stable coronary artery disease: revisiting and cardiac catheterization revascularization; which is...
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Stable Coronary Artery Disease: Revisiting and Cardiac Catheterization
Revascularization; Which is Appropriate?
Cardiology Division The First Affiliated Hospital
Harbin Medical University
Tian Ye M.D./Ph.D.
20121214-SHENYANG
Triple Aim in Cardiovascular Disease
Quality Improved Health Reduced Cost
Quality
Therapy for stable coronary artery disease
Medical therapy (MT) Percutaneous coronary intervention (PCI) Coronary artery bypass graft (CABG)
Which is appropriate?
2007 Circulation
MASS II
The first randomized controlled clinical trial to report on patients with stable CAD treated with 1 of the 3 current therapeutic strategies
611 patients
5MT(n=203)
PCI(n=205)
CABG(n=203)follow up
Primary end points: total mortality, Q-wave myocardial infarction, or refractory angina requiring revascularization
years
Hueb W, et al. Circulation. 2007:115:1082-1089
Probability of survival free of total mortality, unstable angina requiring revascularization, or Q-wave MI among patients in the MT, CABG, and PCI treatment groups.
Hueb W et al. Circulation 2007;115:1082-1089
Copyright © American Heart Association
Probability of survival free of overall mortality among patients in the MT, CABG, and PCI treatment groups.
Copyright © American Heart Association
Hueb W et al. Circulation 2007;115:1082-1089
For the low risk patients with stable CAD to reduce ischemic
events: medical therapy = PCI.
For the high risk patients with stable multivessel coronary
disease, their symptoms can be relieved significantly through
PCI, but the long-term survival advantage from PCI is unclear.
Guideline for stable CAD 2007 CMA
Guideline for stable CAD 2007 CMA
ACC 2012
old patients over 65 years
with stable multivessel coronary
artery disease
86244 cases -CABG
103549 cases - PCI
2004 - 2008
mortality ?
CABG
vs.
PCI
ACC.12 Chicago
6. 55
20. 8
6. 24
16. 4
0
5
10
15
20
25
1 2
PCI
CABG
1 year 4 year
Mortality of PCI and CABG
P > 0.05
P < 0.05
Mortality (%)
ACC.12 Chicago
Why do we select MT ?
Mortality: not higher Convenience Low cost
Improved health
No use of tobacco. Adequate physical activity: at least 30 min five times a week. Healthy eating habits. No overweight. Blood pressure below 140/90 mmHg. Blood cholesterol below 5 mmol/L (190 mg/dL). Normal glucose metabolism. Avoidance of excessive stress.
What are the characteristics of people who tend to stay healthy?
What is CVD prevention Why is it needed Who should benefit from it How can CVD prevention be applied Where prevention programmes should be
provided
Cardiovascular disease prevention
European Heart Jorunal (2012) 33,1635-1701
CVD prevention is defined as a co-ordinated set of actions, at public and individual level, aimed at eradicating, eliminating, or minimizing the impact of CVDs and their related disability.
The bases of prevention are rooted in cardiovascular epidemiology and evidence-based medicine.
What is prevention ?
European Heart Jorunal (2012) 33,1635-1701
Atherosclerotic CVD, especially CHD, remains the leading cause of premature death worldwide.
CVD affects both men and women; of all deaths that occur before the age of 75 years in Europe, 42% are due to CVD in women and 38% in men.
Prevention works: >50% of the reductions seen in CHD mortality relate to changes in risk factors, and 40% to improved treatments.
Why is needed ?
European Heart Jorunal (2012) 33,1635-1701
Percentage of the decrease in deaths from coronary heart disease attributed to treatments and risk factor
changes in different populations
European Heart Jorunal (2012) 33,1635-1701
• Preventive efforts should be lifelong, from birth (if not before) to old age.
• Population and high-risk preventive strategies should be complementary an approach limited to high-risk persons will be less effective.
• Population education programmes are still needed.
European Heart Jorunal (2012) 33,1635-1701
Recommendations regarding risk estimation
Recommendations Class Level GRADE
Total risk estimation using multiple risk factors(such as SCORE) is recommended for asymptomatic adults without evidence of CVD.
I C Strong
High-risk individuals can be detected on the basis of established CVD,diabetes mellitus, moderate to severe renal disease, very high levels of individual risk factors, or a high SCORE risk, and are a high priority for intensive advice about all risk factors.
I C Strong
Who should benefit from it ?
European Heart Jorunal (2012) 33,1635-1701
Behaviour change
Smoking
Nutrition
Physical activity
Psychosocial factors
Body weightBlood pressure
2 type diabetes
Lipids
Antithrombotics
Adherence
How can CVD prevention be applied ?
