Boala cardiaca ischemica stabila

Andreea Catarina Popescu, MD, PhD

 Stable Coronary Artery Disease
Epidemiology
• Annual incidence 1% for males 45-65 y
• Steep increase with age 4% in population of 75-84 y
• Decrease in mortality rates although prevalence did
not decrease (improved prognosis)
• Missing data on vasospastic and microvascular
angina (clinical data: 1/3 of stable angina pts have
no coronary stenosis)
 Boala cardiaca ischemica
Coronary artery disease
sindrom coronarian acut
Angina instabila
Infarct miocardic fara supradenivelare de ST
Infarct miocardic acut cu supradenivelare de ST

boala coronariana stabila

angina stabila
boala silentioasa
Antecedente de infarct miocardic,
fenomene de insuficienta cardiaca
Ford TJ, Corcoran D, Berry C. Heart 2018;104:284-292.
Eur Heart J 2013
What is microcirculation?
• The epicardial arteries
(conductance vessels) give
rise to the pre-arteriolar
arteries, that divide into
arterioles which in turn
feed the capillaries
• The pre-arterioles and
arterioles constitute the
coronary arterial
microcirculation

Braunwald E in Coronary Microvascular

Dysfunction Springer 2014, Crea F, Lanza G,
Camici P
Relationship between epicardial
arteries and microcirculation

Camici PG et al, Nat Rev Cardiol 2015

 Extravascular Compression on Coronary
Microvasculature during Diastole and Systole

Increase of in systolic intramyocardial

and ventricular pressure, as typically
occurs in LVH, may negatively impact
on myocardial perfusion

The detrimental effects of increased

systolic pressure on CBF are more
pronounced in subendocardial than in
subepicardial layers, because of
lower CFR

Class A an B refer to intramural

arteries with non-transmural or
transmural course

Duncker DJ, Physiol Rev, 2008

Ford TJ, Corcoran D, Berry C. Heart 2018;104:284-292.
 Clinical Manifestations of Coronary
Microvascular Dysfunction (CMD)
• CMD in absence of myocardial disease and obstructive coronary
heart disease
Cardiovascular risk factors (hypertension, dyslipidemia, diabetes, inflamation,
smoking)
Stable microvascular angina
Primary acute microvascular angina
Takotsubo cardiomyopathy
• CMD in myocardial disease
Hypertrophic cardiomyopathy
Dilated cardiomyopathy
Aortic stenosis
Myocarditis
• CMD in obstructive CAD
Stable CAD
ACS
Coronary microvascular obstruction
• Iatrogenic CMD (PCI, CABG)
Crea F et al, Coronary Microvascular Dysfunction
Springer 2014
 Consequences of microvascular
dysfunction

• Markedly increased resistance to coronary

blood flow at the site of microcirculation can
trigger myocardial ischemia (“microvascular
angina”)
• Microvascular ischemia express as ST-T
modifications on ECG, myocardial perfusion
deffects and LV dysfunction in presence of
normal epicardial coronary arteries
Etiologies of chest pain
without obstructive coronary
artery disease

The varying pathophysiologic

Mechanisms of chest pain without
obstructive coronary artery disease
are grouped into 3 broad
cathegories: non-cardiac,
cardiac ischemic and cardiac
non-ischemic
Microvascular angina overlaps
Partially with cardiac syndrome X,
but it has a narrower
pathophysiological basis that is
ischemic in nature

JACC Imaging 2015

 Angina
• Sediul tipic retrosternal, mai putin specific precordial
• iradiere in mandibula, brate, coate
• Caracter de apasare, presiune, strangere
• Apare la efort si la emotii, expunerea la frig, postprandial
• Cedeaza la intreruperea efortului si dupa NTG
• Fenomene de insotire transpiratii, dispnee
• Caracter constant
• Durata cateva minute
Diagnostic Assessment in SCAD
Traditional Classification of Chest Pain

2013 ESC guidelines on the management of stable coronary artery disease

European Heart Journal (2013) 34, 2949–3003
Boala cardiaca ischemica stabila

2013 ESC guidelines on the management of stable coronary artery disease

European Heart Journal (2013) 34, 2949–3003
Diagnosticul diferential-Anamneza
Descrierea durerii
caracter,
intensitate
localizare
iradiere
durata
factori provocatori
factori calmanti
Antecedente heredocolaterale
Antecedente personale
Prezenta factorilor de risc
 Angina instabila

Angina aparuta in ultima luna

Angina de repaus
Angina nocturna
Schimbarea patternului
• Apare la efort mai mic
• Dureaza mai mult
• Sunt accese mai frecvente
Angina precoce post infarct
Diagnosticul diferential Examen clinic

Inspectie xantelasme, leziuni ischemice

Palpare puls central si periferic
Percutie aria matitatii cardiace
Auscultatie cord si vase
Diagnosticul diferential Teste paraclinice

