.

SpeakerDr. Gobinda kanti PaulAsst. Prof. of Cardiology.

ChairpersonDr. M.Saiful Bari, Assoc. Prof. & Head of the Dept

Guidelines on Myocardial

Revascularization

Guidelines on Guidelines on MyocardialMyocardial RevascularizationRevascularization

European Heart Journal(2010)31, 2501-European Heart Journal(2010)31, 2501-5555

The Task Force on Myocardial The Task Force on Myocardial Revascularization of the EuropeanRevascularization of the European

Society of Cardiology (ESC) and the Society of Cardiology (ESC) and the European Association forEuropean Association for

Cardio-Thoracic Surgery (EACTS)Cardio-Thoracic Surgery (EACTS)

Authors/Task Force Members:Authors/Task Force Members:

WilliamWijns (Chairperson) (Belgium)*, PhilippeKolhWilliamWijns (Chairperson) (Belgium)*, PhilippeKolh(Chairperson) (Belgium)*, Nicolas Danchin (France), CarloDi Mario (Chairperson) (Belgium)*, Nicolas Danchin (France), CarloDi Mario

(UK),(UK),Volkmar Falk (Switzerland), Thierry Folliguet (France), ScotGarg Volkmar Falk (Switzerland), Thierry Folliguet (France), ScotGarg

(The Netherlands),(The Netherlands),KurtHuber (Austria), Stefan James (Sweden), JuhaniKnuuti (Finland), KurtHuber (Austria), Stefan James (Sweden), JuhaniKnuuti (Finland),

JoseJoseLopez-Sendon (Spain), JeanMarco (France), LorenzoMenicanti (Italy)Lopez-Sendon (Spain), JeanMarco (France), LorenzoMenicanti (Italy)MiodragOstojic (Serbia), Massimo F. Piepoli (Italy), Charles Pirlet MiodragOstojic (Serbia), Massimo F. Piepoli (Italy), Charles Pirlet

(Belgium),(Belgium),Jose L.Pomar (Spain), NicolausReifart (Germany), Flavio L. Ribichini Jose L.Pomar (Spain), NicolausReifart (Germany), Flavio L. Ribichini

(Italy),(Italy),Martin J. Schalij (The Netherlands), Paul Sergeant (Belgium), Martin J. Schalij (The Netherlands), Paul Sergeant (Belgium),

PatrickW. SerruysPatrickW. Serruys(The Netherlands), Sigmund Silber (Germany), Miguel Sousa Uva (The Netherlands), Sigmund Silber (Germany), Miguel Sousa Uva

(Portugal),(Portugal),DavidTaggart (UK)DavidTaggart (UK)

Guidelines on Myocardial Guidelines on Myocardial RevascularizationRevascularization

IntroductionIntroduction

Myocardial revascularization mainstay in the Myocardial revascularization mainstay in the treatment of CAD for almost half a century.treatment of CAD for almost half a century.

CABG-1960CABG-1960 PCI-1977 by Andreas GruentzigPCI-1977 by Andreas Gruentzig Pharmacological revascularization.Pharmacological revascularization. OMT(Optimum medical therapy)OMT(Optimum medical therapy)

The advances in technology, most The advances in technology, most coronary lesions are technically coronary lesions are technically amenable to PCI.amenable to PCI.

Thus pts and physicians need to Thus pts and physicians need to balance short-term convenience of balance short-term convenience of the less invasive PCI against the the less invasive PCI against the durability of the more invasive durability of the more invasive surgical approach.surgical approach.

Myocardial revascularization is Myocardial revascularization is appropriate when the expected appropriate when the expected benefits, in terms of survival or benefits, in terms of survival or health outcomes (symptoms, health outcomes (symptoms, functional status, and/or quality functional status, and/or quality of life), exceed the expected of life), exceed the expected negative consequences of the negative consequences of the procedure.procedure.

