• Share
  • Email
  • Embed
  • Like
  • Save
  • Private Content
Appropriteness Criteria for Coronary Revascularization
 

Appropriteness Criteria for Coronary Revascularization

on

  • 1,694 views

Based on the Criteria published in J Am Coll Cardiol, 2009; 53:530-553

Based on the Criteria published in J Am Coll Cardiol, 2009; 53:530-553

Statistics

Views

Total Views
1,694
Views on SlideShare
1,694
Embed Views
0

Actions

Likes
1
Downloads
142
Comments
0

0 Embeds 0

No embeds

Accessibility

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment
  • Single vsl disease patients esp in the RCA almost always need angioplasty Extensive triple vessle or LM disease get surgery. The question of the comparative effectiveness is relevant for those folks in whom the disease is neither too limited or too extensive, both procedures are technically feasible: SVD of prox LAD, double vsl disease, and less severe 3vsl disease patients.
  • Figure 10-34. The Duke database provided information for evaluating the appropriateness of treatment modalities. They compared medical therapy, coronary artery bypass grafting (CABG), and percutaneous transluminal coronary angioplasty (PTCA). When appropriately adjusted for risk, CABG patients with three-vessel disease had significantly improved survival at 10 years than did individuals treated medically or with PTCA [27], [28].
  • Figure 10-35. Results from the Duke trial comparing percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG). The preferred method of therapy depends on the extent and severity of coronary disease. PTCA seems to be superior in patients with less extensive disease, whereas CABG is more advantageous for patients with more extensive coronary disease [27], [28].

Appropriteness Criteria for Coronary Revascularization Appropriteness Criteria for Coronary Revascularization Presentation Transcript

