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ARIOPS ARIOPS 2013 Conference and Annual General Meeting Cardiac ischaemia, irregularities and interventions Diana Gorog Prof. Diana Gorog MB BS, MD, PhD, FRCP General Clinical Cardiology Update DirectorCardiologist for Cardiology2013 Consultant Consultant Cardiologist [email protected] [email protected] [email protected] Cardiac ischaemia, irregularities and interventions • Angina • Arrhythmias- risk stratification • AF Coronary artery disease • No.1 cause of death in the Western world • ~52,000 new cases of angina in men and ~43,000 new cases in women in UK per annum • CAD deaths falling, but – morbidity increasing! – So…more of them in the workplace. 3 Atherothrombosis: An Interaction Between Lipids, Inflammation, and Thrombosis Lipid-filled Lipid-filled plaque plaque Ruptured plaque Ruptured plaque with thrombus with thrombus 1 1 2 2 Early atherothrombosis Early atherothrombosis 3 3 4 4 5 5 2 Adapted with permission from Libby P. Sci Am. 2002;286:46-55. STRIVE TM Stable angina Implementing NICE guidance July 2011 NICE clinical guideline 126 Anti-anginal drug treatment 1. Beta blocker (e.g. bisoprolol 2.5mg o.d.) 2. Calcium channel blocker (e.g. tildiem LA 200mg o.d.) 3. Isosorbide (e.g. ISMN SR 60mg o.d.) 4. Nicorandil 10mg b.i.d. 5. 4/5th line agents (to be initiated in secondary care)1. Ranolazine 2. Ivabradine Investigation and revascularisation Consider CABG or PCI Investigation and revascularisation When symptoms are not controlled with optimal medical treatment: When either procedure appropriate, explain risks vs. benefits of PCI and CABG for anatomically less complex disease. If no preference, PCI may be more cost effective procedure. Investigation and revascularisation When symptoms are not controlled with optimal medical treatment: If either appropriate, consider potential survival advantage of CABG over PCI for people with multivessel disease who: – have diabetes or – > 65 years or – anatomically complex 3vessel disease, ± LMS involvement. Investigation and revascularisation When symptoms are controlled with medical treatment: Consider CABG or PCI to see if revascularisation indicated Investigation and revascularisation When symptoms are controlled with medical treatment: Answer to each box must be ‘YES’ to proceed Discuss prognosis, likelihood of having left main stem or proximal threevessel disease, the process and risks of investigation, the benefits and risks of CABG with person with stable angina and check they are happy to proceed? Consider a functional or non-invasive test to identify people who might gain a survival benefit from revascularisation? Tests indicate extensive ischemia or likelihood of left main stem or proximal 3-vessel disease? Revascularisation acceptable and appropriate? Consider PCI, or CABG if coronary angiography indicates left main stem or proximal 3-vessel disease Exercise ECG • Sensitivity ~ 70% • Specificity ~ 70% • Markedly influenced by: – Population studied – Diagnostic criteria • Test performs worse in women than in men • Contra-indications – AS – LBBB – Uncontrolled severe HTN Stress echocardiography • Exercise • Dobutamine (+ atropine) • Sensitivity 85-95% • Specificity 80-95% • Improved in populations with higher prevalence of multivessel CAD Thallium Scan (a.k.a. myocardial perfusion scan, MPS) Normal Abnormal Sensitivity 85-90% Prognostic/predictive value of Stress echo or MPS • A stress echo or MPS has a sensitivity of 80-95% in detecting flow limiting CAD • A normal stress echo yields an annual risk of 0.40.9%, implying excellent prognosis and v low rate of events, even without revascularization • In patients with ischemic LV dysfunction and a significant amount of viable myocardium have lower peri-op mortality, and improved survival and reduced HF after revascularization PALPITATIONS PALPITATIONS Palpitations • Common presentation in General Practice • Significant social impact • Often benign cause • Associated with considerable morbidity • Nevertheless potentially lethal • Chapter 8 of NSF for CHD 20 Arrhythmia from a Patient Perspective • “I know something's wrong but nobody takes me seriously” • “My heart keeps missing beats (and I am really worried I am going to die)” • Less than 10% of patients will have a significant arrhythmia 21 Which patient is at clinical risk? When are palpitations