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Coronary Artery Disease Mike Dorsch, Pharm.D.,M.S., BCPS
Chronic Disease Symptoms Acute Disease
CAD IHD ACS
CAD <ul><li>82.6 million American adults have CVD </li></ul><ul><ul><li>16.3 million have CHD or CAD </li></ul></ul><ul><u...
Pathophysiology <ul><li>Atherosclerosis – chronic immunoinflammatory, fibroproliferative disease fueled by lipids </li></u...
Risk Factors <ul><li>Age </li></ul><ul><ul><li>Men ≥ 45 or women ≥ 55 </li></ul></ul><ul><li>Family history of CHD </li></...
Clinical presentation <ul><li>Angina pectoris (chest pain) </li></ul><ul><ul><li>Quality – heavy pressure, SOB </li></ul><...
Diagnosis <ul><li>Related to risk factors </li></ul><ul><li>ECG </li></ul><ul><li>Stress test </li></ul><ul><ul><li>Natura...
Definition <ul><li>>  50% luminal narrowing of at least one major coronary artery at previous coronary angiography </li></...
Classifications <ul><li>Stable exertional angina (chronic) </li></ul><ul><li>Unstable angina </li></ul><ul><li>Vasospastic...
Chronic stable angina <ul><li>Angina that is reproduced by exertion </li></ul><ul><li>Canadian Cardiovascular Society </li...
Chronic stable angina <ul><li>Treatment </li></ul><ul><ul><li>Aggressive risk factor modification! </li></ul></ul>
Chronic stable angina <ul><li>Smoking cessation </li></ul><ul><ul><li>Reduces coronary events by 50% over 2 yrs </li></ul>...
Chronic stable angina <ul><li>Treat hypertension </li></ul><ul><ul><li>Decreases coronary events as well as fewer strokes,...
HOPE trial 9,297 high-risk patients,  >  55 years old, who had evidence of vascular disease or diabetes plus one other car...
HOPE trial MI/Stroke/ CV Death CV Death MI Stroke Total Mortality 22% Risk Reduction p<0.001 25% Risk Reduction p<0.001 20...
Chronic stable angina <ul><li>Hypercholesterolemia </li></ul><ul><ul><li>Reducing LDL reduces events (primary or secondary...
Scandinavian Simvastatin Survival Study (4S) Years since randomization % Surviving 30%  risk reduction p = 0.0003 The Lanc...
Scandinavian Simvastatin Survival Study (4S) 11.5% 8.2%
Chronic stable angina <ul><li>Obesity </li></ul><ul><ul><li>BMI >32 kg/m 2  is associated with increase mortality </li></u...
Chronic stable angina <ul><li>Control diabetes </li></ul><ul><ul><li>DM is a CAD equivalent </li></ul></ul><ul><ul><li>Tre...
Chronic stable angina <ul><li>Antiplatelet therapy </li></ul><ul><ul><li>ASA 81-325mg daily </li></ul></ul>
Antithrombotic Trialists ’ Collaboration Antithrombotic Trialists ’  Collaboration.  BMJ  2002; 324: 71–86. *Vascular even...
Vasospastic angina (Prinzmetal) <ul><li>Vasospasm that occurs at the site of a coronary artery </li></ul>
Vasospastic angina (Prinzmetal) <ul><li>Clinical presentation </li></ul><ul><ul><li>Spontaneous and occurs at rest, with n...
Vasospastic angina (Prinzmetal) <ul><li>Diagnosis </li></ul><ul><ul><li>Same as chronic stable angina </li></ul></ul><ul><...
Vasospastic angina (Prinzmetal) <ul><li>Treatment </li></ul><ul><ul><li>Nitrates </li></ul></ul><ul><ul><li>Calcium channe...