Patient InformationPatient Information Pt. information needs to be objective & unbiased, Pt. information needs to be objective & unbiased,

pt. oriented, evidence based, up-to-date, pt. oriented, evidence based, up-to-date, reliable,understandable,accessible, relevent and reliable,understandable,accessible, relevent and consistent with legal requirements.consistent with legal requirements.

Informed consent should be transparent, Informed consent should be transparent, especially if there is controversy about the especially if there is controversy about the indication for a particular indication for a particular treatment(OMTvsPCIvsCABG).treatment(OMTvsPCIvsCABG).

Pts taking an active role throughout the decision Pts taking an active role throughout the decision making process have better outcomes.making process have better outcomes.

Pts considered for Pts considered for revascularization should also revascularization should also be clearly informed of the be clearly informed of the continuing need for OMT continuing need for OMT including antiplatelet, statin, including antiplatelet, statin, B-blockers, ACEi, as well as B-blockers, ACEi, as well as other secondary prevention other secondary prevention strategies.strategies.

Strategies for pre-intervention Strategies for pre-intervention diagnosis & imagingdiagnosis & imaging

ECG, ECG, ECHOECHO Stress Tests-ETT, Stress Tests-ETT, MDCT(CT angiogram)MDCT(CT angiogram) MPIMPI Stress Echo.Stress Echo. Hybrid/Combined imaging(MDCT & Hybrid/Combined imaging(MDCT &

SPECT, MDCT & PET)SPECT, MDCT & PET)

Invasive TestsInvasive Tests

CAG:CAG: Intermediate or high pretest Intermediate or high pretest CAD likelihood are catheterized CAD likelihood are catheterized without prior functional testing.without prior functional testing.

FibrinolysisFibrinolysis

Fibrinolytic therapy, preferably Fibrinolytic therapy, preferably administered as a pre-hospital administered as a pre-hospital treatment, remains an important treatment, remains an important alternative to mechanical alternative to mechanical revascularization.revascularization.

OMTOMT

Lifestyle modificationLifestyle modification

Pharmacological managementPharmacological management

CABGCABG

Bypass grafts are placed to the mid-Bypass grafts are placed to the mid-coronary vessel beyond the culprit coronary vessel beyond the culprit lesions, providing extra sources of lesions, providing extra sources of nutrient blood flow to the nutrient blood flow to the myocardium.myocardium.

PCIPCI

Coronary stents aim to restore the normal Coronary stents aim to restore the normal

conductance of the native coronary artery conductance of the native coronary artery without offering protection against new disease without offering protection against new disease proximal to the stent.proximal to the stent.

Revascularization for stable CADRevascularization for stable CAD

Persistence of symptoms despite Persistence of symptoms despite OMTOMT

OMT vs. PCI in CSAOMT vs. PCI in CSA In the Atorvastatin vs. Revascularization In the Atorvastatin vs. Revascularization

Treatment (AVERT) trial, aggressive lipid lowering Treatment (AVERT) trial, aggressive lipid lowering by high-dose atorvastatin was marginaly better by high-dose atorvastatin was marginaly better than PCI in reducing ischemic events.than PCI in reducing ischemic events.

One meta analysis reported a survival benefit for One meta analysis reported a survival benefit for PCI over OMT(respective mortalities of 7.4% vs. PCI over OMT(respective mortalities of 7.4% vs. 8.7% at an average follow-up of 51 months).8.7% at an average follow-up of 51 months).

The COURAGE RCT randomized 2287 patients The COURAGE RCT randomized 2287 patients with known significant CAD and objective with known significant CAD and objective evidence of myocardial ischaemia to OMT alone evidence of myocardial ischaemia to OMT alone or to OMT + PCI. At a median follow-up of 4.6 yrs, or to OMT + PCI. At a median follow-up of 4.6 yrs, there was no significant difference in the there was no significant difference in the composite of death, MI, stroke, or hospitalization composite of death, MI, stroke, or hospitalization for UAfor UA

CABG vs. OMT in CSACABG vs. OMT in CSA

The superiority of CABG to medical The superiority of CABG to medical treatment in the management of treatment in the management of specific subsets of CAD.specific subsets of CAD.

