Lecture presented by Dr. Dev Pahlajani at the ACS Conference on Stable Ischemia Heart Disease, Mumbai, 2015

1. STABLE ISCHEMIC HEART
DISEASE-
HOW IS IT DIFFERENT
FROM ACS..?
DEV PAHLAJANI
MD, FACC, FSCAI
HOD Interventional Cardiology
Breach Candy Hospital, Mumbai

2. SIHD – VS – ACS / AMI
 Stable ischemic heart disease (SIHD), Acute coronary
syndrome (ACS): Product of same atherosclerosis (ATH)
Process
 Symptoms And Clinical Presentations
 Prognosis Indices
 Therapeutic Approach

3. PHASES OF ATHEROSCLEROSIS

4. THE TIME COURSE OF ATHEROSCLEROSIS

5. ACUTE INF MI LM
• 82 years male
• Mild hypertension, diabetes mellitus
• Inferior wall myocardial infarction (MI) 1994 ps stent mid
right coronary artery (RCA)
• Acute MI 8hrs duration
• Tenecteplase
• Transferred

6. Stable
Ischemic
Heart
Disease
Stable
Coronary
Heart
Disease
Physiology
CAD
+
Non
CAD-Ischemia
Anatomy -
Coronary Artery Disease
USA
Literature
British Literature

7. MP BNH INF MI LM

8. MP BNH INF MI LM

9. PLAQUE CHARACTERIZATION
PATHOPHYSIOLOGY

10. • RS 65 years Male
• Anterior MI
• Tenecteplase 3HRS.

11. Role of fibrous cap:
adapt. from Libby P, Circulation 91 (1995)
APPEARANCE OF
ATHEROSCLEROTIC PLAQUES
lumenlumen lipid-
corelipid-
core
media
fibrous cap
"shoulder region"
"stable" plaque "vulnerable" plaque

12. CT ATTENUATION CLASSIFICATION OF PLAQUE

13. CT COR ANGIO MIXED PLAQUE

14. PLAQUE CHARACTER
 Correlation of coronary plaque composition on multi-scale computed tomography with
clinical presentation with acute coronary syndromes as compared with stable coronary
artery disease (plaque level logistic regression analysis with the application of generalized
estimating equation method).
Plaque
Characteristics
ACS
(plaque n=179)
Stable CAD
(plaque n=118)
OR
(95%CL)
P-value
Number of non-calcified
plaques
57 (32%) 14 (12%) 3.9
(1.6-9.5)
0.003
Number of mixed plaques 105 (59%) 32 (27%) 3.4
(1.6-6.9)
0.001
Number of Calcified
plaques
17 (9%) 72 (61%) 0.06
(0.02-0.2)
<0.001

16. Why most patients are asymptomatic?

17. PATHOPHYSIOLOGICAL CHARACTERISTICS
OF VULNERABLE PLAQUES
Danger !Large lipid core
Low smooth muscle cells
Thin fibrous cap
High macrophages
fom Davies, Circulation 94 (1996)
Factors needed to produce a vulnerable plaque:

18. HEALED
THROMBUS
HEALED
O2 SUPPLY O2 DEMAND

19. CORONARY – BLOOD FLOW STENOSIS

20. THE POSSIBLE SEQUENTIAL CHANGES OF
ATHEROSCLEROTIC ARTERY ( BASED ON THE
POSTMORTEM ANALYSIS OF 136 LMCA )
Glagov S, et al. NEJM 1987;316;1371-53.
Early Phase : Overcompensation
Vss Enlargement > Plaque Accumulation
Late Phase : Decompensation
Vs Enlargement < Plaque Accumulation

21. Risk stratification
ACS VS SIHD

25. 4.7
8.3
13.2
19.9
26.2
40.9
0
10
20
30
40
50
60
0/1 2 3 4 5
TIMI Risk Score for UA/NSTEMI
D/MI/URby14Days(%)
Antman RM et al JAMA 2000, 284, 835
% Population 4.3 17.3 32.0 29.3 13.0 3.4
6-7
SABATINE AND ANTMAN
TIMI RISK SCORE FOR UA/NSTEMI

26. TACTICS – TIMI 18
12.8
16.1
19.5
11.8
20.3
30.6
0
5
10
15
20
25
30
35
Low (0-2) Intermed (3-4) High (5-7)
TIMI Risk Score for UA/NSTEMI
D/MI/ACSby6months
INV CONS
New Eng. J. Med, 2001, 344 : 1879
21 % risk reduction
(p=0.048)
36 % risk reduction
(p=0.018)

27. SELF REPORTED ANGINA, STRESS ECHO-937
PTS MEAN FOLLOW UP 3.9 YRS
Survival rate free of myocardial infarction or coronary heart disease death by presence of
weekly angina or inducible ischemia at baseline, adjusted for age, sex, race, history or
myocardial infarction, history of congestive heart failure, glycosylated hemoglobin level,
creatinine clearance, left ventricular ejection fraction, systolic blood pressure, and
diastolic blood pressure (p < .001).

