Core Curriculum

• Contemporary Management of Myocardial Ischemia

VBWG06_CORE_CMMI.pdf (15.4MB)VBWG06_CORE_CMMI.pdf (15.4MB)

Contemporary Management of Myocardial Ischemia

Download VBWG06_CORE_CMMI_S01.ppt (8 slides - 0.7MB)

Contemporary Management of Myocardial Ischemia Epidemiology of chronic ischemia (angina) Persistent ischemia (angina) despitecurrent drug therapy Persistent ischemia (angina) despite PCI Persistent ischemia (angina) despite optimal revascularization Myocardial ischemia: Significant clinical burden Myocardial ischemia diminishes quality of life Coexistence of myocardial ischemia and depression

Myocardial Ischemia: View from the Vessel Wall

Download VBWG06_CORE_CMMI_S02.ppt (8 slides - 1.3MB)

Myocardial Ischemia:View from the Vessel Wall Causes of inadequate myocardial O2 supply Ischemia is related to myocardial O2 supply and demand Symptoms occur at end of ischemic cascade Obstructive plaque and ischemia Impaired microvascular perfusion in the anginal syndrome Subendocardial hypoperfusion: Association with anginal syndrome Accumulating evidence implicates coronary microcirculation dysfunction in IHD

New Mechanistic Approaches to Myocardial Ischemia

Download VBWG06_CORE_CMMI_S03.ppt (16 slides - 0.9MB)

New Mechanistic Approaches to Myocardial Ischemia New mechanistic approaches to myocardial ischemia Rho kinase inhibition: Fasudil Metabolic modulation (pFOX): Trimetazidine Metabolic modulation (pFOX) and ranolazine Preconditioning: Nicorandil Sinus node inhibition: Ivabradine Late Na+ current inhibition: Ranolazine Na+ and Ca2+ during ischemia and reperfusion Myocardial ischemia causes enhanced late INa Late Na+ accumulation causes LV dysfunction Na+/Ca2+ overload and ischemia Late INa blockade blunts experimental ischemic LV damage Ranolazine: Key concepts Myocardial ischemia: Sites of action of anti-ischemic medication Summary

Clinical Management of Chronic Stable Angina

Download VBWG06_CORE_CMMI_S04.ppt (5 slides - 0.6MB)

Clinical Management of Chronic Stable Angina Anti-ischemic strategies in stable CAD Older antianginal drugs: Pathophysiologic effects Older antianginal drugs: Clinical conditions that may limit use “Unmet needs” in antianginal therapy

New Therapeutic Options for Chronic Stable Angina

Download VBWG06_CORE_CMMI_S05.ppt (44 slides - 1.0MB)

New Therapeutic Options for Chronic Stable Angina New mechanistic approaches to chronic stable angina Evaluation of fasudil in stable angina: Trial design Results: Fasudil improves exercise duration Results: Fasudil improves exercise time to ≥1 mm ST depression TACT: Study design TACT: Trimetazidine reduces angina episodes IONA: Study design IONA: Reduction in primary outcome INITIATIVE: Study design INITIATIVE: Effects of ivabradine vs β-blockade on primary outcome INITIATIVE: Summary Ranolazine: Late Na+ current inhibitor Ranolazine: Pathophysiologic effects vs older antianginals MARISA: Study overview MARISA: Study design MARISA: Dose-related increase in exercise duration with ranolazine MARISA: Tolerability of treatments MARISA: Summary Antianginals: Effects on exercise duration CARISA: Study overview CARISA: Study design CARISA: Ranolazine increases exercise duration CARISA: Ranolazine reduces angina frequency CARISA: Ranolazine reduces nitrate consumption CARISA: Summary ERICA: Study design ERICA: Ranolazine reduces angina frequency and nitrate consumption ERICA: Summary Ranolazine: Long-term use Ranolazine extended-release tablets:Approved Jan 31, 2006 Ranolazine: Drug interactions Ranolazine extended-release tablets: Dosing Electrophysiologic effects of ranolazine Late INa effect mitigates IKr effect Overview of torsade de pointes Ranolazine: No apparent proarrhythmic characteristics Current nonpharmacologic antianginal strategies Potential cardioprotective benefits of exercise Exercise vs PCI in low-risk CAD EECP improves angina class Surgical laser TMR improves angina class SCS vs CABG: Equivalent symptom relief in high-risk patients Summary

Practical Considerations in Chronic Ischemic Heart Disease Management

Download VBWG06_CORE_CMMI_S06.ppt (28 slides - 1.1MB)

Practical Considerations in Chronic Ischemic Heart Disease Management Angina treatment: Objectives Comprehensive management of myocardial ischemia CAD: Treatment challenges ACC/AHA guidelines: Chest pain evaluation ACC/AHA guidelines: Chronic stable angina treatment Substantial growth in PCI Stable CAD: PCI vs conservative medical management Major benefit of PCI: Angina symptom relief CAD progression: Major cause of post-revascularization angina Conditions limiting repeat revascularization Diabetes and PCI: Factors influencing outcome CARISA: Ranolazine benefits patients with and without diabetes CARISA: Ranolazine reduces A1C Selective vs routine catheterization: Cost reduction Chronic stable angina: Pharmacotherapy CRUSADE: Nonpharmacologic interventions at discharge CRUSADE: Discharge medications following UA/NSTEMI How important is IHD in women? AHA guidelines: Chest pain evaluation in women IHD vasculopathy: Gender differences Ischemia in women: Microvascular dysfunction Less obstructive CAD: Women vs men Women have more adverse outcomes vs men Higher incidence of major CV events in women Increased risk of death/MI in women with CAD CRUSADE: Gender and discharge medications Euro Heart Survey: Undertreatment of women

Ongoing Trials in Managing Myocardial Ischemia

Download VBWG06_CORE_CMMI_S07.ppt (10 slides - 2.0MB)

Ongoing Trials in Managing Myocardial Ischemia MERLIN-TIMI 36: Study design COURAGE: Study design COURAGE: Lifestyle modification goals COURAGE: Medical therapy goals BARI 2D: Study design Biological revascularization: New frontiers Transplanted EPCs: Reduction in fibrosis Stem cell therapy for intractable angina:Study design Summary
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