Coronary Artery Disease-Why Treat Differently

8/14/2019 Coronary Artery Disease-Why Treat Differently

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CORONARY ARTERYDISEASE: WHY TREAT

DIFFERENTLYDr Ainol Sahar, MD

Consultant Interventional Cardiologist, ICL Unit Head

Serdang HospitalMalaysia



Serdang Hospital



Why treat differently?

Treatment is different based on:

• Clinical scenario– Stable CAD

– NSTEACS– STEMI

• Timing of presentation

• Lesion

• Modes of treatment available



Clinical scenario: Stable CAD

Indication

Level of

evidence StudiesObjective large ischaemia

IA

Parisi, Folland,Hartigan 98, Pepine94

Chronic totalocclusion(CTO) IIa C Morrison et al 99

High surgical risk

(EF<35%) IIa B

Multivesseldisease/diabetics IIb C



Clinical scenario: Stable CAD

Indication

Level of

evidence Studies

Unprotected left main(LM) stenosis in the

absence of otherrevascularisation options

IIb C

Parisi, Folland,Hartigan 98, Pepine94

Routine stenting of de

novo lesions IA Surreys et al 94,Fishman et al 94

Routine stenting of denovo lesions in venous

bypass grafts IASavage et al 97,

Hanekamp et al2003



Key points: Stable CAD

PCI in stable CAD: PCI offered if

1. Stable CAD with symptoms,

objective evidence of ischaemia

2. Use with reservation in– Diabetics with multivessel disease

– Unprotected left main stenosis



Clinical scenario: NSTEACS

PCI within 48 hours

Who and which patients to choose?

The Ones at

• at high acute, thrombotic risk for rapidprogression to myocardial infarction or

death

• How do you identify?



Clinical scenario: NSTEACS

NSTEACS : High risk

• Recurrent resting pain

• Dynamic ST-segment changes:– ST- segment depression >0.1 mV or

– transient (<30 min) ST-segment elevation >0.1/ mV

• Elevated Troponin-I, Troponin-T, or CK-MB levels



NSTEACS: Timing of PCI

Procedure Indication

Level of evidence

Studies

Early PCI(<48h)

High-risk

NSTE-ACS I A

"Invasivecompared withnon-invasive,"1999; Cannon

et al., 2001;Fox et al., 2002

ImmediatePCI (<2.5 h)

High-risk

NSTE-ACS

IIa B

Neumann et al.,2003

Routinestenting in de

novo lesionsAll NSTE-ACS

I C



Clinical scenario: STEACS

• Treatment of choice in STEMI wherefacility is available

• Superiority over thrombolysis is between 3

-12 hours after onset of chest pain

• Within the first 3 hours both reperfusionstrategies are equally effective

• No evidence for facilitated PCI





Level of evidence

Studies

Primary PCI

Patientspresenting <12hours after onsetof chestpain/other sx andpreferably up to90 minutes afterfirst contact.

IA

Grines et al.,1993; "A clinicaltrial," 1997;Aversano et al.,2002; Widimskyet al., 2000;Widimsky et al.,2003; Andersenet al., 2003

Primary PCI

Whenthrombolysis iscontraindicated 1C





Level of evidence

Studies

Primary PCI

for patientspresentingwithin >3 hoursand <12 hours

after onset of chestpain/othersymptoms

IC

Grines et al.,1993; "A clinicaltrial," 1997;Aversano et al.,2002; Widimskyet al., 2000;Widimsky et al.,2003; Andersenet al., 2003

PrimaryStenting

Routinestenting during

primary PCI1A

Suryapranata etal., 1998; Grineset al., 1999;Stone et al., 2002





Level of evidence

Studies

Routine post-thrombolysiscoronaryangiographyand PCI, if applicable

Up to 24 hoursafterthrombolysis,independent of

angina and/orischaemia

1A

Scheller et al.,2003;Fernandez-Aviles et al.,

2004; Le Mayet al., 2005

Ischaemia-

guided PCIaftersuccessfulthrombolysis

Pre-discharge

angina and/orischaemia after(first) STEMItreated withthrombolysis

1B

Madsen, 1997



Treatment based on lesion

• Single vessel disease

• Multivessel disease• Long lesions, small vessel

• Bifurcation lesions



Treatment: Single vessel disease

• Single-vessel disease with chronic stable

angina

– No difference in survival between medical and

surgical treatment of patients.

– PCI has been shown to improve symptoms and

quality of life in patients with single-vesseldisease and severe symptoms.




• Single-vessel disease with chronic stable

angina

– Medical therapy may be preferred in patients

with mild or no symptoms– Improvement in survival and prevention of

future events are not established.

– Multiple PTCA procedures or subsequentsurgical treatment may be necessary.




• Single-vessel disease with chronic stableangina

– obtain laboratory evidence of ischemia beforethe procedure

– Stenoses that may lead to future coronary

events cannot be accurately identified byangiography without evidence of ischemia or

symptoms.



Multivessel disease

(BARI) trial• survival benefit among diabetics with multiple-

vessel disease treated with bypass surgery incomparison with balloon angioplasty.

• Indications for contemporary CABG—– double or triple vessel disease including high grade

proximal left anterior descending coronary arterystenosis

– triple vessel disease in diabetic patients

– triple vessel disease in the setting of left ventriculardysfunction

– left main disease and intractable angina after failure of other therapies.



Indication for CABG

class I A

• the presence of significant left main stenosis

• presence of 2-vessel disease with

– significant proximal left anterior descending(LAD) artery stenosis and either abnormal left

ventricular (LV) function (ejection fraction<50%) or ischemia on noninvasive testing.



