Managem ent of Multivessel CAD: Stenting or CABG ? Filippos - PowerPoint PPT Presentation

Managem ent of Multivessel CAD: Stenting or CABG ? Filippos Triposkiadis, MD, FESC, FACC Departm ent of Cardiology, University of Thessaly

Long-term Outcom e of Patients W ith 3 VD Undergoing CABG A Report from CASS Registry Group I Group I I The study was performed as a retrospective analysis of 3,372 nonrandomized surgical patients from the Coronary Artery Surgery Study (CASS) Registry who had three-vessel coronary disease. Group 1 (894 patients) had class I or H angina (Canadian Cardiovascular Society criteria) and group 2 (2,478 patients) had class III or IV angina. Bell, et al. Circulation 1 9 9 2 ;8 6 ;4 4 6 -5 7

Managem ent of Chronic Stable Angina: Lessons from the Random ized Trials Solom on and Gersh. Ann I ntern Med 1 9 9 8 ;1 2 8 :2 1 6 -2 2 3

Managem ent of Chronic Stable Angina: Lessons from the Random ized Trials … … ..When revascularization is considered for the treatment of multivessel CAD, the selection of PTCA or CABG depends on the coronary anatomy, LV function, need for complete revascularization, and patient preference. In high-risk patients who have left main coronary artery disease or three-vessel coronary artery disease with impaired LV function, current data support surgical revascularization as the treatment of choice to achieve complete revascularization… … .. Solom on and Gersh. Ann I ntern Med 1 9 9 8 ;1 2 8 :2 1 6 -2 2 3

 About 4 0 -5 0 % of all cardiovascular deaths are sudden cardiac deaths. Mehra R. J Electrocardiol 2 0 0 7 ;4 0 ( 6 Suppl) :S1 1 8 -2 2 .  Nearly 5 0 % of all SCDs occurr in subjects w ithout a prior history of heart disease. Fox, et al. Circulation. 2 0 0 4 ;1 1 0 :5 2 2 -5 2 7

Reduction in physical Secondary preventive inactivity 5% 5% 11% therapies after MI 10% Reduction or revascularization 12% in smoking 11% prevalence Initial treatments for 10% 9% acute MI or UA Treatments for HF 9% 8% Reduction 20% 19% in SBP 5% Revascularization 5% for chronic angina 12% 11% Other therapies 24% 22% Reduction in total cholesterol Ford, et al. N Engl J Med 2007;356:2388-98

Reperfusion Managem ent of CAD  Pathogenesis of atherosclerosis and its com plications  Coronary im aging  Target and m echanism of intervention  Reperfusion techniques  Prospective random ized trials and registries

Pathogenesis of Atherosclerosis

Pathogenesis of Atherosclerosis  Atherosclerosis is a m ultifocal , smoldering, immuno- inflammatory disease of medium-sized and large arteries fuelled by lipids.  The most devastating consequences of atherosclerosis, such as heart attack and stroke, are caused by superimposed throm bosis .  Approximately 76% of all fatal coronary thrombi are precipitated by plaque rupture . Plaque rupture is a more frequent cause of coronary thrombosis in men (80% ) than in women (60% ).  Ruptured plaques are characterized by a large lipid-rich core, a thin fibrous cap that contains few smooth muscle cells and many macrophages, angiogenesis, adventitial inflammation, and outward remodeling. Falk E. J Am Coll Cardiol 2 0 0 6 ;4 7 :C7 – 1 2

Pathologic, Laboratory, and Clinical Correlates in Chronic Coronary Artery Disease Obstructive Lesions Positive Rem odelling  Stress ischem ia ( + + / - )  Stress angina ( + + / -)  Calcium Score ( + + / -)  Angiography ( + )  I VUS ( + ) Norm al Non-Obstructive Lesions  Stress ischem ia ( --/ + )  Stress angina ( --/ + )  Angiography ( --/ + )  Coronary calcium score ( -/ + )  I VUS ( + ) Coronary throm bosis  Death Triposkiadis, Starling, Stefanadis  Unstable angina Curr Cardiol Rev 2 0 0 7 ;3 :2 2 1 -3 1  Myocardial infarction

Coronary I m aging

Coronary Angiography  Stenosis severity  Qualitative descriptors of lesion com plexity -Eccentricity -I rregularities -Ulcerations -I ntralum inal filling defects and occlusions ( Sensitivity: 3 6 % ; Specificity: 8 6 % ) Am J Cardiol 1 9 9 8 ;8 2 :1 2 7 3 -7 5

Lim itations of Projection I m aging Circulation 1 9 9 5 ;9 2 :2 3 3 3 -2 3 4 2

Coronary Rem odeling Conceals Extensive Disease J Am Coll Cardiol 2 0 0 3 ;4 1 :1 0 3 S– 1 1 2 S

