Chronic Coronary Syndrome ESC 2019.pptx

1. Dr. Mouhammad Al-Halabi MD, Department of Cardiology

6. Chronic coronary syndromes Six common scenarios at outpatient clinics Patientswith suspectedCAD and‘stable’ anginal symptoms, and/or dyspnoea Patientswithnew onsetofHForLV dysfunctionand suspectedCAD Patientswith stabilized symptoms<1 yearafteran ACSorpatients withrecent revascularization Patients>1year afterinitial diagnosisor revascularization Patientswith anginaand suspected vasospasticor microvascular disease Asymptomatic subjectsin whomCADis detectedat screening www.escardio.org/guidelines

17. Genders et al 2011 ESC SCAD 2013 guidelines Juarez-Orozco et al. EHJ CI 2019 ESC CCS 2019 guidelines In 2019 57% of pts with chest pain has PTP<15% Pre-test probability of coronary artery disease 2013  2019 Non-anginal pain Typical angina Atypical angina

25. Case Y-L: Female patient withchest pain during stress ©ESC • Female patient • Age 66 years • Atypical angina during stress www.escardio.org/guidelines PTP in in 2013 ESC Guideline: 28%

26. Case Y-L: Female patient with chest pain during stress ©ESC • Female patient • Age 66 years • Atypical angina • Family history of CAD +++ • Ex ECG Chest pain and 2.5 mm ST inf. leads @HR 164 bpm and MET 7.4 • LDL 3.0 • No smoking • No hypertension • No diabetes www.escardio.org/guidelines

27. Case Y-L: Female patient with chest pain during stress ©ESC • Female patient • Age 66 years • Atypical angina • Family history of CAD +++ • Ex ECG Chest pain and 2.5 mm ST inf. leads @HR 164 bpm and MET 7.4 • LDL 3.0 • No smoking • No hypertension • No diabetes www.escardio.org/guidelines

28. ©ESC Case Y-L: Female patient with chest pain during stress LAD D1 Recommendations Class Level Functional imaging for myocardial ischaemia is recommended if coronary CTA has shown CAD of uncertain functional significance or is not diagnostic. I B Invasive angiography is recommended as an alternative test to diagnose CAD in patients with a high clinical likelihood, severe symptoms refractory to medical therapy or typical angina at a low level of exercise, and clinical evaluation that indicates high event risk. Invasive functional assessment must be available and used to evaluate stenoses before revascularization, unless very high grade (>90% diameter stenosis). I B Invasive coronary angiography with the availability of invasive functional evaluation should be considered for confirmation of the diagnosis of CAD in patients with an uncertain diagnosis on non-invasive testing. www.escardio.org/guidelines IIa B What options guidelines gives?

29. ©ESC Case Y-L: Female patient with chest pain during stress www.escardio.org/guidelines Stress perfusion imaging using PET

30. ©ESC Case Y-L: Female patient with chest pain during stress www.escardio.org/guidelines Hemodynamically significant stenosis in large D1

44. Aims of Pharmacological Management • Reduce angina symptoms and exercise-induced ischaemia. • Prevent cardiovascular events. • Treatment that satisfactorily controls symptoms and prevents cardiac events. • With maximal patient adherence and minimal adverse events. Optimal Treatment

45. “Optimal” Anti-Ischaemic Treatment in CCS Patients • No universal definition of which drug/combination is “optimal” . • Anti-ischaemic drug therapies must be adapted to each patient’s characteristics and preferences. • Initial drug therapy usually consists of one or two antianginal drugs, as necessary, plus drugs for secondary prevention of CVD. – depends on expected tolerance related to the individual patient’s profile and comorbidities, – potential drug interactions with co-administered therapies, – patient’s preferences after being informed of potential adverse effects, – drug availability.

46. Padala SK, et al. J Cardiovasc Pharmacol Ther 2017;22:499-510

51. Clinical Case 55 y.o male Smoker, T2DM, dyslipidemia Anterior STEMI DES in LAD + RCA EF 45% Discharged with ASA + Ticagrelor Follow-up 1 y (CCS patient) No Smoking Cessation HBA1c 8.5% LDL chol 1.7 mmol/l with atorvastatin 40 mg No bleeding BARC 2 and above How To optimize event prevention ?

