Ischemie - lipiden en hartfalen Peter van der Meer Universitair - - PowerPoint PPT Presentation

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ischemie lipiden en hartfalen
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Ischemie - lipiden en hartfalen Peter van der Meer Universitair - - PowerPoint PPT Presentation

Jul 12, 2023 258 likes •527 views

Ischemie lipiden - hartfalen Ischemie - lipiden en hartfalen Peter van der Meer Universitair Medisch Centrum Groningen University Medical Center Groningen Ischemie lipiden - hartfalen Male 77 years old. Did not show up for regular

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Ischemie – lipiden - hartfalen

University Medical Center Groningen

Ischemie - lipiden en hartfalen

Peter van der Meer

Universitair Medisch Centrum Groningen

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Ischemie – lipiden - hartfalen

University Medical Center Groningen

Male 77 years old.

Did not show up for regular check ups. Now shortness of breath, atypical chest pain. Medical History: 2011: Large anterior MI, single vessel disease 2012: LVEF: 25%. Implantation of VVI-ICD Medication: ASA100mg, furosemide 40mg, Bisoprolol 10mg, Enalapril 2dd10mg, spironolactone 25mg ECG: SR 85/min QRS:122ms LBBB NYHA II – III BP 105/70mmHg Lab: K:4.8mmol/L GFR:45ml/min/1.73m2 NT-proBNP:1645pg/mL

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Ischemie – lipiden - hartfalen

University Medical Center Groningen

What is your next step?

A)

Start statin

B)

Coronary Angiogram

C)

Both

D)

None of the above

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Ischemie – lipiden - hartfalen

University Medical Center Groningen

  • Primary Endpoint

▪ All-cause mortality

  • Major Secondary Endpoints

▪ Cardiovascular mortality ▪ Death (all-cause) + cardiovascular hospitalization

CABG vs OMT STICH 10 year follow-up

CABG=Coronary artery bypass graft ; OMT=Optimal medical therapy; STICH=Surgical treatment for ischemic heart failure Velazquez EJ et al. N Engl J Med. 2016 Apr 21;374(16):1511-20

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Ischemie – lipiden - hartfalen

University Medical Center Groningen

  • LVEF ≤ 0.35
  • CAD suitable for CABG
  • Eligibility for medical therapy alone

▪ Absence of left main CAD as defined by an intraluminal stenosis of ≥ 50% ▪ Absence of CCS III angina or greater (angina markedly limiting ordinary activity)

Important inclusion criteria

LVEF=Left ventricular ejection fraction; CABG=Coronary artery bypass graft; CAD=Coronary artery disease; CCS=Canadian Cardiovascular Society Velazquez EJ et al. N Engl J Med. 2016 Apr 21;374(16):1511-20

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Ischemie – lipiden - hartfalen

University Medical Center Groningen

NNT = 14

All-cause mortality

CABG=Coronary artery bypass graft; MED=Medical therapy alone; NNT=Number needed to treat Velazquez EJ et al. N Engl J Med. 2016 Apr 21;374(16):1511-20

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Ischemie – lipiden - hartfalen

University Medical Center Groningen

What is your next step?

A)

Start statin

B)

Coronary Angiogram

C)

Both

D)

None of the above

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Ischemie – lipiden - hartfalen

University Medical Center Groningen

Inclusion criteria:

  • Age > 60 years
  • LVEF <40%
  • NYHA II-IV
  • Ischemic etiology (reported)

Exclusion criteria:

  • Previous statin-myopathy
  • Myocardial infarction < 6months
  • Kreat > 221 umol/L
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Ischemie – lipiden - hartfalen

University Medical Center Groningen

Rosuvastatin in older patients with systolic heart failure baseline

NYHA=New York Heart Association Kjekshus J et al. N Engl J Med. 2007 Nov 29;357(22):2248-61

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Ischemie – lipiden - hartfalen

University Medical Center Groningen

Baseline

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Ischemie – lipiden - hartfalen

University Medical Center Groningen

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Ischemie – lipiden - hartfalen

University Medical Center Groningen

Kjekshus J et al. N Engl J Med. 2007 Nov 29;357(22):2248-61

No effect on primary endpoint (CV death + non fatal MI / stroke)

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Ischemie – lipiden - hartfalen

University Medical Center Groningen

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Ischemie – lipiden - hartfalen

University Medical Center Groningen

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Ischemie – lipiden - hartfalen

University Medical Center Groningen

2nd trial with rosuvastatin in HF

  • GISSI-HF trial
  • Ischemic + non-ischemic HF
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Ischemie – lipiden - hartfalen

University Medical Center Groningen

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Ischemie – lipiden - hartfalen

University Medical Center Groningen

RCT vs real world data

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Ischemie – lipiden - hartfalen

University Medical Center Groningen

Circ HF 2015

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Ischemie – lipiden - hartfalen

University Medical Center Groningen

Potential beneficial effect of statin on mortality in observational study

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Ischemie – lipiden - hartfalen

University Medical Center Groningen

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Ischemie – lipiden - hartfalen

University Medical Center Groningen

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Ischemie – lipiden - hartfalen

University Medical Center Groningen

Digoxin Evaluation in Chronic heart failure: Investigational Study in Outpatients in the Netherlands: DECISION

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Ischemie – lipiden - hartfalen

University Medical Center Groningen

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Ischemie – lipiden - hartfalen

University Medical Center Groningen

2 5

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Ischemie – lipiden - hartfalen

University Medical Center Groningen

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Ischemie – lipiden - hartfalen

University Medical Center Groningen

Conclusions:

  • Ischemic events are common in heart failure
  • CABG has a beneficial effect on the long term
  • 2 large RCTs do not support routine statin use in HF
  • ”real world” data show some effect, but bias is likely
  • PCSK9 predicts outcome, no data on treatment in HF