Revascularisation coronaire
G Berkenboom
Syndromes coronariens aigus (traitements anti-thrombotiques)
Angor stable
EHJ 2010;31:2501
EHJ 2012;33:2569
FV à l’arrivée du
SMUR
Choc massage
noradrénaline, xylo
amiodarone
Aspirine héparine..
FE VG: 65%
Aspirine Plavix
bisoprolol
simva
perindopril
Revalidation
Primary percutaneous coronary intervention-related time delay that nullifies the survival
benefit of primary percutaneous coronary intervention over thrombolytic therapy across
different baseline risk profiles in a patient with a presentation delay of 3 h.
Tarantini G et al. Eur Heart J 2010;31:676-683
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author
2009. For permissions please email: journals.permissions@oxfordjournals.org
STEMI/reperfusion strategies
• Minimize all time delays (specially within
2h symptom onset)
• Transportation to PCI centre (high volume
operators)
• If admission to hosp without PCI:
.transportation to PCI centre if time delay <
2h (1st med contact and ballon inflation)
.if > 2h: thrombolysis and transfer to PCI
center (3h-24h)
STEMI/revascularization
recommendations
• By-pass the emergency room and ICU!!!
• PCI for ONLY the culprit lesion
• Recommendation I A for chest pain < 12h
& persistent ST elevation
• Recommendation IIa C for chest pain
>12h &<24h + persistent ST elevation (or
previously undocumented LBBB)
STEMI/PCI after fibrinolysis
• Routine PCI after successful fibrinolysis
within 24h :I A
• Rescue PCI in patients with failed
fibrinolysis (persistent ST segment
elevation (>50% of the max elevation) &/or persistent
pain): PCI as soon as possible
IIa A
Cardiogenic shock
• Early repefusion & haemodynamic support
• Echography mandatory: LV assessment, MR
(papillary muscle rupture), VSD, free wall rupture,
cardiac tamponnade…
• Circulatory assistance: IABP (if
haemodynamic impairment) : I C; benefits
balanced against complications (Shock II trial)
Extracorporeal membrane oxygenator
(ECMO): AHF with potential for fct recovery after revasc
STEMI/CABG
• Emergency CABG only if a jeopardized
large area & revasc possible < 4h
ie: LM or 3 VD with haemodynamic
instability or life threatening VT: I C
• If absence of chest pain or haemodynamic
instability: waiting period of 3-7d
NSTEMI
ESC guidelines 2011
NSTEMI/high risk for progression
to MI
•
•
•
•
•
Ongoing/recurrent ischemia
Dynamic spontaneous changes
Deep ST depression in V2-V4
Hemodynamic instability
Major ventricular arrhythmia
PURSUIT (0-18), TIMI (0-7), GRACE (0258)
GRACE score
•
•
•
•
•
•
•
•
Age: /decades from <40 to >80
HR: from < 70 to > 200
SBP: from <80 to > 200
Creatinine: from < 0.4 to > 4 mg%
Killip class
Cardiac arrest
Elevated cardiac markers
ST-segment deviation
%
*
Proportion of major bleeding events reported as coronary artery bypass graft related and
non-coronary artery bypass graft related in standard-dose clopidogrel treatment arms.