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Transcript of "CAD"

  1. 1. Coronary Artery Disease Mike Dorsch, Pharm.D.,M.S., BCPS
  2. 2. Chronic Disease Symptoms Acute Disease
  3. 3. CAD IHD ACS
  4. 4. CAD <ul><li>82.6 million American adults have CVD </li></ul><ul><ul><li>16.3 million have CHD or CAD </li></ul></ul><ul><ul><ul><li>7.9 million have had an AMI </li></ul></ul></ul><ul><ul><li>7 million have had a stroke </li></ul></ul><ul><li>CHD caused 1 of 6 deaths in the US 2007 </li></ul><ul><li>CHD is the single largest killer of US adults </li></ul><ul><li>Every 25 secs someone has a coronary event </li></ul><ul><li>Every minute someone will die from a coronary event </li></ul>AHA stats 2011
  5. 5. Pathophysiology <ul><li>Atherosclerosis – chronic immunoinflammatory, fibroproliferative disease fueled by lipids </li></ul><ul><li>Many other mechanisms proposed </li></ul>
  6. 6. Risk Factors <ul><li>Age </li></ul><ul><ul><li>Men ≥ 45 or women ≥ 55 </li></ul></ul><ul><li>Family history of CHD </li></ul><ul><ul><li>Before 55 for male or before 65 for female </li></ul></ul><ul><li>Hyperlipidemia </li></ul><ul><ul><li>LDL </li></ul></ul><ul><li>Smoking </li></ul><ul><li>Hypertension (≥ 140/90 or on meds) </li></ul><ul><li>Low HDL (<40) </li></ul><ul><li>Diabetes mellitus </li></ul>
  7. 7. Clinical presentation <ul><li>Angina pectoris (chest pain) </li></ul><ul><ul><li>Quality – heavy pressure, SOB </li></ul></ul><ul><ul><li>Location – over the sternum, left arm, jaw </li></ul></ul><ul><ul><li>Duration – 0.5-30 minutes </li></ul></ul><ul><ul><li>Precipitating factors – exercise </li></ul></ul><ul><ul><li>Nitroglycerin relief </li></ul></ul><ul><ul><li>Radiation – left shoulder, jaw </li></ul></ul>
  8. 8. Diagnosis <ul><li>Related to risk factors </li></ul><ul><li>ECG </li></ul><ul><li>Stress test </li></ul><ul><ul><li>Natural or pharmacologic </li></ul></ul><ul><ul><li>Nuclear stress test (imaging) </li></ul></ul><ul><li>CT angiogram </li></ul><ul><li>Angiography (cardiac catheterization) </li></ul>
  9. 9. Definition <ul><li>> 50% luminal narrowing of at least one major coronary artery at previous coronary angiography </li></ul><ul><li>history of previous myocardial infarction, percutaneous transluminal coronary intervention or coronary artery bypass graft </li></ul><ul><li>chronic stable angina pectoris associated with a positive exercise tolerance test or pharmacologically induced nuclear imaging or echocardiographic changes (positive nuclear imaging or echocardiographic changes required if female) </li></ul>
  10. 10. Classifications <ul><li>Stable exertional angina (chronic) </li></ul><ul><li>Unstable angina </li></ul><ul><li>Vasospastic angina (Prinzmetal) </li></ul>
  11. 11. Chronic stable angina <ul><li>Angina that is reproduced by exertion </li></ul><ul><li>Canadian Cardiovascular Society </li></ul><ul><ul><li>Class I – normal physical activity does not induce angina </li></ul></ul><ul><ul><li>Class II – slight limitations in ordinary activity </li></ul></ul><ul><ul><li>Class III – marked limitations in ordinal activity </li></ul></ul><ul><ul><li>Class IV – inability to carry on any physical activity w/o discomfort </li></ul></ul><ul><ul><ul><li>Look in Dipiro’s tables in the IHD chapter </li></ul></ul></ul>
  12. 12. Chronic stable angina <ul><li>Treatment </li></ul><ul><ul><li>Aggressive risk factor modification! </li></ul></ul>
  13. 13. Chronic stable angina <ul><li>Smoking cessation </li></ul><ul><ul><li>Reduces coronary events by 50% over 2 yrs </li></ul></ul><ul><ul><li>High relapse rate – encourage patients </li></ul></ul><ul><ul><li>Therapies </li></ul></ul><ul><ul><ul><li>Group counselling, self help </li></ul></ul></ul><ul><ul><ul><li>Nicotine replacement (patches, gums, inhaler) </li></ul></ul></ul><ul><ul><ul><li>Bupropion SR (Zyban) </li></ul></ul></ul><ul><ul><ul><li>Newer agents to come </li></ul></ul></ul>
  14. 14. Chronic stable angina <ul><li>Treat hypertension </li></ul><ul><ul><li>Decreases coronary events as well as fewer strokes, less renal failure and heart failure </li></ul></ul><ul><ul><li>Treatment </li></ul></ul><ul><ul><ul><li>Defer to HTN lectures </li></ul></ul></ul><ul><ul><ul><li>HOPE trial </li></ul></ul></ul>
  15. 15. HOPE trial 9,297 high-risk patients, > 55 years old, who had evidence of vascular disease or diabetes plus one other cardiovascular risk factor P<0.001 HOPE Investigators. NEJM 2000;342:145-53.
