1. Coronary artery Disease Dr. Iyer B. K.

2. Coronary circulation

10. Differential diagnosis to angina for patients with chest pain -Anxiety disorder -Hyperventilation -Panic disorder -Costochondritis -Rib Fracture -Sternoclavicular arthritis -Herpes zoster (before the rash) -Esophageal Spasm Reflux Esophagitis -Biliary Colic Cholecystitis Cholangitis Choledo- cholithiasis -Peptic ulcer -Pancreatitis -Pulmonary embolus -Pneumothorax -Pneumonia -Pleuritis -Aortic dissection -Pericarditis Non-ischemic Cardio-vascular Pulmonary Gastro-intestinal Chest Wall Psychiatric ·

14. ECG showing depressed S-T segment (ischemia)

15. ECG showing elevated S-T segment & pathological Q wave (acute MI)

20. Drug therapy of Angina pectoris

21. Pharmacological actions of Nitrates Vasodilation Reflex tachycardia Hypotension Relaxation

37. Acute coronary syndrome 

38. Acute coronary syndrome 

40. Case studies Implications of the learning

43. Appropriateness criteria for coronary revascularization

46. ACCF/SCAI/STS/AATS/AHA/ASNC 2009 - Appropriateness criteria for coronary revascularization Patel et al. JACC 2009;53:530-553

51. ACCF/SCAI/STS/AATS/AHA/ASNC 2009 - Appropriateness criteria for coronary revascularization Patel et al. JACC 2009;53:530-553 Appropriateness ratings by low-risk findings on noninvasive imaging study & asymptomatic

52. ACCF/SCAI/STS/AATS/AHA/ASNC 2009 - Appropriateness criteria for coronary revascularization Patel et al. JACC 2009;53:530-553 Appropriateness ratings by intermediate-risk findings on noninvasive imaging study and CCS class I or II Angina

53. ACCF/SCAI/STS/AATS/AHA/ASNC 2009 - Appropriateness criteria for coronary revascularization Patel et al. JACC 2009;53:530-553 Appropriateness ratings by high-risk findings on noninvasive imaging study & CCS Class III or IV Angina

54. ACCF/SCAI/STS/AATS/AHA/ASNC 2009 - Appropriateness criteria for coronary revascularization Patel et al. JACC 2009;53:530-553 Chronic Total Occlusions: Indications for PCI

55. ACCF/SCAI/STS/AATS/AHA/ASNC 2009 - Appropriateness criteria for coronary revascularization Patel et al. JACC 2009;53:530-553 Patients With Prior Bypass Surgery (Without Acute Coronary Syndromes)

56. Appropriateness criteria for coronary revascularization Patel et al. JACC 2009;53:530-553

57. Appropriateness criteria: method of revascularization of advanced CAD Patel et al. JACC 2009;53:530-553

58. Concordance of Physician Ratings with the Appropriate Use Criteria (AUC) for Coronary Revascularization Chan et al, J Am Coll Cardiol 2011;57:1546

59. Appropriateness Use Criteria for PCI 84.6 11.6 1.1 11.2 0.3 38.0 4.1 98.6 50.4 Appropriate Uncertain Inappropriate % AUC Criteria from ACC-NCDR Results (n=500,00) Paul Chan. ACC i2 Summit 2011 NYS PCI dataset (n=58,000) Inappropriate PCI 13.4%

60. Appropriateness Use Criteria [AUC] for PCI 84.6 11.6 1.1 11.2 0.3 38.0 4.1 98.6 50.4 Appropriate Uncertain Inappropriate % AUC Criteria from ACC-NCDR Results (n=500,00) Paul Chan. ACC i2 Summit 2011 NYS PCI dataset (n=58,000) Inappropriate PCI 13.4%

61. Appropriate Use Criteria (AUC) for PCI Independent evaluation of random cases for 2010 n=354

62. Appropriateness Criteria: Method of Revascularization of Advanced CAD Patel MR et al. J Am Coll Cardiol. 2009;53(6):530-55 SC<33 SC<33 SC<33 Nov 24, 2009 Focused PCI update from ACC/AHA making LMCA PCI as Class IIb for Selected cases with less extensive CAD (SYNTAX score <33). It has been Class IIa for pts with high surgical risk

63. Pattern & Intensity of Optimal Medical Therapy (OMT) during PCI: Impact of COURAGE Trial: Data from ACC-NCDR CathPCI Registry W Borden et al. JAMA 2011;305:1882 Implications: There is a large practice gap in medical care of PCI pts. Important opportunity to develop innovative and aggressive strategies to increase OMT in PCI pts , both before PCI (by referring MDs) & after PCI (by the Interventional team)

65. Diagnostic IVUS Intermediate or inconclusive angiographic lesion in a symptomatic Patient

66. Diagnostic IVUS: Predictive Ability Abizaid et al. Circulation 1999;100:256. MLA Criteria for Deferred PCI • Patients with an event (29) during the first 12-months had a lesion MLA of 4mm 2 and 52% CSA stenosis , compared to 6.2 mm 2 and 37% for those (328) without .

67. Summary of 6 trials of IVUS- guided bare metal stent placement Combined End-Point Results

68. Potential Clinical Utility of IVUS in Pts Undergoing PCI with DES Roy P et al . European Heart Journal 2008;29:1851 12 month outcomes

69. MAIN-COMPARE Registry: Impact of IVUS Guidance on Long-Term Mortality in Stenting for ULMCA Stenosis Park SJ et al. Circ Cardiovasc Intervent 2009;2;167 Event Rates at 18 Months

70. Schematic representation: Various functional haemodynamic measurements

71. FAME Trial: Fractional Flow Reserve (FFR) vs. Angiography for Guiding Multi-vessel PCI Tonino PA, et al. JACC. 2010;55:2816

72. FAME Trial: Fractional Flow Reserve (FFR) vs. Angiography for Guiding Multi-vessel PCI Primary and Secondary Points at 2-Year Follow-Up Fearon WF et al. TCT 2009 Functional revascularization using FFR in the cath lab of significant angiographic lesions can appropriately select lesions who will benefit from PCI without compromising patient’s safety and will result in less MI, MACE, stent use and reduced procedural cost. It should be done in cases with 50-70% lesions before proceeding to PCI

73. Intravascular Ultrasound Criteria: Assessment of the Functional Significance of Intermediate Coronary Artery Stenoses and Comparison With Fractional Flow Reserve IVUS IVUS Area Stenosis >70% 25 lesions Area Stenosis <70% 25 lesions FFR < 0.75 12 Cases 48% FFR > 0.75 13 Cases 52% FFR > 0.75 100% Cases Area Stenosis >70% 25 lesions Area Stenosis <70% 20 lesions MLD < 1.8 mm 22 Cases 88% MLD < 1.8 mm 22 Cases 88% MLD < 1.8 mm 22 Cases 88% FFR < 0.75 12 Cases 54.5% FFR > 0.75 10 Cases 45.5% FFR > 0.75 3 Cases 100% Sensitivity = 100% Specificity = 68% Sensitivity = 100% Specificity = 76% Briguori et al, Am Journal of Cardiology 2001;87:136

74. IVUS vs FFR Correlation Kang et al. Circ Cardiovasc Interv. 2011;4:65

75. Outcomes of PCI in intermediate coronary artery disease (40-70% obstruction) : FFR vs. IVUS guided (N= 167; 177 lesions) The rate of Performing PCI According to Type of Guiding Device Nam et al. J Am Coll Cardiol Intv. 2010;3:815

78. Thank you