Cardiology Morning Report:Revascularization in Stable

Ischemic Heart DiseaseBobby Mathew, MD

LSU Internal Medicine, HO-II

Definitions

• Recommendations for revascularization in the setting of symptomatic, stable ischemic heart disease; does not include revascularization in the setting of acute MI

• Significant Stenosis:– Left Main Disease– Fractional Flow Reserve

• “Protected” vs “Unprotected” LM disease• STS Score/SYNTAX score

STS Score

SYNTAX Score

Approach Considerations

• Class I– Heart Team Approach

• Class IIa– STS/SYNTAX Scores

Left Main Disease• Class I

– CABG for LMD ≥ 50%

• Class IIa– PCI is reasonable in:

• SYNTAX ≤ 22 & STS Mortality ≥ 5%• UA/NSTEMI with unprotected LM & not CABG candidate• STEMI with unprotected LM as the culprit lesion with TIMI 3 flow and time

constraints

• Class IIb– PCI may be reasonable in:

• SYNTAX < 33, STS > 2%, previous surgery, mod-severe COPD

Non-LM Disease

• Class I– CABG for significant 3VD (w w/o prox LAD) or prox LAD + 1 other

major coronary artery– CABG or PCI for SCD 2/2 significant stenosis (PCI LOE C)

• Class IIa– CABG for significant 2VD with extensive myocardial ischemia or target

vessels supply large area of viable myocardium– CABG for significant MVD or Prox LAD w/ mild-moderate LV systolic

dysfunction w/ viable myocardium– CABG w/ LIMA for significant proximal LAD and extensive ischemia– CABG > PCI w/ SYNTAX > 22 if good candidates– CABG probably recommended > PCI with DM and MVD

Non-LM Disease Cont’d

• Class IIb– CABG uncertain w/ 2VD (w/o prox LAD) and w/o extensive ischemia– PCI to improve survival uncertain in 2VD/3VD (w/ w/o prox LAD) or

isolated prox LAD disease– CABG for sole intent of survival benefit in SIHD w/ EF < 35% regardless

of viable myocardium– CABG or PCI uncertain w/ previous CABG and extensive anterior wall

ischemia

Symptom Relief

• Class I– CABG/PCI is beneficial w/ ≥ 1 significant lesions amenable to

revascularization and unacceptable angina w/ GDMT

• Class IIa– CABG/PCI for above when GDMT can’t be implemented– PCI reasonable in previous CABG w/ 1 or more significant lesions– CABG reasonable w/ SYNTAX > 22 and good candidate

• Class IIb– CABG might be reasonable w/ previous CABG and 1 or more significant

lesions not amenable to PCI– Transmyocardial laser revascularization for non-graftable vessels

CABG vs MT

• 3 RCTs in 1970s and 80s show CABG > Medical therapy– VA Cooperative Study– European Coronary Surgery Study– Coronary Artery Surgery Study (CASS)

• 1994 Meta-analysis showed CABG > MT in LM/3VD• CABG > MT for angina• Medicine, Angioplasty, or Surgery Study II (MASS II) in early

2000s; CABG with less subsequent MI, revascularization, cardiac death at 10 years

PCI vs MT

• Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) & Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D)

• No survival advantage for PCI• PCI reduces angina• PCI may increase short-term risk of MI• PCI does not reduce long-term risk of MI

References1. L. David Hillis et. Al, 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: A Report

of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, Circulation 2011; 124

2. Morice MC, Serruys PW, Kappetein AP, et al. Outcomes in patients with de novo left main disease treated with either percutaneous coronary intervention using paclitaxel-eluting stents or coronary artery bypass graft treatment in the Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery (SYNTAX) trial. Circulation. 2010;121:2645–53.

3. White AJ, Kedia G, Mirocha JM, et al. Comparison of coronary artery bypass surgery and percutaneous drug-eluting stent implantation for treatment of left main coronary artery stenosis. J Am Coll Cardiol Intv. 2008;1:236–45.

4. Makikallio TH, Niemela M, Kervinen K, et al. Coronary angioplasty in drug eluting stent era for the treatment of unprotected left main stenosis compared to coronary artery bypass grafting. Ann Med. 2008;40: 437–43.