Updates on Coronary Artery Disease and Interventional Cardiology - - PowerPoint PPT Presentation

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Updates on Coronary Artery Disease and Interventional Cardiology - - PowerPoint PPT Presentation

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Partner Logo Updates on Coronary Artery Disease and Interventional Cardiology Joseph Yang, MD Assistant Clinical Professor Division of Cardiology Department of Medicine San Francisco VA Health Care System University of California, San

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Partner Logo

Updates on Coronary Artery Disease and Interventional Cardiology

Joseph Yang, MD Assistant Clinical Professor Division of Cardiology Department of Medicine San Francisco VA Health Care System University of California, San Francisco

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Disclosures

  • I have no relevant financial relationships with any companies related

to the content of this course.

  • I am an Interventional Cardiologist (more of a disclaimer, not of

financial relevance)

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2018-2019: A Potpourri

Thiele NEJM 2018. Stone NEJM. Mack NEJM 2019. Popma NEJM 2019.

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2019-2020: Mostly Coronary Disease

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The Year in Interventional Cardiology

  • Complete Revascularization after Myocardial Infarction
  • Revascularization in Stable Coronary Disease
  • Duration of Antiplatelet Therapy with Drug Eluting Stents
  • CABG vs. PCI for Left Main Disease
  • COVID-19 and Myocardial Infarction
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Complete Revascularization after Myocardial Infarction

  • COMPLETE Trial
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  • First, a quick trip back to 2013: The PRAMI Trial

Mehta NEJM 2019

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Wald NEJM 2013

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Levine Circulation 2016

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COMPLETE Trial

Mehta NEJM 2019

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  • First Co-Primary Endpoint:

Composite of Cardiovascular Death and MI

  • Second Co-Primary Endpoint:

Composite of Cardiovascular Death, MI, or Ischemia-Driven Revascularization

Mehta NEJM 2019

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Mehta NEJM 2019

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Mehta NEJM 2019

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Revascularization in Stable Coronary Disease

  • ISCHEMIA Trial
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ISCHEMIA Trial

twitter.com: #ISCHEMIA

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Bolden NEJM 2007

  • First, a look back:
  • COURAGE Trial
  • 2007
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Maron NEJM 2020

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  • Primary

Composite Outcome:

  • Death from CV

causes

  • MI
  • Hospitalization

for unstable angina

  • Heart failure
  • Resuscitated

cardiac arrest

Maron NEJM 2020

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Maron NEJM 2020

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Maron NEJM 2020

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Maron NEJM 2020

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Maron NEJM 2020

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Spertus NEJM 2020

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twitter.com: #ISCHEMIA www.latimes.com

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Duration of Antiplatelet Therapy with Drug Eluting Stents

  • STOPDAPT-2 Trial
  • TWILIGHT Trial
  • ONYX ONE Trial
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Watanabe JAMA 2019

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Watanabe JAMA 2019

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Watanabe JAMA 2019

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Mehran NEJM 2019

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Mehran NEJM 2019

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Primary Outcome: Bleeding

Mehran NEJM 2019

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Secondary Endpoint: Ischemic Events

Mehran NEJM 2019

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Windecker NEJM 2020

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Windecker NEJM 2020

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Windecker NEJM 2020

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CABG vs. PCI for Left Main Disease

  • EXCEL Trial: 5 year results
  • PRECOMBAT Trial: 10 year results
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Stone NEJM 2019

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Stone NEJM 2019

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  • PCI: higher Death from

any cause

  • 18/30 additional deaths

in PCI group adjudicated as non-cardiac

  • Stroke and MI did not

differ

  • PCI: more

revascularization

Stone NEJM 2019

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Stone NEJM 2019

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  • Composite endpoint:
  • Death
  • Stroke
  • MI
  • Early benefits of PCI

diminished over time

  • 0-30 days: less

events after PCI

  • 30 days-1 year:

Similar

  • 1-5 years: less events

after CABG

Stone NEJM 2019

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www.bbc.co.uk

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Watanabe Circulation 2020

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Watanabe Circulation 2020

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Brophy JAMA Int Med 2020

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  • Kinnaird. Circ Cardiovasc Interven 2020
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COVID-19 and Myocardial Infarction

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Mahmud Catheter Cardiovasc Interven 2020

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Mahmud Catheter Cardiovasc Interven 2020

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Bangalore NEJM 2020

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www.nytimes.com Slide courtesy of Gregory Judson, MD

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Garcia JACC 2020 Slide courtesy of Gregory Judson, MD

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Solomon NEJM 2020

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Late Presentations

www.twitter.com Slide courtesy of Gregory Judson, MD

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Take Home (No Contact Delivery) Points

  • STEMI: Complete revascularization preferred over culprit-vessel
  • nly.
  • Stable CAD: Can be managed medically if you exclude left main
  • disease. PCI improves symptoms and maybe more? Longer-term
  • utcomes hopefully still on the way.
  • DAPT duration: Guidelines still say 6 or 12 months. In high

bleeding risk, single agent is likely safe after 1-3 months.

  • Left main disease: Heart Team discussion is needed. Operator

volume seems to matter.

