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Guidelines on
Myocardial
Revascularization

Speaker
Dr. Gobinda kanti Paul
Asst. Prof. of Cardiology.
Chairperson
Dr. M.Saiful Bari,
Assoc. Prof. & Head of the Dept

Guidelines on Myocardial
Revascularization
European Heart Journal(2010)31, 250155
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

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)

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 Information

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.

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

ECG,
ECHO
Stress Tests-ETT,
MDCT(CT angiogram)
MPI
Stress Echo.
Hybrid/Combined imaging(MDCT &
SPECT, MDCT & PET)

Invasive Tests

CAG: Intermediate or high pretest


CAD likelihood are catheterized
without prior functional testing.

Fibrinolysis

Fibrinolytic 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 midcoronary 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 CSA

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

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

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.

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

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

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

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

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

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

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

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

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 Revascularization

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 reevaluated 4-6 weeks after an acute
event and/or initiation of lipid-lowering
therapy.
Next lipid profile after 3 months

Conclusion

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.