Draw backs of Coronary Angiography  Depicts rather poor representation of cross-sectional coronary anatom y from sim ple planar silhouette or lum inogram of the contrast-filled lum en.  Confounded by observer variability, w ith differences in the estim ation of stenosis approaching 5 0 % .  Functional testing often reveals discordance betw een the severity of angiographic lesions and physiologic effects.  Necropsy studies and I VUS dem onstrate that coronary lesions, particularly after plaque rupture, are com plex, w ith distorted lum inal shapes that are difficult to assess using a planar angiographic silhouette. JACC 2 0 0 3 ; 4 1 : 1 0 3 S-1 1 2 S

Morphology vs. Activity I m aging Thermography, Spectroscopy, Molecular Imaging, (radionuclear, MRI, CT… … ) targeted to markers of activity (MMP , Ox-LDL, LOX) Different Activity I nactive and Active and non-inflam ed inflam ed plaque plaque Sim ilar Morphology MRI I VUS OCT Circulation 2 0 0 3 ; 1 0 8 :1 0 6 4 - 7 2

Target and Mechanism of I ntervention

Coronary Revascularization in CAD: Are W e Treating The W rong Plaques?  PCI  CABG ?

Methods of Coronary Revascularization: Things May Not Be as They Seem !! N Engl J Med 2 0 0 5 ; 3 5 2 2 2 3 5 -7

Coronary Bypass Grafting Percutaneous Coronary I ntervention Stent Triposkiadis, Starling, Stefanadis. Curr Cardiol Rev 2 0 0 7 ;3 :2 2 1 -3 1

Reperfusion Techniques

POBA vs. Stent: Rate of Restenosis Ann I ntern Med 2 0 0 3 ;1 3 8 :7 7 7 -7 8 6

POBA vs. Stent: Rate of Death or MI Ann I ntern Med 2 0 0 3 ;1 3 8 :7 7 7 -7 8 6

Outcom es Associated w ith DES and BMS: A Collaborative Netw ork Meta- Analysis • 38 trials (18,023 patients) with a follow-up of up to 4 years were included. • Safety outcomes included mortality, MI, and definite stent thrombosis; the effectiveness outcome was TLR. • Trialists and manufacturers provided additional data on clinical outcomes for 29 trials. • We did a network meta- analysis with a mixed- treatment comparison method to combine direct within-trial comparisons between stents with indirect evidence from other trials while maintaining randomisation. Stettler, et al. Lancet 2 0 0 7 ; 3 7 0 : 9 3 7 –4 8

Stent Throm bosis TLR Stettler, et al. Lancet 2 0 0 7 ; 3 7 0 : 9 3 7 –4 8

Stratified Analysis According to Presence or Absence of Diabetes Mellitus Stettler, et al. Lancet 2 0 0 7 ; 3 7 0 : 9 3 7 –4 8

Random ized Controlled Trials and Registries: CABG vs. PCI

Long-Term Safety and Efficacy of PCI W ith Stenting and CABG for Multivessel CAD A Meta-Analysis W ith 5 -Year From ARTS, ERACI -I I , MASS-I I , and SoS We performed a pooled analysis of 3051 patients in 4 randomized trials evaluating the relative safety and efficacy of PCI with stenting and CABG at 5 years for the treatment of multivessel coronary artery disease. The primary end point was the composite end point of death, stroke, or myocardial infarction. The secondary end point was the occurrence of major adverse cardiac and cerebrovascular accidents, death, stroke, myocardial infarction, and repeat revascularization. Daem en, et al. Circulation 2 0 0 8 ;1 1 8 :1 1 4 6 -5 4

Kaplan– Meier Event-Free Survival Analysis Daem en, et al. Circulation 2 0 0 8 ;1 1 8 :1 1 4 6 -5 4

Characteristics of Patients in CABG vs. PCI Trials for Multivessel CAD  The trials involved alm ost 9 0 0 0 patients but probably only around 5% ο f the total eligible population  There w ere no patients w ith left m ain stem stenosis  Only about one third ο f patients had true 3 VD  Only about 40% ο f patients had proxim al LAD disease  Most patients had a LVEF > 0 .5 0 .

Long-Term Outcom es of CABG versus Stent I m plantation ( New York Registries) New York’s cardiac registries were used to identify 37,212 patients with MVD who underwent CABG and 22,102 patients with MVD who underwent PCI from January 1, 1997, to December 31, 2000. The rates of death and subsequent revascularization within three years after the procedure were determined in various groups of patients according to the number of diseased vessels and the presence or absence of involvement of the LAD. N Engl J Med 2 0 0 5 ;3 5 2 :2 1 7 4 -8 3

New York Registries N Engl J Med 2 0 0 5 ;3 5 2 :2 1 7 4 -8 3

New York Registries N Engl J Med 2 0 0 5 ;3 5 2 :2 1 7 4 -8 3