Download Geriatric Cardiology – You CAN treat Angina! Part 2

• Goal: Prevention of recurrent events
• Life style changes – exercise, smoking,
weight
• Hypertension
• Diabetes
• Aspirin
• ACE/ARB
• Influenza vaccine
• LIPID LOWERING - CONTROVERSIAL
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Ref: Electronic Publication. Braunwald’s Heart Disease
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• Benefits in most trials did
not start for 3-5 years
• TNT – excluded patients
above the age of 75
• High dose statins may be
associated with more
myopathy: CKD, old
age, Frailty, Multisystem
disease, Drug
interactions
• ? Use the lowest
effective dose.
Angina 2012
TREATING TO NEW
TARGETS
N ENGL J MED 2005; 352:
1425
3
NITROGLYCERI
N
BETA
BLOCKER
CALCIUM
CHANNEL
BLOCKER
IMPROVE
SUPPLY
++
-
+
LOWER
DEMAND
++
++++
++
ACUTE BENEFIT
+++
++
++
CHRONIC
BENEFIT
+/-
+++++
++
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• Mechanism: NO contributor, vasodilate
• Physiology: Reduce preload, afterload,
Dilate collaterals, counteract spasm
• Action: Rapid onset
• Administration: iv, sl, buccal, topical, (PO)
• Limitations
– Tachyphylaxis rapidly develops
– Hypotension, tachycardia
• MAINSTAY FOR ALL PATIENTS WITH
ANGINA
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• Postural hypotension
– Rapid absorption with Isosorbide dinitrate
– Interaction with alpha blockers (BPH in men)
– Bradycardia
– Volume depletion
• Approaches
– Isosorbide mononitrate
– Topical nitrates
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• Mechanism: Competitive inhibition at beta
1 and beta 2 receptors
• Physiology: Reduce demand through
slower heart rate, lower BP, and reduced
contractility
• Action: Variable onset, usually slow
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• Pitfalls in Elderly
– Titrate to resting heart rate – sick sinus
syndrome
• ? Role of pacemaker for therapy
– Inadequate doses to achieve reduced
contractility
– Short actions of drugs – metoprolol, atenolol –
multiple dosing.
– CNS penetration – lipophilic
• Favor nadolol, atenolol
• Only anti-anginal with evidence for
prolonging life in patients post MI
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• Mechanism: Vascular Smooth muscle
relaxation and reduced contractility
• Physiology:
– Demand reduced by reducing BP, contractility,
and heart rate (for some)
– Supply improved by blocking spasm
• Action: Duration longer, rapid onset
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• Limitations in elderly
– Dihydropyridines induce reflex tachycardia
– Contraindicated in low EF patients post MI
– Edema formation (venous insufficiency)
– Sick sinus syndrome – non dihydropyridines,
combinations with beta blockers
– Constipation
– Postural hypotension
• Role: “triple therapy”
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• Dose: 500 mg bid increasing to 1000 mg bid
• Added to existing antianginals
• Contraindications:
– • With pre-existing QT prolongation
– • With hepatic impairment (Child-Pugh Classes A
[mild], B [moderate] or C [severe])
– • On QT prolonging drugs
– • On potent and moderately potent CYP3A
inhibitors, including diltiazem
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• Piperazine
derivative
• Anti-ischemic effect
without effect on
heart rate or blood
pressure
• Inhibits late I (slowly
na
inactivating component of
sodium current) =
reduce
intracellular calcium
and sodium
overload Angina 2012
•
•
•
•
Randomized, 3-group parallel,
double-blind, placebo-controlled trial
of 823 eligible adults.
Patients received twice-daily
placebo or 750 mg or 1000 mg of
ranolazine
Treadmill exercise 12 hours (trough)
and 4 hours (peak) after dosing was
assessed after 2, 6 (trough only),
and 12 weeks of treatment.
Trough exercise duration increased
by 115.6 seconds … vs 91.7
seconds in the placebo group (P =
.01).
•
The increases did not depend on
changes in blood pressure, heart
rate, or background antianginal
therapy and persisted throughout 12
JAMA. 2004;291:309-316
weeks.
Angina 2012
• 6560 patients over 442
sites (17 countries)
2004-2006
• ACS, TIMI > 3
• Placebo v IV then po
ranolazine (1000 mg
bid)
• Endpoint: Occurrence
of Death, MI, Recurrent
Ischemia Result: No
Difference
• Median follow: 348
days
Angina 2012
• Side effects more common
– Dizziness
– Constipation, Nausea, dyspepsia, abdominal
pain
– Asthenia
– Headache
• QT prolongation due to drug interactions
Angina 2012
ABNORMAL CORONARY
CIRCULATION
• Proximal LAD: 99 %
stenosis, site of prior
stent.
– ·Mid LAD: 80 % stenosis.
– ·D1: 80 % stenosis.
– ·D2: 99 % stenosis.
• ·Mid circumflex: 40 %
stenosis.
• ·Mid RCA: 99 %
stenosis.
– ·Distal RCA: 60 % stenosis.
2012
– RPDA: 90 % Angina
stenosis.
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• All therapy requires lifestyle changes and
drugs for secondary prevention of
ischemic events
• Revascularization
– Surgical (1968)
– Percutaneous (1978)
• PCI v. Surgery
• Medical v. Intervention
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• Lesion angioplasty
POBA
• Atherectomy and
occluded vessels
• Adjunctive Platelet
Therapies
• Stenting – BMS, DES
– Bare Metal
– Drug Eluting
• Efficacy: Equivalent to
surgical intervention in
short term relief
Angina 2012
• Indications
– Symptomatic – refractory to medical therapy
– Prognostic
• Left main stenosis > 50%
• Three vessel disease +/- impaired LV function
• Two vessel disease with LAD involvement
• Risks – Mortality 1-2%, increased by gender,
emergency surgery, LV function, reoperation
• Advances – Off Pump, Limited access, Arterial
Conduits
• Comparisons – anti-anginal effect long term
85%
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Lee, S. J. et al. JAMA 2006;295:801-808
Copyright restrictions may apply.
• Switzerland
• Patients over 75
• Chronic stable
angina
• 148 optimized Med
• 153 invasive
• Similar outcomes
for symptoms,
QOL, Death or
Nonfatal Infarction
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COURAGE
N Engl J Med 2007;356:150316.
Chronic Stable Angina
Angina 2012
Average age 61
85% Male
86% White
•
•
•
•
•
•
Vitamin E
Garlic
Gingko Biloba
Salmon oil
Red Algae
Chelation Therapy
Angina 2012
• Decision: PCI of LAD
• Readmitted emergently with severe pain
and palpitations – RCA ischemia and atrial
fibrillation
• Converted to NSR, RCA revascularized
• Referred for cardiac rehab – completely
asymptomatic
• 2 years later – recurrent angina then ACS
– new RCA lesion.
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Conclusions:
• Angina pectoris is a classic
syndrome of ischemia
•Evaluation depends on a
history – 95% specific; In the
elderly it often has reduced
sensitivity
•Clinical assessment focuses on
stability and high risk cases
•Therapy always involves
secondary prevention, but not
all is proven for elderly patients
•Drug therapy can be effective
with caution.
•Interventional therapies work
well. They do NOT always offer
survival benefit.
•Drug therapy should be
mastered for those in whom
intervention carries risks
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