Post on 14-Apr-2017
Revascularización completa o incompleta en enfermedad
coronaria José Miguel Vegas Valle
Servicio de CardiologíaHospital de Cabueñes, Gijón
josemivv@secardiologia.es
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
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.
Heterogeneity of Patients with Multivessel Disease:Implication for Revascularisation Strategies
Multivessel disease and outcome in CAD
Visual coronary artery disease in angiography is a prognostic marker
Heterogeneity of Patients with Multivessel Disease:Implication for Revascularisation Strategies
Definition of Multivessel Coronary Artery Disease
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
STEMI
Heterogeneity of Patients with Multivessel Disease:Implication for Revascularisation Strategies
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.
Heterogeneity of Patients with Multivessel Disease:Implication for Revascularisation Strategies
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.
Patients with Multivessel Disease:Culprit vs multivessel revascularization
STEMI
EuroIntervention 2014;10-T47-T54
Advantages (+) and
disadvantages (–) of different
PCI strategies for non-culprit
lesions in patients with STEMI
and MVD
Patients with Multivessel Disease:Culprit vs multivessel revascularization
STEMI: Variables to choose strategy
EuroIntervention 2014;10-T47-T54
Patients with Multivessel Disease:Culprit vs multivessel revascularization
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
Patients with Multivessel Disease:Culprit vs multivessel revascularization
STEMI: Prior evidence
Patients with Multivessel Disease:Culprit vs multivessel revascularization
STEMI: Prior evidence
Patients with Multivessel Disease:Culprit vs multivessel revascularization
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
Patients with Multivessel Disease:Culprit vs multivessel revascularization
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
Patients with Multivessel Disease:Culprit vs multivessel revascularization
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
Patients with Multivessel Disease:Culprit vs multivessel revascularization
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
Patients with Multivessel Disease:Culprit vs multivessel revascularization
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.
Patients with Multivessel Disease:Culprit vs multivessel revascularization
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
Patients with Multivessel Disease:Culprit vs multivessel revascularization
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
ACS
Patients with Multivessel Disease:Culprit vs multivessel revascularization
Acute Coronary Syndromes
J Am Coll Cardiol 2007;49:849–54
No differences in death or MI
Patients with Multivessel Disease:Culprit vs multivessel revascularization
Acute Coronary Syndromes
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
Patients with Multivessel Disease:Culprit vs multivessel revascularization
Acute Coronary Syndromes
• 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.