ESC Refreshes Guidelines for Stable CAD, CVD With Diabetes

September 02, 2013

AMSTERDAM — In the latest crop of guidelines [1,2] for European cardiologists:

The functional impact of coronary lesions plays a larger PCI-determining role than in the past, compared with their angiographic severity, in patients with stable CAD.

Pretest probabilities (PTP) for a CAD diagnosis get a makeover using data more contemporary than those that went into the 34-year-old Diamond and Forrester Chest Pain Prediction Rule [3].

Standards for glycemic control loosen a bit for the elderly with both diabetes and CVD, in favor of quality of life.

In diabetic patients with complex multivessel CAD, CABG is the first choice but if the patient prefers PCI, it should be with a drug-eluting stent.

Attendees here at the European Society of Cardiology (ESC) 2013 Congress were given a peek at the society's newly minted guidelines for the diagnosis and treatment of stable coronary artery disease and on managing patients with both CVD and diabetes or prediabetes.

Stable CAD

The guidelines increase reliance on PTP for stable CAD, according to Dr Udo Sechtem (Robert Bosch Krankenhaus, Stuttgart, Germany), who cochaired the development task force and overviewed them for ESC attendees. Importantly, the "new set of pretest probabilities" were developed based on a 2011 data set, he told heartwire .

"Customarily, [they have been based on] the Diamond and Forrester data from 1979, but compared with 1979 the prevalence of stenosis in 2013 in patients with angina has clearly come down." However, the new PTP are still based on angina characteristics (typical angina vs atypical angina vs nonanginal pain), patient age, and sex.

For example, in a patient with suspected CAD using the new criteria, as he outlined in his presentation, if the PTP is <15%, "investigate other causes and consider functional coronary disease." If the PTP is intermediate, from 15% to 85%, the patient should go to noninvasive testing. If the PTP is high, >85%, a diagnosis of CAD is established; "proceed to risk stratification." In patients with severe symptoms "or a clinical constellation suggesting high-risk coronary anatomy," guideline-directed medical therapy should be initiated.

The guidelines also give a larger role for "modern imaging techniques," especially cardiac magnetic resonance (CMR) and coronary computed-tomography angiography (CCTA) but with a critical eye, according to Sechtem. "We tried to be conservative, but not as conservative as the US guidelines in 2012 and not as progressive as the NICE guidelines in 2010," he said.

"We have a not-so-strong recommendation for CT. It's only IIA [class II recommendation, level of evidence A], because there was a lot of debate in the task force [regarding its use]," he said.

 
We tried to be conservative but not as conservative as the US guidelines in 2012, and not as progressive as the NICE guidelines in 2010.
 

The guidelines say CT angiography "should be considered" for ruling out stable CAD as an alternative to stress-imaging techniques in patients "within the lower range of intermediate PTP for stable CAD in whom good image quality can be expected." It also should be considered in patients "within the lower range of intermediate PTP for stable CAD after an inconclusive exercise ECG or stress imaging test" or those in whom stress testing is contraindicated, "if fully diagnostic image quality of coronary CTA can be expected."

"We also have three 'no-go' recommendations," Sechtem said. The IIIC recommendations are: "We shouldn't do calcium scoring in patients who are symptomatic. We shouldn't do CT in asymptomatic patients as a screening test. And we shouldn't do a CT angiography in a patient who has a high likelihood of calcifications."

Also noteworthy and perhaps a bit more aggressive than US guidelines, Sechtem observed, the guidelines recommend "a resting echocardiogram on first contact with every person with chest pain."

They also acknowledge that microvascular angina and vasospasm are more common as causes of angina than previously believed, he said. "The problem is that most clinicians think of coronary artery disease as an entity that is caused by stenosis. Of course it is, but there's more to it than that."

