Contemporary Management of Myocardial Ischemia

1
Contemporary Management of Myocardial Ischemia
2
Epidemiology of chronic ischemia (angina)

• 6.516.5 million Americans suffer with angina
  pectoris
• Despite therapeutic advances
• gt13 million episodes of angina per week in the US
• gt1000 episodes of angina every minute
• Growing prevalence of chronic ischemia (angina)
  due to residual CAD after PCI and CABG
• Improved treatment of recurring ischemia (angina)
  is an important goal

AHA. Heart Disease and Stroke Statistics2006
Update. Gibbons RJ et al. ACC/AHA 2002
guidelines. www.acc.org/clinical/guidelines/stabl
e/stable.pdf. Pepine CJ et al. Am J Cardiol.
199474226-31.
3
Persistent ischemia (angina) despitecurrent drug
therapy

• Despite use of traditional antianginal agents
  (?-blockers, CCBs, and nitrates), patients
  reported a median of 2 anginal attacks/week
• A significant percentage of patients have
  relative intolerance to full doses of ?-blockers,
  CCBs, and nitrates
• ?-blockers and many CCBs have similar depressive
  effects on BP, HR and/or AV nodal conduction
• Antianginal drugs without these limitations are
  needed

Gibbons RJ et al. ACC/AHA 2002 guidelines.
www.acc.org/clinical/guidelines/stable/stable.pdf
Pepine CJ et al. Am J Cardiol. 199474226-31.
4
Persistent ischemia (angina) despite PCI
N 1620 consecutive NHLBI Dynamic Registry
patients 1 year post-PCI

• Despite adjunctive antianginal therapy, 26 of
  patients reported recent angina

Holubkov R et al. Am Heart J. 2002144826-33.
5
Persistent ischemia (angina) despite optimal
revascularization
Arterial Revascularization Therapies Study
60 to 80 taking antianginal medication 10 to
20 had angina
1 year after optimal revascularization
(stenting or surgery) for ischemia relief (not
to prolong survival)
Serruys PW et al. N Engl J Med. 20013441117-24.
6
Myocardial ischemia Significant clinical burden
Coronary artery disease
Hypertension
Hypertrophic cardiomyopathy
Valvular heart disease
6.516.5 million patients with stable angina1,2
1.9 billion in direct costs3
1. AHA. Heart Disease and Stroke Statistics2006
Update. 2. Gibbons RJ et al. ACC/AHA 2002
guidelines. www.acc.org/clinical/guidelines/stabl
e/stable.pdf 3. Javitz HS et al. Am J Manag Care.
200410(suppl)S358-69.
7
Myocardial ischemia diminishes quality of life
N 934 post-PCI/CABGAssessment of general
health status during follow-up visits
50
40
Health statusexcellent/ very good ( of
patients)
30
20
10
0
1
5
10
Follow-up (years)
Free from angina
Angina
Hlatky MA et al. Circulation. 20041101960-6.
8
Coexistence of myocardial ischemia and depression
N 1957 7 months post-discharge following MI/UA
History of depression ()
Angina frequency
Rumsfeld JS et al. Am Heart J. 2003145493-9.
Seattle Angina Questionnaire