1. The document discusses factors, evidence, and treatment options for decisions regarding management of ischemic heart disease (IHD). 2. It outlines 4 objectives including identifying decision factors, describing decision-making protocols, reviewing evidence for treatments, and illustrating treatments through cases. 3. Several cases are presented and treatment options of medical management, percutaneous coronary intervention (PCI), and coronary artery bypass grafting (CABG) are discussed in the context of each case based on symptoms, anatomy, and evidence from clinical trials.

1. Exploring the Landscape:
Choices and Decisions in
IHD
Mustafa Toma, MD SM FRCPC ABIM
June 11th, 2016

2. Disclosures
• Honoraria: Pfizer, Servier, AstraZeneca
• Advisory Board: Novartis, Servier
• Clinical Trials: Novartis, Servier

3. Objectives:
1. Identify factors used to make decisions about
management of IHD
2. Describe the process/protocols/tools used for
decision-making
3. List evidence that supports the decision for one
treatment modality over another
4. Illustrate the three treatment modalities through
patient examples

4. Objectives:
1. Identify factors used to make decisions about
management of IHD
2. Describe the process/protocols/tools used for
decision-making
3. List evidence that supports the decision for one
treatment modality over another
4. Illustrate the three treatment modalities through
patient examples

5. Case
• 50 yo male with CCS class II stable angina
– HTN
– Dyslipidemia
– Smoker
– Positive family history CAD
• Positive stress test

6. Case 1: Angiogram shows:
Single vessel disease
Multi-vessel disease
Non-obstructive CAD

7. Options for treatment of CAD
• Medical Rx
• PCI
• CABG

8. Medical Rx
• ASA
• Statin
• Ace inhibitor
• Beta blocker
• Anti-anginals:
– Nitrates
– Amlodipine
– Ranolazine

9. PCI

10. CABG

11. Factors used in decision making
• Symptoms
• Stable
• ACS
• STEMI
– Time from symptom onset
• Anatomy
• LM
• Multi-vessel disease
• Lesion complexity
– SYNTAX Score
• Comorbidities
• Diabetes
• LV dysfunction
• Other valvular lesions
• Operative Risk
• STS Score
• EuroScore
• Life expectancy

12. Coronary disease Lesion Types

14. Objectives:
1. Identify factors used to make decisions about
management of IHD
2. Describe the process/protocols/tools used for
decision-making
3. List evidence that supports the decision for one
treatment modality over another
4. Illustrate the three treatment modalities through
patient examples

16. Avoiding Oculostenotic reflex
“Reflexes are an unconscious motor response to
an outward stimulus, hard-wired into our
neurologic system”
“The oculostenotic reflex is the stent
deployment upon visualization of coronary
disease”

17. Decision Making
• Coronary anatomy is the gateway to decision
making
– Coronary angiogram
– CCTA

18. • Fix what we know to be broken
• If it ain’t broke, don’t fix it!

19. Revascularization procedures performed in countries throughout the Western world.
Stuart J. Head et al. Eur Heart J 2013;eurheartj.eht059
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author
2013. For permissions please email: journals.permissions@oup.com

20. “Informed Consent”
• “is a process for getting permission before conducting
a healthcare intervention on a person” – Wikipedia
– Is treatment is necessary now or if it can wait
– Your health problem and the reason for the treatment
– What happens during the treatment
– The risks of the treatment and how likely they are to occur
– How likely the treatment is to work
– Other options for treating your health problem
– Unknown risks or possible side effects that may happen
later on

21. Informed Consent
• Cardiologists and surgeons provide different
information
– Alternate revascularization strategy not discussed
in:
• 68% of patients undergoing PCI
• 59% of patients undergoing CABG

22. Factors influencing (lack of) discussion
• ‘Building an empire’ leading to (inter)national recognition
• Conflict of interest with industry
• Knowledge of patient’s preferences
• No appreciation of personal therapeutic limits
• Not being up-to-date regarding PCI and/or CABG (technology, outcomes,
indications, etc.)
• Opportunity to include a patient in an enroling randomized trial
• Personal conflict between interventional cardiologist and/or surgeon
• Physician–patient bonding
• Preservation of patient–referral pathways
• The physician’s centre is a centre of excellence in PCI or CABG ‘Turf
protection’ (protection of patient access and salary)

