Guias ESC Angina Crónica Estable ¿Son relevantes? José López-Sendón Hospital Universitario La Paz. Madrid. Spain <ul><li>C...
<ul><li>Chronic Stable Angina </li></ul><ul><li>Chest pain </li></ul><ul><li>Secondary to myocardial ischemia </li></ul><u...
Circulation 2003;108:1263.  Kern MJ. In: Braunwald’s Heart Disease. 7th ed. 2005. Sigwart U et al. Silent Myocardial Ische...
Vasospastic Angina Syndrome X Angina due to fixed coronary flow limitation Typical Angina Atypical Angina  >70% Coronary L...
 
Angina 20.000 - 40.000 / 1.000.000
Knowledge/Science (Clinical trials) Education Marketing  <ul><li>Implementation </li></ul><ul><li>Tools </li></ul><ul><li>...
Knowledge/Science (Clinical trials) Education Marketing  <ul><li>Implementation </li></ul><ul><li>Tools </li></ul><ul><li>...
Source Value Evidence Clinical experience worthless C Surrogate terrible C Observation registry poor C Case control poor C...
¨ C ¨ evidence  Impressionist medicine
Knowledge/Science (Clinical trials) Education Marketing  <ul><li>Implementation </li></ul><ul><li>Tools </li></ul><ul><li>...
AIMS  of therapy 1  Immediate pain relief 2  Relief of symptoms, control of ischemia, improve functional class 3  Improve ...
<ul><li>Ischaemic Heart Disease: Therapeutic Options </li></ul><ul><li>Lifestile: Exercise, Diet, No smoking </li></ul><ul...
 
Contraindications Intolerant / contraindications Aspirin  75-150 mg od Statin ACEI  in proven CVD β-blocker  in post MI Cl...
Treatments aimed at Symptom Relief  Betablockers, 1 st  line treatment Contraindication  or intolerant Insuficient control...
Treatments aimed at  Symptom Relief  Betablockers, 1 st  line treatment Ca antagonists : Amlodipine: Low heart rate, HT   ...
Treatments aimed at Symptom Relief  Betablockers, 1 st  line treatment Contraindication  or intolerant Insuficient control...
EHS Stable angina BMJ 2006;332:262
PCI ESC Stable Angina Guidelines Eur Heart J 2006;27:1341
Revascularisation. PCI ESC Stable Angina guidelines 2006 (draft) CABG
Survival Free of Death from Any Cause and Myocardial Infarction Number at Risk Medical Therapy  1138  1017  959 834   638 ...
Freedom from Angina During Long-Term Follow-up The comparison between the PCI group and the medical-therapy group was sign...
NEJM 2007;356:1506 Optimal Medical Treatment
Optimal Medica therapyl vs Optimal Revascularization BARI 2D N Engl J Med 2009;360:2503-15
BARI 2D N Engl J Med 2009;360:2503-15 Optimal Medical Treatment
Knowledge/Science (Clinical trials) Education Marketing  <ul><li>Implementation </li></ul><ul><li>Tools </li></ul><ul><li>...
Full text www.escardio.org CME programs European National Local
What influence your decision in practice most SAPHE study: Internists and geriatricians Internist Geriatrician Cardiologis...
Knowledge/Science (Clinical trials) Education Marketing  <ul><li>Implementation </li></ul><ul><li>Tools </li></ul><ul><li>...
Knowledge/Science (Clinical trials) Education Marketing  <ul><li>Implementation </li></ul><ul><li>Tools </li></ul><ul><li>...
Knowledge/Science (Clinical trials) Education Marketing  <ul><li>Implementation </li></ul><ul><li>Tools </li></ul><ul><li>...
 
0 50 100 ACEI Rx Readmissions Treatment Rates (%) 1-year Mortality Pre-Intervention (n=11,038) Post-Intervention (n=8,045)...
<ul><li>Conclusions </li></ul><ul><li>Guidelines provide evidence based recommendations </li></ul><ul><li>Following guidel...
Gracias
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Angina crónica estable - Dr. José Luis López Sendón

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Angina crónica estable: La punta del iceberg de la cardiopatía isquémica crónica
Congreso de las enfermedades cardiovasculares
Barcelona 22/10/2009
Sociedad Española de Cardiología

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Angina crónica estable - Dr. José Luis López Sendón

