pham gia khai

Cardiovascular mortality increases with follow-up SBP < 120 mmHg in the ONTARGET trial 75 % had coronary heart disease at baseline treatment with ACEi and/or ARB... • Early CV risk stra

Hypertension in Patients with

Coronary Artery Disease

Prof Pham Gia Khai, MD PhD FACC FESC

Conflict of interest

• Nil

• ECG: LV hypertrophy; cannot rule out CAD

• Cardiac Echo: LVDd: 57 mm; EF: 45%

• Diagnosis of Diabetes mellitus

• (A) Fasting Blood Glucose ≥ 7 mmol/L (≥ 126 mg/L) and/or HbA1C ≥ 6.5

• (B) Fasting Blood Glucose ≥ 7 mmol/L and 2hr post-prandial Blood Glucose ≥ 7.8 mmol/L (C) Both (A) and (B) Choose the right answer

• Diagnosis of coronary heart disease

• (A) Chest pain relieved by Nitrates, cardiac enzymes normal

• (B) Chest pain not relieved by Nitrates, cardiac enzymes normal

• (C) Suggestive coronary angiogram, cardiac enzymes normal

• (D) Elevated cardiac enzymes, but coronary angiogram normal

• Choose the right answer

ECG

Questions ???

• Relationship between HTN and CAD

• What is the difference of CAD profile in HTN

vs normotensive patients?

• Pretest possibility of CAD? %?

• Which is the best test for diagnosis of CAD in this patients?

• Optimal strategy for CAD pts with HTN?

Incidence of MI and total stroke by systolic BP

D’Agostino RW, et al BMJ 1991; 303:385-389

Intensive Lowering BP levels increases risk of MI

Messerli et al Ann Intern Med 2006;144:884–893

Mortality increases with follow-up DBP < 70 mmHg

in the INVEST trial

Cardiovascular mortality increases with follow-up SBP

< 120 mmHg in the ONTARGET trial

75 % had coronary heart disease at baseline treatment with ACEi and/or ARB

Cusham W, et al N Engl J Med 2010;362:1575-85

ACCORD-BPLA Trial

* 26-MAY-2010

ROADMAP: Lowest SBP and/or highest SBP reduction

S BP reduction Last SBP before event

mmHg mmHg

Cohort of patients with pre-existing CHD (n=1104)

ROADMAP: The increased mortality was only seen in

p = 0.02

Incidence of MI and Stroke

INVEST Trial

Messerli, et al Ann Intern Med 2006;144:884–893

The Diagnostic dilemma of CAD in hypertensive

patients

• Early CV risk stratification and evaluation of markers of organ

Chin D, Battistoni A, Tocci G, Passerini J, Parati G, Volpe M Am J Hypertens 2012 ; 25:1226-35

• Exercise ECG tests have a low specificity and sensitivity for

Chin D, Battistoni A, Tocci G, Passerini J, Parati G, Volpe M Am J Hypertens 2012;25: 1226-35

•

•

•

•

Stress echocardiography

Strengths:

events)

Chin D, Battistoni A, Tocci G, Passerini J, Parati G, Volpe M Am J

Hypertens 2012;25: 1226-35

Weaknesses:

• lower sensitivity in identifying one vessel disease or

moderate stenosis

• the inability to visualise the entire left ventricle in a

single window in certain patient groups

•the assessment of the images is operator-dependent

• it is mainly a qualitative, rather than a quantitative

assessment

• an inadequate acoustic window in certain patient groups limits the sensitivity and specificity of the test (such as

Chronic obstructive pulmonary disease patients)

Chin D, Battistoni A, Tocci G, Passerini J, Parati G, Volpe M Am J Hypertens 2012;25: 1226-35

SPECT

Strengths:

•

l

Quantitative method, which reduces operator bias

and inter-observer variability

New nuclear techniques such as the “gated” SPECT,

enable a contemporary functional and perfusional

assessment of the myocardium, hence increasing the specificity of the diagnosis of coronaropathy

Weaknesses:

l

l

Poor spatial resolution ( approx 1cm)

