Risk Stratification in Chronic Stable Angina. By M.Wafaie Aboleineen,MD,FACC.

Transcription

1 Risk Stratification in Chronic Stable Angina By M.Wafaie Aboleineen,MD,FACC.

2 Risk Stratification

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4 Risk dictates management Predicted annual mortality < 1 % can be managed medically Pts with mortality 1-3 % / yr consider either cath or exercise imaging study for further risk assessment Pts with mortality >3 % / yr should be referred for cath.

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6 Risk Stratification long-term survival with CAD The patient's risk is usually a function of 4 types of patient characteristics: 1 ) LV functioning. 2 ) Anatomic extent and severity CAD. 3) Recent coronary plaque rupture. 4) General health and noncoronary comorbidity

7 Risk Stratification With Clinical Parameters History Age and gender Risk factors and previous MI Physical examination Vascular disease. Long-standing hypertension. AS or HCM. CHF.

8 Classification of chest pain Typical angina 1. Substernal chest discomfort with characterstic quality and duration 2. Provoked by exertion or emotional stress 3. Relieved by rest or NTG Atypical angina Meets 2 of the above characteristics Noncardiac chest pain Meets one or none of the typical characteristics

9 Pre-test likelihood of CAD Nonanginal chest pain Atypical angina Typical angina Age M F M F M F

10 Prognostic angina score. The pattern of angina occurrence can be used to predict prognosis

11 Risk Stratification of Chronic Stable Angina ECG abnormalities at rest higher risk (LVH, persistent ST-T wave inversions in V1-V3, Q waves in multiple leads or R wave in V1, BBB, and arrythmias. Chest X-ray cardiomegaly or pulmonary vascular congestion on are also associated with poor prognosis.

12 Risk Stratification Once the clinical diagnosis of angina is probable or confirmed then the pt needs risk assessment The choice of test is based on the pt s ECG and physical ability Normal ECG may use GXT With an abnormal ECG use stress imaging If unable to exercise use pharmacological stress For some patients angiography may be the best initial test

13 Algorithm for exercise electrocardiography (ECG) and angiography. Snow V et al. Ann Intern Med 2004;141: by American College of Physicians

14 Risk stratification by ETT: Class I I. All patieints with normal ECG and intermediat probability. (level of evidence B) II. After a significant change in symptoms (level of evidence C) Class IIa I. Patients post-revascularization with a significant deterioration in symptoms. (level of evidence B)

15 Interpreting Exercise Tests 4 components to interpreting a stress test 1. Symptoms (angina) during or after the test 2. ECG changes during or after exercise ST depression > 1mm 80ms after J point ST elevation 3. Hemodynamic response to exercise (HR and BP change) 4. Workload in METs Need to consider all 4 parts when interpreting test For prognosis: workload in METs is more important than ST changes Use the Duke Treadmill Score to calculate risk/prognosis

16 Duke Treadmill Score (DTS) DTS = [exercise time (mins)] [ 5 x ST segment deviation 0 no angina (mm)] [ 4 x angina index ] 1 angina occurs 2 angina reason for stopping test Risk (DTS) 4-yr survival Annual mortality Low (>5) 99% 0.25% Mod (-10 to 4) 95% 1.25% High (< -10 ) 79% 5%

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19 Prevalence of LV Ischemia by Exercise Capacity Bourque, J. M. et al. J Am Coll Cardiol 2009;54: Copyright 2009 American College of Cardiology Foundation. Restrictions may apply.

20 Exercise Testing After CABG chest pain is often atypical after surgery rest ECG abnormalities are frequent stress imaging tests are preferred 30% have an abnormal ECG response on treadmill exercise testing early after bypass surgery 1/00 medslides.com 20

21 ETT After PTCA ETT, insensitive (40% to 55%); stress imaging preferred Evaluate only patients with a significant change in angina, and high-risk patients: LV dysfunction, multivessel CAD, proximal LAD disease, previous sudden death, DM, hazardous occupations, suboptimal PTCA result 1/00 medslides.com 21

22 2D ECHO Restig ECHO in the diagnosis of chest pain or CAD? Class I Pts with signs of AS or HOCM Pts with findings of CHF Class III Pts with none of the above findings i.e. routine echo is not indicated in the dx of angina

23 Risk stratification by exercise stress imaging (perfusion or echocardiography) : Class I I. Patients with resting ECG abnormalities, LBBB, >1 mm ST-depression, paced rhythm, or WPW (level of evidence C) II. Non-conclusive ETT, but intermediate or high probability of disease (level of evidence B) Class IIa III. Post-revasc. deterioration in symptoms (B) IV.As an alternative to ETT. ( B)

24 Survival Free of Major Adverse Cardiac Events Bouzas-Mosquera, A. et al. J Am Coll Cardiol Img 2009;2: Copyright 2009 American College of Cardiology Foundation. Restrictions may apply.

25 Overall Survival Curves Bouzas-Mosquera, A. et al. J Am Coll Cardiol Img 2009;2: Copyright 2009 American College of Cardiology Foundation. Restrictions may apply.

26 Noninvasive Risk Stratification High-Risk (>3% annual mortality rate) 1) Severe resting LV dysfunction (LVEF < 35%) 2) Severe exercise LV dysfunction (LVEF < 35%) 3). Echocardiographic wall motion abnormality (involving > 2 segments) developing at low dose of dobutamine ( 10 mg/kg/min) or at low heart rate (< 120 beats/min) 4). Stress echocardiographic evidence of extensive ischemia Intermediate-Risk (< 3% annual mortality rate) 1) Mild-moderate resting LV dysfunction (LVEF - 35% to 49%) 2) Limited stress echocardiographic ischemia with a wall motion abnormality only at higher doses of dobutamine involving two segments Low-Risk (< 1% annual mortality rate) 1). Normal stress echocardiographic wall motion or no change of limited resting wall motion abnormality during stress???

27 Noninvasive Risk Stratification High-Risk (>3% annual mortality rate) 1). Stress-induced large perfusion defect (particularly if anterior) 2). Stress-induced multiple perfusion defects of moderate size 3). Large, fixed perfusion defect with LV dilation or increased lung uptake (thallium-201) 4) Stress-induced moderate perfusion defect with LV dilation or increased lung uptake (thallium-201) Intermediate-Risk (< 3% annual mortality rate) 1). Stress-induced moderate perfusion defect without LV dilatation or increased lung uptake (thallium-201) Low-Risk (< 1% annual mortality rate) 1) Normal or small myocardial perfusion defect at rest or with stress

28 Coronary Angiography 1/00 medslides.com 28

29 Angiography for Risk Stratification Angiography for risk assessment Class I Pts with CCS III or IV angina Pts with high risk noninvasive tests Pts with angina and CHF or poor LV function Class III Pts with angina responding to medical Tx and low risk or normal stress test

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32 Previous CABG Prone to rapid progression and thrombotic occlusion Low threshold for angiographic evaluation is recommended for patients who develop chronic stable angina >5 years after surgery, especially when ischemia is documented

33 Test Characteristics of Non-invasive testing Diagnostic test Sn Sp LR + LR - Exercise Test Nuclear Stress Stress Echo

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