likely to be an arrhythmia? High Positive Predictive Value of : • Symptoms assoc. with syncope • Symptoms during exercise • Symptoms disturbing sleep • Regular palpitations High Pre test odds or red flags: •Known Structural heart Disease •Family history SCD •Personal Hx Syncope •Male •Increased age 24 Characteristic ECG abnormalities associated with increased risk of/with arrhythmia: • • • • • Evidence of an old myocardial infarction. – Pathological Q waves – Inversion of T waves – Loss of R wave progression across the chest leads following an anterior MI. Left ventricular hypertrophy. Right ventricular hypertrophy. Evidence of Wolff–Parkinson–White syndrome – Short PR interval. – Slight widening of the QRS: delta wave with normal terminal QRS segment. – Dominant R wave in V1. – Inverted T waves in V1 – V4. Prolonged QT – Calculate the corrected QT (QTc) by dividing the QT/√R-R interval. – Normal <0.45. Palpitations: Workup • Good history (inc. past medical & FH) • Check FBC, U&E and thyroid function • 12 lead ECG • 24 hour Holter monitor • Ambulatory ECG – Continuous loop event recorder – Event recorders with auto-activation (features of both Holter and event recorder) (e.g. Novacor) • Echocardiogram • Treadmill test (for sxs with or after exercise) • Implantable loop recorder • E.P. testing Ambulatory ECG recording Implantable loop recorders – Combined arrhythmia detection and patient activation – Up to 3 years – Device can be interrogated and data downloaded multiple times “Reveal” interrogation Echo • LV dysfunction – Scar – Ischaemic – other • LVH • Valvular disease • Cardiomyopathy – HCM – Dilated – arrhythmogenic MRI • If – Malignant arrhythmia of unknown cause – Frequent RVOT ectopy suggestive of runs – Relevant FHx SCD • • • • • Scar (small) Features of ARVC Sarcoid Amyloid HCM Coronary Angiogram • Assessment of VT – More often scar – Ischemia may be important in 30% cases VT scar VF ischaemia Which people with palpitations should I refer? • Following initial assessment refer all people with: – Risk factors for a serious arrhythmia: • A family history of sudden cardiac death below the age of 40 years. • Presence of major structural heart disease. – A major ECG abnormality. – Symptoms of ventricular tachycardia or supraventricular tachycardia – WPW – Symptoms of serious complications from arrhythmias. • Following ambulatory monitoring, refer people with proven: – Ventricular tachycardia – Supraventricular tachycardia – Atrial flutter – PAF if needing ablation AF – a modern epidemic AF – a modern epidemic Heeringa J et al. Eur Heart J 2006;27:949–53; Miyasaki Y et al. Circulation 2006;114:119–25 AF management Identification Symptoms Opportunistic screening Assessment & modification of risk Anticoagulation (?? Rhythm control) Arrhythmia management Rate control Rhythm control Annual % risk of stroke without antithrombotic therapy is… CHADS2 Score Stroke Risk % 95% CI 0 1.9 1.2 – 3.0 1 2.8 2.0 – 3.8 2 4.0 3.1 – 5.1 3 5.9 4.6 – 7.3 4 8.5 6.3 – 11.1 5 12.5 8.2 – 17.5 6 18.2 10.5 – 27.4 The CHADS2 method for estimating stroke risk was validated by a cohort study of 1,733 nonrheumatic atrial fibrillation patients aged 65 to 95 who were tracked through Medicare claims. The patients were not given antithrombotic therapy, such as the anticoagulant warfarin or aspirin. Refinement of stroke assessment in relatively low risk groups Camm AJ, Kirchhof P, Lip GY, et al., Guidelines for the management of atrial fibrillation (ESC), Eur Heart J, 2010;31:2369–429. CHA2DS2 - VASc Risk Scoring for AF patients and Thromboprophylaxis Guidelines (ESC)1 Score 0 Risk Low Considerations Aspirin daily or no antithrombotic therapy Preferred: No antithrombotic therapy 1 Moderate Oral anticoagulant or Aspirin daily Preferred: Oral anticoagulant therapy 2 or more Moderate High / Oral anticoagulant therapy 1. Camm et al, 2010 AF management: Rate & rhythm control RATE CONTROL RHYTHM CONTROL RATE OR RHYTHM CONTROL? Drug therapy for Rhythm Control Drug therapy for Rhythm Control Composite Mortality J Am Coll Cardiol 2011;58:1975–85 Last 2 years – disappointing results with promising AAD • Dronedarone • Amiodarone • Cerivarone Can we improve on what can be achieved using these strategies? • Yes – role of ablation Rationale for ablation of AF • Increased morbidity & possibly mortality with AAD • Wish to correct the negative effects of AF on: – – – – – General AF symptoms Quality of life Heart function (esp. in pts with HF) Stroke risk Survival • Ablation makes sense – it targets the mechanisms of AF: – Initiators (PV triggers) – Substrate (macro and micro-reentry, rotors) 2010 ESC GUIDELINES • • European Society of Cardiology Guidelines for the management of atrial fibrillation. 