23. Those with indication for CABG
53%
34%
12%
1%
CABG PCI Medial Rx no Rx

24. Stuart J. Head et al. Eur Heart J 2013;eurheartj.eht059
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author
2013. For permissions please email: journals.permissions@oup.com
The ‘Heart team’

25. The ‘Heart team’ – Why not
• ‘novelty’
• Lack of experience
• Lack of proven benefit
• Logistic issues
• Turf protection

26. Objectives:
1. Identify factors used to make decisions about
management of IHD
2. Describe the process/protocols/tools used for
decision-making
3. List evidence that supports the decision for one
treatment modality over another
4. Illustrate the three treatment modalities through
patient examples

27. Case 1
• 50 yo male with CCS class II stable angina
– HTN
– type 2 DM
– Dyslipidemia
– Smoker
– Positive family history CAD
• Cath: 3-vessel disease

28. Stable angina: COURAGE

29. Case 1 – cont’d
• 50 yo male with CCS class II stable angina
DESPITE medical Rx
• Cath: 3- vessel disease
• What would you do next?
– Continue medical Rx
– Multi-vessel PCI
– CABG

30. Multi-Vessel disease: PCI vs. CABG
SYNTAX Trial
Serruys PW et al. N Engl J Med 2009;360:961-972

31. Rates of Outcomes among the Study Patients, According to Treatment Group.
Serruys PW et al. N Engl J Med 2009;360:961-972

32. Case 2
• 50 yo male with CCS class II stable angina
– HTN
– Type 2 DM
– Dyslipidemia
– Smoker
– Positive family history CAD
• Cath: 3 vessel disease

33. Farkouh ME et al. N Engl J Med 2012;367:2375-2384
Multi-Vessel disease in Diabetics: PCI vs. CABG
Freedom Trial

34. Case 3: STEMI
• Time is muscle
• Revascularization crucial:
– Fibrinolytics: ‘lytics’
– Primary PCI
• Urgent coronary angiogram

35. Case 3
• 50 yo male, acute chest pain
• ECG shows anterior STEMI
• Emergent cath:
– Occluded LAD
• PCI with stenting of LAD

36. Case 4
• 50 yo male, acute chest pain
• ECG shows anterior STEMI
• Emergent cath:
– Occluded LAD
– 80% LCx
– 80% RCA

37. Case 4
• What would you do?
– PCI LAD only
– Emergent CABG
– PCI of LAD, LCx, RCA at the same time?
– PCA of LAD now, bring back to cath lab later for
PCI of LCx, RCA

38. 90-day Mortality:
Non-culprit vs Culprit-only
15.0
10.0
5.0
0.0
300 60 90
Days to follow-up
CumulativeMortality,%
NIRA-PCI (n=238)
13.1%
IRA-only PCI
(n=5135) 4.0%
p(log-rank)<0.001
Toma et al. EHJ 2010

39. PRAMI Results
Wald DS et al. N Engl J Med 2013;369:1115-1123

40. PRAMI - Prespecified Clinical Outcomes.
Wald DS et al. N Engl J Med 2013;369:1115-1123

41. Case 5
• 50 yo male, Chronic shortness of breath
• No history of angina
• Echo: LVEF 30%
• cath:
– 90% LAD
– 80% LCx
– 70% RCA

42. Case 5
• What would you do?
– Medical Rx
– Multi-vessel PCI
– CABG

43. Long-term benefit of revascularization
Velazquez EJ et al. N Engl J Med 2016;374:1511-1520
STICH long-term follow up
Med 9.8 years
CABG associated with reduced all cause
mortality, CV mortality,
death or CV hospitalization

44. Conclusions
• Different factors involved in decision making
re revascularization strategy
• The process should involve a Heart Team
• Decisions re treatment should be
individualized and guided by best evidence

45. Thank you!