Guidelines on the Management of Stable Angina Pectoris ... - Cardio

More documents

Recommendations

Info

38 ESC <strong>Guidelines</strong>(1) Treatment with calcium antagonists and if necessarynitrates in patients whose coronary arteriogram isnormal or shows only non-obstructive lesions (level ofevidence B)Myocardial revascularizationThere are two well-established approaches to revascularizationfor treatment of chronic stable angina caused bycoronary atherosclerosis: surgical revascularization, coronaryartery bypass graft (CABG), and percutaneous coronaryintervention (PCI). Currently, both methods are facingrapid development with the introduction of minimally invasiveand off-pump surgery and drug-eluting stents. As in thecase of pharmacological therapy, the potential objectives ofrevascularization are two-fold, to improve survival or survivalfree of infarction or to diminish, or eradicate symptoms.The individual risk of the patient as well as symptomaticstatus must be a major factor in the decision-makingprocess.Coronary artery bypass surgeryFavorolo first described the use of saphenous vein to bypassa diseased coronary artery in 1969. Since then CABG hasbecome the most common operation for CAD and one ofthe most commonly performed surgical operations worldwide.There are two main indications for CABG: prognosticand symptomatic. Prognostic benefit of CABG is mainly dueto a reduction in cardiac mortality, as there is less evidencefor reduction in MI. 69,290 Evidence of prognostic benefit ofCABG compared with medical therapy has not been demonstratedin low-risk patients (annual mortality ,1%). 69 In ameta-analysis of surgical trials comparing CABG withmedical therapy, CABG was shown to improve prognosis inthose at medium to high risk, but even those in themedium risk had a 5-year mortality rate with medicaltherapy of 13.9%, annual mortality 2.8%, which by contemporarystandards appears high. Further observational datafrom the Duke registry confirmed that long-term mortalitybenefit associated with surgery was limited to high-riskgroups. 558 Analyses of observational and randomized controlledtrial data have revealed that the presence of specificcoronary artery anatomy is associated with a better prognosiswith surgery than with medical treatment. 69,288 Suchdisease includes the following:(1) significant stenosis of the left main (LM) stem(2) significant proximal stenosis of the three major coronaryarteries(3) significant stenosis of two major coronary arteries,including high grade stenosis of the proximal leftanterior descending coronary arterySignificant stenosis was defined for these studies as 70%of major coronary arteries or 50% of the LM stem. The presenceof impaired LV function increases the absolute prognosticadvantage of surgery over medical treatment in allcategories. This information comes from two major randomizedstudies: the European Coronary Artery study and theNorth American CASS study. 287,559Surgery has been convincingly shown to reduce symptomsand ischaemia and to improve quality of life in patients withchronic angina. These effects are evident in a much widerrange of subgroups than in which it has been shown toimprove survival. 290 However, despite improvements overtime, operative morbidity and mortality remain importantconsiderations. Thus individual risks and benefits should bediscussed as thoroughly in low-risk patients, in whomsurgery is undertaken on symptomatic grounds alone, as inhigh-risk patients.The overall operative mortality for CABG is between 1 and4% 51,560–563 depending on the population studied, and thereare well-developed risk stratification models available forthe assessment of risk in individual patients. 564,565 There isthe paradox that the higher the risk of operation, thegreater is the benefit of surgical over medical treatment.Most patients are angina-free following CABG, but recurrentangina may occur in the years after surgery. Although thelong-term patency rates for the left internal thoracicartery (LITA) graft are extremely good, saphenous veingrafts have a significant rate of attrition. Thrombotic occlusioncan occur in the early post-operative period, 10% bythe end of the first year, and after 5 years, the vein itselfcan develop atheromatous disease. The patency rate ofvein grafts is 50–60% at 10 years. 566,567Over the last 20 years, the standard procedure has been tograft the LAD with the LITA and use saphenous vein for theother bypass grafts. Because at least 70% of patients arealive 10 years following surgery, the recurrence of symptomsfrom vein graft disease remains a clinical problem. Largeobservational studies have shown that the use of the LITAgraft improves survival and reduces the incidence of thelate MI, recurrent angina, and the need for further cardiacinterventions. 