jose miguel vegas valle sec sept2015

Revascularización completa o incompleta en enfermedad

coronaria José Miguel Vegas Valle

Servicio de CardiologíaHospital de Cabueñes, Gijón

[email protected]

mailto:[email protected]

Background

• The definition of MVD varies from study to study.

• Depending on wich definition is used the frecuency varies substantially, as do the outcomes of patients with MVD.

• The diferent definitions are one of the reason that is difficult to compare CABG vs PCI in non-randomized trials.

MULTILESION PCI IS NOT MULTIVESSEL PCI

Heterogeneity of Patients with Multivessel Disease:Implication for Revascularisation Strategies

Definition of Multivessel Coronary Artery Disease



Coronary Artery Surgery Study (CASS) definition of coronary artery disease (CAD):

1-vessel: > 70% stenosis one epicardial vessel

2-vessels: > 70% stenosis two epicardial vessels > 50% stenosis of the left main

3-vessels: > 70% stenosis three epicardial vessels Any of the above leading to three

William JR et als, Circulation 68, No. 5, 939-950, 1983.


Multivessel disease and outcome in CAD

Visual coronary artery disease in angiography is a prognostic marker



Sant’Anna FM et al, AJC: 2007,(99),504

Revascularization in

SCAD

European Guidelines: Revascularization in SCAD

2014 ESC/EACTS Guidelines on myocardial revascularization. European Heart Journal. doi:10.1093/eurheartj/ehu278

Revascularization and outcome.SCAD

n engl j med 356;15

Revascularization and outcome.SCAD

• Relevant in the context of the ongoing multicenter ISCHEMIA trial, which studies effects of revascularization compared with MT in patients with at least moderate ischemia.• Differs importantly from a recently meta-analysis of PCI versus MT that includes studies in which ischemia was based on either suggestive symptoms or abnormal electrocardiography (or routine ETT) without adjunctive documenting ischemia.

RCTs that enrolled patients with objective evidence of myocardial ischemia as assessed by noninvasive stress imaging or abnormal FFR.

Am J Cardiol 2015;115:1194e1199JAMA Intern Med 2014;174:232e240

Patients with Multivessel Disease and SCAD:Complete vs incomplete revascularization

• Observational studies and subgroup analysis of randomized clinical trials (RCT) from 1970 through September 2012• 89,883 patients, of whom 45,417 (50.5%) received CR and 44,466 (49.5%) received IR

IR was more common after PCI than after CABG (56% vs. 25%; p < 0.001)

CR was associated with lower long-term mortality

Mortality benefit associated with CR was consistent irrespective of revascularization modality

J Am Coll Cardiol 2013;62:1421–31

NEJM Vol 360, No 3, pp 213-224.

No diferences in basal characteristicsSignificant less contrast media, material cost and length hospital

stay in FFR-Guided PCI group

Patients with Multivessel Disease and SCAD:FAME trialStudy population, basal and angiographyc tools

Routine FFR in patients with multivessel CAD undergoing PCI with drug-eluting stents significantly reduces

mortality and myocardial infarction at 2 years compared with standard angiography-guided PCI

NEJM Vol 360, No 3, pp 213-224. J Am Coll Cardiol 2010;56:177–84

4,2%

Patients with Multivessel Disease and SCAD:FAME trialStudy population, basal and angiographyc tools

No diferences in death or MIRepeat revascularization: CABG 5,9% vs PCI 13,7%

Patients with Multivessel Disease and SCAD:Recommendations according to extent

2014 ESC/EACTS Guidelines on myocardial revascularization. European Heart Journal. doi:10.1093/eurheartj/ehu278


Multivessel disease and outcome in STEMI

30-Day Mortality for Patients With or Without Non–Infarct-Related Coronary Artery Disease

4.3% vs 1.7%, risk difference, 2.7%[95%CI, 2.3%to 3.0%] P < .001

68 765 patients enrolled in 8 trials, 28 282 patients with valid angiographic data. Defined as stenosis of 50% or more of a major epicardial artery.

52.8% (14 929) had obstructive non-IRA disease:• 29.6%: 1vessel • 18.8%: 2 vessels

JAMA. 2014;312(19):2019-2027.


Multivessel disease and outcome in STEMI

Sorajja P et al. Eur Heart J 2007;28:1709-16

CADILLAC trial: 2082 patients with acute myocardial infarction and primary PCI

Patients with Multivessel Disease:Culprit vs multivessel revascularization

STEMI: ESC Guidelines

2014 ESC/EACTS Guidelines on myocardial revascularization.

European Heart Journal. 2014. doi:10.1093/eurheartj/ehu278

Patients with Multivessel Disease:Culprit vs multivessel revascularizationSTEMI: Pros & Cons for Preventive PCI

• Non culprit lesion not associated withsymptoms/ ischemia• Overestimation of severity at time of acute angiography

J Am Coll Cardiol Intv 2015;8:131–8)EuroIntervention 2014;10-T47-T54n engl j med 369;12

• Improve hemodynamics• Prevent reinfarction– Vulnerable non-culprit lesion can become culprit(“pan-coronary inflammation”)– STEMI is a pan-coronary inflammatory disease.


