Noon conference

1. Outpatient Management of Coronary
Artery Disease: Case Reviews
Gordon Kritzer MD FACC
Director, Cardiac Catheterization Laboratory and
Interventional Cardiology
Director, Cardiac Rehabilitation
Virginia Mason Medical Center

2. Case #1
• 65 yo male with 3-4 months exertional and
anxiety related chest tightness
• PMH +HTN, +FH of brother 64 CABG,
Chol 220
• Meds:HCTZ and Viagra
• ECG SR with borderline LVH & Tw
inversion V6
• What is initial therapy in office and what
tests to order?

3. Case #1
• Day # 1
 Add aspirin 81-325 mg a day
 Beta blocker
 Statin
 Nitroglycerin sl (NOT with VIAGRA!)
 Order stress test with imaging (echo or
sestamibi) due to baseline stt abn

4. Case #1
• Stress Test results:
 7 min Bruce protocol, mild chest tightness,
0.5-1 mm ST dep, normal BP/HR response
 Mild inducible inferoapical hypokinesis
• ?Cardiac catheterization
• What is optimal medical therapy?

5. Case #1
• Catheterization revealed 80% distal RCA
stenosis with normal flow and 30-40%
LAD and circumflex stenoses with normal
LVEF
• Initial Rx: Stent vs Medical Therapy?
• Did he need a catheterization?

6. Courage Trial
• 2287 patients with mild angina and CAD
documented by angiography with disease
which could be stented
• Ramdomized to stenting + Optimal
Medical therapy (OMT) vs OMT
• Followed out for 5 years (1999-2004)
• End point: all cause mortality and non fatal
MI

7. Boden WE et al. N Engl J Med 2007; available at:
http://www.nejm.org.
COURAGE: Cumulative event rates*
Outcome PCI
(%)
Medical
therapy
(%)
Hazard
ratio
95% CI p
Death, MI 19 18.5 1.05 0.87–1.27 0.62
Death, MI, stroke 20 19.5 1.05 0.87–1.27 0.62
Death 7.6 8.3 0.87 0.65–1.16 0.38
Nonfatal MI 13.2 12.3 1.13 0.89–1.43 0.33
Stroke 2.1 1.8 1.56 0.80–3.04 0.19
Hospitalization for
ACS
12.4 11.8 1.07 0.84–1.37 0.56
Revascularization
(PCI or CABG)
21.1 32.6 0.60 0.51–0.71 <0.001
*At a median of 4.6 years

8. COURAGE: Freedom from angina
Boden WE et al. N Engl J Med 2007; available at:
http://www.nejm.org.
Time point
(y)
PCI (%) Medical
therapy (%)
p
Baseline 12 13 NS
1 66 58 <0.001
3 72 67 0.02
5 74 72 NS

9. Dual Goals of Management of
Stable Ischemic Heart Disease
Prevent MI and Death (Disease Modification)
Improve “Quantity of Life”
Reduce Ischemia & Relieve Anginal Symptoms
Improve “Quality of Life”

10. Optimal Medical Therapy in the
Management of Ischemic Heart
Disease
•Lifestyle interventions
•Disease-modifying pharmacologic
therapy and secondary prevention
•Ischemic treatment and symptom
control

11. Optimal Medical Therapy in the
Management of Ischemic Heart Disease
Risk factor
Smoking
Total Dietary Fat/Sat Fat
Fish
Dietary cholesterol
Dietary Sodium
Physical Activity
Weight loss:Initial BMI 25-27.5
BMI >27.5
Blood Pressure
LDL
HDL
Diabetes
Goal
Cessation
<30% calories/<7% calories
>3 servings/week
<200 mg /day
<2000 mg/day
>30 min/day 5 days/week
<25
<10% relative wt loss
<130/80
<70 mg/dl
>40 mg/dl men >50 mg/dl women
Hemoglobin A1C <7%

12. Pharmacologic Therapy in SIHD in 2000
Disease Modifying
Therapy
• Aspirin
• Statin
• ACE Inhibitor or ARB
• Beta blocker post MI
Symptomatic Treatment
of Angina/Ischemia
Control
• Beta blocker without MI
• Calcium antagonists
• Nitrates

13. Pharmacologic Therapy in SIHD: Today
Disease Modifying
Therapy
• Aspirin
• Thienopyridines
• Statin
• ACE Inhibitor or ARB
• Beta blocker post MI
• Aldosterone Inhibitors
• ?Extended Release
Niacin
Symptomatic Treatment of
Angina/Ischemia Control
• Beta blocker without MI
• Calcium antagonists
• Nitrates
• Ranolazine

14. Case #2
• 43 yo male with +family history of 47 yo
brother requiring a stent
• No symptoms, exercises 4days/wk at gym
• Cholesterol 208, HDL 45 LDL 112
• No Hypertension, DM, or smoking
• ?Recommendations
 ?Tests-Stress test, Cor Calcium CT, CT
angio, CIMT
 ?Medications-?Statin for life

15. Case #3
• 76 yo male recent NSTEMI and LAD stent
 Also, 50% circumflex , 65% distal RCA, normal LVEF
• PMH: DM2, HTN and LDL 94
• Meds:ASA, Plavix, Metoprolol, lisinopril, glyburide
and simvastatin
• Recommendations
 Optimize risk factors-lipids, bp, dm, diet, exercise,
smoking, etc
 If chest pain, stress test early and cardiology consult
 Future stress tests ?timing
 ?Duration of Plavix therapy
• If heartburn not responsive to H2 blocker ?PPI