COX HEART SUMMIT 2017 11 [Read-Only] · (Individual vs Public Health Considerations) ... Robinson...
Transcript of COX HEART SUMMIT 2017 11 [Read-Only] · (Individual vs Public Health Considerations) ... Robinson...
11/9/2017
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New Twist To Old Disease :Cardiovascular Update 2017
Sridevi R Pitta, M.D.,MBA, F.S.C.A.I., R.P.V.IMedical Director for STEMI,
Medical Director for CV Quality Council,Interventional Cardiologist & Endovascular Medicine ,
Cox Health
OBJECTIVES
� Prevention� Pre-operative � Coronary Artery Disease
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Less clear other
groups use
Additional factors
Clinical
ASCVD
Age >75yr or not candidate
for high Intensity statin
Moderate intensity statin
Age <75yrs High intensity statin
(Moderate inensity if not
candidate for high)Adults age >21yr
and a candidate for
statin therapy
yesyes
LDL>190
mg/dlHigh intensity statin
(Moderate intensity if not
candidate for high
High
>50%
Definition for high
and moderate
intensity statin
Moderate
30 to
<50%
No
yes
Estimate 10yr ASCVD risk
>7.5%
High intensity statin
Diabetes
Age 40 75yr
Diabetes Type Ior 2
Age 40-75yr
Moderate intensity statin
yes
No
Moderate to high
intensity statinyes
>7.5%Estimated
10yrASCVD
risk and age 40-
75yr
Estimate 10yr ASCVD
Risk with Pooled cohort
equations
No
No
IMPROVE – IT: Primary Endpoint
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Secondary Prevention: Is the Lower, the Better for LDL-C
What is the Future of LDL-Lowering Therapy?
Is 10yr-year NNT for ASCVD Morbidity/Mortality a valuable tool for patient
discussion? (Individual vs Public Health Considerations)
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Major Recommendations for
ASCVD Statin therapy
Major Recommendations for
ASCVD Statin therapy
Heart Healthy lifestyle
habits: Foundation
“Should be the beginning of the discussion,
not end of the discussion”
AHA/ACC Guidelines 2013: Primary Prevention
PCSK9 INHIBITORS
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Robinson JG et al. N Engl J Med 2015;372:1489-1499.
Calculated LDL Cholesterol Levels over Time
Cumulative Incidence of Cardiovascular Events
Sabatine MS et al. N Engl J Med 2015;372:1500-1509.
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PCKS9 Inhibitors
• Dramatic drops in LDL cholesterol
• Long term data
• Cost effectiveness
OBJECTIVES
� Prevention� Pre-operative � Coronary Artery Disease
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Palmerini et al. EuroPCR 2012
Timing of First DAPT Interruption and ST Through 1 year
Circulation, 2000
Lancet,2009
• Restoration of
Vasomotor
function
• Free of late
stent thrombosis
• Antiplatelet
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“ Major advances in health care occur not from results of randomized clinical trials or real world registries, but from the application of those results to complex healthcare systems which requires the successful
interaction of healthcare workers and their patients”.
Tim Henry, MD
Circulation,2012
ACC/AHA: 2013
Case Discussion
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Mortality From Cardiogenic Shock according to age (<75yrs vs >75yrs)
IABP IMPELLA
Case Discussion
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Platelet -Mediated Thrombosis
Targets
Meadows et al.Circulation Res 2007
P2Y12 Receptor Antagonists
Agent Class IPA Time to
peak
onset
Reversiblit
y
Ticlopidine
250mg po bid
Thienopyridine
(Prodrug)
25% 48hrs Non-reversible
5days
Clopidogrel
300mg LD
600mg LD
75mg qd
150mg qd
Thienopyridine
(Prodrug)
30-40%
35%-50%
30-35%
45%-50%
12hrs
6hrs
-
-
Non-reversible
5days
Prasugrel 60mg LD
Prasugrel 10mg po qd
Prasugrel 5mg po qd
Thienopyridine
(Prodrug)
80%
60%
40%
1-2hrs
-
-
Non-reversible
7days
Ticagrelor 180mg LD
Ticagrelor 90mg po
bid
Cyclo-pentyl
triazolo-
pyrimidine
80%
70%
1-2hrs Reversible
2-5days
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Treatment Algorithm for Duration of P2Y12 Inhibitor Therapy in Patients Treated with PCI
Case Discussion
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ACUITY Study Showed TRI Had Reduced Access Bleeding
Hamon M, et al. Choice of Arterial Access site and outcomes in patients with acute coronary syndromes managed with an early invasive strategy: The ACUITY trial. Eurointervention. 2009; 5: pp 115-120.