  16. 16. HOPE trial MI/Stroke/ CV Death CV Death MI Stroke Total Mortality 22% Risk Reduction p<0.001 25% Risk Reduction p<0.001 20% Risk Reduction p=<0.001 31% Risk Reduction p=<0.001 16% Risk Reduction p=0.006 Non CV Death 0% Risk Reduction p=0.78 HOPE Investigators. NEJM 2000;342:145-53.
  17. 17. Chronic stable angina <ul><li>Hypercholesterolemia </li></ul><ul><ul><li>Reducing LDL reduces events (primary or secondary prevention) </li></ul></ul><ul><ul><li>Treatment </li></ul></ul><ul><ul><ul><li>Defer to Lipid lectures </li></ul></ul></ul><ul><ul><ul><li>Statins </li></ul></ul></ul><ul><ul><ul><li>Goal LDL <100 or <70 </li></ul></ul></ul>
  18. 18. Scandinavian Simvastatin Survival Study (4S) Years since randomization % Surviving 30% risk reduction p = 0.0003 The Lancet, Vol 344, November 19, 1994 4,444 patients with CAD
  19. 19. Scandinavian Simvastatin Survival Study (4S) 11.5% 8.2%
  20. 20. Chronic stable angina <ul><li>Obesity </li></ul><ul><ul><li>BMI >32 kg/m 2 is associated with increase mortality </li></ul></ul><ul><ul><li>Treatment </li></ul></ul><ul><ul><ul><li>Dietary modification </li></ul></ul></ul><ul><ul><ul><li>Exercise program </li></ul></ul></ul><ul><ul><ul><li>Pharmacologic therapy </li></ul></ul></ul><ul><ul><ul><ul><li>Newer agents coming to market </li></ul></ul></ul></ul>
  21. 21. Chronic stable angina <ul><li>Control diabetes </li></ul><ul><ul><li>DM is a CAD equivalent </li></ul></ul><ul><ul><li>Treatment </li></ul></ul><ul><ul><ul><li>Refer to DM lectures </li></ul></ul></ul><ul><ul><ul><li>ACEi, statin </li></ul></ul></ul><ul><ul><ul><li>Newer agents coming to market </li></ul></ul></ul>
  22. 22. Chronic stable angina <ul><li>Antiplatelet therapy </li></ul><ul><ul><li>ASA 81-325mg daily </li></ul></ul>
  23. 23. Antithrombotic Trialists ’ Collaboration Antithrombotic Trialists ’ Collaboration. BMJ 2002; 324: 71–86. *Vascular events = myocardial infarction, stroke or vascular death Control better Antiplatelet better Category % Odds Reduction Acute myocardial infarction Acute stroke Prior myocardial infarction Prior stroke/transient ischemic attack Other high risk Coronary artery disease (e.g. unstable angina, heart failure) Peripheral arterial disease (e.g. intermittent claudication) High risk of embolism (e.g. atrial fibrillation) Other (e.g. diabetes mellitus) All trials 1.0 0.5 0.0 1.5 2.0
  24. 24. Vasospastic angina (Prinzmetal) <ul><li>Vasospasm that occurs at the site of a coronary artery </li></ul>
  25. 25. Vasospastic angina (Prinzmetal) <ul><li>Clinical presentation </li></ul><ul><ul><li>Spontaneous and occurs at rest, with no clear association with exertion </li></ul></ul><ul><ul><li>Pain often cyclical (ie, same time of day), usually midnight to early a.m. </li></ul></ul><ul><ul><li>Pain is similar to angina of effort but may be longer in duration </li></ul></ul><ul><ul><li>Pain may resolve spontaneously or with SL nitroglycerin </li></ul></ul>
  26. 26. Vasospastic angina (Prinzmetal) <ul><li>Diagnosis </li></ul><ul><ul><li>Same as chronic stable angina </li></ul></ul><ul><ul><li>Can give ergonovine, acetylcholine, or methacholine to provoke vasospasm </li></ul></ul>
  27. 27. Vasospastic angina (Prinzmetal) <ul><li>Treatment </li></ul><ul><ul><li>Nitrates </li></ul></ul><ul><ul><li>Calcium channel blockers </li></ul></ul>
  28. 28. Questions
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