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Myocardial Revascularisation In Chronic Heart Failure • Coronary artery disease remains the most common cause of CHF • Patients with depressed LV function remain ar risk of sudden cardia

PCI In Heart Failure

Dr Tan Huay Cheem

MBBS, M Med(Int Med) MRCP(UK), FRCP(Edinburgh), FAMS, FACC, FSCAI

Director, National University Heart Centre, Singapore Associate Professor of Medicine, Yong Loo Lin School of Medicine

National University of Singapore President, Asia Pacific Society of Interventional Cardiology

14 th Vietnam National Congress of Cardiology

Da Nang City Vietnam 2014

National University Heart Centre, Singapore

(NUHCS)

Case Study

M/46 CVRF smoking Admitted for NSTEMI 2D echo showed LVEF 20%

Case Study

Case Study

Case Study

Two-Dimensional Echocardiogram Pre-& Post-PCI

LVEF improved from visual estimate 20% to 40%

Myocardial Revascularisation In Chronic Heart Failure

• Coronary artery disease remains the most common cause of CHF

• Patients with depressed LV function remain ar risk of sudden cardiac death with or without revascularisation

• Revascularisation with CABG or PCI is indicated for symptomatic relief

of angina pectoris in patients with heart failure

• The risk-benefit balance for revascularization in patients without

angina/ischemia or viable myocardium remains uncertain

PCI In Heart Failure

• PCI in Heart Failure (Balloon to DES)

- feasibility and safety

• PCI in Heart Failure with Support

• PCI vs CABG vs Medical Therapy

Impact of LV Dysfunction on Hospital Mortality Among Patients Undergoing Elective PCI: New York State Registry

Wallace TW et al Am J Cardiol 2009; 103: 355-360

Retrospective study of 55 709 PCI pts in 1998/1999

Conclusions

• Elective PCI is commonly performed in pts with reduced EFs

• Risk for hospital mortality increases as the EF decreases

• EF 45% is associated with higher adjusted hospital mortality

Hospital Mortality 2.7% 1.2% 0.6% 0.2% 0.3%

P<0.001

GRACE Registry: PCI In ACS Pts with Heart Failure

• 1788 had HF at the time of hospital admission

• Patients with HF less likely to undergo cardiac cath

(46.5% vs 54.2%, p=0.0001) and PCI (26% vs 31.8%, p=0.0001)

compared with pts without HF

• CABG rates similar between groups

• Combined risk of in-hospital and post-discharge 6-month mortality

was significantly higher in pts with HF on admission

(20.7% vs 5.9%, p<0.001)

• Pts with HF who underwent in-hospital revascularisation

(predominantly PCI) had significantly lower rate of

post-discharge 6-month mortality (14% vs 23.7%, P<0.0001)

Steg PG et al Circulation 2004; 109: 494-9

Impact of PCI On Acute Heart Failure Among Patients Hospitalised

For AMI: Long Term Outcomes by Killip Class

L Carvalho et al Singapore Cardiac Society Annual Meeting 2014

A Mortality curves of patients who underwent PCI

B Mortality curves of patients who did not undergo PCI

Killip I Killip II Killip IV

Impact of PCI On Acute Heart Failure Among Patients Hospitalised

For AMI: Long Term Outcomes

L Carvalho et al Singapore Cardiac Society Annual Meeting 2014

PCI in Patients with Left Ventricular Systolic Dysfunction:

Systematic Review and Meta-Analysis

11 studies including 1284 pts with LVEF <50% All except one study use BMS

MACE at hospital discharge MACE at 18 mths followup

Sardi GL et al Am J Cardiol 2012; 109: 344-351

Outcomes of PCI Utilising DES in Pts with Reduced LVEF

• 5377 pts in Washington Heart Centre retrospectively analysed

• Pts with normal LVEF (>50%) compared with mild (41% to 50%), moderate (25% to 40%) and severe (<25%) decrease in LVEF

• Pts with abnormal LVEF were older, more diabetic, renal insufficiency and

heart failure syndrome , more angiograpically complex lesions and less freq received DES

• Primary endpoint: 1-yr MACE all-cause death, Q-wave MI, ST and TLR

• Primary endpoint significantly increase in pt with lower LVEF (9.7% for normal LVEF

vs 20.6% for severely decreased LVEF, p<0.001)

• Higher ST in pts with lower LVEF (1.4% for normal LVEF vs 6% for

severely decrease LVEF, p<0.001), not impacted by DES use

1 Yr All-cause Mortality 1 Yr Stent Thrombosis

Death Rates for Patients With and Without Myocardial Viability

Treated by Revascularization or Medical Therapy

HR Phillips et al Am Heart J 2007; 153: S65-S73

PCI In Heart Failure

• PCI in Heart Failure (Balloon to DES)

- feasibility and safety

• PCI in Heart Failure with Support

• PCI vs CABG vs Medical Therapy

BCIS-1 Trial: Elective IABP in High Risk PCI

Perera D et al JAMA 2010; 304: 867-874

Conclusions:

• Elective IABP did not reduce the incidence of MACCE at discharge

• Mortality at 6 months was numerically lower in the elective (IABP) group but not statistically significant (4.6% vs 7.4%, P = 0.32)

• RCT in 17 UK tertiary centres bet Dec 2005 and Jan 2009

• 301 pts with severe LV dysfunction (EF <30%), extensive coronary disease

(jeopardy score ≥8/12)

TandemHeart Percutaneous VAD

• Removes oxygenated blood from LA via transseptal cannula inserted through the femoral vein

• Returns blood via femoral artery

Benefits:

• Reduce preload

• Reduce ventricular workload

• Reduce myocardial oxygen demand

• Increase MAP

• Improve microvascular and systemic perfusion

IMPELLA Catheter Mounted Micro Axial Flow Pump

Meyns B et al J Am Coll Cardiol 2003; 41: 1087-1095

++++ HOURS TO

DAYS

2.2

MetaAnalysis RCT of Percutaneous Left Ventricular Assist Devices

versus IABP for Treatment of Cardiogenic Shock

JM Cheng et al CRT 2009

Thiele et al Burkhoff et al Seyfarth et al

Results: 30-day Mortality

Percutaneous LVAD patients had similar mortality as IABP

0.95 (0.48 ; 1.90) 1.33 (0.57 ; 3.10) 1.00 (0.44 ; 2.29) 1.06 (0.68 ; 1.66)

Pooled

Favors LVAD Favors IABP

30-day mortality Relative Risk

LVAD n/N

IABP n/N

PCI In Heart Failure

• PCI in Heart Failure (Balloon to DES)

- feasibility and safety

• PCI in Heart Failure with Support

• PCI vs CABG vs Medical Therapy

Role of PCI vs CABG

• No clinical trial comparing revascularisation with CABG or PCI

of patients with heart failure and reduced ejection fraction exists

• All available data comparing the revascularisation of such patients comes from large observational studies

Effect of Heart Failure on Long Term Mortality

After Coronary Revascularisation (BARI Trial)

EM Holper et al Am J Cardiol 2007; 100: 196-202

3133 pts from BARI randomised trial and registry included

Results:

• 10 years after initial revascularisation, cumulative rates of

freedom from cardiac death were

- 90% in pts without HF

- 75% in pts with HFpEF

- 59% in pts with HFrEF (p<0.001, 3-way comparison)

• In diabetic pts with HFpEF, there was a significant increase in

cardiac mortality compared with pts without HF (p<0.001)

AWESOME: PCI vs CABG in Pts with Medically Refractory

Myocardial Ischemia & Risk factors for Adverse Outcomes with Bypass

• 232 pts randomised to CABG and 222 to PCI (POBA)

• Has 1 or more risk factors for adverse outcome with CABG: prior open-heart surgery, age > 70yrs, LVEF <0.35, myocardial infarction within 7 days or IABP required

Morrison DA et al Am Coll Cardiol 2001; 38: 143-9

3-year survival for CABG and PCI were 79% and 80%

respectively (p=0.46)

Survival free of UAP

(p=0.16)

HEART (Heart Failure Revascularisation Trial):

Conservative vs Invasive (PCI or CABG) in Heart Failure Pts

Cleland JGF et al Eur J Heart Failure 2011; 13: 227-233

• Patients with heart failure, CAD, and LVEF  35% who had substantial volume of

viable myocardium with contractile dysfunction assessed by standard imaging technique

• Only 138 of planned 800 pts enrolled because of funding withdrawal due to slow recruitment

At median 59 mths, mortality rates of 37% in conservative vs 38% invasive group

Conclusion: Conservative strategy may not be inferior to revascularisation in patients with heart failure However, study was underpowered

Registry Studies

O’Keefe JH et al Am J cardiol 1993; 71: 897-901

Balloon Angioplasty vs CABG for Multivessel CAD With LVEF  40% Single centre (Mid America Heart Institute) , 100 consecutive pts who underwent CABG

matched with cohort of 100 PTCA pts bet Feb 1985 and Sep 1988

Long term survival

Survival by extent of revascularisation

• Late follow-up favoured CABG:

Trend towards improved survival (76% vs 67%, p=0.09)

superior relief from angina (99% vs 89%) less repeat revascularisation (0 vs 50%)

New York Cardiac Registries

Rouleau JL et al Can J Cardiol 2014; 30: 281-287

• 37 212 pts with multivessel CAD who underwent CABG compared

with 22 102 pts who underwent PCI from Jan 1997 to Dec 2000

• Pts with LVEF <40% and 2-vessel CAD, but without proximal LAD disease, more

frequently received PCI than CABG, and had similar outcomes

• When pts had 2-vessel CAD with prox LAD disease, or 3-vessel CAD with or without prox LAD disease, they more frequently had CABG and with better survival

• Difference in survival remained after adjusting for other risk factors

BJ Gersh et al N Engl J Med 2005; 352: 2235-2237

Difference in the Approach to the Lesion with PCI and CABG

PCI targets at the ‘culprit’ lesion or lesions, where CABG is directed at

the epicardial vessel, including the ‘culprit’ lesion or lesions and future culprits,

a difference that may account for the superiority of CABG

2011 ACCF/AHA/SCAI Guideline for PCI:

Revascularisation to Improve Survival Compared with Med Therapy

2011 ACCF/AHA/SCAI Guideline for PCI J Am Coll Cardiol published online Nov 7, 2011

ESC Committee for Practice Guidelines Online Publish 19 May 2012 ESC Guidelines 2014: Recommendations for Myocardial Revascularisation

In Patients with Chronic HF and Systolic LV dysfunction (EF ≤35%)

Consideration of Various Clinical Variables When

Recommending Best Therapeutic Options

Color blue favours medical therapy alone, and

colour red favours surgical therapy in addition to medical therapy

Rouleau JL et al Can J Cardiol 2014; 30: 281-287

Conclusions

• Revascularisation decisions in patients with HF cannot be

based on randomised clinical trial data

• Revascularisation is reasonable in pts with HF who have

appropriate coronary anatomy, substantial myocardium in jeopardy and no contraindications

• Viability testing can identify pts who may have hibernating or stunned myocardium, and may play a supportive role in decision making

• Choice of revascularisation technique should be made on the basis of anatomical, clinical and patient preference issues

• Ability to achieve complete revascularisation is an important

consideration beyond just types of method (PCI vs CABG)