Complete or partial revascularization in patients with chronic stable angina: why and how?. Revascularization, Ischemia, & Completeness… • Challenges in defining complete revasculariz
Trang 1Complete or partial revascularization in patients with
chronic stable angina: why and
how?
Peter M Pollak MD
Trang 3Revascularization, Ischemia, &
Completeness…
• Challenges in defining complete
revascularization
• Presence & degree of ischemia is associated
with adverse outcomes
• Relief of ischemia associated with improved
outcomes
• More complete revascularization is associated
with improved outcomes
• Surgical revascularization appears more
durable than percutaneous revascularization
Trang 4Challenges in assessing complete
revascularization
• There has been no universal definition
• Anatomic criteria using stenosis >50% have
been common
• Fails to describe physiology
• Fails to account for viability
• Jeopardy score & Functional SYNTAX may
be better
• Factors associated with IR are known
predictors of adverse outcome
• CTO, Calcific disease, poor EF, DM, CKD,
prior MI
Trang 5Angiographic stenosis ≠ functional stenosis
Gössl M et al Circ Cardiovasc Interv 2012;5:597-604
20%
60%
Trang 6WHY REVASCULARIZE?
Trang 7Ischemic Burden Treated Medically
Cardiac Death at 1.9 Years
0 1 2 3 4 5 6 7 8
Hachamovitch R, et al Circulation 2003;107:2900-2907
Total myocardial ischemia (%)
Trang 8Ischemia Reduction in COURAGE
Survival Stratified by Residual Ischemia
0 20 40 60 80 100
Shaw LJ, et al Circulation 2008;117:1283-1291
More Residual ischemia more events
Trang 9Revascularization vs Medical Therapy in Stable CAD: A Network Meta-Analysis
The European Myocardial Revascularization Collaboration: BMJ, 2014
100 RCTs – 93,553 patients randomized Follow-up of 262,090 patient-years
Pts randomized 8,920
Follow-up 38,709 PY CABG
PTCA
BMS EES
Trang 10Rate ratio (95% CI) Surgery
Revascularization vs Medical Therapy in
Stable CAD: A Network Meta-Analysis
Primary Endpoint: All-Cause Mortality
Favors medical therapy
The European Myocardial Revascularization Collaboration: BMJ, 2014
Trang 11Rate ratio (95% Crl) Rate ratio (95% CrI)
Myocardial infarction
(92 trials; 90,472 patients)
CABG vs medical treatment 0.79 (0.63-0.99)
PTCA vs medical treatment 0.88 (0.70-1.11)
BMS vs medical treatment 1.04 (0.84-1.27)
PES vs medical treatment 1.18 (0.88-1.54)
SES vs medical treatment 0.94 (0.71-1.22)
E-ZES vs medical treatment 0.80 (0.56-1.10)
R-ZES vs medical treatment 0.82 (0.52-1.26)
EES vs medical treatment 0.75 (0.55-1.01)
Revascularization vs Medical Therapy in
Stable CAD: A Network Meta-Analysis
Trang 12Rate ratio (95% CI) Surgery
Revascularization vs Medical Therapy in
Stable CAD: A Network Meta-Analysis
Secondary Endpoint: Repeat Revascularization
The European Myocardial Revascularization Collaboration: BMJ, 2014, ahead of print
Trang 13Windecker et al: BMJ 348, 2014
Conclusion: Among patients with stable coronary
artery disease, coronary artery bypass grafting reduces the risk of death, myocardial infarction, and
subsequent revascularisation compared with medical treatment All stent based coronary revascularisation technologies reduce the need for revascularisation to a variable degree Our results provide evidence for
improved survival with new generation drug eluting
stents but no other percutaneous revascularisation
technology compared with medical treatment
Trang 14COMPLETE OR INCOMPLETE
REVASCULARIZATION?
Trang 15Completeness of Revascularization
subsequent clinical outcomes
major epicardial vessel
Trang 20Aggarwal et al: EuroIntervention 7:1095, 2012
Conclusions: In patients with multivessel coronary disease, complete revascularisation with PCI may be associated with better outcomes than incomplete
revascularisation
Trang 21More grafts improved survival in patients
with reduced LV function
Gössl M et al Circ Cardiovasc Interv 2012;5:597-604
Trang 22More CABG grafts Less Events
Gössl M et al Circ Cardiovasc Interv 2012;5:597-604
Trang 231924 Asian patients with MVCAD undergoing
PCI (1900) or CABG (514) over 5 yrs
Kim Y et al Circulation 2011;123:2373-2381
Trang 24Arterial Revascularization Therapies Study trial
Serruys NEJM 2001
Trang 25936 patients with LIMA-LAD but no graft to RCA or LCX
Rastan A J et al Circulation 2009;120:S70-S77
Risk from IR may vary by territory or myocardial jeopardy
Trang 26Outcome of PCI-IR stratified by SYNTAX
Tertile (ARTS II)
Sarno AJC 2010
Low Tertile
High Tertile
P = 0.04
Trang 27HOW TO REVASCULARIZE?
CABG & PCI
Trang 285 year SYNTAX Trial Data
*Only 56.7% had PCI-CR even when CR was intended
Trang 30• Sicker patients (MVCAD, LV Fxn & viability)
derive more benefit from CR
• Surgical revascularization appears more
durable with less MACCE compared to PCI in
more complex MVCAD
• Apparent inferiority of PCI in MVCAD may
reflect challenge of achieving PCI-CR
©2011 MFMER | 3138928-31
Trang 31Thank you!
Pollak.peter@mayo.edu
Trang 32In patients with stable coronary artery disease and functionally significant stenoses, FFR- guided PCI plus the best available medical therapy, as compared with the best available medical therapy alone, decreased the need for urgent revascularization In patients without ischemia, the outcome appeared to be favorable with the best available medical therapy alone