The need to use radioactive material limits the use

of this diagnostic technique as a regular “screening”

test in hypertensive patients

Chin D, Battistoni A, Tocci G, Passerini J, Parati G, Volpe M Am J

Hypertens 2012;25: 1226-35

Coronary angiography

Coronary angiography in HT

- CV risk profiling in HT is of clinical value

Patel MR et al , NEJM 2010

The majority of patients with Hypertension

Framingham Study

Kannel, Am J Hypertens, 2000; 13: 3S-10S

Yusuf S, et al Lancet 2004;364:937–52

INTERHEART Study

Risk of acute myocardial infarction associated with

exposure to multiple risk factors

CV risk charts

Estimation of ten-year risk of fatal cardiovascular disease in Europe: the SCORE project.Eur Heart J24:987Z 1003

Clinical Likelihood of Disease (pretest) (ESC 2013)

This risk is modified if

- ECG indicates abnormalities

- LV EF < 50%

- Visualization of coronary stenoses

3 Step Algorithm for Diagnosis CAD (ESC 2013 Guidelines)

Determine the Clinical Likelihood of Disease

Testing for CAD

1 Optimal Medical Therapy

2 Assessment of Risk (mortality)

YES

Can it apply for

Hypertensive

Patient?

LOW

CHD RISK Risk score

Exercise ECG

High threshold positive test

low threshold positive test

CORONARY ANGIOGRAPHY

LVH

Identify the most appropriate imaging technique on the basis of different criteria, such as :

-Gender -Patient structure -Baseline ECG changes

Stress

echocardiography CoronaryCT

Cardiac Radionuclide

•Positive Calcium score

•Carotid artery atherosclerosis by US

Early and accurate CV risk stratification

Diagnostic flow chart of CAD in hypertensive patients

FRS/SCORE Target organ damage

HIGH RISK

Stress

echo CCT RNI CMR EXERCISE EKG

High threshold positive test

Low threshold positive test

Positive test

CORONARY ANGIOGRAPHY

- Visualization of coronary stenoses

3 Step Algorithm for SCAD (ESC Guidelines 2103)

Determine the Clinical Likelihood of Disease

Testing for CAD

1 Optimal Medical Therapy

2 Assessment of Risk (mortality)

European Heart Journal 2013 - doi:10.1093/eurheartj/eht296

All CAD Patients need Optimal Medical

Management, NOT all Patients need

Revascularization

May add or switch (1 st time for some cases)

Short-acting nitrates plus

• -blockers or CCB heart rate

• Consider CCB-DHP if low HR or intolerance/contraindications

Control well global CV Risk Factors is the key for the

Treatment of CAD

Framingham Heart Study

Risk of acute myocardial infarction associated

with exposure to multiple risk factors

50

Use of the IMPACT mortality model to explain the fall

in CHD deaths in England & Wales 1981–2000

Bridging science and health policy in cardiovascular disease: focus on lipid management

A Report from a Session held during the 7th International Symposium on Multiple Risk Factors

in CV Diseases: Prevention and Intervention – Health Policy, in Venice, Italy, on 25 October,

Emberson et al Eur Heart J 2004;25:484-491

Adapted from Emberson et al Eur Heart J 2004;25:484-491

Treatment Based on BP

Treatment Based on Overall Absolute Risk (ASA, lipids, BP)

MCQ (slide 44)

Stratification of risk factors

(A) No (B) Yes

Choose the right answer

Risk factors as has been proved

BP – Cholesterol – Age – Smoking – DM – Gender…

(A) Ranking No (B) Ranking Yes

Choose the right answer

Pretest as established by ESC 2013

Chest pain (Present-Atypical-Absent) – Age – Gender

(A) Meaning Yes (B) Meaning No

Treatment of HTN in Patients with

CAD

Pharmacological Treatment of Hypertension in the Management

of Ischemic Heart Disease

Hypertension 2015;65:000-000 DOI: 10.1161/HYP.0000000000000018

Revascularization Strategy for Stable Ischemic Heart Disease Patients with Multivessel Disease

and Hypertension CABG vs PCI ?

Not all SCAD patients benefit from revascularization

Not all SCAD patients benefit from revascularization

Indications for Revascularization in patients with stable angina or silent ischaemia

European Heart Journal doi:10.1093/eurheartj/ehu278

Recommendation for the type of revascularization (CABG or PCI) inpatients with SCAD with suitable coronary anatomy for both procedures and low predicted surgical mortality

European Heart Journal doi:10.1093/eurheartj/ehu278

MCQ (slide 53)

• Risk stratification for appropriate approach in

diagnosis and treatment

infrastructure

be adapted to individual basis

What did we do with our patient

Cor angiogram

Post PCI (total revascularization)

Many Thanks