Major bleeding in standard dose clopidogrel arms
Quinlan D J et al. Eur Heart J 2011;32:2256-2265
NSTEMI/revascularization
• Early invasive strategy (<24h) is indicated
if GRACE score> 140 or high risk criteria:
IA
• Late invasive strategy (< 72 h) is indicated
if GRACE score< 140 or absence of high
risk criteria: I A
• Invasive strategy should not be performed
if low risk or high risk for intervention: III A
Bleeding complications
•
•
•
•
•
•
Assess bleeding risk in every pt
Avoid crossover UFH/LMWH
Adjust doses < weight & renal fct
Radial access
Stop anticoag after procedure
Selective DOWNSTREAM use of GIIb-IIIa
inhibitors
Chronic stable angina
84 y old
NTEMI > 1 y early
Stent BMS mid Cx
Angina for exercise in the morning
LVEF: 50%
Med: perindopril 10 mg, aspirin,
rosuvastatin , nitrates
Creat <2,0 mg%, CRP>1 mg%
Impact on morbi/motality
• Myocardial revascularization is appropriate
when the expected benefits, in terms of
survival & quality of life , exceed the
expected negative consequences of the
procedure
• The patients should be offered time
between the diagnostic procedure & the
intervention (to discuss the findings, to seek 2d opinion)
ESC guidelines on stable angina (2006)
Stable angina for medical management
Immediate
short term
relief
Short-acting sublingual or
buccal nitrate, prn
Aspirin 75-150 mg od
Treatment
Statin
aimed at ± titrate dose  to get target cholesterol
improving
prognosis
Contraindication (e.g. aspirin allergic)
Intolerant or
contraindication
Clopidogrel 75 mg od
Interchange statins, or ezetimibe with lower dose statin,
or replacewith alternativelipid-lowering agent
ACE-inhibitor in proven CAD
β-blocker
Intolerant (e.g. fatigue) or contraindication*
If inhibitor
Symptoms not controlled after dose optimisation
Treatment
aimed at
relief of
symptoms
Add calcium antagonist
or long acting nitrate
Symptoms not controlled
after dose optimisation
Consider suitability for revascularisation
or calcium antagonist† or long-acting nitrate or K-channel opener
Intolerant
Symptoms not controlled after dose optimisation
Either substitute alternative
subclass of calcium antagonist
or long-acting nitrate
Combination of nitrate
and calcium antagonist or
K-channel opener
Symptoms not controlled on 2 drugs
after dose optimisation
Adapted from the Guidelines on the management of stable angina pectoris. Eur Heart J. 2006 27:1341-1381.
COURAGE Trial
• 2287 pts with stable cad, evidence of
myocardial ischemia
• 10% asymptomatic, 70 % class I & II, 20%
class III
• exclusion: persistent class IV; very positive
ex test; EF< 30%; revasc in the previous 6
months
COURAGE Trial (2)
• 5 y f up; I end point: death, non fatal MI
19% in PCI group vs 18.5% in medical
group
• No diff in the composite end points: death,
MI, stroke, hospi for ACS
• All pts received aggressive therapy, target
LDL: <80 mg/dl (simva ezetimibe)
HDL > 40 mg/dl (exercise, niacin, fibrates)
FAME 2 : FFR-Guided PCI versus Medical Therapy in Stable CAD
Flow Chart
Stable CAD patients scheduled for 1, 2 or 3 vessel DES-PCI
N = 1220
FFR in all target lesions
Registry
Randomized Trial
At least 1 stenosis
with FFR ≤ 0.80 (n=888)
When all FFR > 0.80
(n=332)
Randomization 1:1
PCI + MT
MT
73%
MT
27%
Follow-up after 1, 6 months, 1, 2, 3, 4, and 5 years
50% randomly
assigned to FU
FAME 2 : FFR-Guided PCI versus Medical Therapy in Stable CAD
Urgent Revascularization
Cumulative incidence (%)
30 PCI+MT vs. MT:
HR 0.13 (0.06-0.30); p<0.001
PCI+MT vs. Registry: HR 0.63 (0.19-2.03); p=0.43
25
MT vs. Registry:
20
HR 4.65 (1.72-12.62); p=0.009
Exactly the same finding in COURAGE trial
but on a f up of 7 years
15
10
5
0
0
1
2
3
4
5
6
7
8
9
10
11
12
129
160
53
101
119
42
71
93
26
38
53
13
Months after randomization
No. at risk
MT
PCI+MT
Registry
441
447
166
414
421
156
371
395
145
325
356
133
286
315
117
256
285
106
223
248
94
195
217
75
164
180
65
Indication of revascularisation
stable cad or silent ischemia
CABG vs PCI in stable patients
• 1VD/2VD non proximal LAD: IIb C vs I C
• 1VD/2VD proximal LAD: I A vs IIa B
• 3VD simple lesions (SYNTAX < 22):
I A vs IIa B
• Left main (ostium/distal): I A vs IIa/b B
• Left main with SYNTAX score> 33: I A vs
III B
Specific recommendations for
diabetic patients
• In sable pts with extensive cad; recommendation for
revasc: I A
with DES : I A
CABG if MVD: IIa B (both RCT & registry data show a trend for
CABG)
In pts on metformin: renal function should be monitored
after coronary angio : I C
Metformin should be stopped 48h before the procedure if
renal dysfunction
But NO convincing evidence for discontinuing systematically
metformin
Prevention of CIN
• Hydratation with isotonic saline, started >12 h
before and continued for 24 h (1ml/kg/h (0.5 ml if LV
dysfunction))
• Separate diagnostic & interventional
procedures!!