2010 Role of AF ablation • Second line of treatment in patients with symptomatic AF who have failed, or have failed to tolerate treatment with at least one class Ic or class III drug – Class I (Level of evidence A) indication in paroxysmal – Class IIa persistent – Class IIb long-standing persistent • First line of treatment in patients with symptomatic AF in whom AAD have not been tried – IIa paroxysmal – IIb other Calikins et al. J Interv Card Electrophysiol (2012) 33:171–257 2012 HRS-EHRA-ECAS expert consensus statement for AF Targets for AF ablation Ablation strategies Ablation results • Depend on: – Pattern of AF (paroxysmal vs. persistent vs. longlasting persistent) – Comorbidity – Concomitant use of AAD – Number of ablations AF Ablation non-randomised comparison with medical Rx AF-free Survival 78 vs. 37% at 3yrs (p<0.001) Pappone et al. JACC 03 AF Ablation non-randomised comparison with medical Rx • Quality of life Quality of life Physical (SF-36) Mental (SF-36) Pappone et al. JACC 03 DOES ABLATION AFFECT PROGNOSIS? Rationale for ablation of AF • Prognostic benefit? • Comparison of: – 4,212 consecutive pts who underwent AF ablation – 16,848 age/gender matched controls with AF (no ablation) – 16,848 age/gender matched controls without AF Bunch et al. JCE 2011 Rationale for ablation of AF • Prognostic benefit? • Death Conclusion: “AF ablation patients have a significantly lower risk of death, stroke, and dementia in comparison to AF patients without ablation. AF ablation may eliminate the increased risk of death and stroke associated with AF” CVA Bunch et al. JCE 2011 (e-pub ahead of print) AF ablation • Can long-term freedom from AF be achieved? Comparison of AF ablation vs. AAD in randomised trials Study Patients Age (y) (n) Type of AF Previous use of AAD • Randomised studies Ablation technique Repeat Crossed to ablation in the ablation in the ablation group AAD group Krittayaphong 2003 55+/-10 (ablation) Paroxysmal, 30 47 +/- 15 (AAD) Persistent >1 PVI + LA lines + CTI ablation + RA lines Not stated Wazni 2005 53+/-8 (ablation) 70 54+/-8 (AAD) No PVI Paroxysmal, persistent >2 PVI + LA lines +/- CTI ablation No exact data Persistent >1 (mean 2.1+/-1.2) CPVA >2 (mean 2+/-1) CPVA + CTI ablation Stabile 2005 62+/-9 (ablation) 245 62+/-10 (AAD) Mainly paroxysmal Oral 2006 245 57+/-9 Pappone 2006 55+/-10 (ablation) 198 57+/-10 (AAD) Paroxysmal Jais 2008 Forleo 2008 112 51+/-11 63+/-9 (ablation) 70 65+/-6 (AAD) 40% 49% 87% 37% 57% 56% 9% 77% 74% 4% 42% 86% 22% 89% 23% 80% 43% 66% 16% 69.9% 7.3% >1 >1 Packer 2010 79% Not stated 19% within Cryo-PVI +/- 90 days after LA lines 1st procedure Paroxysmal, persistent 56.7 (ablation) 56.4 245 (AAD( Paroxysmal AAD >1 (mean 1.3) >1 55.5(ablation) 56.1 167 (AAD) Paroxysmal 26% for AF, 6% for LA flutter 6% for AF 3% for LA tachycardia Ablation PVI +/- LA Mean 1.8 +/lines +/- CTI 0.8 median 2 ablation per patient 63% PVI +/- LA lines +/- CTI ablation Not stated Not stated PVI +/- LA lines +/CFAEs +/- CTI 12.6% within ablation +/- 80 days after RA lines 1st procedure 59% Paroxysmal Wilber 2010 12% Freedom from AF at 1 year 79% PAROXYSMAL AF – long term success Single procedure success rate Multiple procedure success rate* 171 patients, all paroxysmal, recruited between 2003-4; *after median of 1 (1-3) procedures Ouyang et al. Circulation. 2010;122:2368-2377. Longer-term outcome Arrhythmia-free survival Single procedure success rate – 87% - 1 year – 81% - 2 years – 63% - 5 years Weerasooriya, … Haissaguerre & Jais. JACC 2011:57;160-6 AF management: summary – Virtually no AAD improves prognosis due to the risk of pro-arrhythmia – Catheter ablation: • • • is vastly superior to AAD in terms of maintenance of SR Is vastly superior to AAD in achieving symptom control/QOL Avoids the risk of pro-arrhythmia and may improve prognosis Summary • Angina • tests of ischemia burden and their prognostic usefulness • role of revscularisation • Arrhythmia • Risk profiling • AF management- role of ablation Thank you for your attention