  • COVID-19: Public awareness of cardiovascular disease is

important!

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Thank you

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References

  • Bangalore, S., Sharma, A., Slotwiner, A., et al. 2020. ST-Segment Elevation in Patients with Covid-19 - A Case Series. The New England

Journal of Medicine. In press.

  • Boden, W.E., O’Rourke, R.A., Teo, K.K., et al. 2007. Optimal medical therapy with or without PCI for stable coronary disease. The New

England Journal of Medicine 356(15), pp. 1503–1516.

  • Brophy, J.M. 2020. Bayesian interpretation of the EXCEL trial and other randomized clinical trials of left main coronary artery revascularization.

JAMA internal medicine. In press.

  • Garcia, S., Albaghdadi, M.S., Meraj, P.M., et al. 2020. Reduction in ST-Segment Elevation Cardiac Catheterization Laboratory Activations in

the United States During COVID-19 Pandemic. Journal of the American College of Cardiology 75(22), pp. 2871–2872.

  • Kinnaird, T., Gallagher, S., Anderson, R., et al. 2020. Are higher operator volumes for unprotected left main stem percutaneous coronary

intervention associated with improved patient outcomes?: A survival analysis of 6724 procedures from the british cardiovascular intervention society national database. Circulation. Cardiovascular Interventions 13(6), p. e008782.

  • Levine, G.N., Bates, E.R., Blankenship, J.C., et al. 2016. 2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary

Intervention for Patients With ST-Elevation Myocardial Infarction: An Update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention and the 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation 133(11), pp. 1135–1147.

  • Mack, M.J., Leon, M.B., Thourani, V.H., et al. 2019. Transcatheter Aortic-Valve Replacement with a Balloon-Expandable Valve in Low-Risk
  • Patients. The New England Journal of Medicine 380(18), pp. 1695–1705.
  • Maron, D.J., Hochman, J.S., Reynolds, H.R., et al. 2020. Initial invasive or conservative strategy for stable coronary disease. The New

England Journal of Medicine 382(15), pp. 1395–1407.

  • Mehran, R., Baber, U., Sharma, S.K., et al. 2019. Ticagrelor with or without Aspirin in High-Risk Patients after PCI. The New England Journal
  • f Medicine 381(21), pp. 2032–2042.
  • Mehta, S.R., Wood, D.A., Storey, R.F., et al. 2019. Complete Revascularization with Multivessel PCI for Myocardial Infarction. The New

England Journal of Medicine 381(15), pp. 1411–1421.

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References continued

  • Park, D.-W., Ahn, J.-M., Park, H., et al. 2020. Ten-Year Outcomes After Drug-Eluting Stents Versus Coronary Artery Bypass Grafting for Left

Main Coronary Disease: Extended Follow-Up of the PRECOMBAT Trial. Circulation 141(18), pp. 1437–1446.

  • Popma, J.J., Deeb, G.M., Yakubov, S.J., et al. 2019. Transcatheter Aortic-Valve Replacement with a Self-Expanding Valve in Low-Risk
  • Patients. The New England Journal of Medicine 380(18), pp. 1706–1715.
  • Solomon, M.D., McNulty, E.J., Rana, J.S., et al. 2020. The Covid-19 Pandemic and the Incidence of Acute Myocardial Infarction. The New

England Journal of Medicine. In press.

  • Spertus, J.A., Jones, P.G., Maron, D.J., et al. 2020. Health-Status Outcomes with Invasive or Conservative Care in Coronary Disease. The

New England Journal of Medicine 382(15), pp. 1408–1419.

  • Stone, G.W., Kappetein, A.P., Sabik, J.F., et al. 2019. Five-Year Outcomes after PCI or CABG for Left Main Coronary Disease. The New

England Journal of Medicine 381, pp. 1820–1830.

  • Stone, G.W., Lindenfeld, J., Abraham, W.T., et al. 2018. Transcatheter Mitral-Valve Repair in Patients with Heart Failure. The New England

Journal of Medicine 379(24), pp. 2307–2318.

  • Thiele, H., Akin, I., Sandri, M., et al. 2018. One-Year Outcomes after PCI Strategies in Cardiogenic Shock. The New England Journal of

Medicine 379(18), pp. 1699–1710.

  • Wald, D.S., Morris, J.K., Wald, N.J., et al. 2013. Randomized trial of preventive angioplasty in myocardial infarction. The New England Journal
  • f Medicine 369(12), pp. 1115–1123.
  • Watanabe, H., Domei, T., Morimoto, T., et al. 2019. Effect of 1-Month Dual Antiplatelet Therapy Followed by Clopidogrel vs 12-Month Dual

Antiplatelet Therapy on Cardiovascular and Bleeding Events in Patients Receiving PCI: The STOPDAPT-2 Randomized Clinical Trial. The Journal of the American Medical Association 321(24), pp. 2414–2427.

  • Windecker, S., Latib, A., Kedhi, E., et al. 2020. Polymer-based or Polymer-free Stents in Patients at High Bleeding Risk. The New England

Journal of Medicine 382(13), pp. 1208–1218.