non-Invasive assessment (eg ExECG) indicates Risk

Medical treatment

Angiography

High Risk

Low Risk


Coronary Revascularisation: 2Coronary Revascularisation: 2Limiting Angina despite

Medical treatment Recent MI

or Unstable Angina

Non-Invasive assessment (eg ExECG) indicates Risk

Medical treatment

PTCA ± Stent CABG MICAS

Balance Risk v Benefit

Angiography

High Risk

Low Risk Normal or Mild CHD

1-2 vessel CHD

3 vessel CHD or LMS


Extent and severity of coronary disease and LV dysfunction are the most powerful clinical predictors of long-term outcome proximal coronary stenoses

severe left main coronary artery stenosis

In the CASS registry of medically treated patients, the 12-year survival rate by

Coronary arteries Ejection fraction

normal coronary arteries 91% 50% to 100% 73%one-vessel disease 74% 35% to 49% 54%two-vessel disease 59% <35% 21%three-vessel disease 40%

Risk Stratification With Coronary AngiographyRisk Stratification With Coronary Angiography

CASS Circulation 1994;90:2645-57


Prognosis of CHD by severity at AngioPrognosis of CHD by severity at Angio

Balcon R, Davies S The management of stable angina RCP;1994:p61

1 2 3 4Years

5

0

60

20

40

100

80

Pro

bab

ility

of

Su

rviv

al (

%)

Distal coronary disease

1 vessel CHD

2 vessel CHD

3 vessel CHDLeft Mainstem Stenosis

Distal coronary disease

1 vessel CHD

2 vessel CHD

3 vessel CHDLeft Mainstem Stenosis


Canadian Cardiovascular Society Canadian Cardiovascular Society Classification of Stable Angina severityClassification of Stable Angina severity

Class I: Ordinary physical activity does not cause anginaNo angina on ordinary walking or climbing stairs.Angina with strenuous or rapid or prolonged exertion at work or recreation.

Class II: Slight limitation of ordinary activityAngina on walking or climbing stairs rapidly, walking uphill, walking or stair climbing after meals, in cold, or in wind, or when under emotional stress, or only during the few hours after awakening; walking more than 100-200m on the level or climbing more than one flight of stairs at a normal pace and in normal conditions.

Class III: Marked limitation of ordinary physical activityAngina on walking 100-200m on the level or climbing one flight of stairs in normal conditions and at normal pace.

Class IV: Inability to carry on any physical activity without discomfortAnginal syndrome may be present at rest.

Campeau L. Circulation 1976;54:522–523

stable angina, guidelines & racpc

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