Angina and Women Does Heart Rate Matter? Adam Timmis NIHR Biomedical Research Unit BartsHealth and QMUL

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1 Angina and Women Does Heart Rate Matter? Adam Timmis NIHR Biomedical Research Unit BartsHealth and QMUL

2 Angina They who are afflicted with it, are seized while they are walking, (more especially if it be up hill, and soon after eating) with a painful and most disagreeable sensation in the breast, which seems as if it would extinguish life, if it were to increase or continue; but the moment they stand still, all this uneasiness vanishes. Heberden W. Some account of a disorder of the breast. Medical Transactions 2, (1772) London: Royal College of Physicians.

3 Age adjusted hazard ratios for coronary presentation in men vs women CALIBER data for 1,937,360 people

4 Different faces of chronic angina Women - prognosis approximately equal to men Nitrate angina (n>90,000) Test +ve angina (n>27,000) Hemingway et al JAMA 2006

5 Chronic stable angina: things we take for granted Atypical presentations of angina are more common in women than in men False +ve and false -ve exercise tests occur more commonly in women Abrams J NEJM 2005

6 2. Atypical chest pain presentations? Probability of CHD death/acs by typicality in women compared with men (n=7794) 0.15 Typical p= Atypical p=0.001 Conclusion: prognostic validity of chest pain typicality is independent of gender Follow-up (years) Men Women Zaman et al CMAJ 2008

7 3. Unreliable ETT in women? ETT in pts with suspected angina: CHD mortality/acs during 2.5 years followup (n=1564) 25 Event rate (%) Men Women 0 +ve ETT -ve ETT Equivocal ETT Conclusion: prognostic validity of ETT is independent of gender (data on file)

8 Diagnosis of angina: ischaemia testing Clinical assessment Electrocardiography LV wall motion analysis Perfusion imaging

9 Diagnosis of angina: noninvasive tests Case 1 22 year old man, grandfather died of AMI in his 80s, experiences intermittent, unprovoked left sided discomfort often lasting several hours. The ECG is normal. Case 2 68 year old woman, smoker experiences constricting chest discomfort radiating to throat when she walks up stairs. It is associated with shortness of breath and eases gradually with rest. The ECG is normal. WHICH TEST? Exercise ECG Myocardial Perfusion Scan Stress Echo CT coronary angiogram None of the above

10 Investigation of stable chest pain (NICE 2010) Low risk of CAD Intermediate risk of CAD High risk of CAD <10% 10-29% 30-60% 61-90% >90% First diagnostic test CT Ca++ scoring ± CTCA Functional testing SPECT stress echo/mri Invasive Angiography If revasc considered Rule out non-cardiac causes of chest pain Optimal medical therapy ± angiography Indicative frequency 29% 17% 18% 22% 14%

11 Angina: symptom relief with drugs Increase O 2 delivery Coronary flow Nitrates CaBs Nicorandil Revasc Reduce O 2 demand heart rate BB ivabridine LV wall tension BB Nitrates Nicorandil CaBs ranolazine contractility BB CaBs modify energy metabolism trimetazidine

12 Angina: 2 prevention Aspirin Statins Beta-blockers Clopidogrel ACE-I SPOT THE DELIBERATE MISTAKE(S)

13 Age adjusted rate per 1000 per year The British Regional Heart Study IHD major events IHD mortality Sudden Cardiac Death 7735 males yrs 8 year follow up No pre-existing IHD Strong association between resting HR and SCD and IHD (major events & mortality) > >90 Heart rate (bpm) Shaper BHJ 1993

14 Association between the initial presentation of CVDs per heart rate quintile CALIBER Data: HRs ref. 1st Q (n=233,970)

15 Heart rate reduction - a therapeutic target after AMI? Reduction in mortality (%) timolol 35 metoprolol practolol propanolol sotolol 10 5 oxprenolol pindolol Reduction in resting heart rate (bpm) Kjekshus et al AJC 1986

16 Heart rate reduction - a therapeutic target in heart failure? Change in mortality % CIBIS BHAT ANZ NOR TIMOLOL GESICA MOCHA US CARVEDILOL XAMOTEROL VHeFT (prozosin) SOLVD CONSENSUS VHeFT (HDZ/ISDN) PROFILE Change in heart rate (beats/min -1 ) PROMISE Kjekshus and Gullestad. Eur Heart J Supplements 1999, Vol. 1 (Suppl H):H64-H69

17 Β-blocker use and clinical outcomes in stable patients With CAD and no prior MI 7198 patients from REACH registry in matched propensity score analysis Bangalore S et al JAMA 2012

18 SIGNIFY: Effects of heart rate reduction to <60bpm with ivabradine on nonfatal MI and CV death

19 Correcting ischaemia by revasc may not protect against acute coronary events Stable angina FFR 0.93 NSTEMI - 18 months after RCA & LAD grafts Stable angina in 63 year old man Severe proximal LAD disease plus RCA occlusion Referred for CABG No further angina

20 Beta blockers/pci/cabg are not disease-modifying interventions Relief of ischaemia in stable CAD corrects symptoms but evidence thin (CABG, Beta blockers) non-existent (PCI) for protection against other clinical endpoints

21 Medicine at its worst the case of George W Bush August 2013: Asymptomatic when annual physical threw up abnormal exercise ECG PCI next day at Texas Health Presbyterian Hospital. Steven Nissen, Cleveland Clinic This is really American medicine at its worst: the stent doesn t prolong life, it doesn t prevent heart attacks and it s hard to make a patient who has no symptoms feel better. It s one of the reasons we spend so much on health care and we don t get a lot for it

22 Does Heart Rate Matter in patients with stable angina? No it s symptoms that matter

23 The end

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