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

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

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)

2018-2019: A Potpourri Thiele NEJM 2018. Stone NEJM. Mack NEJM 2019. Popma NEJM 2019.

2019-2020: Mostly Coronary Disease

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

Complete Revascularization after Myocardial Infarction  COMPLETE Trial

 First, a quick trip back to 2013: The PRAMI Trial Mehta NEJM 2019

Wald NEJM 2013

Levine Circulation 2016

COMPLETE Trial Mehta NEJM 2019

 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

Mehta NEJM 2019

Mehta NEJM 2019

Revascularization in Stable Coronary Disease  ISCHEMIA Trial

ISCHEMIA Trial twitter.com: #ISCHEMIA

 First, a look back:  COURAGE Trial  2007 Bolden NEJM 2007

Maron NEJM 2020

 Primary Composite Outcome: • Death from CV causes • MI • Hospitalization for unstable angina • Heart failure • Resuscitated cardiac arrest Maron NEJM 2020

Maron NEJM 2020

Maron NEJM 2020

Maron NEJM 2020

Maron NEJM 2020

Spertus NEJM 2020

twitter.com: #ISCHEMIA www.latimes.com

Duration of Antiplatelet Therapy with Drug Eluting Stents  STOPDAPT-2 Trial  TWILIGHT Trial  ONYX ONE Trial

Watanabe JAMA 2019

Watanabe JAMA 2019

Watanabe JAMA 2019

Mehran NEJM 2019

Mehran NEJM 2019

Primary Outcome: Bleeding Mehran NEJM 2019

Secondary Endpoint: Ischemic Events Mehran NEJM 2019

Windecker NEJM 2020

Windecker NEJM 2020

Windecker NEJM 2020

CABG vs. PCI for Left Main Disease  EXCEL Trial: 5 year results  PRECOMBAT Trial: 10 year results

Stone NEJM 2019

Stone NEJM 2019

 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

Stone NEJM 2019

 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

www.bbc.co.uk

Watanabe Circulation 2020

Watanabe Circulation 2020

Brophy JAMA Int Med 2020

Kinnaird. Circ Cardiovasc Interven 2020

COVID-19 and Myocardial Infarction

Mahmud Catheter Cardiovasc Interven 2020

Mahmud Catheter Cardiovasc Interven 2020

Bangalore NEJM 2020

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

Garcia JACC 2020 Slide courtesy of Gregory Judson, MD

Solomon NEJM 2020

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

Take Home (No Contact Delivery) Points  STEMI: Complete revascularization preferred over culprit-vessel only.  Stable CAD: Can be managed medically if you exclude left main disease. PCI improves symptoms and maybe more? Longer-term outcomes 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!

Thank you

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 of 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.

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 of 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.