Stable Ischemic Disease

General¶

• Aka "Chronic Stable Angina"

Management¶

• Stop Smoking, Low-fat diet, 30-60 minutes of exercise 5-7 days a week
• Weight loss, BP management
• Goals of Pharmacologic Management
  • Reduce risk of MI/CV death
    • Anti-platelet
      • Aspirin or clopidogrel
    • 4S: Statins reduce Death, MI, Revasc in Angina/MI patients
      • SATURN: Crestor better LDL reduction, no better mortality than Lipitor
      • Atorvastatin (Lipitor)
        • Muscle toxicity w/concurrent Amiodarone use (0.7%)
      • Rosuvastatin (Crestor)
        • Crestor FDA (Renal Dosing)
        • Crestor to prevent vascular events in patients with elevated CRP
      • Side Effects
        • Statin induced diabetes and its clinical implications
        • Risk of incident diabetes with intensive-dose compared with moderate-dose statin therapy: a meta-analysis
        • Statins and risk of incident diabetes: a collaborative meta-analysis of randomized statin trials
        • Statin-Associated Myopathy
          • Adverse events with concomitant amiodarone and statin therapy
        • Asymptomatic hypothyroidism and statin-induced myopathy
    • LVEF <40% or prior MI
      • Beta-Blockers
    • LVEF <40%, T2DM, HTN. CKD
      • ACEI/ARB
  • Symptom alleviation and improvement of QOL
    • Beta-Blockers as initial therapy
    • CCBs or LA-Nitrates if BBs can not be used or are not controlling angina
    • Ranolazine if on maximal tolerable medical therapy
    • COURAGE: PCI w/BMS in Stable CAD non-superior to medical therapy
    • In life expectancy <1, discontinuation of statin did not increase 60-day mortality

Revascularization (CABG)¶

• [SYNTAX]: Less CV events at 1 year w/CABG vs. PCI in 3-vessel and/or LM disease3
  • 17.8% vs. 12.4%; driven by need for repeat revascularization in PCI group
  • Use of only paclitaxel stents, which have higher rate of angiographic restenosis than either the sirolimus- or everolimus-eluting stents
  • Five-year outcomes
    • Roughly equivalent unless high Syntax score which favors surgery
• Syntax Score
  • The SYNTAX score is a grading system that evaluates the complexity and prognosis of patients undergoing percutaneous coronary intervention (PCI)
  • Calculator
• Indications for CABG
  • Class 1
    • LM w/complex CAD
    • LM w/Syntax score >33
    • LM w/complex CAD + Syntax score >33 + Suitable Candidate
    • MVCAD w/suitable anatomy + Suitable Candidate + LVEF (\(\leq\)) 35%
  • Class 2a
    • MVCAD w/suitable anatomy + Suitable Candidate + LVEF (\(\geq\)) 35%
      • ISCHEMIA, FAME-2, and 10-year updates from the MASS -II trial showing a reduction in CV mortality
  • Class 2b
  • MVCAD w/suitable anatomy + LVEF >50% (Note PCI also 2b)
  • IMA (internal mammary artery) remains preferred choice for LAD
    • Radial preferred over SVG for 2^nd most important vessel (non-LAD)
      • AATS disagrees with this without patient specifiers

Post-CABG Management¶

• ~10-20% readmitted within 30 days
• Consider the 3 "I"s
  • Infectious
    • Sternal wounds
  • Inflammatory
    • Pericarditis
      • Get TTE, contact primary surgeon
      • May lead to Tamponade
        • Commonly presents early (<7 days)
  • Ischemic
    • Myocardial Infarction
• Dyspnea is common post-operatively
  • Once discharged, new-onset dyspnea should be evaluated for (Most to Least likely):
    • Pleural effusion (50%), atelectasis, congestive heart failure (13%), pneumonia (2.4%) and pulmonary embolism
    • Diaphragmatic Paralysis
      • Dyspnea at rest or with exertion and supine hypoxemia
      • FVC dropped in the supine position
      • Elevated hemidiaphragm
      • Diagnosis: Confirmed via the “sniff test” under fluroscopy
• 30% develop Atrial Fibrillation
  • Usually self-limiting if new-onset
  • Return to NSR by 6-12 weeks out
• 30% AKI
• 50-70% develop cognitive dysfunction
• Delirium in 73%