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9. Special Groups or Considerations
9.1 Women (See Web Addenda)
Coronary artery disease develops 5–10 years later in women than in men. Recent studies indicate that the decline in mortality from CAD does not extend to younger women, in whom it has remained constant. CVD guidelines in general are based on research conducted primarily in men, the mean percentage of women enrolled in clinical trials since 2006 being 30%. CVD risk factors in women and men are the same, although their distribution differs over time and between regions. Stable angina is the most common initial presentation of CAD in women. There is a widespread understanding that women with CAD present with symptoms that are different from those in men. Some of this is due to women presenting at older ages and symptoms becoming less specific with advancing age. Several studies have indicated gender-related differences in the care of both acute and chronic CAD, in part related to differences in presentation and pathophysiology. Compared with men, women have higher rates of procedural complication, including mortality, stroke and vascular complications. Women also have higher complication rates following CABG but, although the numbers of women included in trials are limited, results do not indicate gender-related differences in outcome. Nonetheless, it may be prudent to adopt a more conservative approach in undertaking PCI and CABG in women.
Probably the most important difference between CAD in men and women is that women, presenting with MI and angina twice as often as men, have no significant obstructive CAD. (see section 6.7.1 on microvascular angina). However, the notion that these women have 'normal' coronary arteries should be reconsidered in light of the IVUS sub-study within the Women's Ischemia Syndrome Evaluation (WISE) showing that, among a sample of 100 such women, ~80% had definite coronary atherosclerosis that was concealed by positive remodelling. Until sufficient trial-based evidence is available, women with chest pain and no obstructive coronary disease should be screened for CVD risk factors and treated according to risk stratification, as described in CVD prevention Guidelines, supplemented by individualized symptomatic treatment for angina (see sections 7.5.1 and 7.5.2 on treatment of microvascular and vasospastic angina). At present HRT is not recommended for primary or secondary prevention of CVD.
9.2 Patients With Diabetes (See Web Addenda)
Mortality due to CVD is increased three-fold in diabetic men and two- to five-fold in diabetic women, compared with age- and sex-matched non-diabetic persons. A target HbA1c <7% (<53 mmol/mol) and target blood pressure <140/85 mmHg are recommended in recent European Guidelines on CVD prevention. The high prevalence of significant CAD and prohibitively high cardiovascular mortality may suggest the usefulness of routine screening extended to asymptomatic patients. In the absence of outcome trials confirming a clinical benefit, this strategy is not recommended. Coronary artery revascularization of diabetics remains a challenge. The decision to use either PCI or CABG as preferred mode of revascularization should be based on anatomical factors, together with clinical factors and other logistical or local factors (see chapter 8 and Figure 6). As a rule, PCI is recommended in diabetic patient with single-vessel disease. Conversely, given the results of the FREEDOM trial, CABG is recommended in diabetic patients with multivessel disease after discussion in a Heart Team meeting.
9.3 Patients With Chronic Kidney Disease (See Web Addenda)
Chronic kidney disease is a risk factor for—and strongly associated with—CAD and has a major impact on outcomes and therapeutic decisions. The use of drugs and iodinated contrast agents is exposes patients to more complications. This is also a group of patients poorly explored in clinical trials, with limited strong evidence based medicine.
9.4 Elderly Patients (See Web Addenda)
This population is specific in many ways:
Higher prevalence of comorbidities.
Population is usually undertreated and under-represented in clinical trials.
Difficult diagnosis due to atypical symptoms and difficulties in performing stress testing.
Patients are more often referred to PCI than CABG but age should not be the sole criterion for the choice of type of revascularization.
Higher risk of complications during and after coronary revascularization.
9.5 The Patient After Revascularization (See Web Addenda)
Therapy and secondary prevention should be initiated during hospitalization, when patients are highly motivated. Follow-up strategies should focus on the assessment of the patient's symptoms, functional status and secondary prevention, and not only on the detection of re-stenosis or graft occlusion. Recommendations are given below in Table 34.
9.6 Repeat Revascularization of the Patient With Prior Coronary Artery Bypass Graft Revascularization (See Web Addenda)
Repeat revascularization in the patient who has undergone prior CABG poses a clinical challenge. Considerations in determining the preferred modality of revascularization include the age of patients, co-morbidities and diffuseness of coronary disease, as well as the potential for damage to patent grafts, intraluminal embolization in saphenous vein grafts, lack of suitable arterial and venous conduits and instability of a graft-independent circulation. PCI may be preferred in patients with discrete lesions in grafts and preserved LV function or accessible native vessel disease. Repeat bypass surgery may be preferred when the vessels are unsuitable for PCI and when there are good distal vessel targets for bypass graft placement.
The use of distal embolic protection devices is recommended in saphenous vein graft interventions. Any revascularization strategy needs to be accompanied by optimizing medical therapy with anti-anginal drugs and risk factor reduction.
9.7 Chronic Total Occlusions (See Web Addenda)
Chronic total occlusions (CTO) are identified in 15–30% of all patients referred for coronary angiography. A worse prognosis has been attached to chronic total occlusions. Revascularization needs to be discussed in patients with symptoms of occlusion or large ischaemic areas. Percutaneous coronary intervention (PCI) of CTOs is technically challenging and requires familiarity with advanced techniques and specialized equipment. Surgical treatment, with the implantation of a distal bypass graft, is also a valid option for discussion.
9.8 Refractory Angina (See Web Addenda)
The term 'refractory angina' is defined as "a chronic condition caused by clinically established reversible myocardial ischaemia in the presence of CAD, which cannot be adequately controlled by a combination of medical therapy, angioplasty or coronary artery bypass graft". For this patient group, a number of treatment options has emerged, including some new pharmacological options (see section 7.1.3.2 on drugs) and non-pharmacological treatments (see Table 35). Among non-pharmacological treatments, enhanced external counterpulsation therapy and neurostimulatory techniques have shown that they can ameliorate symptoms and improve quality of life, although convincing evidence regarding reduction in both ischaemia burden and mortality is still lacking. Conversely, transmyocardial or percutaneous myocardial revascularization have been abandoned because they are ineffective.
9.9 Primary Care (See Web Addenda)
Primary care physicians have an important role in the identification and management of patients with SCAD. In particular:
identifying those patients presenting with symptoms of possible SCAD that requires further evaluation and investigation
identifying those at increased risk of developing SCAD and ensuring that modifiable risk factors are actively managed, with lifestyle and therapeutic interventions, in order to reduce their future risk
ensuring that those with SCAD are aware of the benefits, both in respect of symptom control and prognosis, of optimal medical therapy and, in appropriate cases, the benefits of percutaneous intervention or surgery
establishing a systematic approach to the follow-up of patients with SCAD, at appropriate intervals, for the primary care physician to re-appraise the patient's clinical symptoms, medication and risk factors.
9.10 Gaps in Evidence (See Web Addenda)
These guidelines suffer from limitations inherent in the evidence available, uncertainties on the best imaging modalities, on what is the best modern pharmacologic approach and on what is the real benefit from myocardial revascularization.
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