  1. 1. Guias ESC Angina Crónica Estable ¿Son relevantes? José López-Sendón Hospital Universitario La Paz. Madrid. Spain <ul><li>Conflict of interest: Research support from: </li></ul><ul><li>Servier, BMS, Sanophy-Aventis, Lilly, Bayer, Roche, GKS, Menarini </li></ul>
  2. 2. <ul><li>Chronic Stable Angina </li></ul><ul><li>Chest pain </li></ul><ul><li>Secondary to myocardial ischemia </li></ul><ul><li>Not unstable </li></ul><ul><li>Recent onset </li></ul><ul><li>Progressive </li></ul><ul><li>Prolonged </li></ul><ul><li>Urgent admission to hospital (not really!) </li></ul>
  3. 3. Circulation 2003;108:1263. Kern MJ. In: Braunwald’s Heart Disease. 7th ed. 2005. Sigwart U et al. Silent Myocardial Ischemia. New York: Springer-Verlag; 1984: 29 Abnormalities evolving during ischaemia Magnitude of ischaemia Duration of ischaemia (sec) V entricular dysfunction ECG changes ANGINA Metabolic alterations Necrosis Sudden Death
  4. 4. Vasospastic Angina Syndrome X Angina due to fixed coronary flow limitation Typical Angina Atypical Angina >70% Coronary Lesion(s) Intermediate Lesion(s) Angiographically Smooth
  5. 6. Angina 20.000 - 40.000 / 1.000.000
  6. 7. Knowledge/Science (Clinical trials) Education Marketing <ul><li>Implementation </li></ul><ul><li>Tools </li></ul><ul><li>Programs </li></ul><ul><li>Quality controls </li></ul><ul><li>Implementation </li></ul><ul><li>- Surveys </li></ul><ul><li>Quality controls </li></ul><ul><li>Impact on outcome </li></ul><ul><li>- Trials-Euroaction-like </li></ul>Guidelines Recommendations Refinement
  7. 8. Knowledge/Science (Clinical trials) Education Marketing <ul><li>Implementation </li></ul><ul><li>Tools </li></ul><ul><li>Programs </li></ul><ul><li>Quality controls </li></ul><ul><li>Implementation </li></ul><ul><li>- Surveys </li></ul><ul><li>Quality controls </li></ul><ul><li>Impact on outcome </li></ul><ul><li>- Trials-Euroaction-like </li></ul>Guidelines Recommendations Refinement
  8. 9. Source Value Evidence Clinical experience worthless C Surrogate terrible C Observation registry poor C Case control poor C Small clinical trial well, … B Metaanalysis Good ? B Large clinical trial Good B ≥ 2 clinical trials Appropriate A Guidelines. What evidence ? JP Bassand Circa 2007
  9. 10. ¨ C ¨ evidence Impressionist medicine
  10. 11. Knowledge/Science (Clinical trials) Education Marketing <ul><li>Implementation </li></ul><ul><li>Tools </li></ul><ul><li>Programs </li></ul><ul><li>Quality controls </li></ul><ul><li>Implementation </li></ul><ul><li>- Surveys </li></ul><ul><li>Quality controls </li></ul><ul><li>Impact on outcome </li></ul><ul><li>- Trials-Euroaction-like </li></ul>Guidelines Recommendations Refinement
  11. 12. AIMS of therapy 1 Immediate pain relief 2 Relief of symptoms, control of ischemia, improve functional class 3 Improve prognosis ESC Stable Angina Guidelines Eur Heart J 2006;27:1341
  12. 13. <ul><li>Ischaemic Heart Disease: Therapeutic Options </li></ul><ul><li>Lifestile: Exercise, Diet, No smoking </li></ul><ul><li>Medication: Aspirin, Statin, BB, ACE-i, other </li></ul><ul><li>Revascularization </li></ul>
  13. 15. Contraindications Intolerant / contraindications Aspirin 75-150 mg od Statin ACEI in proven CVD β-blocker in post MI Clopidogrel Lower dose / alternative agent Treatments aimed at Improving Prognosis ESC Guidelines Stable Angina Eur Heart J. 2006; 27:1341
  14. 16. Treatments aimed at Symptom Relief Betablockers, 1 st line treatment Contraindication or intolerant Insuficient control of angina / ischaemia Add Other option
  15. 17. Treatments aimed at Symptom Relief Betablockers, 1 st line treatment Ca antagonists : Amlodipine: Low heart rate, HT Diltiacem, verapamil: Tach, HT Ivabradine : Heart rate > 70 b/m Nitrate / Nicorandil : General Option Ranolazine : Post ACS (no incluido en guias 2006) Contraindication or intolerant Insuficient control of angina / ischaemia Add Other option
  16. 18. Treatments aimed at Symptom Relief Betablockers, 1 st line treatment Contraindication or intolerant Insuficient control of angina / ischaemia Add Other option Consider revascularization if high risk or ischemia Not controlled Ca antagonists: Amlodipine: Low heart rate, HT Diltiacem, verapamil: Tach, HT Ivabradine : Heart rate > 70 b/m Nitrate / Nicorandil : General Option Ranolazine : Post ACS