  • Appropriateness Criteria for Revascularization – Making sense of the recommendations Dr. Lalit Kapoor Chief Cardiac Surgeon Apollo Hospital, Ranchi www.heartsurgery.in
  • Left Main Left Main Equivalent TVD DVD with LAD
  • Which procedure is best?
  • Angioplasty of the culprit lesion has been proven to be of value:
    • ST elevation MI compared to thrombolytics Reduces mortality and strokes (and likely reinfarction)
    • In high risk non-ST elevation ACS
    • Reduces new MI and likely deaths and avoids repeated rehospitalization for UA.
    • In both acute conditions, appropriate and timely PCI is an important advance.
  • COURAGE
    • Showed that treating patients with PCI at the outset had no more impact on death or myocardial infarction (MI) than treating patients with an initial strategy of optimal medical therapy
    • Led to polarization of cardiovascular professionals. "Some people have pitted this as the mother of all battles between PCI and others - that is absolutely 100% incorrect
    • Remember that the COURAGE trial dealt with only a small subset — stable angina — of all the patients who are treated with revascularization.
    Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation trial
  • 8% 0 1 2 3 4 5 6 7 8 9 Aspirin Aspirin  -bloq Aspirin  -bloq Statin Aspirin  -bloq Statin ACEI None 6% 4,5% 3% 2,3% RRR 25% RRR 30% RRR 25% RRR 25% SECONDARY PREVENTION Event rate* (2 years) Impact of pharmacological treatment * CV death, AMI or stroke Yusuf S. Lancet 2002;360:2 Statin ACEI  -bloq Aspirin 25 40 60 70
  • Medical Treatment - Outcomes Califf RM, Armstrong PW, Carver JR, et al. Task Force 5. Stratification of patients into high-, medium-, and low-risk subgroups for purposes of risk factor management. J Am Coll Cardiol. 1996;27:964–1047 (4).
  • Comparison of medical therapy, CABG and PTCA
  • Results from Duke trial
  • Main results from SYNTAX randomized trial Serruys PW et al. European Society of Cardiology Congress 2008; September 1, 2008; Munich, Germany. Dr Friedrich W Mohr (University of Leipzig, Germany), pointed out, almost one-third of patients considered for randomization in SYNTAX were deemed ineligible for PCI, primarily due to complex disease or anatomy Serruys PW, et al. N Engl J Med 2009;360:961-72 End point CABG (%) DES (%) p MACCE 12.1 17.8 0.0015 Death/MI/stroke 7.7 7.6 0.98 Revascularization 5.9 13.7 <0.0001 Stroke 2.2 0.6 0.003 MI 3.2 4.8 0.11 All-cause death 3.5 4.3 0.37
  • Main results from SYNTAX randomized trial End point CABG (%) DES (%) p Angina Free (1mth) 61.6 64.4 Angina Free (6mth) 72.0 68.5 Angina Free (12mth) 76.3 71.6 <0.05 Cost $33,254 $27,560 Additional Cost (1yr) $2,500 Cost in India 150000 550000 Additional Cost (1yr) 125000
  • SYNTAX
    • MACCE was significantly lower in CABG arm compared with PCI (12.4% vs. 17.8%, p = 0.002), especially for diabetics (p = 0.0025)
    • Significant ↓ in the need for repeat revascularization in CABG arm (p < 0.001)
    • Death and MI were similar; CVA ↑ with CABG (p = 0.003)
    % 0 5 15 5.9 13.5 20 Trial design: Patients with severe three-vessel or LM disease were randomized to CABG or DES-PCI with paclitaxel-eluting stents . Clinical outcomes were compared at 12 months. Results Conclusions
    • CABG was associated with fewer repeat revascularizations compared with DES-PCI in patients with LM or three-vessel disease, but a higher rate of stroke
    • No difference in death, MI, or thrombosis
    • Diabetics are especially more likely to benefit with CABG compared with DES-PCI
    Serruys PW, et al. N Engl J Med 2009;360:961-72 5 10 15 20 12.4 17.8 % 0 MACCE Repeat revascularization 10 (p = 0.002) CABG (n = 897) DES-PCI (n = 903) p < 0.001)
  • Appropriateness Criteria for Coronary Revascularization ACCF/SCAI/STS/AATS/AHA/ASNC 2009 Appropriateness Criteria for Coronary Revascularization A Report by the American College of Cardiology Foundation Appropriateness Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, and the American Society of Nuclear Cardiology Endorsed by the American Society of Echocardiography, the Heart Failure Society of America, and the Society of Cardiovascular Computed Tomography J Am Coll Cardiol, 2009; 53:530-553
  • Dr Gregory J Dehmer (Texas A&M University College of Medicine, Temple)
    • &quot;If anything, the number of cardiac bypasses being done is decreasing and the number of PCI procedures is decreasing. So this is not motivated in any way by the concern that these procedures are out of control, it's just a matter of making sure that indications for these procedures are appropriate.&quot;
  • Cont’d
    • But all we were trying to do in all of this . . . was to come up with something that would help guide a physician to make the best decisions, to provide the right care for the right patients, at the right time
    • a &quot;useful supplement&quot; to professional societies guidelines
  • Method
    • Combines
        • Evidence-based medicine
        • Guidelines
        • Practice experience
    • By engaging a technical panel in a modified Delphi exercise as described by RAND.
  • Study Design
    • 180 clinical scenarios mimicking practice