Survival benefit of CABG in pts with Survival benefit of CABG in pts with LM or 3 vessel CAD. Benefits were LM or 3 vessel CAD. Benefits were greater in those with severe greater in those with severe symptoms, early positive ETT.symptoms, early positive ETT.

OMT vs. PCI vs. CABG in multi-OMT vs. PCI vs. CABG in multi-vessel diseasevessel disease

5 year follow-up of the MASS II study 5 year follow-up of the MASS II study of 611 pts.of 611 pts.

Composite primary endpoint (total Composite primary endpoint (total mortality, Q-wave MI or refractory mortality, Q-wave MI or refractory angina requiring revascularization) in angina requiring revascularization) in 36% of OMT, 33% of PCI and 21% of 36% of OMT, 33% of PCI and 21% of CABG.CABG.

PCI vs. CABGPCI vs. CABGProximal LAD stenosis.Proximal LAD stenosis.

Two meta-analysis of >1900 & >1200 Two meta-analysis of >1900 & >1200 pts.pts.

No significant difference in mortality, No significant difference in mortality, MI, CVA.MI, CVA.

Three fold increase in recurrent angina Three fold increase in recurrent angina & a five fold increase in repeat TVR & a five fold increase in repeat TVR with PCI at up to 5 years of follow-up.with PCI at up to 5 years of follow-up.

SYNTAX TrialSYNTAX Trial

The authors concluded at both 1 and 2 The authors concluded at both 1 and 2 years that CABG remains the standard years that CABG remains the standard of care for pts with 3 vessel or LM CAD.of care for pts with 3 vessel or LM CAD.

Survival advantage and a marked Survival advantage and a marked reduction in the need for repeat reduction in the need for repeat intervention with CABG in comparison intervention with CABG in comparison with PCI in pts with more severe CADwith PCI in pts with more severe CAD

LM stenosisLM stenosis CABG is still conventionally regarded CABG is still conventionally regarded

as the standard of care for significant as the standard of care for significant LM disease in pts eligible for surgery.LM disease in pts eligible for surgery.

LM stenosis is a potentially attractive LM stenosis is a potentially attractive target for PCI because of its large target for PCI because of its large diameter and proximal position in the diameter and proximal position in the coronary circulation.coronary circulation.

LM stenosisLM stenosis

Two factors may mitigate against the Two factors may mitigate against the success of PCI-(i)up to80% of LM disease success of PCI-(i)up to80% of LM disease involves the bifurcation, high risk of involves the bifurcation, high risk of restenosis.(ii) up to 80% of LM pts also have restenosis.(ii) up to 80% of LM pts also have multivessel disease.multivessel disease.

Meta-analysis of 10 studies, includings two Meta-analysis of 10 studies, includings two RCT & the large MAIN –COMPARE registry, of RCT & the large MAIN –COMPARE registry, of 3773 pts with LM stenosis, there was no 3773 pts with LM stenosis, there was no difference between PCI & CABG in mortality, difference between PCI & CABG in mortality, MI, CVA up to 3 years but up to a 4 fold MI, CVA up to 3 years but up to a 4 fold increase in repeat revascularization with PCI.increase in repeat revascularization with PCI.

Revascularization in non-STEMIRevascularization in non-STEMI

The ultimate goals of CAG & The ultimate goals of CAG & revascularization are mainly 2 fold: revascularization are mainly 2 fold: symptom relief, & improvement of symptom relief, & improvement of prognosis in the short & long term.prognosis in the short & long term.

The most recent meta-analysis The most recent meta-analysis confirms that an early invasive confirms that an early invasive strategy reduces cardiovascular strategy reduces cardiovascular death and MI at up to 5 years of death and MI at up to 5 years of follow-up.follow-up.