28. TROPONINS SIHD NEJM,2009,2361,26,2538

29. Hs Trop SIHD N Eng J Med 2009,2361,26,2538

30. TREATMENT OF SIHD

31. ASPIRIN IN SIHD
REACH REGISTRY JACC 2014,63,12
1. No prior ischemic event (n=13,091)
OUTCOME EVENTS (%) HR P VALUE
All-cause death,
MI or stroke
980 (7.5%) 1.11 0.13
All-cause death,
MI, stroke or Bleeding
1040 (7.9%) 1.12 0.10
CV death, MI or stroke 597 (4.6%) 1.18 0.06
All-cause mortality 775 (5.9%) 0.97 0.74
CV mortality 382 (2.9%) 0.97 0.76
Nonfatal MI 125 (1.0%) 1.23 0.34
Nonfatal stroke 102 (0.8%) 1.86 0.0039

32. REACH REG : NO PREVIOUS MI BENEFIT
ONLY IN PATIENTS WITH PRIOR MI
JAMA 308, 1340, 2012

33. CAD PROGNOSTIC INDEX
Extent of CAD Prognostic
Weight
(0-100)
5 – Year
Survival
Rate (%)*
1-vessel disease, 75% 23 93
1-vessel disease, 50% to 74% 23 93
1-vessel disease, ≥ 95% 32 91
2-vessel disease 37 88
2-vessel disease, both ≥ 95% 42 86
1-vessel disease, ≥ 95% proximal LAD artery 48 83
2-vessel disease, ≥ 95% LAD artery 48 83
2-vessel disease, ≥ 95% proximal LAD artery 56 79
3-vessel disease 56 79
3-vessel disease, ≥95% in ≥1 vessel 63 73
3-vessel disease, 75% proximal LAD artery 67 67
3-vessel disease, ≥95% proximal LAD artery 74 59

34. CURRENT TREATMENT FOR
CORONARY ARTERY DISEASE
7% 2%
91%
PCI CABG Medical
Current treatment breakdown for 15 million Americans
with self-reported coronary artery disease.
JACC 2007, 50, 16, 1598

35. TRENDS IN PCI BEFORE THE COURAGE
TRIAL
Population
Based Rates
of PCI by
Year in
Hospital
Referral
Regions
(HRRs) With
Cardiac
Hospitals
Years
Rateper10,000
JAMA. 2007;297(9):962-968.

36. Changes in Geographic Variation in the
Use of Percutaneous Coronary
Intervention for Stable Ischemic Heart
Disease After Publication of the Clinical
Outcomes Utilizing Revascularization
and Aggressive Drug Evaluation
(COURAGE) Trial
by Arun V. Mohan, Reza Fazel, Pei-Hsiu Huang, Yu-Chu Shen,
and David Howard
Circ Cardiovasc Qual Outcomes
2014;7:125-130

37. Quarters
PercentByIndication
Courage March 2007
P value <0.01
Among the stable angina patient population, there was a peak 25% decline
in percutaneous coronary intervention (PCI) for stable angina after COURAGE
relative to pre-COURAGE Quarter 1 2006. Change was maintained through June 2009.
Circulation: Cardiovascular Quality and Outcomes.2011; 4: 300-305

38. A
Circulation: Cardiovascular Quality and Outcomes.2011; 4: 300-305
There was a significant decline in total percutaneous coronary intervention (PCI)
volumes over the study period from January 2006 to June 2009.
Quarters
NumberofPCIs
P value <0.01

39. LESSONS FROM COURAGE TRIAL
N Engl J Med. 2007;356:1503-1516

40. PCI outcomes in Patients with Stable
Obstructive Cor. Art Disease Meta
analysis
• Five trials –5286 patients
• Ischemia by stress testing, echo, nuclear, FFR
• 231 days-5yrs follow up-median 5 yrs.
Stergiopoulos et al. JAMA Int. Med 2014