69. Clinical Case 55 y.o male Smoker, T2DM, dyslipidemia Anterior STEMI DES in LAD + RCA EF 45% Discharged with ASA + Ticagrelor Follow-up 1 y: No Smoking Cessation HBA1c 8.5% LDL chol 1.7 mmol/l with atorvastatin 40 mg No bleeding BARC 2 and above How To optimize event prevention ? Smoking cessation, appropriate life style Optimized antithrombotic strategy after 1Y Low bleeding risk /High ischemic risk Good drug tolerance Reach LDL objective: Increase statin +/- Ezetimibe Improve Diabetes control

73. Chow, et al. 2010; OASIS (n = 18809)

85. Follow-up Assessment Symptoms Function Prognosis

87. Long-standing diagnosis of CCS (>12 months) Antithrombotic therapy in CCS patients in sinus rhythm www.escardio.org/guidelines Recommendations Class Level Adding a second antithrombotic drug to aspirin for long-term secondary prevention should be considered in patients with a high risk of ischaemic events and without high bleeding risk IIa A Adding a second antithrombotic drug to aspirin for long-term secondary prevention may be considered in patients with at least a moderately increased risk of ischaemic events and without high bleeding risk IIb A High risk of ischemic events include diffuse multivessel CAD with at least one of the following: diabetes mellitus requiring medication, recurrent MI, PAD, or CKD with eGFR 15-59 mL/min/1.73 m2. Moderate risk of ischemic events include at least one of the following: multivessel/diffuse CAD, diabetes mellitus requiring medication, recurrent MI, PAD, HF or, CKD with eGFR 15-59 mL/min/1.73 m2. High bleeding risk include prior history of intracerebral haemorrhage or ischaemic stroke, history of other intracranial pathology, recent gastrointestinal bleeding or anaemia due to possible gastrointestinal blood loss, other gastrointestinal pathology associated with increased bleeding risk, liver failure, bleeding diathesis or coagulopathy, extreme old age or frailty, or renal failure requiring dialysis or with eGFR <15 mL/min/1.73 m2.

88. Long-standing diagnosis of CCS (>12 months) Decision-making on optional antithrombotic therapy www.escardio.org/guidelines Drug option Dose Indication Additional cautions Clopidogrel 75 mg o.d. Post-MI in patients who have tolerated DAPT for 1 year Prasugrel 10 mg o.d. or 5 mg o.d. if body weight <60 kg or age >75 years Post-PCI for MI in patients who have tolerated DAPT for 1 year Age >75 years Rivaroxaban 2.5 mg b.i.d. Post-MI >1 year or multivessel CAD Creatinine clearance 15-29 mL/min Ticagrelor 60 mg b.i.d. Post-MI in patients who have tolerated DAPT for 1 year Treatment options for dual antithrombotic therapy in combination with aspirin 75-100 mg daily are reported for patients who have a high or moderate risk of ischaemic events, and do not have a high bleeding risk.

89. Risk score(s) stratification e.g., ABC-CHD risk model Cardiovascular death at 1 year 24 www.escardio.org/guidelines 22 ABC-CHD score points 4 6 8 10 12 14 16 18 20 2 0 Age (A) Biomarkers (B) Clinical variables (C) Age NT-proBNP (ng/L) Smoking Hs-Troponin T (mg/L) Diabetes LDL Peripheral artery disease High discriminatory ability for CV death (c-index 0.81 in the derivation cohort [n=13,164], 0.78 in the validation cohort), with adequate calibration in both cohorts 0.001 0.005 0.01 0.02 0.03 0.05 0.1 0.2 0.3 0.5 Lindholm D, et al. J Am Coll Cardiol. 2017;70:813-826

90. Risk score(s) stratification e.g., ABC-CHD risk model www.escardio.org/guidelines

92. Patients with a long-standing diagnosis of chronic coronary syndromes Coronary anatomy definition in asymptomatic patients Recommendation Class Level In patients with mild or no symptoms receiving medical treatment in whom non-invasive risk stratification indicates a high risk, and for whom revascularization is considered for improvement of prognosis, invasive coronary angiography (with iwFR/FFR when necessary) is recommended. I C Invasive coronary angiography is not recommended solely for risk stratification. III C Coronary CTA is not recommended as a routine follow-up test for patients with established CAD. III C Asymptomatic www.escardio.org/guidelines

93. Patients with a long-standing diagnosis of chronic coronary syndromes Clinical evaluation in symptomatic patients www.escardio.org/guidelines Symptomatic Recommendation Class Level Invasive coronary angiography (with iwFR/FFR when necessary) is recommended for risk stratification in patients with severe CAD, particularly if the symptoms are refractory to medical treatment or if they have a high-risk clinical profile. I C Recommendation Class Level It is recommended to expeditiously refer patients with significant worsening of symptoms for evaluation. I C Reassessment of CAD status is recommended in patients with deteriorating LV systolic function that cannot be attributed to a reversible cause (e.g. long-standing tachycardia or myocarditis). I C Risk stratification is recommended in patients with new or worsening symptom levels, preferably using stress imaging or, alternatively, exercise stress ECG. I B

124. Final word on non-invasive tests • Mainstay diagnostic step in the 21st century • Can substitute FFR in decision making in patients with high clinical likelihood of CAD • Provides indications for revascularization in asymptomatic patients • Assessment in follow-up and patient response to treatment • Treatment success in testing for residual ischemia

125. Thank You

Chronic Coronary Syndrome ESC 2019.pptx

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