Revascularization in STEMIRevascularization in STEMI

Primary PCI:Primary PCI:

PCI in the setting of STEMI without previous PCI in the setting of STEMI without previous or concomitant fibrinolytic treatmentor concomitant fibrinolytic treatment

Primary PCI should be performed by Primary PCI should be performed by operators who perform>75 elective operators who perform>75 elective procedures per year and at least 11 procedures per year and at least 11 procedures for STEMI in institutions with procedures for STEMI in institutions with an annual volume of >400 elective and an annual volume of >400 elective and >36 primary PCI >36 primary PCI

STEMISTEMI

Pts presenting between 12 and 24 Pts presenting between 12 and 24 and possibly up to 60h from and possibly up to 60h from symptom onset, even if pain free and symptom onset, even if pain free and with stable haemodynamics, may still with stable haemodynamics, may still benefit from early CAG & PCI.benefit from early CAG & PCI.

PCI vs. CABG in Diabetic CADPCI vs. CABG in Diabetic CAD

A recent meta-analysis on individual A recent meta-analysis on individual data from 10 RCTs of elective data from 10 RCTs of elective myocardial revascularization myocardial revascularization confirms a distinct survival confirms a distinct survival advantage for CABG over PCI in advantage for CABG over PCI in diabetic pts.diabetic pts.

5 years mortality was 20% with PCI, 5 years mortality was 20% with PCI, compared with 12% with CABG.compared with 12% with CABG.

Hybrid revascularizationHybrid revascularization

Hybrid myocardial revascularization Hybrid myocardial revascularization is a planned, intentional combination is a planned, intentional combination of CABG,& PCI to other suitable of CABG,& PCI to other suitable coronary artery during the same coronary artery during the same hospital stay.hospital stay.

Recommended duration of dual Recommended duration of dual antiplatelet therapyantiplatelet therapy

1 month after BMS stent.1 month after BMS stent. 6-12 months after DES.6-12 months after DES. 1 year in all pts after ACS, 1 year in all pts after ACS,

irrespective of revascularization irrespective of revascularization strategy.strategy.

Surgery in pts on dual antiplatelet Surgery in pts on dual antiplatelet therapytherapy

High to very high bleeding risk, including High to very high bleeding risk, including CABG:CABG:

Clopidogrel should be stopped 5 days Clopidogrel should be stopped 5 days before surgery & ASA continued.before surgery & ASA continued.

Prasugrel, stopped, 7 days before surgeryPrasugrel, stopped, 7 days before surgery

Ticagrelor, stopped, 2 to 3 days before Ticagrelor, stopped, 2 to 3 days before surgerysurgery

DAPT should be resumed as soon as DAPT should be resumed as soon as possible including a loading dose for possible including a loading dose for clopidogrel and prasugrel.clopidogrel and prasugrel.

Follow-up after RevascularizationFollow-up after Revascularization

Physical examination, resting ECG & Physical examination, resting ECG & routine test should be performed within routine test should be performed within 7 days after PCI.7 days after PCI.

Puncture site healing, haemodynamics Puncture site healing, haemodynamics and possible anaemia or CIN.and possible anaemia or CIN.

For ACS pts, plasma lipids should be re-For ACS pts, plasma lipids should be re-evaluated 4-6 weeks after an acute evaluated 4-6 weeks after an acute event and/or initiation of lipid-lowering event and/or initiation of lipid-lowering therapy.therapy.

Next lipid profile after 3 monthsNext lipid profile after 3 months

ConclusionConclusion

Despite the numerous improvements Despite the numerous improvements in the management of ACS/CAD, it in the management of ACS/CAD, it remains one of the leading causes of remains one of the leading causes of morbidity and mortality worldwide.morbidity and mortality worldwide.

The Key steps in the management of The Key steps in the management of these pts include rapid diagnosis, these pts include rapid diagnosis, prompt delivery of initial therapeutic prompt delivery of initial therapeutic agents, immediate reperfusion in agents, immediate reperfusion in some cases.some cases.