Troponina, profil lipidic, HLG, Creatinina, glicemie

ECG
Test ECG de efort
Ecocardiografia, ecocardiografia de stres
scintigafie
coronarografie
CT torace
angioCT coronare
Radiografia cord pulmon
RM cardiac
Diagnostic diferential Durerea
toracica
Spasm esofagian
Boala ulceroasa
Pericardita
• Durere accentuata de inspir
• Iradiere in umar
Classification of Angina Severity according to
Canadian Cardiovascular Society

Eur Heart J 2013

 Confirmarea diagnosticului de
boala coronariana
Teste care confirma prezenta factorilor de risc
pentru boala coronariana (glicemie, profil lipidic, indice
glezna brat, Doppler carotidian)

Teste care confirma prezenta ischemiei functionale

Teste care confirma prezenta stenozelor coronariene –
anatomic

Folosirea acestora functie de probabilitatea de a avea

boala coronariana
Initial Diagnostic Management in Patients with
Suspected SCAD
 Indications

- Diagnosis of CAD (in patients with intermediate PTP=15-85%)

Sicari R. EJE 2008;9:415

PTP < 15%

PTP 15–65%

PTP PTP
> 85% 66–85%
2013 ESC guidelines on the management of SCAD
 Blood Tests in Assessment of Known or
Suspected SCAD to Optimize Medical Therapy

Eur Heart J 2013

Blood tests for Routine Re-assessment
in SCAD

Eur Heart J 2013

Electrocardiograma

ECG de repaus cel mai ades normal

ECG in timpul durerii
Resting ECG for Initial Diagnostic
Assessment of SCAD

Eur Heart J 2013

Ambulatory ECG Monitoring for Initial
Diagnostic Assessment in SCAD

Eur Heart J 2013

Chest X-Ray for Initial Diagnostic
Assessment in SCAD
Characteristics of Tests Commonly Used to
Diagnose SCAD (and available in Romania)
2013 ESC guidelines on the management of stable coronary artery disease
European Heart Journal (2013) 34, 2949–3003
Investigation in patients with Suspected
Coronary Microvascular Angina

Eur Heart J 2013

 Rolul ecocardiografiei de repaus
la pacientii cu angina
Prezenta tulburarii localizate de cinetica
ca semn al ischemiei (hipo sau akinezie)
Evolutia tulburarii de cinetica
Diagnostic diferential al durerii toracice
Diagnosticul comorbiditatilor
Rol prognostic FEVS
Ischemia miocardica
 Ischemia miocardica

Tulburarea de cinetica
- lipsa ingrosarii miocardice
- lipsa deplasarii spre centru
Tulburare localizata de cinetica apare cand
cel putin ½ din grosimea peretelui este
ischemica
- Hipokinezie 2
- akinezie 3
 Rolul ecocardiografiei de repaus
la pacientii cu angina

Examen ecografic complet, standardizat

Achizitie digitala pentru comparatia studiilor
 Scorul cineticii
parietale
1 normokinezie,

Lang et al.
2 hipokinezie
3 akinezie
4 diskinezie sau
anevrism

Lang et al. Recommendations for Cardiac Chamber Quantification

by Echocardiography in Adults: An Update from the American Society of
Echocardiography and the European Association of Cardiovascular Imaging
European Heart Journal – Cardiovascular Imaging (2015) 16, 233–271
Lang et al. Recommendations for Cardiac Chamber Quantification
by Echocardiography in Adults: An Update from the American Society of
Echocardiography and the European Association of Cardiovascular Imaging
European Heart Journal – Cardiovascular Imaging (2015) 16, 233–271
 Fractia de ejectie
a ventriculului stang

Measurement of
LV volumes and LVEF

• LVEF >45-50%
• LVEDVi <97 ml/m2
• LVESVi <49 ml/m2

ASE/EAE 2005
Eur J Echocardiogr 2006;7:79-108
Speckle tracking echocardiography

Longitudinal and radial deformation

30 strain
[%]
20 radial
strain
10

0
longitudinal
- strain
10 AVO AVC MVO MVC
-
20 ECG
Courtesy: prof JU Voigt
LONG

RADIAL

CIRCUMF
• 296 pts with suspected angina
• No Hx of HD, normal EF & resting ECG
• 2D strain, exercise ECG, coro angio
• GLS was lower in pts with CAD
• GLS: independent predictor of CAD
• Regional long. systolic strain analysis
identifies the stenotic coronary artery

Biering-Sorensen T, et al. Circ Cardiovasc Img 2014

 In pts with stable angina, GLS by 2D strain echo at rest predicts
significant CAD and significantly improves the diagnostic
performance of exercise test.
Regional long. systolic strain analysis identifies the stenotic
coronary artery Biering-Sorensen T, et al. Circ Cardiovasc Img 2014
Initial Diagnostic Management in Patients with
Suspected SCAD
 Indications

