1. The document discusses decision making for revascularization in patients with diabetes and multi-vessel coronary artery disease (CAD). Patients with diabetes often have more diffuse and complex disease as well as poorer outcomes after revascularization.
2. When deciding between medical therapy alone, percutaneous coronary intervention (PCI), and coronary artery bypass grafting (CABG), factors to consider include clinical status, anatomical complexity, amount of ischemia, surgical risk, and completeness of revascularization. Patient preferences are also important.
3. A multidisciplinary heart team approach can help decide the best revascularization strategy on a case-by-case basis. Clinical guidelines provide general recommendations but individual patient and disease factors need to be considered
3. Diffuse and more complex vessel affection (disease
burden)
1/3 of CAD PTs requiring MR are diabetics.
Poor distal targets……incomplete MR, residual
ischemia,
High likely for repeat revascularizations.
Poorer LV function/recovery independent of
territorial affection.
Diabetic Coronaries Vs. Diabetic Heart Vs diabetic
CVS.
Diabetic Heart Burden
4. Decision Making
When Rx alone is enough?
When to revascularise?
Which is Better: PCI or CABG?
5. “Decide for the best strategy from the Pt.'s
perspectives and not from the physician
perspectives”
Patient’s benefit is your only Target
Sabbah 2109.
6. The medical TTT, PCI, and CABG; should
be look at as a complementary rather than
an alternative strategies
An Important Concept
Sabbah 2109.
10. Patient Involvement in
Decision-Making
Pts. should be actively participated.
Provided info. should be unbiased, evidence-based,
up-to-date, reliable, accessible, and relevant.
Procedure-related and long-term risks and benefits
Uncertainties associated with different treatment
strategies.
12. Multidisciplinary decision-making
(Heart Team) , Why?
The underuse of revascularization procedures in 18–
40% of CAD
Inappropriate use of revascularization strategies with
a lack of case discussions, in (10–15%)PCI
The marked variability in PCI-to-CABG ratios
between European countries (ranging from 2.4–7.6 in
2013).
In the USA, up to 30% of patients undergoing ad hoc
PCI are potential candidates for CABG
- Filardo G, et al, EHJ 2001
- Yates et al. Thorac Cardiovasc Surg.2014
19. Stable on Rx,
No limiting angina,
Absence of significant ischemia “Silent” (>10%)
and/or
Absence of High-risk coronary anatomy.
When Rx. alone is enough?
27. Guidelines Vs. Real-life
Group of recommendations made up by group of
expert researchers (usually not Clinician), revising
the relevant literature for specific clinical scenarios.
They are always pooling different dataset, PTs,
lesions, clinical scenarios……..leads to flawed
conclusions and wrong generalization
Clinical practice, real-life situations, are much more
complex with unlimited complex case scenarios to be
only guided by GL…..
28. Non-practical and non-real (even in the high-
standared countries),
Pt appropriateness (Appropriate surgical Pt vs.
approp. PCI Pts.)
Pooled data (not always reflect reality).
no mention for the distal targets , which
independently affecting the graft patency
DM is much more than a Y/N factor.!!!!!
Age (frailty).
Guidelines: Critical Appraisal, Misleading
evidence?
30. “GL will not treat your Pts, they are only teaching
you how to take and what the evidence behind
your treatment choice and, sometimes which is
better in a carefully selected case-scenarios. “
الجايدلينز لمتبعي نداء
Sabbah 2109.
31. “You have to decide who’s would really
benefit from surgery from those who could
have a pretty good outcome with PCI”
Sabbah 2109.
The significant benefit that has been shown in most of the observational studies, created enthusiasm in the scientific community and led to the initiation of multiple RCTs evaluating lipid-lowering therapy in AS.
Unfortunately, none of these trials were able to demonstrate reduced hemodynamic progression, reduced aortic valve calcification, or improved clinical outcomes
خلاصة الinterventional Cardiology
Does the patients really need PCI?
This means that we have always ask ourselfes.Is there a strong evidence of significant ischemia and or angina which undoubtedly requires PCI? Or. Could the Pt and the lesion be better served by medical treatment؟
وأخيرا
في كثير من الاحيان الادويه اللي بعشرات الجنيهات. افضل للمريض بكتير من معاددن الدعامات اللي بعشرات الالاف من الجنيهات