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

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. Vasospastic Angina Syndrome X Angina due to fixed coronary flow limitation Typical Angina Atypical Angina >70% Coronary Lesion(s) Intermediate Lesion(s) Angiographically Smooth

6. Angina 20.000 - 40.000 / 1.000.000

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

10. ¨ C ¨ evidence Impressionist medicine

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

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

16. Treatments aimed at Symptom Relief Betablockers, 1 st line treatment Contraindication or intolerant Insuficient control of angina / ischaemia Add Other option

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

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

19. EHS Stable angina BMJ 2006;332:262

20. PCI ESC Stable Angina Guidelines Eur Heart J 2006;27:1341

21. Revascularisation. PCI ESC Stable Angina guidelines 2006 (draft) CABG

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

24. NEJM 2007;356:1506 Optimal Medical Treatment

25. Optimal Medica therapyl vs Optimal Revascularization BARI 2D N Engl J Med 2009;360:2503-15

26. BARI 2D N Engl J Med 2009;360:2503-15 Optimal Medical Treatment

28. Full text www.escardio.org CME programs European National Local

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)

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

36. Gracias