- Diagnosis of CAD (in patients with intermediate PTP=15-85%)

Sicari R. EJE 2008;9:415

PTP < 15%

PTP 15–65%

PTP PTP
> 85% 66–85%
2013 ESC guidelines on the management of SCAD
Non-invasive Testing in Patients with Suspected
SCAD with an Intermediate Pre-test Probability

2013 ESC guidelines on the management of stable coronary artery disease European Heart
Journal (2013) 34, 2949–3003
2013 ESC guidelines on the management
of stable coronary artery disease European
Heart Journal (2013) 34, 2949–3003
Exercise ECG for Initial Diagnosis and
Pharmacologic Imaging Stress Tests

Eur Heart J 2013

Sensitivity and specificity of exercise
stress test and immaging stress tests
Test ECG de efort
• BC, barbat, 60 ani
• Dislipidemie, HTA
• Durata efortului 4 min
• Angor 4 Kattus
• GC, barbat, 44 ani
• Dislipidemie, fumat
 Coronarografie

Leziune unicoronariana: subocluzie de ostiu ADA

IM, barbat, 62 ani
Dureri atipice
Durata efortului = 10 min, 11 METs
Motivul opririi testului - oboseala
Test de efort – electrocardiograma de repaus
Test de efort – perioada de recuperare
Test de efort – perioada de recuperare

Test cu modificari la limita

(slab pozitiv) in inferior

Coronarografie-subocluzie ACD segm.I

Traseu ECG inregistrat la acelasi pacient in criza de angor
Traseu ECG inregistrat dupa adm. de NTG
 Ecocardiografia de stres

Testele de stres imagistice vs testul ECG de efort

- Sensibilitate crescuta in
identificarea ischemiei
- Localizeaza si cuantifica
ischemia
- Ofera informatii la pacienti
cu modificari ECG sau
care nu pot efectua efort
2013 ESC guidelines on
the management of stable
coronary artery disease
 Testele de stres imagistice

Ecocardiografia de stres furnizeaza informatii diagnostice si prognostice cu

acuratete similara tehnicilor imagistice alternative.
Montalescot et al. European Heart Journal 2013;34:2949
 Testele de stres imagistice

2013 ESC guidelines on the management of stable coronary artery disease—addenda

Standarde minimale pentru eco de stres

Popescu BA, et al. Eur Heart J Cardiovasc Imaging 2014;15:1188

Popescu BA, et al. Eur J Echocardiogr 2009;10:893

Teste imagistice vs
- neinvaziva
- localizeaza ischemia
- evalueaza severitatea ischemiei
- evaluarea ocluziilor cronice
- investigatie indicata initial in
evaluarea pacientului cu BCS
- rezultate suboptimale in boala
multicoronariana
Metode complementare
FFR
- invaziva
- localizeaza ischemia
- nu apreciaza severitatea ischemiei
- nu poate evalua ocluziile
- investigatie indicata la finalul
evaluarii pacientului cu BCS
- preferat in boala multicoronariana
 Ecocardiografia de stres - metode

Ecocardiografie de efort

2013 ESC guidelines on the management of SCAD

Teste de stres farmacologic

- Dobutamina
- Dipiridamol
- Adenozina

Pacing (la purtatorii de stimulator cardiac)

 Ischemic stressors and protocols
Exercise Dypiridamole
Dobutamine Adenosine
Pacing
reveal ↓ CFR

increase O2 demand reduce O2 supply

“horizontal steal / vertical steal”

CAD CAD
Microvascular disease
(HT, DZ)

Wall motion Wall motion Without wall motion

abnormalities abnormalities abnormalities
 Efort sau stres farmacologic?
- pacienti la care efortul este contraindicat (severe HT)
- pacienti care nu pot efectua efort (ex. boli neurologice, claudicatie)
- test de efort submaximal

Dobutamine

Dipyridamole

Adenozine
- 140 microg/kg/min in 6 min
Sicari R. EJE 2008;9:415
 Ce informatii furnizeaza?
Diagnostice:
- anomalii de cinetica noi sau agravarea unora preexistente = ischemie
(afectarea a cel putin 2 segmente adiacente)
- ameliorarea cineticii = viabilitate (cel putin 5 segmente)

- cresterea cavitatii VS, aparitia regurgitarii mitrale ischemice sau a

obstructiei intraventriculare
Ce informatii furnizeaza?
Prognostice:

Test negativ Test pozitiv

Criterii Risc foarte Risc

Risc scazut Risc inalt
scazut intermediar
(1-3%/an) (>10%/an)
(< 0,5%/an) (1-3%/an)
Doza/nivel de efort maximal submaximal inalt scazut
VE FS in repaus >50% < 40% >50% < 40%
Terapie antiischemica prezenta absenta - +
Rezerva de flux coronara >2 <2 >2 <2
Teritoriul coronarian - - Cx/CD ADA
WMSI la stres maximal - - crescut scazut
Recuperare - - rapid lent
Valoarea prognostica a unui test ecografic de stres anormal
- 1477 cu teste eco de stres anormale
- 480 (32.5%) teste fals pozitive (stenoze <50% /coronare epicardice normale)

Predictorii independenti ai absentei leziunilor coronariene semnificative dupa

un test eco de stres anormal au fost: varsta tanara, sexul feminin, absenta DZ
si un test ECG de efort negativ.
From et al. JASE 2010;23:207
Valoarea prognostica a unui test ecografic de stres anormal

Pe perioada urmaririi (2,4 ±1 ani) au fost 140 de decese.

From et al. JASE 2010;23:207

Prognosticul pacientilor cu teste fals pozitive a fost similar cu al celor

cu leziuni coronariene semnificative si teste de stres pozitive.
Impact practic: Pacientii cu ischemie la testele de stres ecografice
trebuie sa fie urmariti si tratati agresiv chiar in absenta leziunilor
coronariene semnificative.
 Safety concerns
Dobutamine major complications: 0.2 %

Geleijnse et al. Circulation 2010;121:1756

Atropine – the strongest predictor of neuropsychiatric symptoms

Wuthiwaropas et al. JASE 2011; 24:367
 Ecocardiografie de efort

- 100 W, timp de 8 minute, FC 150/min (86%)

- fara angina, cu toleranta buna la efort
Ecocardiografie de efort
Ecocardiografie de efort
Ecocardiografie de efort
Repaus Nivel redus de efort

Recuperare (2 min) Recuperare (4 min)

Ecocardiografie de efort
 Acquisition technique

F, 60 years old, CABG

When < 80% of the endocardial border is adequately visualized, the use
of contrast agents for endocardial border delineation is mandatory
Evangelista A, et al. Eur J Echocardiogr 2008;9:438
 Myocardial perfusion

Slow replenishment of
myocardial microbubbles
during low power imaging
following a transient
increase in acoustic power
(flash imaging) can indicate
decreased perfusion.

Improved de identification of ischemia as compared with wall motion

assessment alone
Shah BN, et al. JASE 2014;27:520

Limitations: is a time-consuming technique requiring extensive training

 Circulation. 2003;107:2120-2126.)

During DSE, SRI quantitatively and qualitatively

differentiates ischemic and nonischemic regional
myocardial response to dobutamine stress. The ratio
of PSS to maximal strain may be used as an objective
marker of
ischemia during DSE.
2013 ESC guidelines on the management of stable coronary artery disease
European Heart Journal (2013) 34, 2949–3003
 SPECT Stress Testing
Inducible Ischemia vs Myocardial Infarction

Zamorano J, The ESC Textbook of

Cardiovascular Imaging, Springer 2010
MRI Stress Testing with
Dobutamine

Zamorano J, The ESC Textbook of

Cardiovascular Imaging, Springer 2010
Coronary MSCT

Zamorano J, The ESC Textbook of

Cardiovascular Imaging, Springer 2010
Diagnostic anatomic al bolii coronariene

2013 ESC guidelines on the management of stable coronary artery disease European
Heart Journal (2013) 34, 2949–3003
 The Risk Assessment Strategy

• Risk stratification by clinical evaluation

• Risk stratification by ventricular function
• Risk stratification by response to stress testing
• Risk stratification by coronary anatomy

Low event rate – annual mortality<1%

Intermediate event rate –annual mortality >1%
and<3%
High event rate –annual mortality >3%
 Risk stratification
Definitions for Risk for Various Non-invasiveTest Modalities
ESC Congress 2013
Rates of MI and Cardiac Death According to Severity
of Myocardial Perfusion Abnormalities and LVEF
 Risk Stratification by Coronary
Anatomy
• Patients with LM severe disease have a poor
prognosis on medical treatment
• Three vessel disease and >95% proximal
LAD 59% survival at 5y
• Medically treated patients survival at 12y in
CASS Registry
– 91% normal coronary arteries at invasive angio
– 74% one vessel disease
– 59% two vessel disease
– 50% three vessel disease
Management Based on Risk Determination
for Prognosis in Patients with Suspected
SCAD
Pharmacologic properties of BB
Beta blockers in SCAD
Nitrates mechanism of action
ACEIs in SCAD
JACC Nov 2017
Revascularization vs optimal medical
therapy in SCAD
2018 ESC/EACTS Guidelines onmyocardial
Revascularization European Heart Journal (2018) 00, 1–96