568 Recent observational studies havesuggested benefit for bilateral internal thoracic artery(BITA) grafting. 569 There appears to be significant survivalbenefit when using BITA grafts irrespective of age, ventricularfunction, and the presence of diabetes. Furthermore,the benefit of using BITA increased with the duration offollow-up, particularly in terms of the need for redosurgery, which at 10 years was 40% for single ITA and 8%for BITA grafting in well-matched patients. Ten years afterCABG 90% of ITA grafts continue to function well.With experience, including the use of skeletonized ITApedicles, the risk of sternal devascularization and subsequentdehiscence is much reduced, even in diabetics.Other arterial grafts which have been used include theradial artery and the right gastroepiploic artery. The greatestexperience has been with the radial artery where reportshave indicated patency rates of .90% in the first 3 years ofsurgery. 570,571The use of extra-corporeal circulation (cardiopulmonarybypass) to perform coronary artery surgery remains themost commonly used approach. But there are risks attached,including a whole-body inflammatory response and the productionof micro-emboli. The need for aortic cannulationand manipulation of the ascending aorta may lead torelease of emboli, especially in elderly, atheromatouspatients. The so-called ‘off-pump’ surgery may lead to areduction in peri-operative mortality and morbidity. Therecent introduction of stabilization devices, which allow isolationand control of epicardial arteries, facilitates attachmentof the bypass graft without stopping the heart andhas enabled surgeons to perform surgery without the useof cardiopulmonary bypass. Randomized trials comparingoff-pump with the standard procedure are now available.Although the use of blood products was reduced in the
ESC <strong>Guidelines</strong> 39off-pump group (3 vs. 13%) and the release of CK-MB isoenzynmewas 41% less in the off-pump group, there were nodifferences in the peri-operative complication rates. Therewas no difference in outcome in the first 1–3 years aftersurgery between off-pump and standard groups. 572,573More recently, Khan et al., 574 in a further randomized trialwith angiographic follow-up of 3–6 months, showed a significantreduction in graft patency (90 vs. 98%) in the off-pumpgroup. These studies suggest that the use of off-pumpsurgery is not a panacea but should be applied cautiouslyand selectively to patients with good target vessels andsignificant co-morbidity.Percutaneous coronary interventionAlthough percutaneous transluminal angioplasty was initiallyonly used for the treatment of one-vessel disease, advancesin experience, equipment, particularly stents, and adjuvanttherapy, have lead to a considerably expanded role for thismodality of treatment in recent years. In patients withstable angina and suitable coronary anatomy, the use ofstents and adequate adjuvant therapy allows a competentpractitioner to perform either one- or multi-vessel PCIwith a high likelihood of initial procedural success andacceptable risk. 575 The risk of death associated with the procedurein routine angioplasty is 0.3–1%, although this canvary quite considerably. Contrary to the case of bypasssurgery, on available evidence, PCI compared with medicaltherapy does not seem to provide substantial survivalbenefit in stable angina. 576Trial-based evidence indicates, however, that PCI is moreoften effective than medical treatment in reducing eventsthat impair quality of life (angina pectoris, dyspnoea, andthe need for re-hospitalisation or limitation of exercisecapacity). The ACME investigators 577 demonstrated superiorcontrol of symptoms and better exercise capacity in patientsmanaged with PCI when compared with medical therapy.Death and MI were similar in both groups. However,mid-term results in patients with two-vessel disease didnot demonstrate superior control of symptoms comparedwith medical therapy (similar improvement in exercise duration,freedom from angina, and improvement in quality oflife at the time of 6-month follow-up) as was experienced bypatients with one-vessel disease. 