Risk Stratification In Patients With Chronic Myocardial Ischemia

1
Risk Stratification In Patients With Chronic
Myocardial Ischemia
2
Available methods for risk stratification in CAD
patients

• Clinical parameters
• ECG
• Chest x-ray
• Noninvasive testing
• Resting LV function
• Exercise test
• Stress imaging
• Coronary angiography

Gibbons RJ et al. www.acc.org.
3
High-risk criteria
gt3 annual mortality rate

• Severe resting LV dysfunction (LVEF lt35)
• High-risk treadmill score (-11)
• Severe exercise LV dysfunction (LVEF lt35)
• Stress-induced large perfusion defect (esp
  anterior)
• Multiple, moderate-sized perfusion defects
• Large, fixed perfusion defect with LV dilation or
  increased lung uptake (thallium-201)
• Stress-induced moderate perfusion defect with LV
  dilation or increased lung uptake (thallium-201)
• Echocardiographic wall motion abnormality (gt2
  segments) at low dobutamine dose (10 mg/kg per
  min) or low HR (lt102 bpm)
• Stress echocardiographic evidence of extensive
  ischemia

Gibbons RJ et al. www.acc.org.
4
Intermediate-risk criteria
1-3 annual mortality rate

• Mild/moderate resting LV dysfunction (LVEF
  35-49)
• Intermediate-risk treadmill score (-11 lt score lt
  5)
• Stress-induced moderate perfusion defect without
  LV dilation or increased lung intake
  (thallium-201)
• Limited stress echocardiographic ischemia with a
  wall motion abnormality only at higher doses of
  dobutamine involving 2 segments

Gibbons RJ et al. www.acc.org.
5
Low-risk criteria
lt1 annual mortality rate

• Low-risk treadmill score (5)
• Normal or small myocardial perfusion defect at
  rest or with stress
• Normal stress echocardiographic wall motion or no
  change of limited resting wall motion
  abnormalities during stress

Gibbons RJ et al. www.acc.org.
6
Comparison of 3 different risk scores
N 460 consecutive patients with NSTE-ACS
PURSUIT risk score
GRACE risk score
TIMI risk score
30
30
30
25
25
25
20
20
20
Deathor MI()
15
15
15
10
10
10
5
5
5
0
0
0
lt96
96-112
113-133
gt133
lt10
10-12
13-14
gt14
0-2
3-4
5-7
30 days 1 year
Death/MI
de Araújo Gonçalves P et al. Eur Heart J.
200526865-72.
7
Summary

• Chronic IHD continues to impose a high
  socioeconomic burden
• Mechanistic understanding has undergone a
  paradigm shift
• Traditional focus Determinants of myocardial O2
  supply/demand
• Contemporary focus Changes in Na and Ca2
  currents during ischemia
• Contemporary management
• Aggressive treatment of multiple risk factors
• Multifactorial treatment of symptoms
• Renewed interest in the role of optimal medical
  therapy vs PCI