  17. 19. EHS Stable angina BMJ 2006;332:262
  18. 20. PCI ESC Stable Angina Guidelines Eur Heart J 2006;27:1341
  19. 21. Revascularisation. PCI ESC Stable Angina guidelines 2006 (draft) CABG
  20. 22. Survival Free of Death from Any Cause and Myocardial Infarction Number at Risk Medical Therapy 1138 1017 959 834 638 408 192 30 PCI 1149 1013 952 833 637 417 200 35 Years 0 1 2 3 4 5 6 0.0 0.5 0.6 0.7 0.8 0.9 1.0 PCI + OMT Optimal Medical Therapy (OMT) Hazard ratio: 1.05 95% CI (0.87-1.27) P = 0.62 7 NEJM 2007;356:1506
  21. 23. Freedom from Angina During Long-Term Follow-up The comparison between the PCI group and the medical-therapy group was significant at 1 year ( P<0.001) and 3 years (P=0.02) but not at baseline or 5 years. NEJM 2007;356:1506 PCI + OMT OMT Angina free – no. <ul><ul><li>Baseline </li></ul></ul>12% 13% <ul><ul><li>1 Yr </li></ul></ul>66% 58% <ul><ul><li>3 Yr </li></ul></ul>72% 67% <ul><ul><li>5 Yr </li></ul></ul>74% 72%
  22. 24. NEJM 2007;356:1506 Optimal Medical Treatment
  23. 25. Optimal Medica therapyl vs Optimal Revascularization BARI 2D N Engl J Med 2009;360:2503-15
  24. 26. BARI 2D N Engl J Med 2009;360:2503-15 Optimal Medical Treatment
  25. 27. Knowledge/Science (Clinical trials) Education Marketing <ul><li>Implementation </li></ul><ul><li>Tools </li></ul><ul><li>Programs </li></ul><ul><li>Quality controls </li></ul><ul><li>Implementation </li></ul><ul><li>- Surveys </li></ul><ul><li>Quality controls </li></ul><ul><li>Impact on outcome </li></ul><ul><li>- Trials-Euroaction-like </li></ul>Guidelines Recommendations Refinement
  26. 28. Full text www.escardio.org CME programs European National Local
  27. 29. What influence your decision in practice most SAPHE study: Internists and geriatricians Internist Geriatrician Cardiologist Guidelines 27% 9 R - 41 NL 32% 9 R - 53 NL Expert opinion 31% 21 UK,S - 47 R 30% 19 S - 40 S Articles 11% 29% Health care authorities 6% 1 -19 F,S 4% (0 - 14 F,S)
  28. 30. Knowledge/Science (Clinical trials) Education Marketing <ul><li>Implementation </li></ul><ul><li>Tools </li></ul><ul><li>Programs </li></ul><ul><li>Quality controls </li></ul><ul><li>Implementation </li></ul><ul><li>- Surveys </li></ul><ul><li>Quality controls </li></ul><ul><li>Impact on outcome </li></ul><ul><li>- Trials-Euroaction-like </li></ul>Guidelines Recommendations Refinement
  29. 31. Knowledge/Science (Clinical trials) Education Marketing <ul><li>Implementation </li></ul><ul><li>Tools </li></ul><ul><li>Programs </li></ul><ul><li>Quality controls </li></ul><ul><li>Implementation </li></ul><ul><li>- Surveys </li></ul><ul><li>Quality controls </li></ul><ul><li>Impact on outcome </li></ul><ul><li>- Trials-Euroaction-like </li></ul>Guidelines Recommendations Refinement Need & Opportunity
  30. 32. Knowledge/Science (Clinical trials) Education Marketing <ul><li>Implementation </li></ul><ul><li>Tools </li></ul><ul><li>Programs </li></ul><ul><li>Quality controls </li></ul><ul><li>Implementation </li></ul><ul><li>- Surveys </li></ul><ul><li>Quality controls </li></ul><ul><li>Impact on outcome </li></ul><ul><li>- Trials-Euroaction-like </li></ul>Guidelines Recommendations Refinement
  31. 34. 0 50 100 ACEI Rx Readmissions Treatment Rates (%) 1-year Mortality Pre-Intervention (n=11,038) Post-Intervention (n=8,045) 18* 23 65 95* 38* 46 Intermountain Health Care: 10 Hospitals Pre- 1/96-12/98 n=11,038 to 1/99-3/00 n=8,045. Pearson. Circulation. 2001;104:II-838. HR 0.80 P <0.0001 HR 0.77 P <0.0001 Institutional heart failure discharge medication program reduces readmissions and mortality
  32. 35. <ul><li>Conclusions </li></ul><ul><li>Guidelines provide evidence based recommendations </li></ul><ul><li>Following guidelines improve outcomes? </li></ul><ul><li>New information needed </li></ul><ul><li>Implementation tools needed </li></ul><ul><li>Update of guidelines needed </li></ul>
  33. 36. Gracias

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