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Nonobstructive Coronary Artery Disease & MI

Nonobstructive Coronary Artery Disease & MI | Heart and Vascular Health | Scoop.it

Little is known about cardiac adverse events among patients with nonobstructive coronary artery disease (CAD).

Among 37 674 patients, 8384 patients (22.3%) had nonobstructive CAD and 20 899 patients (55.4%) had obstructive CAD. Within 1 year, 845 patients died and 385 were rehospitalized for MI.

Among patients with no apparent CAD, the 1-year MI rate was 0.11% (n = 8, 95% CI, 0.10%-0.20%) and increased progressively by number of vessels involved.

Patients with:

1-vessel nonobstructive CAD had a hazard ratio for 1-year MI of 2.0

2-vessel nonobstructive HR, 4.6

3-vessel nonobstructive HR, 4.5

1-vessel obstructive HR, 9.0

2-vessel obstructive HR, 16.5

3-vessel or LM obstructive HR, 19.5

One-year mortality rates were associated with increasing CAD extent, ranging from 1.38% among patients without apparent CAD to 4.30% with 3-vessel or LM obstructive CAD.

Conclusions and Relevance  In this cohort of patients undergoing elective coronary angiography, nonobstructive CAD, compared with no apparent CAD, was associated with a significantly greater 1-year risk of MI and all-cause mortality. These findings suggest clinical importance of nonobstructive CAD and warrant further investigation of interventions to improve outcomes among these patients.

Seth Bilazarian, MD's insight:

The usual definition of coronary artery disease (CAD) severity causes doctors to not "label" the patient with CAD unless stenosis (narrowing) in the coronary artery are greater than 50%.  This paper does a great job bringing attention to the issue that even minor plaques (>20%) predict future heart risk.  As an interventional cardiologist, I am always concerned that patents get the message that they did not have "any significant disease" means that they should not intensify their risk modification efforts like diet, exercise & smoking cessation.  The presence of plaques are important, predictive and an opportunity for doctors to leverage the angiogram pictures we show patients to encourage life stye changes.

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β-Blocker Use & Clinical Outcomes in Stable Outpatients

β-Blocker Use & Clinical Outcomes in Stable Outpatients | Heart and Vascular Health | Scoop.it

My comment: Another icon of medicine is challenged!  If you've had a heart attack (MI), it is the standard of care now to be treated with beta blocker medicines like metoprolol or atenolol indefinitely.  Physicians are graded for their use of beta blockers.  If these are not used with adequate frequency the physician is considered to not be practicing evidence based medicine.  This large study challenges the curent recommendations.  This data suggests no benefit with a history of MI from long ago and possibly harm in patients with only risk factors. How long will it take for guidelines to consider this new data is unknown?

 

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Reduction of Atherothrombosis for Continued Health (REACH) registry who were divided into 3 cohorts: known prior MI (n = 14 043), known CAD without MI (n = 12 012), or those with CAD risk factors only (n = 18 653).  The primary outcome was a composite of cardiovascular death, nonfatal MI, or nonfatal stroke.

Results: Among the 44,708 patients, 21,860 were included in the propensity score–matched analysis. With a median follow-up of 44 months, event rates were not significantly different in patients with β-blocker use compared with those without β-blocker use. In the cohort with CAD risk factors only, the event rates were higher for the primary outcome with β-blocker use.  However, in those with recent MI (≤1 year), β-blocker use was associated with a lower incidence of the secondary outcome.

Conclusion In this observational study of patients with either CAD risk factors only, known prior MI, or known CAD without MI, the use of β-blockers was not associated with a lower risk of composite cardiovascular events.

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Prognostic Value of Exercise Capacity

Prognostic Value of Exercise Capacity | Heart and Vascular Health | Scoop.it
To examine the prognostic value of exercise capacity in patients with nonrevascularized and revascularized coronary artery disease (CAD) seen in routine clinical practice.Conclusion

Exercise capacity was a strong predictor of mortality, MI, and downstream revascularizations in this cohort. Furthermore, patients with similar exercise capacities had an equivalent mortality risk, irrespective of baseline revascularization status.

Seth Bilazarian, MD's insight:

Authors from the FIT Project have put together beautifully the data and summarized it in this one image on the benefits of being fit or "in shape" and the benefits of having arteries "fixed" with angioplasty (PCI or stents) or bypass surgery (CABG), for patients who have coronary artery disease.

What the slide means:

The top row looks at mortality (death).  The term METS refers to the amount of energy spent and  roughly correlates with the number of minutes on the treadmill using the standard exercise protocol called the Bruce protocol.  Looking across the top row you can see that death rate falls as the amount of exercise increases.  The hazard of death falls by 75% for those who can exercise more than 12 minutes compared to those who exercise less than 6 minutes.

In the second & third rows the reduction of heart attacks (MIs) and need for future angioplasty or bypass surgery is effected by revascularization.  Patients that are "fixed" have lower rates of heart attack and needing to be fixed compared to those that haven't been fixed.

For coronary disease patients revascularization with stents or bypass and being fit based on exercise capacity provides the best prognosis

TAKE HOME MESSAGE - It's best to be ""fixed" and fit.

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