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
♦️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
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
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
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
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
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
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)
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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