Stable Angina Pectoris Epidemiology and prognosis Is it ... · Initial clinical presentation of...
Transcript of Stable Angina Pectoris Epidemiology and prognosis Is it ... · Initial clinical presentation of...
Stable Angina PectorisEpidemiology and prognosisIs it improving?
GK Efthimiadis, MD
William Harvey (1578 –1657)
third circulation
de circulo sanguinis
in corde
Classic description of angina pectoris
William Heberden
Royal College
of Physicians
1768
Angina Pectoris
Angina (αγχόνη): ―strangling‖ or infection of the throat
Pectoris: pectus (chest)
Angina Pectoris (1700-1800)
Unknown pathogenesis
Treatment: bloodletting, tincture of opium, bed rest
Caleb Parry (1799) :
Coronary-artery ossification
Predominantly in men ≥50 years
Angina Pectoris
….is excited more especially upon walking up hill, and after a meal
...accompanied with a sensation, which threatens instant death if the motion is persisted
…on stopping, the distress immediately abates
Angina Pectoris (1800-1900)
1844: cardiac catheterized in animals (Claude Bernard) 1867:Brunton L. On the use of nitrite amyl in angina pectoris.
Lancet 1879:coronary thrombosis ―secondary to sclerotic changes in
the coronaries 1889: occlusion of a coronary artery in the dog:―quivering‖
(VF) of the ventricles-rapidly fatal. 1910: total bed rest 1919: electrocardiography 1920: first human cardiac catheterization (Forssman — on
himself ) standard of care until the mid-20th century.
Egyptian princess Ahmose-Meryet-Amon (Thebes, 1580 and 1550 BC)First Person in Human History With Diagnosed Coronary Artery Disease Ancient Egyptian PrincessScience Daily (May 17, 2011)
Angina Questionnaire ItemsRose GA et al. Cardiovascular
Survey Methods. 2nd ed. Switzerland: WHO;1982.
1. Have you ever had any pain or discomfort in your chest? (yes)
2. Do you get it when you walk uphill or hurry?3. Do you get it when you walk at an ordinary pace
on the level?If the answer to question 2 or question 3 is ―yes,‖ then proceed toquestion 4
4. What do you do if you get it while walking? (stop or slow down)
5. If you stand still what happens? (relieved)6. How soon? (10 minutes or less)7. Location? (central chest or left arm)
Typical Progression of Coronary Atherosclerosis.
Abrams J. N Engl J Med 2005;352:2524-2533.
Angina/MI as first manifestation of coronary artery disease (Rochester, Minn1960-1980)
MI/SD: 66% in men (m age 72y), 54% in women (62y)
Angina pectoris:
34% in men (m age 60y)
incidence of MI/Death in 20 y 60%
46% in women (m age 67y)
incidence of MI/Death in 20 y 40% JAMA. 1993;269:2392-2397
Prevalence of angina pectoris
(total cases/population)
Women: 45-54-y 0.1–1%, 65-74-y 10–15%
Men: 45-54-y 2-5%, 65-74-y 10–20%
Europe: 20,000–40,000/million
High prevalence of angina pectoris in women?
Small epicardial arteries
Angina with normal coronaries
Higher heart rate
Gestation diabetes and hypertension
YANO K, UEDA S. CORONARY HEART DISEASE IN HIROSHIMA, JAPAN: ANALYSIS OF THE DATA AT THE INITIAL EXAMINATION, 1958-1960. Yale J Biol Med. 1963 Jun;35:504-22
Incidence (new cases per year/population): 0.5%
Date of download: 11/25/2012Copyright © 2012 American Medical
Association. All rights reserved.
From: Incidence and Prognostic Implications of Stable Angina Pectoris Among Women and Men
JAMA. 2006;295(12):1404-1411. doi:10.1001/jama.295.12.1404
CI indicates confidence interval. The size of the data markers represents the number of angina cases.*Annual risk per 100
population, using estimated total population of Finland in 1996. Because the case definitions of angina are mutually exclusive, the
same population denominator was used for each.†Age-standardized to the combined (women and men) population.
Figure Legend:
Date of download: 11/25/2012Copyright © 2012 American Medical
Association. All rights reserved.
From: Incidence and Prognostic Implications of Stable Angina Pectoris Among Women and Men
JAMA. 2006;295(12):1404-1411. doi:10.1001/jama.295.12.1404
CI indicates confidence interval.
Figure Legend:
PROGNOSIS
Curtin RG. Statistics of Sixty Deaths from Angina Pectoris. Trans Am Climatol Assoc. 1907;23:253-61.
Curtin RG. Statistics of Sixty Deaths from Angina Pectoris. Trans Am Climatol Assoc. 1907;23:253-61.
Prognosis (1970-1990)
Mortality rates for men with Rose questionnaire angina
2.6 -17.6/1000 patient-years (1970-1990)
(European data) Lampe FC, Morris RW, Whincup PH, Walker M, Ebrahim S, Shaper
AG. Is the prevalence of coronary heart disease falling in British men? Heart. 2001;86:499–505.
WHO MONICA project populations. Monitoring trends and determinants in cardiovascular disease. monica Lancet 1999;353:1547–1557.
Prognosis (1970-1990)
Initial clinical presentation of stable angina 2-year: MI and CHD death 14.3 and 5.5% in men 6.2 and 3.8% in women Framingham Heart Study. Am J Cardiol
1972;29:154–163. Reunanen A. Prognosis after the onset of coronary heart
disease. An investigation of differences in outcome between the sexes according to initial coronary disease presentation. Circulation 1993;88:2548–2555.
Prognosis in recent years
Data from clinical trials:
antianginal therapy
revascularization (selected nature of the populations)
Mortality: 0.9–1.4%/year
Incidence of non-fatal MI:
0.5% (INVEST)
2.6% (TIBET)
Prognosis in recent years
More aggressive investigation and treatment
Important: select those patients with a less severe form of disease
good outcome
avoiding unnecessary procedures
Risk stratification
Annual cardiovascular mortality
2%: high risk
1%: low risk
1–2%: intermediate risk
Risk stratification
by clinical evaluation
by response to stress testing
by ventricular function
by coronary anatomy
Predictors of prognosis
Conventional risk factors for CAD
Hypertension
Hypercholesterolaemia
Diabetes
Smoking
Predictors of prognosis
LV function (strongest)
Left main disease
Three-vessel disease
Proximal LAD
Myocardial revascularization
Age- and Sex-Adjusted Incidence Rates of Acute Myocardial Infarction, 1999 to 2008
Yeh RW et al. N Engl J Med 2010;362:2155-2165
Decline in Deaths from Cardiovascular Disease in Relation to Scientific Advances.
Nabel EG, Braunwald E. N Engl J Med 2012;366:54-63