Sechtem's cochair on the task force, Dr Gilles Montalescot (Pitié-Salpêtrière University Hospital, Paris, France), also presented the new guidelines to meeting attendees, focusing on new aspects of stable CAD treatment. "Many patients, probably too many patients, present to the cath lab without a demonstration of ischemia. But we have this tool available in the [cardiac catheterization] laboratory to measure flow in the coronary arteries"--that is, fractional flow reserve (FFR). It gets a class I, level of evidence A, recommendation for identifying hemodynamically relevant lesions "when evidence of ischemia is not available." Intravascular ultrasound or optical coherence tomography "may be considered" (class II recommendation, level of evidence B) to characterize lesions and to improve stent deployment.

The guidelines also venture deep into the highly charged debate between surgeons and interventional cardiologists vying for patients who are sent for coronary revascularization, observed Sechtem. There are clear, specific recommendations in large part dependent on SYNTAX scores, which categorize patients by CAD severity based on coronary and lesion anatomy.

In patients with a clinically important left main coronary artery stenosis, for example: if there is only one-vessel involvement, PCI should be used for ostial or mid-shaft lesions, but there should be a "heart-team discussion" to decide on PCI or CABG for lesions at a distal bifurcation. For multivessel involvement, the SYNTAX score should be used; if it's <32, the heart team should discuss, but CABG should be chosen if it's >33.

"There isn't much new" with respect to drug therapy for stable CAD, Sechtem said, except for the incorporation of three agents making their debuts as antianginals: ranolazine (Ranexa, Gilead Sciences), nicorandil, and ivabradine (Procoralan, Servier), all as second-line options.

Diabetes and Prediabetes

 
Many patients, probably too many patients, present to the cath lab without a demonstration of ischemia.
 

New in the guidelines for patients with diabetes or those with or at high risk of CVD, observed Dr Lars Ryden (Karolinska Institutet, Stockholm, Sweden), cochair of the development task force, is an emphasis on patient-centered care, a less aggressive approach to glycemic control for the elderly, "simplified diagnostics" that put glycosylated hemoglobin or fasting plasma glucose first and reserves the oral glucose-tolerance test only for "cases of uncertainty," and an emphasis on CABG as the first revascularization choice, rather than PCI, as has been common in recent years.

"It's clear that it takes a long time to reduce cardiovascular disease by glycemic control," according to Ryden's cochair Dr Peter J Grant (University of Leeds, UK). "If you've got someone who is maybe 70 or 80 years of age, with a lot of comorbidities, and you're thinking about tightening up their glycemic control a bit," he said to heartwire , "you have to have a clear idea of what you hope to achieve. Tightening control is often associated with increased hypoglycemia and decreased quality of life, with lots of restrictions on the life of the individual."

 
There's no value in having tight glycemic control that's perfect for the heart and the eyes, but they're hypoglycemic all day long.
 

It's important, he said, to consider each patient individually and "decide with them whether they want to make those restrictions in their lives. It certainly needs a frank and open discussion about what the options are and how to achieve them. As people get older, many don't want to have tightened [glycemic] control, with everything that it means. Quality of life is something that shouldn't be ignored. There's no value in having tight glycemic control that's perfect for the heart and the eyes, but they're hypoglycemic all day long."

Another group that would benefit from less aggressive glycemic control, according to Grant, includes patients with "long-standing diabetes with autonomic neuropathy." He said they "lose the ability to sense hypoglycemia." When that happens, they become more subject to its effects on quality of life--so tight glycemic control may not be worth the risk of inducing hypoglycemia.

As for revascularization, Ryden described for heartwire , the recently reported FREEDOM trial "clearly shows that bypass surgery is superior to PCI, even PCI using drug-eluting stents," in diabetics with complicated coronary artery disease. So in a shift in the guidelines, complete revascularization with CABG, "particularly using arterial grafts as much as possible," he said, "is superior to PCI. The patient may prefer PCI, but the patient should be informed that there is a difference in morbidity and even mortality after a few years if they have had their vessels [bypassed] rather than dilated."

So in the guidelines, he said, if coronary disease isn't complex, medical therapy should be pursued first. If there are complex coronary lesions or the patient has a lot of comorbidities, CABG rather than PCI should be used; and if the patient prefers PCI, drug-eluting stents should be chosen.

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