• NAC 600-1200 mg/24h: IIb A (AHA 2010?)
Elective haemodialysis not recommended
• LOW volume of contrast < 100ml;
use of LOCM or IOCM: I A (also ACC/AHA
guideline 2010)
JACC 2010;56:2126
CAD & peripheral vascular disease
• (B-B), aspirin & statins indicated prior to
and continued post-op in cad patients
scheduled for high-risk vascular surgery:
IB
• Prophylactic myocardial revascularisation
rarely indicated! (exception: extensive ischaemia despite
OMT and high risk vacsular surgery)
CAD & Vascular surgery
Revascularisation/ chronic
kidney disease
• Moderate kidney disease (= 30< GFR< 60
ml/min/1.73 m2): CABG preferred
treatment; if PCI indication: DES not
superior to BMS (prolonged dual
antiplatelet therapy, complex calcified
lesions…)
• End stage RF: fragile patient, >less
invasive approach. PCI with BMS if renal
transplantation is scheduled
Graft patency
Early graft failure: 8-30 % of
cases
Crossed revasc procedures
• In early graft failure,
.coronary angio: if post-op instability &
ECG suggestive of periop MI IC
.PCI of the native vessel (not the occluded
SVG) or ITA graft IC
• In late graft failure,
PCI or redo CABG is indicated in pts with
severe symptoms or extensive ischaemia
despite OMT IB
Crossed revasc procedures
• In early failure following PCI:
.repeat PCI is recommended (if
symptomatic restenosis)
IB
.Immediate CABG if failed PCI is likely to
cause a large MI IC
• In late failure following PCI: CABG
required if severe angina or ischemia
and repetitive restenosis IC
Triple antithrombotic therapy
• DAPT + vit K antag : shortest duration with
frequent INR control (target 2-2,5)
• IE: CHADS2 > 2, mechanical valve, recent
(or recurrent) deep venous thrombosis
Drug interactions
• Statins & CYP 3A4: not clinical relevant
• PPI: only from observational studies ,probably also not relevant
< post hoc analyses of CREDO & TRITON-TIMI
38. (pantozol is not metabolized by CYP12C19)
• Genetic variability (= 12% of the variability of clop response)
.Absorption ( ABCB1 gene): bioavailabilty
reduced ( CT & TT genotypes)
. CYP2C19: loss-of-fct allele (3x risk of ST)
.P2Y12 receptor: no association with clopi resp
• Prasugrel & Ticagrelor: not affected by these
genetic variants: indicated in high-risk situations
Antithrombotic drugs & renal failure
• No adjustment for clopi, prasugrel &
ticagrelor
• No adjustment for abciximab (><
adaptation for tirofiban & eptifibratide)
• UFH: dose adapted with APTT
LMWH & fondaparinux: avoid if GFR<
30mL/min/1.73 m2
Bivalirudin: reduction of infusion rate to
1mg/kg/h in pts severe renal dysfunction
Therapy after myocardial
revascularization
Ramipril, perindopril
LDL chol < 100 mg%
Follow-up
Appropriate lifestyle changes
& OMT
*
LM PCI should be scheduled
for control angio within
3-12 months
CT angio reliable for graft
patency detection but NOT
For evaluation of native
coronary arteries
*
Early onset of ischaemia,large /multiple zones of reversiblel perf defect
Euroaspire III trial
• 18% cad pts still smoked
• 46% did not attain chol < 175 mg%
• 61% did not attain BP <140/90 (non diab
pts) & 130/80 (diab pts)