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

1. Diabetes and Multi-Vessel CAD
The Decision Making
Mahmoud Sabbah, MD, PhD, FESC, FSCAI
Consultant Interventionalist, Lecturer of Cardiology
Cardiology department, FOM-SCU

2. Conflict of Interest
I am one of those enemy guys,
“Interventional Cardiologists”

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.

7. Decision Making

8. Criteria for Decision Making:
 Clinical Status,
 Anatomical complexity of CAD,
 Amount of territorial ischemia
 Predicted surgical mortality,
 Completeness of revascularization.(Functional),
 Patient preferences!!!!!!!!
Decision Making

9. The Process for decision-making
&
patient information

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.

11. PCICABG

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

13. When Rx alone is enough?

14. Rx. Vs.………….others

15. Coronary Angiography First.
!!!! Why

16. Criteria for Decision Making:
 Clinical Status,
 Anatomical complexity of CAD,
 Amount of territorial ischemia
 Predicted surgical mortality,
 Completeness of revascularization.(Functional),
 Patient preferences!!!!!!!!
Decision Making

17. 2018 ESC/EACTS Guidelines on myocardial revascularization

18. It’s Different!!!!!
Assessment of CAD by CAG
and
The decision to revascularise!!!!!

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?

20. When to revascularise?

21. 1. Guideline-recommended Rx.
2. Limiting symptoms and /or
3. Improve Prognosis
Requirements

22. 2018 ESC/EACTS Guidelines on myocardial revascularization

23. Which is Better: PCI or CABG?

24. 2018 ESC/EACTS Guidelines on myocardial revascularization

25. “We are not comparing between :
Good and Bad

26. PCICABG

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?

29. The Procedural Burden
PCICABG

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.

33. Final Comments

34. Thank you