      • Clinical scenario
      • Symptoms severity
      • Extent of Medical Therapy
      • Risk level (Non-invasive)
      • Coronary Anatomy
    • 17 member panel – 4 Interventional Cardiologist, 4 Cardiac Surgeons, 8 non-invasive cardiologists, 1 medical officer from a health plan
    • Only considered Revascularization and did not specify CABG / PCI
    • Only in a small subset was the type specified
    • Scores (7-9) for appropriate and 1-3 for inappropriate
  •  
  • Copyright ©2009 American College of Cardiology Foundation. Restrictions may apply. Patel, M. R. et al. J Am Coll Cardiol 2009;53:530-553 Appropriateness Ratings by Risk Findings on Noninvasive Imaging Study and Symptom Status
  • Copyright ©2009 American College of Cardiology Foundation. Restrictions may apply. Patel, M. R. et al. J Am Coll Cardiol 2009;53:530-553 Appropriateness Ratings by High-Risk Findings on Noninvasive Imaging Study and CCS Class III or IV Angina (Patients Without Prior Bypass Surgery) ` `
  • Copyright ©2009 American College of Cardiology Foundation. Restrictions may apply. Patel, M. R. et al. J Am Coll Cardiol 2009;53:530-553 Appropriateness Ratings by Intermediate-Risk Findings on Noninvasive Imaging Study and CCS Class I or II Angina (Patients Without Prior Bypass Surgery) ` `
  • Copyright ©2009 American College of Cardiology Foundation. Restrictions may apply. Patel, M. R. et al. J Am Coll Cardiol 2009;53:530-553 Appropriateness Ratings by Low-Risk Findings on Noninvasive Imaging Study and Asymptomatic (Patients Without Prior Bypass Surgery) ` `
  • Copyright ©2009 American College of Cardiology Foundation. Restrictions may apply. Patel, M. R. et al. J Am Coll Cardiol 2009;53:530-553 Method of Revascularization of Advanced Coronary Artery Disease SYNTAX
  • Copyright ©2009 American College of Cardiology Foundation. Restrictions may apply. Patel, M. R. et al. J Am Coll Cardiol 2009;53:530-553 Acute Coronary Syndromes*
  • High-Risk Features for Short-Term Risk of Death or Nonfatal MI for UA/NSTEMI
    • At least 1 of the following :
    • History—Accelerating tempo of ischemic symptoms in preceding 48 hours
    • Character of pain—Prolonged ongoing (greater than 20 minutes) rest pain
    • Clinical findings
      • Pulmonary edema, most likely due to ischemia
      • New or worsening mitral regurgitation murmur
      • S3 or new/worsening rales
      • Hypotension, bradycardia, tachycardia
      • Age greater than 75 years
    • Electrocardiogram
      • Angina at rest with transient ST-segment changes greater than 0.5 mm
      • Bundle-branch block, new or presumed new
      • Sustained ventricular tachycardia
  • Clinical scenarios appropriate for coronary revascularization
    • ST-segment elevation MI within 12 hours of symptom onset
    • Left main stenosis
    • Any patient with 2- or 3-vessel coronary artery disease and at least moderate-risk findings on stress testing; receiving maximal anti-ischemic medical therapy
    • 1-vessel coronary artery disease involving the proximal LAD; low-risk findings on stress testing; slight impairment of activity because of angina; receiving maximal anti-ischemic medical therapy
    • 1- or 2-vessel coronary artery disease without involvement of the proximal LAD; low-risk findings on stress testing; marked limitation of activity because of angina; receiving maximal anti-ischemic medical therapy
    • 1- or 2-vessel coronary artery disease without involvement of the proximal LAD; high-risk findings on stress testing; slight limitation of activity because of angina; not receiving anti-ischemic medical therapy
  • Clinical scenarios in which the benefit vs risk for coronary revascularization is uncertain
    • 1-vessel coronary artery disease involving the proximal LAD; intermediate-risk findings on stress testing; slight or no impairment of activity because of angina; not receiving anti-ischemic medical therapy
    • 2-vessel coronary artery disease involving the proximal LAD; intermediate-risk findings on stress testing; asymptomatic (uncertain regardless of use of anti-ischemic medical therapy)
    • In patients with advanced coronary artery disease, PCI was considered inappropriate in patients with left main stenosis. Coronary artery bypass grafting is preferred for these patients as well as patients with 3-vessel coronary artery disease .
  • Clinical scenarios not appropriate for coronary revascularization
    • ST-segment elevation MI for 12 hours or more after symptom onset; patient asymptomatic
    • ST-segment elevation MI with presumed successful treatment with fibrinolysis ; patient asymptomatic with normal left ventricular ejection fraction
    • 1- or 2-vessel coronary artery disease without involvement of the proximal LAD; low-risk findings on stress testing; asymptomatic; not receiving anti-ischemic medical therapy
    • Chronic total occlusion of 1 major epicardial artery without other coronary stenosis; low-risk findings on stress testing; asymptomatic; not receiving anti-ischemic medical therapy
  • For copies of this presentation please send a request to drlalitkapoor@gmail.com