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Highlights from 2014 American Heart Association & European Society of Cardiology in the Management of Coronary Heart Disease and Percutaneous Coronary Intervention - for the Primary Care Physician

Cardiovascular diseases remain the number one cause of death globally, mainly due to Coronary Heart Disease (CHD) and Stroke [1]. An  estimated 17.3 million people died from cardiovascular diseases in 2008, representing 30% of all global deaths.

The 2014 meetings of the American Heart Association [2] & European Society of Cardiology [3] in the Management of Coronary Heart Disease and Percutaneous Coronary Intervention made updates.

CHD can be categorised into Stable Coronary Artery Disease (SCAD) or Acute Coronary Syndromes (ACS).

Depending on any symptoms, electrocardiographic changes and cardiac marker (e.g. Troponin) changes, ACS can be further sub-categorised into: ST Elevation and Non-ST Elevation Myocardial Infarction; and Unstable Angina.

Optimal Medical Therapy remains the cornerstone treatment for all forms of CHD, with: Antiplatelets; Antiischaemics; Statins; Angiotensin  Converting Enzyme Inhibitors/Angiotensin Receptor Blockers; together with optimal blood pressure and glycaemic control if required.

In SCAD, revascularisation (PCI/CABG) is indicated for symptomatic angina or prognostic CHD associated with substantial ischaemic territory (Table 1). The roles of PCI v CABG are better defined with PCI preferable in more simple CHD anatomy, whereas CABG with internal mammary artery graft(s) can be considered in simple and more complex CHD, particularly if patients have a low surgical risk (Table 2).
 
Table 1. Indications for Revascularisation in Stable Angina or Silent Ischaemia
 Extent of CAD*
For prognosis> 50% LM
 Any proximal LAD stenosis > 50%
 2 or 3 vessel with stenosis > 50% with impaired LV function (LVEF < 40%)
 Large area of ischaemia ( > 10% of LV)
 Single remaining patent coronary artery with stenosis > 50%
For symptomsFor symptoms Any coronary stenosis > 50% with limiting angina or angina equivalent unresponsive to medical therapy
* With documented ischaemia or FFR ≤ 0.80 for diameter stenosis < 90%.
 
 
Table 2. Stable Coronary Artery Disease Recommendations for PCI or CABG*
Choice of RevascularisationRecommendation
1 or 2 vessel without proximal LAD stenosisPCI more preferable
1 vessel with proximal LAD stenosisPCI or CABG
2 vessel with proximal LAD stenosisPCI or CABG
Simple Left Main disease**PCI or CABG
Intermediate Left Main disease**CABG more preferable
Complex Left Main disease**CABG
3 Vessel disease with simple disease anatomy**PCI or CABG
3 Vessel disease with intermediate disease anatomy**CABG
3 Vessel disease with complex disease anatomy**CABG
*Suitable anatomy for both PCI or CABG and with low surgical mortality
**Simple, Intermediate, Complex anatomical disease are equivalent to Syntax score ≤ 22, 23-32, > 32
 
 
In Non-ST Elevation ACS, urgent coronary angiography and revascularisation should be considered in suitable high-risk patients with: elevated cardiac markers (e.g. Troponin); dynamic ST or T wave changes; high GRACE risk score; refractory/post infarction angina; haemodynamic instability; cardiogenic shock; ischaemia-related cardiac failure; and arrhythmias.

All ST Elevation or New Left Bundle Branch Block Myocardial Infarction patients who present within 48 hours of symptom onset and have no contraindication to revascularisation should be considered for primary PCI. The goal of treatment is to re-perfuse as soon as possible to save myocardium and save lives. Moreover, new generation Drug Eluting Stents are preferred in both SCAD and ACS patients with a low bleeding risk who do not require major non-cardiac surgery in the near future.

Dual Antiplatelet treatment post PCI in ACS patients i.e. Aspirin with P2Y12 inhibitors such as Prasugrel or Ticagrelor (or Clopidogrel, if Prasugrel or Ticagrelor are not available) are essential to reduce stent thrombosis and death. However, the optimal duration of dual Antiplatelet treatment remains unclear. Current guidelines propose varying the duration according to the clinical scenario and bleeding risk of patients (Table 3).
 
Table 3. Antiplatelet Treatment after PCI in Non-ST Elevation ACS and ST Elevation MI
Non-ST Elevation ACS & ST Elevation MI
Aspirin 75 - 100mg daily
A P2Y12 inhibitor is recommended in addition to Aspirin for 12 months, unless contraindications such as excessive bleeding risk. Options are:
 
-  Prasugrel 10mg daily
-  Ticagrelor 90mg twice daily
-  Clopidogrel 75mg daily, only if Prasugrel or Ticagrelor are not available or contraindicated
 
 
 
Among CHD patients who require long-term anticoagulation, current guidelines advocate the use of Novel Oral AntiCoagulants (NOAC) – e.g. Pradaxa, Rivaroxaban, Apixaban instead of Warfarin, in a triple (NOAC + Aspirin + Clopidogrel) or double (NOAC + Aspirin or Clopidogrel) combination therapy. The use of Prasugrel or Ticagrelor in the combination is not currently recommended (Table 4).

 

Table 4. Antithrombotic Treatment after PCI in Patients Requiring
Oral AntiCoagulation (OAC)
Recommendation
OAC is recommended in addition to Antiplatelet Rx in patients with a firm indication
(e.g. CHADs-VASc score ≥ 2, Venous Thromboembolism, LV Thrombus, Mechanical Valve)
In Stable CAD and AF CHADs-VASc score ≥ 2 with Low Bleeding Risk (HAS-BLED ≤ 2), initial Triple Rx (NOAC + ASA 75 - 100mg/day + Clopidogrel 75 mg/day) for at least 1m, followed by Dual Rx (NOAC + ASA / Clopidogrel) for up to 12m.
In Stable CAD and AF CHADs-VASc score ≤ 1, Dual Antiplatelet Rx should be considered as an alternative to initial Triple Rx
In ACS and AF with Low Bleeding Risk (HAS-BLED ≤ 2), initial Triple Rx (NOAC + ASA + Clopidogrel) for 6m, then NOAC + ASA / Clopidogrel for up to 12m
In patients with High Bleeding Risk (HAS-BLED ≥ 3), initial Triple Rx (NOAC + ASA + Clopidogrel) for 1m, then (NOAC + ASA / Clopidogrel), irrespective of clinical setting or stent type
Dual Rx (NOAC + Clopidogrel) may be considered as an alternative to initial Triple Rx in selected patients The use of Ticagrelor or Prasugrel as part of initial Triple Rx is not recommended
ASA + Clopidogrel + Rivaroxaban 2.5 mg twice daily may be considered in selected patents with ACS + PCI
 
 
Newer and better cardiovascular drugs and Drug Eluting Stents are adding to our existing successes in treating CHD.

Research and guidelines are available to improve patient treatment and care. 

References

1. World Health Organisation.
http://www.who.int/mediacentre/factsheets/fs317/en/

2. American Heart Association, Scientific Sessions 2014.
http://my.americanheart.org/professional/Sessions/ScientificSessions/Scientific-Sessions_UCM_316900_SubHomePage.jsp

3. European Society of Cardiology, ESC Congress 2014.
http://www.escardio.org/congresses/esc-2014/Pages/welcome.aspx?hit=nav

 

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