578 This small study(n ¼ 328) suggests that PCI may be less effective in controllingsymptoms in patients with two-vessel and stable anginawhen compared with one-vessel disease.The RITA-2 trial 579 showed that PCI results in better controlof symptoms of ischaemia and improves exercise capacitycompared with medical therapy, but is associated with ahigher combined endpoint of death and peri-procedural MI.In this trial, 1018 patients (62% with multi-vessel CAD and34% with significant disease in the proximal segment of theleft anterior descending coronary artery) with stable anginawere randomized to PCI or medical therapy and followedfor a mean of 2.7 years. Patients who had inadequatecontrol of their symptoms with optimal medical therapywere allowed to cross-over to myocardial revascularization.Death and definite MI occurred in 6.3% of the PCI patientsand 3.3% of the medical patients (P ¼ 0.02). Of the 18deaths (11 PCI and seven medical), only eight were due toheart disease. Twenty-three per cent of the medical patientsrequired a revascularization procedure during follow-up.Angina improved in both groups, but there was a 16.5%absolute excess of worse angina in the medical group at 3months following randomization (P , 0.001). Duringfollow-up, 7.9% of the patients randomized to PCI requiredCABG surgery when compared with 5.8% of the medicalpatients. AVERT 580 randomly assigned 341 patients withstable CAD, normal LV function, and Class I and/or II anginato PCI or medical therapy with 80 mg daily atorvastatin. At18 months follow-up, 13% of the medically treated grouphad ischaemic events when compared with 21% of the PCIgroup (P ¼ 0.048). Angina relief was greater in thosetreated with PCI. These data suggest that in low-risk patientswith stable CAD, medical treatment including aggressivelipid-lowering therapy may be as effective as PCI in reducingischaemic events. Greater improvement in anginal symptomsoccurred with PCI.Elective stent insertion and drug-eluting stents (DES). Inameta analysis of 29 trials involving 9918 patients, therewas no evidence for a difference between routine coronarystenting and standard balloon angioplasty in terms of deathor MI or the need for CABG surgery. However, coronary stentingreduces the rate of restenosis and the need for repeatPCI, 581 findings confirmed in a further more recentmeta-analysis. 582 However in-stent restenosis remains alimitation in the efficacy of PCI for patients with stablecoronary disease, with a need for target lesion revascularizationbetween 5 and 25%.Drug-eluting stents have been the focus of attention ofinterventional coronary therapy after the RAVEL study. 583The frequently interchangeable use of the term ‘coatedstent’ and ‘drug-eluting stent’ is misleading becausecoated stent also includes the so-called passive coatings,which have failed to prove their benefit and, in someseries, have even showed harmful effect. Hence, the termdrug-eluting stent is recommended instead of coatedstent. Presently, three drugs have shown significantly positiveeffects in prospective randomized studies (paclitaxel,sirolimus, and its derivative everolimus). To date, randomizedtrials include only patients with one-vessel diseaseand with stable or unstable angina. The use of drugelutingstents shows a consistently better treatment effectcompared to bare metal stents, reducing the risk of restenosisand major adverse cardiac events including target vesselrevascularization. Reported incidence of major adversecardiac events over 9 months range between 7.1 and10.3% with drug-eluting stents compared with between13.3 and 18.9. 584–586 More specific guidelines on the use ofDES are available in the ESC guidelines on PCI. 587Revascularization vs. medical therapyAside from studies dealing exclusively with the effects ofeither PCI vs. medical therapy or surgery vs. medicaltherapy, several hybrid studies have investigated theeffects of revascularization, (either PCI or surgery) comparedwith medical therapy. The Asymptomatic CardiacIschaemia Pilot 70 study provides additional information comparingmedical therapy with PCI or CABG revascularizationin patients with documented CAD and asymptomatic ischaemiaby both stress testing and ambulatory ECG monitoring.This small study (n ¼ 558) randomized patients withminimal symptoms but evidence of ischaemia on testing,who were suitable for revascularization by PCI or CABG toone of three treatment strategies: angina-guided drug
Page 3: ESC Guidelines 3so
Page 6 and 7: 6 ESC Guidelinesim
Page 8 and 9: 8 ESC Guidelinesfr
Page 10 and 11: 10 ESC GuidelinesT
Page 12 and 13: 12 ESC Guidelinesi
Page 14 and 15: 14 ESC Guidelinesa
Page 16 and 17: 16 ESC Guidelinesa
Page 18 and 19: 18 ESC GuidelinesF
Page 20 and 21: 20 ESC Guidelinesm
Page 22 and 23: 22 ESC GuidelinesR
Page 24 and 25: 24 ESC Guidelinese
Page 26 and 27: 26 ESC Guidelinesw
Page 28 and 29: Figure 7 Algorithm for medical mana
Page 32 and 33: 32 ESC Guidelines2
Page 34 and 35: 34 ESC GuidelinesH
Page 36 and 37: 36 ESC Guidelinesf
Page 40 and 41: 40 ESC Guidelinest
Page 42 and 43: 42 ESC GuidelinesT
Page 44 and 45: 44 ESC GuidelinesC
Page 54 and 55: 54 ESC Guidelinesm
Page 56 and 57: 56 ESC GuidelinesO

Guidelines on the Management of Stable Angina Pectoris ... - Cardio

Create successful ePaper yourself

Delete template?

Save as template?