Eve
nt R
ate
P = 0.78 P = 0.18 P = 0.03
N=798N=11,989
Net clinical outcome was defined as composite ischemia or major bleeding
TRI can reduce Hospital Charges
FemoralN=77
RadialN=68
P Value
Postprocedure length of stay, days
2.3 1.4 P < 0.01
Total hospital length of stay, days
4.5 3.0 P < 0.01
Total hospital charge, $ $23,389 $20,476 P < 0.01
Mann JT, et al. Stenting in acute coronary syndromes: a comparison of radial versus femoral access sites. Journal of the American College of Cardiology. 1998;32:572-576.
TRI can Reduce Nurse Workload
Amoroso G, et al. Overview of the transradial approach in percutaneous coronary intervention. J Cardiovasc Med (Hagerstown) 2007;8:230-7.
Nurse workload after invasive procedures according to the arterial access used
The transradial approach results in a significant reduction (P < 0.01) in nurse workload
P < 0.01
P < 0.01
Cathlab Ward/CCU
1000
750
500
250
0
Nur
se W
orkl
oad
(min
)
Radial Femoral Radial Femoral
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Patients Prefer TRIHistogram of patient preference for catheterization method rated on visual analog scale
Cooper CJ, et al. Effect of transradial access on quality of life and cost of cardiac catheterization: a randomized comparison. American Heart Journal.1999;138:430-436.
0
20
40
60
80
100
120
Strongly Prefer Radial
No Preference Strongly Prefer
Femoral
Num
ber
of P
atie
nts
P < 0.0001
Amin AP et al.
SAME DAY DISCHARGE
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IC-460115-AB JUN2017
0
50
100
150
200
250
300
350
CAD
Patients Diagnosed w/ Patients undergoing Revascularization
(PCI or CABG)
Underutilization of Coronary Revascularization (PCI or CABG) in CAD Patients
>75,000,000 patient record database analysis Commercial Payers & Medicare data, 1/2010 –
4/2014
Truven Health Analytics MarketScan Comercial and Medicare Supplemental Databases (01/01/2010 - 4/30/2014)
CAD
52% of CADpts NOT revascularized
CAD + CHF
-
10
20
30
40
50
60
70
80
Patients Diagnosed w/CAD
& CHF
Patients undergoing Revascularization (PCI or CABG)
56%of CAD +CHF pts NOTrevascularized
CTO Prevalence and Treatment
CTO 18.4%
Patients with CoronaryArtery Disease
N = 14,439
Attempted
CTO-PCI
10%Non-CTO PCI
20%
Medical
Therapy
44%
CABG
26%
Treatment of Patientswith CTOs
N = 1,697
Fefer et al. JACC 2012. IC-460115-AB JUN2017
IC-308913-AB JUN2015
0
15
22
0%
10%
20%
30%
40%
Medical Therapy May Not be EnoughHigher Ischemic Burden Correlated to Mortality
Dea
thor
MI
Rat
e
Shaw et al, Circulation 2008;117
p=0.063
p=0.023
p=0.002
39
>10%(n=62)
5%-9.9%(n=88)
0%(n=23)
1%-4.9%
(n=141)
Ischemic Burden
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IC-308913-AB JUN2015
CTO Impact on Non-CTO Vessel AMI MortalityHigher 1-year Mortality Rate w/ CTO
Van der Schaff RJ et al. Am J Cardiol 2006.
CTO is an
independent
predictor of
mortality
Lessons of the Heart -- Cardiovascular Disease: A Mind, Body, and Spirit Approach
"the heart is not just a pump, but a home to the soul"
Sridevi R Pitta, M.D.,MBA, F.S.C.A.I., R.P.V.I3800 S National Ave Wheeler Heart Center 4th Floor
Springfield, MO 65807
Office number: 417-875-2628
Fax number: 417-875-3718