Essentials of Stable Ischemic Heart Disease

♦️Plaque Characteristics & Progression
♦️Choosing From Imaging Toolbox
♦️Perils of Polypharmacy
♦️Who & When To Revascularize
♦️Overview of Guidelines

🧵on this great @ACCinTouch session from today #ACC21 #ACCMedStudent
1/Plaque Progression #ACC21

Non-atherosclerotic intimal lesions➡️progressive atheroscl. lesions (fibroatheroma)➡️lesions w/ acute thrombi

Plaque rupture = lesion growth
Lumen area maintained till 40% narrowing
Narrowing beyond 40% occurs w/ plaque rupture+intraplaque hemorrhage
2/Plaque Characteristics #ACC21

Coronary artery calcification begins as micro-calcification➡️fragment➡️sheet➡️nodular

Stable plaque?
🔸Associated with DM, HTN, smoking
🔸Most common is fibrocalcific plaque (mostly sheet Ca)

Unstable plaque is mostly fragmented Ca
3/Imaging in SIHD #ACC21

Guided by pre-test risk score
-Diamond-Forrester overestimates disease
-CAD consortium more aligned w/ prevalence of obstructive CAD

Low risk➡️defer testing or stress ECG
Intermediate risk:
Anatomic-CCTA, FFR CT
Functional-stress echo/CMR, SPECT/PET MPI
4/ CCTA-📈neg predictive value, limited specificity
FFR CT-functional assessment,🚫efficient

Stress Echo-widely available, higher event rate in normal studies
SPECT- ischemia/infarct quant

🚫widely available:
Stress CMR-high resolution scar assessment
PET-superior dx accuracy
5/Polypharmacy #ACC21

Guidelines recommend many meds
Risk of adverse drug events📈w/ more meds

Approach to prioritizing pills
♦️Reduce mortality (vs. softer composite endpoints)
♦️Greater absolute reductions/lower NNT (vs. RRR)
♦️One a day dosing
♦️Consolidate whenever possible
6/Revascularization #ACC21

COURAGE, BARI2D, and FAME2:🚫benefit (death/MI) w/ revasc in angiographically selected pts w/ chronic stable angina
🌟Benefit noted in higher-risk pts

ISCHEMIA: no benefit w/ revasc for CV outcomes, but 📈QOL in pts w/ frequent angina at baseline
7/ Guidelines #ACC21

ACC/AHA guidelines are from 2012
2019 ESC⤵️6 step approach
-New focus on process of chronic coronary syndrome instead of stable CAD
-Emphasis on anatomic over functional imaging (CCTA as initial test for diagnosing CAD, but functional can further guide)

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More from @Gurleen_Kaur96

16 May
💥The Ultimate Guide to Lipids💥
🟢Lipid biology
🟢Physical exam clues for lipid disorders
🟢Lipid tests & interpretation
🟢CV risk assessment
🟢Fundamentals of lipid management
🟢Review of guidelines

🧵on this great @ACCinTouch session from today #ACC21 #ACCMedStudent #ACCPrev
1/ Lipid Biology #ACC21 #ACCMedStudent
Lipoprotein-central core of cholesterol ester/TG surrounded by apolipoprotein

Dietary fat➡️chylomicrons➡️TG metabolized in muscle & adipose by lipoprotein lipase➡️chylomicron remnants liver uptake➡️VLDL➡️FFA & IDL ➡️LDL➡️LDL receptor uptake
2/ Lipid Biology continued...#ACC21 #ACCMedStudent

HDL formed by liver/intestines - acquire cholesterol through reverse cholesterol transport

Lp(a) - modified LDL particle w/ additional apolipoprotein (a). Oxidation pro-inflammatory,⬆️atherosclerosis.
Read 10 tweets
16 May
#ACCMedStudent, it's Day 2 of #ACC21! Benefits of virtual meeting⏪old sessions available onDemand.

Great @ACCinTouch session yesterday on Advanced Heart Failure Therapies, ending w/ debate on Transplant vs. LVAD! #ACCHFT

🧵on some take-home points from the 6 presentations
1/ Moving Beyond NYHA Class #ACC21
Vague w/ wide inter & intra observer variability
Utility breaks down in advanced HF

🌟Reclassifying advanced HF: INTERMACS Profiles (lower score = sicker) helps prognosis/triage

🔑Assign profile after identifying features of advanced HF
2/ Cardiac Transplantation #ACC21

♦️ Strategies to expand cardiac donor pool➡️ donation after circulatory death (DCD) - first performed in Duke Dec 2019

♦️ Advances in post-transplant care➡️prevention of cardiac allograft vasculopathy & molecular tools for rejection monitoring
Read 6 tweets
16 May
🌟Future of Dyslipidemia Management🌟
🧵on this great session from #ACC21 #ACCMedStudent

1/ Team-based approach to improve CV outcomes
🔸pharmacist interventions reduce LDL-C
🔸sessions with dietitian improves lipids &📉costs
🔸Multi-D lipid clinic⬆️guideline-directed treatment
2/ Familial Hypercholesterolemia (FH)
♦️ Genetically inherited, autosomal dominant
♦️ LDL-C >190 mg/dL
♦️ Family hx of premature coronary disease

Presence of corneal arcus (ring of cholesterol precipitate) or tendon xanthoma (>8mm Achilles tendon) before age 45 highly suggestive
3/ Genetic Testing for pts at risk due to family history or w/ FH phenotype

🌟Up to 30% of patients with very high LDL-C have high polygenic risk score (PRS) vs. single gene mutation🌟
Read 6 tweets
14 May
1/ Ready for a #Tweetorial on coronary artery calcium (CAC) score?

Keep reading to:
☢️Understand the pathophysiology of coronary artery calcium
☢ Identify the utility of the CAC score
☢️Recognize the limitations of CAC scoring
2/ How do you feel about the following statement:

I understand the utility of CAC score and can recognize its strengths and limitations.
3/ Let's start with a case!

58 yo👨in office asks about future CVD risk and starting a statin. No angina. Family h/o early MI and 10-year risk-score = 9%. Uncertain about starting meds. In addition to lifestyle changes, next step?
Read 18 tweets

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