.
Guidelines on
Myocardial
Revascularization
Speaker
Dr. Gobinda kanti Paul
Asst. Prof. of Cardiology.
Guidelines on Myocardial
Revascularization
European Heart Journal(2010)31,
2501-55
The Task Force on Myocardial
Revascularization of the European
Society of Cardiology (ESC) and the
European Association for
Cardio-Thoracic Surgery (EACTS)
Authors/Task Force Members:
WilliamWijns (Chairperson) (Belgium)*, PhilippeKolh
(Chairperson) (Belgium)*, Nicolas Danchin (France), CarloDi
Mario (UK),
Volkmar Falk (Switzerland), Thierry Folliguet (France),
ScotGarg (The Netherlands),
KurtHuber (Austria), Stefan James (Sweden), JuhaniKnuuti
(Finland), Jose
Lopez-Sendon (Spain), JeanMarco (France), LorenzoMenicanti
(Italy)
MiodragOstojic (Serbia), Massimo F. Piepoli (Italy), Charles
Pirlet (Belgium),
Jose L.Pomar (Spain), NicolausReifart (Germany), Flavio L.
Ribichini (Italy),
Martin J. Schalij (The Netherlands), Paul Sergeant (Belgium),
PatrickW. Serruys
(The Netherlands), Sigmund Silber (Germany), Miguel Sousa
Uva (Portugal),
DavidTaggart (UK)
Guidelines on Myocardial
Revascularization
Introduction
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Myocardial revascularization mainstay in the
treatment of CAD for almost half a century.
CABG-1960
PCI-1977 by Andreas Gruentzig
Pharmacological revascularization.
OMT(Optimum medical therapy)
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The advances in technology, most
coronary lesions are technically
amenable to PCI.
Thus pts and physicians need to
balance short-term convenience of
the less invasive PCI against the
durability of the more invasive
surgical approach.
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Myocardial revascularization is
appropriate when the expected
benefits, in terms of survival or
health outcomes (symptoms,
functional status, and/or quality
of life), exceed the expected
negative consequences of the
procedure.
Patient Information
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Pt. information needs to be objective & unbiased,
pt. oriented, evidence based, up-to-date,
reliable,understandable,accessible, relevent and
consistent with legal requirements.
Informed consent should be transparent,
especially if there is controversy about the
indication for a particular
treatment(OMTvsPCIvsCABG).
Pts taking an active role throughout the decision
making process have better outcomes.
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Pts considered for
revascularization should also
be clearly informed of the
continuing need for OMT
including antiplatelet, statin,
B-blockers, ACEi, as well as
other secondary prevention
strategies.
Strategies for pre-intervention
diagnosis & imaging
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ECG,
ECHO
Stress Tests-ETT,
MDCT(CT angiogram)
MPI
Stress Echo.
Hybrid/Combined imaging(MDCT &
SPECT, MDCT & PET)
Invasive Tests
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CAG: Intermediate or high pretest
CAD likelihood are catheterized
without prior functional testing.
Fibrinolysis
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Fibrinolytic therapy, preferably
administered as a pre-hospital
treatment, remains an important
alternative to mechanical
revascularization.
OMT
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Lifestyle modification
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Pharmacological management
CABG
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Bypass grafts are placed to the midcoronary vessel beyond the culprit
lesions, providing extra sources of
nutrient blood flow to the
myocardium.
PCI
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Coronary stents aim to restore the normal
conductance of the native coronary artery
without offering protection against new disease
proximal to the stent.
Revascularization for stable CAD
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Persistence of symptoms despite
OMT
OMT vs. PCI in CSA
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In the Atorvastatin vs. Revascularization
Treatment (AVERT) trial, aggressive lipid lowering
by high-dose atorvastatin was marginaly better
than PCI in reducing ischemic events.
One meta analysis reported a survival benefit for
PCI over OMT(respective mortalities of 7.4% vs.
8.7% at an average follow-up of 51 months).
The COURAGE RCT randomized 2287 patients
with known significant CAD and objective
evidence of myocardial ischaemia to OMT alone
or to OMT + PCI. At a median follow-up of 4.6
yrs, there was no significant difference in the
composite of death, MI, stroke, or hospitalization
for UA
CABG vs. OMT in CSA
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The superiority of CABG to medical
treatment in the management of
specific subsets of CAD.
