.SpeakerDr. Gobinda kanti PaulAsst. Prof. of Cardiology.ChairpersonDr. M.Saiful Bari, Assoc. Prof. & Head of the DeptGuidelines on Myocardial Revascularization

Guidelines on Myocardial RevascularizationEuropean 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), JoseLopez-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

Myocardial revascularization mainstay in the treatment of CAD for almost half a century.CABG-1960PCI-1977 by Andreas GruentzigPharmacological revascularization.OMT(Optimum medical therapy)

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.

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 InformationPt. 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.

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 & imagingECG, ECHOStress Tests-ETT, MDCT(CT angiogram)MPIStress Echo.Hybrid/Combined imaging(MDCT & SPECT, MDCT & PET)

Invasive TestsCAG: Intermediate or high pretest CAD likelihood are catheterized without prior functional testing.

FibrinolysisFibrinolytic therapy, preferably administered as a pre-hospital treatment, remains an important alternative to mechanical revascularization.

OMT

Lifestyle modification

Pharmacological management

CABG

Bypass grafts are placed to the mid-coronary vessel beyond the culprit lesions, providing extra sources of nutrient blood flow to the myocardium.

PCI 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

Persistence of symptoms despite OMT

OMT vs. PCI in CSAIn 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

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 multi-vessel disease5 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. CABGProximal LAD stenosis.

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 TrialThe 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 stenosisCABG 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 stenosisTwo 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-STEMIThe 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 STEMIPrimary 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

STEMIPts 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 CADA 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 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

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 RevascularizationPhysical 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 lipid-lowering therapy.Next lipid profile after 3 months

ConclusionDespite 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.