STEMI

EuroIntervention 2014;10-T47-T54

Advantages (+) and

disadvantages (–) of different

PCI strategies for non-culprit

lesions in patients with STEMI

and MVD


STEMI: Variables to choose strategy

EuroIntervention 2014;10-T47-T54


STEMI: Prior evidence

Four prospective and 14 retrospective studies involving 40,280 patients.

Meta-analysis supports current guidelines discouraging performance of multivessel primary PCI for STEMI.

When significant nonculprit vessel lesions are suitable for PCI, they should only be treated during staged procedure


STEMI: Prior evidence


STEMI: PRAMI Trial

• IRA had been successfully treated• PCI treatable stenosis of 50% or more in one or more• Staged PCI in non preventive group without angina was discouraged (angina driven stage PCI)

465 patients randomly assigned to preventive PCI (234) or no preventive PCI (231 patients).

N Engl J Med 2013;369:1115-23


STEMI: PRAMI Trial

N Engl J Med 2013;369:1115-23

• During 5 years recruited 465 patients in 5 centers.• Low number of events (Cardiac death: 4/10)• Demographics• Angiographic characteristics unknown• Non fatal MI due to spontaneous MI or peri-procedural MI?• End-point includes refractory angina


STEMI: CvLPRIT Trial

• Randomized 146 primary PCI patients to treatment of the IRA only and 150 to complete revascularization that treated the culprit vessel plus any other arteries with >70% stenosis.• PCI to non-culprit vessel was performed in the same index admission

JACC , 2015-03-17, Volume 65, Issue 10, Pages 963-972


STEMI: CvLPRIT Trial

• Low number of events (Cardiac death: 2/6)• End-point includes refractory angina/revascularization and heart failure• None of the individual endpoints reached statistical significance

JACC , 2015-03-17, Volume 65, Issue 10, Pages 963-972


STEMI: DANAMI 3-PRIMULTI

627 patients; 313 PCI of the infarct-related artery only and 314 complete revascularisation guided by FFR.Median follow-up was 27 months.Two university hospitals in Denmark 2011-2014.


STEMI: DANAMI 3-PRIMULTI

In patients with STEMI and multivessel disease, complete revascularisation guided by FFR significantly reduces the risk of future events compared with no further invasive intervention. This effect is driven by fewer repeat revascularisations


STEMI: Real world

Mortality at 30 days (4.2% versus 8.7%; P=0.025), and at 1 year (6.8% versus 10.2%; P=0.05)

• CVI versus multivessel intervention • 3984 patients with multivessel disease undergoing PPCI • Between 2004 and 2011 • 8 tertiary cardiac centers

Circ Cardiovas Qual Outcomes. 2014;7:936-943


Acute Coronary Syndromes

J Am Coll Cardiol 2007;49:849–54

No differences in death or MI



EuroIntervention 2013;9:916-922

Retrospective cohort study of 990 consecutive patients who underwent either single-vessel PCI (n=379) or multivessel PCI (n=611) in Non-ST ACS



• 8 observational studies with 8,425 patients (3,227 multivessel and 5,198 culprit-only PCI) • Mean follow-up duration was 18 months.

There were no significant differences in all-cause mortality and myocardial infarction.

Am J Cardiol 2015;115:1027e1032

Patients with Multivessel Disease:Culprit vs multivessel revascularizationAcute Coronary Syndromes: FFR Guided

revascularization

Rev Esp Cardiol. 2012;65(2):164–170JACC Cardiovasc Interv, 2011 Vol 4, No 11, pp 1183-89.

FAME substudy: 328 patiens with Non-ST-ACS:

Similar data in outcomes, contrast media, hospital stay

Special Settings

Muhlestein J.Am Heart J. 2003;146 Hlatky, The Lancet, Vol 373 April 4, 2009

SPECIAL SETTINGS Diabetes

SPECIAL SETTINGS Chronic total occlusion

Eur Heart J. 2012 Mar;33(6):768-75

HORIZONS AMI Subestudy:• 3283 patients undergoing primary PCI, 283 (8.6%) had MVD with a CTO.• MVD with CTO in a non-IRA was an independent predictor of both 30-day and 3-year mortality.• During 3-year follow-up, patients with failed procedure had higher cardiac mortality (22.9% versus 9.0%, P = 0.020) and lower MACE-free survival (50.0% versus 72.0%, P = 0.009) compared to patients with successful procedure.

jose miguel vegas valle sec sept2015

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