Survival benefit of CABG in pts with
LM or 3 vessel CAD. Benefits were
greater in those with severe
symptoms, early positive ETT.
OMT vs. PCI vs. CABG in multivessel disease
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5 year follow-up of the MASS II
study of 611 pts.
Composite primary endpoint (total
mortality, Q-wave MI or refractory
angina requiring revascularization) in
36% of OMT, 33% of PCI and 21% of
CABG.
PCI vs. CABG
Proximal LAD stenosis.
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Two meta-analysis of >1900 &
>1200 pts.
No significant difference in mortality,
MI, CVA.
Three fold increase in recurrent
angina & a five fold increase in
repeat TVR with PCI at up to 5 years
of follow-up.
SYNTAX Trial
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The authors concluded at both 1 and
2 years that CABG remains the
standard of care for pts with 3 vessel
or LM CAD.
Survival advantage and a marked
reduction in the need for repeat
intervention with CABG in
comparison with PCI in pts with more
severe CAD
LM stenosis
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CABG is still conventionally regarded
as the standard of care for significant
LM disease in pts eligible for surgery.
LM stenosis is a potentially attractive
target for PCI because of its large
diameter and proximal position in the
coronary circulation.
LM stenosis
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Two factors may mitigate against the
success of PCI-(i)up to80% of LM disease
involves the bifurcation, high risk of
restenosis.(ii) up to 80% of LM pts also
have multivessel disease.
Meta-analysis of 10 studies, includings two
RCT & the large MAIN –COMPARE registry,
of 3773 pts with LM stenosis, there was no
difference between PCI & CABG in
mortality, MI, CVA up to 3 years but up to
a 4 fold increase in repeat
revascularization with PCI.
Revascularization in non-STEMI
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The ultimate goals of CAG &
revascularization are mainly 2 fold:
symptom relief, & improvement of
prognosis in the short & long term.
The most recent meta-analysis
confirms that an early invasive
strategy reduces cardiovascular
death and MI at up to 5 years of
follow-up.
Revascularization in STEMI
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Primary PCI:
PCI in the setting of STEMI without
previous or concomitant fibrinolytic
treatment
Primary PCI should be performed by
operators who perform>75 elective
procedures per year and at least 11
procedures for STEMI in institutions with
an annual volume of >400 elective and
>36 primary PCI
STEMI
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Pts presenting between 12 and 24
and possibly up to 60h from
symptom onset, even if pain free and
with stable haemodynamics, may still
benefit from early CAG & PCI.
PCI vs. CABG in Diabetic CAD
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A recent meta-analysis on individual
data from 10 RCTs of elective
myocardial revascularization
confirms a distinct survival
advantage for CABG over PCI in
diabetic pts.
5 years mortality was 20% with PCI,
compared with 12% with CABG.
Hybrid revascularization
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Hybrid myocardial revascularization
is a planned, intentional combination
of CABG,& PCI to other suitable
coronary artery during the same
hospital stay.
Recommended duration of dual
antiplatelet therapy
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1 month after BMS stent.
6-12 months after DES.
1 year in all pts after ACS,
irrespective of revascularization
strategy.
Surgery in pts on dual antiplatelet
therapy
High to very high bleeding risk, including
CABG:
Clopidogrel should be stopped 5 days
before surgery & ASA continued.
Prasugrel, stopped, 7 days before surgery
Ticagrelor, stopped, 2 to 3 days before
surgery
DAPT should be resumed as soon as
possible including a loading dose for
clopidogrel and prasugrel.
Follow-up after Revascularization
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Physical examination, resting ECG &
routine test should be performed
within 7 days after PCI.
Puncture site healing,
haemodynamics and possible
anaemia or CIN.
For ACS pts, plasma lipids should be
re-evaluated 4-6 weeks after an
acute event and/or initiation of lipidlowering therapy.
Next lipid profile after 3 months
Conclusion
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Despite the numerous improvements
in the management of ACS/CAD, it
remains one of the leading causes of
morbidity and mortality worldwide.
The Key steps in the management of
these pts include rapid diagnosis,
prompt delivery of initial therapeutic
agents, immediate reperfusion in
some cases.