41. Stergiopoulos K, et al. . JAMA Intern Med. 2014
Percutaneous Coronary Intervention Outcomes in Patients With
Stable Obstructive Coronary Artery Disease and Myocardial
Ischemia A Collaborative Meta-analysis of Contemporary
Randomized Clinical Trials

42. Percutaneous Coronary Intervention Outcomes in Patients
With Stable Obstructive Coronary Artery Disease and
Myocardial Ischemia A Collaborative Meta-analysis of
Contemporary Randomized Clinical Trials
In patients with stable CAD and objectively documented
myocardial ischemia,PCI with MT was not associated with a
reduction indeath, nonfatal MI, unplanned revascularization,
or angina compared with MT alone.
Stergiopoulos K, et al. . JAMA Intern Med. 2014

43. Meta analysis
• 67 Hospital referral regions examined for PCI
changes in SIHD before 2006 and after 2008
• COURAGE Trial 2007
• 272659 PCI’s from 526 hospital in SIHD
• After COURAGE, PCI’s volume declined by 25%
for SIHD vs 12% for ACS (p = 0.001)
– Highest decline was 35% in highest tertile vs 18%
in lowest tertile
Circ Cardiovasc Qual Outcomes, Feb 2014 Vol 7(1):125-130

44. Changes in Geographic Variation in the Use of Percutaneous
Coronary Intervention for Stable Ischemic Heart Disease After
Publication of the Clinical Outcomes Utilizing Revascularization and
Aggressive Drug Evaluation (COURAGE) Trial
• Substantial decline in the number of PCI
for stable ischemic heart disease (SIHD)
• Decline was also observed for PCI for acute
coronary syndrome (ACS)
• Changes in the numbers were strikingly
observed in the post COURAGE trial period
• Greater change in the hospitals with high
levels of utilization of PCI
Mohan A et al. Circ Cardiovasc Qual Outcomes 2014;7:125-130

45. Changes in Geographic Variation in the Use of Percutaneous Coronary
Intervention for Stable Ischemic Heart Disease After Publication of
the Clinical Outcomes Utilizing Revascularization and Aggressive Drug
Evaluation (COURAGE) Trial
• PCI volume declined by 25% (p<0.001) for
SIHD
• Procedures performed for ACS decreased
by12% (p<0.001)
• Those with the highest utilization pre
COURAGE had the maximum decline
• 35% decline in highest tertile versus 18 %
in lowest
Mohan A et al. Circ Cardiovasc Qual Outcomes 2014;7:125-130

46. Changes in Geographic Variation in the Use of Percutaneous Coronary
Intervention for Stable Ischemic Heart Disease After Publication of the
Clinical Outcomes Utilizing Revascularization and Aggressive Drug
Evaluation (COURAGE) Trial
Circ Cardiovasc Qual Outcomes, 2014 Vol 7(1):125-130
There was a substantial decline in the use of
and geographic variation in PCI for SIHD
after the publication of the COURAGE trial.
However, geographic variation in the use
of PCI for SIHD remained high.

47. Changes in Geographic Variation in the Use of Percutaneous
Coronary Intervention for Stable Ischemic Heart Disease After
Publication of the Clinical Outcomes Utilizing Revascularization
and Aggressive Drug Evaluation (COURAGE) Trial
The decline in geographic variation could indicate that
many low risk SIHD patients who could have been
managed with OMT were the subjects of referrals for PCI

48. Decline in the PCI numbers for SIHD
and geographic variation
Reasons :
• Compelling results of COURAGE trial
• Adherence to appropriateness criteria
• guidelines
• Reimbursement schedules by the insurance companies
• Media attention as regards to the overuse of the stents

49. JACC

50. Elective Cor. Angio
• 76 Card. Cath Labs
• 2007-2010
• 22538 elective cor angio
• 4829 (21.4%) normal

51. VARIATIONS IN COR ANGIO IN SIHD
JACC 63,5,2014

52. CONCLUSIONS
• Athero basis of SIHD and ACS
• Changes in symptoms and prognosis due to
pathophysiological process
• Generally SIHD has good short and medium term prognosis
• Beta blockers beneficial only in prior MI
• Aspirin effective if prior ischaemia
• Surgery not indicated in majority
• Treatment should be directed to plaqe
regression/passivisation