angina with no obstructed coronary arteries fileangina with no obstructed coronary arteries eva...
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Angina with no obstructed coronary arteries
Eva Prescott, MD, DMScDepartment of Cardiology
Bispebjerg HospitalUniversity of Copenhagen
Bispebjerg University Hospital
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I have nothing to declare
Department of Cardiology, Bispebjerg University Hospital
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Standardized mortality rates from ischaemic heart disease in selected European countriesPer 100.000, World Health Organization
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Standardised 30 days and 365 days mortality after first MI
Mortality has been reduced by 50% in all groups
Schmidt et al, BMJ 2012
Improvement in survival after MI
30d and 1-yr mortality 1984-2008, Denmark
DEPARTMENT OF CARDIOLOGY, BISPEBJERG UNIVERSITY HOSPITAL
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Patients who survive the first month after an STEMI treated with primary PCI have an
excellent prognosis, with a
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Angina with no obstructed coronary arteries
How common is angina with no obstructive CAD?
What is prognosis in terms of CV outcome?
What is prognosis in terms of continued symptoms, health related quality of life and disability?
What are the costs to society?
DEPARTMENT OF CARDIOLOGY, BISPEBJERG UNIVERSITY HOSPITAL
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Figure 1. Angina prevalence in women vs men.
Harry Hemingway et al. Circulation. 2008;117:1526-1536
Copyright © American Heart Association, Inc. All rights reserved.
Population weighted
mean 6.7%
Femalemale ratio
1.2
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Angina with no obstructive CAD:Prognosis, disability and costs
Angina and NOCAD
Continuedsymptoms
Depression, anxiety
Health related
Quality of life
Disability
CostsDirect and
indirect
CV morbidity Patients
perspective
Societal perspective
Cardiologist perspective
Department of Cardiology, Bispebjerg University Hospital
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In ACS women twice as often as men have nosignificant CAD
Data from 11 randomised studies 1993-2006 comprising 35.000 persons
Berger at al, JAMA 2009;302:874-82
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Rate of NOCAD from clinically indicated angiograms
Patel et al, NEJM 2010
398,978 patients without known CAD undergoing elective CAG
37.6% obstructive CAD (>50% stenosis of LM, >70% of major epicardial vessel)
Men: 47%
Women: 27%
DEPARTMENT OF CARDIOLOGY, BISPEBJERG UNIVERSITY HOSPITAL
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How common is no obstructive CAD in stable angina?
Danish data: 11,000 persons without known CVD referred to angiography because of stable angina.
Proportion with and without obstructive CAD in the period 2000-2009
Jespersen L, European Heart Journal, 2012
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The PROMISE trial – of 10.000 patients assessed for CAD, 5% were ultimately revascularized
DEPARTMENT OF CARDIOLOGY, BISPEBJERG UNIVERSITY HOSPITAL
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Angina with obstructive CAD – tip of the iceberg?
Bispebjerg University Hospital
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Change of paradigm from purelymacrovascular to microvascular disease
0
20
40
60
80
100
Medical treatment Invasive treatment
baseline1 yr3 yr5 yr
Changing paradigm of angina and CAD with less focus on treatment of the epicardial
stenosis
Department of Cardiology, Bispebjerg University Hospital
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Survival free of MACE (CV mortality, MI, HF or stroke) by degree of CAD in patients referred to CAG due to angina
Department of Cardiology, Bispebjerg University Hospital
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Persistence of angina by degree of CAD
Follow up 2-3 years after first angiogram
Jespersen et al, Clin Res Cardiol, 2013
357 patients (response rate 83%)
with CAG due to angina reassessed by
Seattle angina questionnaire and Hospital Anxiety and Depression
Scale after 2-3 years
Department of Cardiology, Bispebjerg University Hospital
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Persistance of angina at follow-up of patients referred to CAG for angina
010203040506070
Normal Diffuse CAD
1-2 VD
% persistent
angina
Men Women
Jespersen et al, Clin Res Cardiol, 2013
P
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Persistent angina associated with depression and anxiety
Depression
Anxiety
Jespersen et al, Clin Res Cardiol,
2013
Department of Cardiology, Bispebjerg University Hospital
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Quality of life determined by angina, not degree of CAD
DEPARTMENT OF CARDIOLOGY, BISPEBJERG UNIVERSITY HOSPITAL
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Risk of disability pension and premature exit from workforce
Jespersen et al, EHJ 2013
DEPARTMENT OF CARDIOLOGY, BISPEBJERG UNIVERSITY HOSPITAL
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Survival free of disability pension
Jespersen et al, EHJ 2013
DEPARTMENT OF CARDIOLOGY, BISPEBJERG UNIVERSITY HOSPITAL
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Angina, NOCAD, CAD and subsequent risk of disability pension
Age-and gender
adjusted
Multivariable adjusted(co-morbidity,
socioeconomic factors, cardiac risk factors),
Jespersen et al, EHJ 2013
Department of Cardiology, Bispebjerg University Hospital
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Burden of hospital admission in angina with and without CAD
Jespersen et al, PLOS one 2014
DEPARTMENT OF CARDIOLOGY, BISPEBJERG UNIVERSITY HOSPITAL
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Burden of CV hospitalization: Comparing repeated events risk by angiography findingrecurrent event models
Jespersen et al, PLOS one 2014
Adjusted for age, gender, risk factors, medication, co-morbidity, ses
DEPARTMENT OF CARDIOLOGY, BISPEBJERG UNIVERSITY HOSPITAL
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Burden of CV hospitalization: Comparing repeated events risk by angiography finding
Jespersen et al, PLOS one 2014
DEPARTMENT OF CARDIOLOGY, BISPEBJERG UNIVERSITY HOSPITAL
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Angina with no obstructed coronary arteries
How common is angina with no obstructive CAD?Depends on diagnostic work-upTwice as common in women as in men
What is prognosis in terms of CV outcome?Depends on comparison groupDiffers between populations depending on referral patternsIs poorer than the background population
What is prognosis in terms of continued symptoms, healthrelated quality of life and disability?Symptoms and disability similar across CAG findingsSymptom persistence drives QoL
What are the costs to society?Considerable
DEPARTMENT OF CARDIOLOGY, BISPEBJERG UNIVERSITY HOSPITAL
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Thank you for your attention
Bispebjerg University Hospital
Angina with no obstructed coronary arteriesI have nothing to declare�Standardized mortality rates from ischaemic heart disease in selected European countries�Per 100.000, World Health OrganizationFoliennummer 4Foliennummer 5Angina with no obstructed coronary arteriesFoliennummer 7Angina with no obstructive CAD:�Prognosis, disability and costsIn ACS women twice as often as men have no significant CADRate of NOCAD from clinically indicated angiogramsHow common is no obstructive CAD in stable angina?Foliennummer 12Angina with obstructive CAD – tip of the iceberg?Change of paradigm from purely macrovascular to microvascular diseaseFoliennummer 15Persistence of angina by degree of CAD��Follow up 2-3 years after first angiogramPersistance of angina at follow-up of patients referred to CAG for angina Persistent angina associated with depression and anxietyQuality of life determined by angina, not degree of CADRisk of disability pension and premature exit from workforceSurvival free of disability pensionAngina, NOCAD, CAD and subsequent risk of disability pensionBurden of hospital admission in angina with and without CADBurden of CV hospitalization: Comparing repeated events risk by angiography finding�recurrent event modelsBurden of CV hospitalization: Comparing repeated events risk by angiography findingAngina with no obstructed coronary arteriesFoliennummer 27