Hypertension in Patients with Coronary Artery Disease Prof Pham Gia Khai, MD PhD FACC FESC Conflict of interest • Nil Case • 61 yrs F • HTN: 10 yrs: well controlled for yrs; recent yrs Not well controlled • DM: yrs Rx: SU + Metformin • Atypical chest pain • Dyspnea on exertion • ECG: LV hypertrophy; cannot rule out CAD • Cardiac Echo: LVDd: 57 mm; EF: 45% MCQ (slide 4) • • • • • • • • • • • • • • Diagnosis of Hypertension : (A) Systolic ≥ 140 mmHg or Diastolic ≥ 90 mmHg (B) Systolic ≥ 140 mmHg and Choose the right answer Diastolic ≥ 90 mmHg Diagnosis of Diabetes mellitus (A) Fasting Blood Glucose ≥ mmol/L (≥ 126 mg/L) and/or HbA1C ≥ 6.5 (B) Fasting Blood Glucose ≥ mmol/L and 2hr post-prandial Blood Glucose ≥ 7.8 mmol/L (C) Both (A) and (B) Choose the right answer Diagnosis of coronary heart disease (A) Chest pain relieved by Nitrates, cardiac enzymes normal (B) Chest pain not relieved by Nitrates, cardiac enzymes normal (C) Suggestive coronary angiogram, cardiac enzymes normal (D) Elevated cardiac enzymes, but coronary angiogram normal Choose the right answer ECG Questions ??? • Relationship between HTN and CAD • What is the difference of CAD profile in HTN vs normotensive patients? • Pretest possibility of CAD? %? • Which is the best test for diagnosis of CAD in this patients? • Optimal strategy for CAD pts with HTN? BP levels are directly related to ischemic heart disease at any decade of age 128 64 Age at risk: 80–89 years 70–79 years 60–69 years 32 16 256 50–59 years IHD mortality (floating absolute risk and 95% CI) IHD mortality (floating absolute risk and 95% CI) 256 128 64 80–89 years 70–79 years 60–69 years 32 16 50–59 years 1 0 120 140 160 180 Usual SBP (mmHg) Age at risk: 70 Usual DBP (mmHg) 80 90 Lewington et al Lancet 2002;360:1903–13 Incidence of MI and total stroke by systolic BP strata in the in the Framingham population D’Agostino RW, et al BMJ 1991; 303:385-389 Intensive Lowering BP levels increases risk of MI in patients at high or very high CV risk Incidence of primary outcome, % Mortality increases with follow-up DBP < 70 mmHg in the INVEST trial 60 50 40 30 20 10 60 > 60 to 70 > 70 to 80 > 80 to 90 > 90 to 100 > 100 to 110 > 110 Diastolic Blood Pressure, mmHg Patientswith primaryoutcome,n 56 389 176 2239 Patientswith primaryoutcome 124.3 131.7 Patientswithout primaryoutcome 127.0 129.1 Totalpatients,n 1003 596 174 33 17 7376 1230 202 46 135.1 143.7 160.2 171.6 186.0 131.0 138.8 154.2 169.4 187.5 11306 Meansystolicbloodpressure,mmHg 100 % had coronary heart disease; treatment with beta blocker or calcium channel blocker Messerli et al Ann Intern Med 2006;144:884–893 MCQ (slide 44) Stratification of risk factors (A) No (B) Yes Choose the right answer Risk factors as has been proved BP – Cholesterol – Age – Smoking – DM – Gender… (A) Ranking No (B) Ranking Yes Choose the right answer Pretest as established by ESC 2013 Chest pain (Present-Atypical-Absent) – Age – Gender (A) Meaning Yes (B) Meaning No Treatment of HTN in Patients with CAD Pharmacological Treatment of Hypertension in the Management of Ischemic Heart Disease Hypertension 2015;65:000-000 DOI: 10.1161/HYP.0000000000000018 Revascularization Strategy for Stable Ischemic Heart Disease Patients with Multivessel Disease and Hypertension CABG vs PCI ? + Optimal Medical Treatment Not all SCAD patients benefit from revascularization Not all SCAD patients benefit from revascularization Indications for Revascularization in patients with stable angina or silent ischaemia European Heart Journal doi:10.1093/eurheartj/ehu278 Recommendation for the type of revascularization (CABG or PCI) inpatients with SCAD with suitable coronary anatomy for both procedures and low predicted surgical mortality European Heart Journal doi:10.1093/eurheartj/ehu278 MCQ (slide 53) • Risk stratification for appropriate approach in diagnosis and treatment • (A) Should be done • (B) Optional because of patient and local infrastructure • • • • • Choose the appropriate answer Treatment of HTN and accompanying diseases (A) Treat HTN first (B) Treat HTN and accompanying diseases (C) The approach to diagnosis and treatment should be adapted to individual basis What did we with our patient • • • • Stress ECG: not preferred (LV hypertrophy) Echo stress: > 15% Myocardium ischemic Risk stratification: high risk Optimal Medical Rx:  DAPT (aspirin + clopidogrel)  Statin  ACEi  Betablocker  Insulin + Metformine • Coronary Angiography and Intervention Cor angiogram Post PCI (total revascularization) Many Thanks ... Case • 61 yrs F • HTN: 10 yrs: well controlled for yrs; recent yrs Not well controlled • DM: yrs Rx: SU + Metformin • Atypical chest pain • Dyspnea on exertion • ECG: LV hypertrophy; cannot rule... 80–89 years 70–79 years 60–69 years 32 16 256 50–59 years IHD mortality (floating absolute risk and 95% CI) IHD mortality (floating absolute risk and 95% CI) 256 128 64 80–89 years 70–79 years... coronary heart disease (A) Chest pain relieved by Nitrates, cardiac enzymes normal (B) Chest pain not relieved by Nitrates, cardiac enzymes normal (C) Suggestive coronary angiogram, cardiac enzymes