Indication for CABG

Class I B

• 1- or 2-vessel disease without left anteriordescending artery stenosis but with a large area

of viable myocardium and high-risk criteria onnoninvasive testing

• Unsuccessfully treated medically who have anacceptable risk for CABG.



Indication for CABG

Other recommendations:

• patients with 1- or 2-vessel disease withoutsignificant LAD CAD who survived sudden death(Class I C)

• have a moderate area of viable myocardium anddocumented ischemia (Class IIa B)

• 1-vessel disease with significant LAD arterystenosis (Class IIa B)

• The last 2 indications are shared w ith PTCA.



CABG and PTCA

are not recommended (Class III C)• 1- vessel disease or 2-vessel disease without LAD

CAD and mild symptoms, who have

– nondemonstrable ischemia or a small area of viable myocardium,

– or have received inappropriate medicaltreatment

• borderline stenoses and no demonstrableischemia

• patients with stenoses <50%.

l l



Multivessel stenting versus CABG

What they (surgeons) say…….BARI and [ARTS]

• PCI accomplished less complete revascularizationbut did not diminish early to mid-term survival.

• These findings, coupled with the diminishment of in-stent re-stenosis achieved with DES, haveencouraged the current practice of ischemia-

directed revascularization in patients withmultivessel coronary disease.

.

M l i l i CABG




What they (surgeons) say…….Surgery or Stent trial

• on bare metal stents versus CABG

• showed a 1-year and 5-year survival benefit for

CABG versus PCI, although this result has largelybeen overlooked

DES versus CABG?• Arterial Revascularization Therapies Study

(ARTS)-II trial (ACC March 05)



Multivessel DES versus CABG

(ARTS II)

607 patients :sirolimus stents

• non-randomized registry• The outcomes of these patients were comparedto :the CABG (n = 602) and BMS arms (n = 600)of ARTS-I

In the ARTS-II trial• patients were more frequently diabetic (26.2%

vs. 18.2%),• had more three-vessel CAD (54% vs. 28%),• and had more C-type lesions (13.9% vs. 7.5%)

compared to the ARTS-I trial.

M lti l t ti CABG




What they (surgeons) say…….• There was no difference in the major

cardiovascular events at one year between the

– ARTS-II DES trial registry patients and– CABG randomized patients in the ARTS-I trial

(10.4% vs. 11.6%)

• This study is widely interpreted as suggestingthat current generation DES have similar

outcomes as CABG; however,

– its non-randomized nature and the comparisonis with a non-concurrent CABG group



What the surgeons say…

Taggart in the 2006 Thomas B. Ferguson lectureto The Society of Thoracic Surgeons

• these trials systematically enrolled patients– with limited disease burden

• who had little plausible survival benefit fromsurgery versus medical therapy.

• More than 90% of screened patients wereexcluded from randomization, frequently due toanatomic complexity of the coronary lesionsdeeming ineligibility for entry into the PCI arm.




• Many patients randomized in these studies didnot have left anterior descending coronary artery

disease.

• In other words, these investigations only

represented a small portion of the spectrum of multivessel disease, but their results were usedto justify PCI in much more anatomically complex

patients.




• Evidence from total population-based studiessuch as the New York State registry indicate that

when all patients are considered

– CABG provides superior survival in the setting

of all patients with left anterior descendingcoronary artery disease and at least one otherdiseased vessel

• Importantly, this survival benefit is evident in a2-year to 3-year time span.





What they (surgeons) say…….• Yang et al :CABG versus PCI in the DES era

– not randomized

– clear differences in the anatomic complexityand medical comorbidities between thepatients.

• Patients who underwent CABG– unstable angina,– poorer ejection fraction,

– more left anterior descending coronary artery and triple-vessel disease, and– a higher incidence of diabetes, which is generally

associated with more diffuse and distal coronary disease.





What they (surgeons) say…….• Patients who underwent CABG achieved more

complete revascularization

– more than 95% of patients received multiplearterial grafting.

• The almost exclusive use of multiple arterialgrafting in the surgical group and DES in the PCIgroup enable evaluation of state-of-the-arttechniques with both modalities.





What they (surgeons) say…….PCI in multivessel disease

• increased repeat revascularization• increased myocardial infarction within the first

year after revascularization compared with CABGpatients, although the sample sizes were small.

• As seen in the ARTS and BARI trials, the diabeticpatients particularly benefited from surgical

revascularization.





CABG

• lower mortality rates than does treatment withdrug-eluting stents

• associated with lower rates of death ormyocardial infarction and repeat

revascularization.

Ischaemia driven revascularization /"incompleterevascularization," is an inferior strategy inpatients with true multiple vessel coronary

disease.





What they (surgeons) say…….• New York State registry have convincingly shown

that incomplete revascularization was highly

associated with early and late cardiac mortality.

In the current discussion of surgery versusstents, one critical question has largely beenignored:

Does re-stenosis cause recurrent cardiac eventsin PCI patients?





What they (surgeons) say…….Although larger observational studies and clinicaltrials will continue to attempt to clarify the role of

PCI, CABG and medical therapy in multivesselcoronary disease….

• careful, stratified recruitment of specific anatomic

subsets, and pre-specified subgroup comparisonswill be required to provide definitive guidance.

• In the meantime, cardiovascular practitionersmust distill, out of the data currently available,an optimal revascularization strategyindividualized for each patient.



Why treat differently?

Treatment is different based on:

• Clinical scenario– Stable CAD

– NSTEACS– STEMI

• Timing of presentation

• Lesion

• Modes of treatment available



Thank you

Coronary Artery Disease-Why Treat Differently

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