European Heart Jorunal (2012) 33,1635-1701
Where prevention programmes should be provided ?Recommendations on programme provision Class Level GRADE
Actions to prevent CVD should be incorporated into everyone’s daily lives, starting in early childhood and continuing throughout adulthood and senescence.
IIa B Strong
Recommendations on nurse-co-ordinated care Class Level GRADE
Nurse-coordinated prevention programmes should be
well integrated into healthcare systems.
IIa B Strong
Recommendations on self-help programmes Class Level GRADE
All patients with CVD must be discharged from hospital with clear guideline-orientated treatment recommendations to minimize adverse events.
I B Strong
Recommendations for specialized prevention centres
Class Level GRADE
All patients requiring hospitalization or invasive intervention after an acute ischemic event should participate in a cardiac rehabilitation programme to improve prognosis by modifying lifestyle habits and increasing treatment adherence.
IIa B Strong
European Heart Jorunal (2012) 33,1635-1701
Narrowing the gap in health inequalities. Cost savings from the number of CVD events avoided. Preventing other conditions such as cancer, pulmonary diseases, and type 2
diabetes. Cost savings associated with CVD such as medications, primary care visits,
and outpatient attendances. Cost savings to the wider economy as a result of reduced loss of production
due of illness in those of working age, reduced benefit payments, and reduced pension costs from people retiring early from ill health.
Improving the quality and length of people’s lives.
Prevention of cardiovascular disease pays off
European Heart Jorunal (2012) 33,1635-1701
Primary prevention Secondary prevention
CMA2007
CMA 2007
Say good bye to bad hobby
Couch potato - a new unhealthy life style – is
threatening human health.
A report from WHO in 1997
Healthy food pyramid
most
least
corn
vegetable and fruit
milk, meat, fish, egg and
bean
oil, sugar and salt
right amount
more
6 – 8 cups of drink (water, tea and soup)
Medical Therapy
Aspirin Statins ACEI β-blocker Nitrate CCB Trimetazidine, nicorandil
Revisiting
call
medicine
laboratory test
examination
cardiologist
resident
Why do we select MT + revisiting ?
Mortality Convenient to run Low cost
Reduced Cost
Annual disposable income of Chinese family
51569
70876
22278
0
10000
20000
30000
40000
50000
60000
70000
80000
1 2 3
The annual disposable income of Chinese family was ￥ 51,569 ，and ￥ 70,876 in city ，￥ 22,278 in countryside
Annual disposable income of Chinese family ￥
《 Chinese family financial report 》 2011
Three major expenditure of Chinese family
Medical care Basic necessities of life Children’s education
70% consumers think medical care expenditure
is the majority of their family expenditure
Data from Beijing, Shanghai, Guangzhou, etc. 13 Cities 2005
67
22
5 6
0
10
20
30
40
50
60
70
80
1 2 3 4Percent of patients planted coronary stents
Average: 1.5 stents per patient
Expense: ￥ 25,000 per stent
Cost: ￥ 30,000 -60,000 per patient
Supported by medical insurance: 50 -80%
%
Cost per PCI patient
Cost of MT , PCI and CABGMT + Revisiting PCI + Revisiting CABG + Revisiting
Expense in hospital --￥ 30,000 – 60,000
￥ 60,000
Daily expense outpatient
￥ 5 - 20 ￥ 25 - 40 ￥ 25 - 40
Expense one year outpatient
￥ 1,825 – 7,300 ￥ 9,125 – 14,600 ￥ 9,125 – 14,600
Revisiting outpatient
￥ 500 – 3,000 ￥ 500 – 3,000 ￥ 500 – 3,000
Total ￥ 2,325 – 10,300
￥ 39,625 – 77,600
￥ 69,625 – 77,600
Data from 1st Hospital HMU
Disease = Medical cost = Overburden？
income:￥ 70,876
/ year
expenditure:
￥ (30,000~70,000) x 1/2
= 15,000~35,000
Expensive medical care = overloaded expenditure (city)
income:￥ 22,000
/ year
expenditure:
￥ (30,000~70,000) x 2/3
=20,000~47,000
Expensive medical care = overloaded expenditure (urban)
Why do we select MT + revisiting ?
Mortality Convenience Low cost
Take precautions after suffering a loss---
亡羊补牢 Nip in the bud --- 防患于未然 Doctors-patients together --- 医患共携手
Conclusion
:How to improve medical quality and health, and reduce cost ?
Thanks for your attention !