- CABG may offer benefits over PCI for patients with type 2 diabetes and multivessel CAD or left ventricular systolic dysfunction based on evidence from studies like BARI and SYNTAX. PCI with drug-eluting stents is equivalent to CABG for single-vessel disease when LV function is normal.
- The BARI 2D trial found that for patients with type 2 diabetes and established heart disease, an initial strategy of prompt revascularization plus intensive medical therapy was not more effective than intensive medical therapy alone in reducing mortality or major cardiovascular events.
- Screening for CAD in asymptomatic patients with diabetes remains controversial. Studies like DIAD found that routine screening with stress myocardial perfusion imaging did not significantly reduce cardiac events
SOLACI Chile Congress 2011. Dr.Ajay Kirtane. Drug-Eluting Stents for Multivessel PCI: Indications and Outcomes. Find more presentations on the web site: www.solaci.org/
SOLACI Chile Congress 2011. Dr.Ajay Kirtane. Drug-Eluting Stents for Multivessel PCI: Indications and Outcomes. Find more presentations on the web site: www.solaci.org/
Six angiographic indicators of large thrombus burden by
Yip and colleagues,depending upon the angiographic morphology are
features indicated “high-burden thrombus formation”:
1. A cut-off pattern of occlusion
2. Accumulated thrombus proximal to the occlusion
3. A reference lumen diameter of the IRA of >4.0 mm
4. An incomplete obstruction with an angiographic thrombus with
the greatest linear dimension more than 3 times the reference
lumen diameter
5. The presence of floating thrombus proximal to the lesion
6. A persistent dye stasis distal to the occlusion
In the NOACs era , how to deal with liver cirrhosis needing anticoagulation?magdy elmasry
Is My Cirrhotic Patient Auto-anticoagulated?
Does "Auto-anticoagulation" Protect Against thrombosis in Patients with Liver Disease?
The normal balance of hemostasis and rebalanced hemostasis in liver disease.Should we anti-coagulate patients with cirrhosis?How safe is anticoagulation therapy to use in those with chronic liver disease?
DANISH is a major breakthrough trial published in NEJM on 29/09/2016 regarding Defibrillator Implantation in Patients with Nonischemic Systolic Heart Failure. All content of this slide is Copy right of NEJM.
Six angiographic indicators of large thrombus burden by
Yip and colleagues,depending upon the angiographic morphology are
features indicated “high-burden thrombus formation”:
1. A cut-off pattern of occlusion
2. Accumulated thrombus proximal to the occlusion
3. A reference lumen diameter of the IRA of >4.0 mm
4. An incomplete obstruction with an angiographic thrombus with
the greatest linear dimension more than 3 times the reference
lumen diameter
5. The presence of floating thrombus proximal to the lesion
6. A persistent dye stasis distal to the occlusion
In the NOACs era , how to deal with liver cirrhosis needing anticoagulation?magdy elmasry
Is My Cirrhotic Patient Auto-anticoagulated?
Does "Auto-anticoagulation" Protect Against thrombosis in Patients with Liver Disease?
The normal balance of hemostasis and rebalanced hemostasis in liver disease.Should we anti-coagulate patients with cirrhosis?How safe is anticoagulation therapy to use in those with chronic liver disease?
DANISH is a major breakthrough trial published in NEJM on 29/09/2016 regarding Defibrillator Implantation in Patients with Nonischemic Systolic Heart Failure. All content of this slide is Copy right of NEJM.
Cardiovascular disease - more common in diabetic patients than in the general population
Dyslipidemia – common in patients with both types of diabetes.
Aggressive lipid treatment goals have been recommended for patients with type 2 diabetes
Diabetic Dyslipidemia is highly prevalent in the Indian diabetic population
Dyslipidemia in diabetes differs significantly with hypertriglyceridemia and small dense LDL-C
"Спорные вопросы коррекции гипергликемии у больных с острым коронарным синдро...rnw-aspen
Доклад с XVI Межрегиональной научно-практической конференции "Искусственное питание и инфузионная терапия больных в медицине критических состояний" 21-22 апреля 2016 г.
Chronic Total Occlusions: The Road Less TraveledAllina Health
By M. Nicholas Burke, MD. The use of pioneering percutaneous treatments for chronic total occlusions: indications, limitations, outcomes and current research.
La aterosclerosis como enfermedad sistémica una visión integral de la enfermedad cardiovascular
Miércoles, 22/06/16 18:00h-20:00h Casa del Corazón, Madrid
http://cvvt.secardiologia.es
#CVVT
La enfermedad aterosclerótica en cardiología: particularidades y novedades
Dr. Leopoldo Pérez de Isla. Hospital Universitario Clínico San Carlos, Madrid
Presentation at the annual scientific conference of the DOST-National Research Council of the Philippines, 12 Mar 2024. Philippine International Convention Center, Manila.
Artificial Intelligence: Ethical Issues in Residency TrainingIris Thiele Isip-Tan
Symposium presentation at the annual convention of the Philippine Academy of Family Physicians, 8 March 2024. Philippine International Convention Center.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
Follow us on: Pinterest
Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
263778731218 Abortion Clinic /Pills In Harare ,ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group of receptionists, nurses, and physicians have worked together as a teamof receptionists, nurses, and physicians have worked together as a team wwww.lisywomensclinic.co.za/
Revascularization vs Medical Treatment for Coronary Disease in Diabetes
1. Revascularization vs
Medical Treatment
for Coronary
Disease in Diabetes
Iris Thiele Isip Tan MD, FPCP, FPSEM
Clinical Associate Professor, UP College of Medicine
Section of Endocrinology, Diabetes & Metabolism
Department of Medicine, Philippine General Hospital
2. Disclosure
I’m not a cardiologist :)
“Heads, you get a quadruple bypass.
Tails, you take a baby aspirin.”
3. When does CABG offer
benefits over PCI?
When can
revascularization be
offered to patients on
medical therapy?
Who should be screened
for CAD?
4. Who should be
screened for CAD?
Silent myocardial
infarction (SMI) is more
frequent in diabetes
Which asymptomatic
diabetic should be
screened?
Which is the more
appropriate non-invasive
test to determine the
presence of CAD?
CAD accounts for
>75% of deaths in
diabetes
5. Screening for
CAD in diabetes
Other atherosclerotic
vascular disease
Microalbuminuria and
chronic kidney disease
Abnormal resting ECG
Autonomic neuropathy
Retinopathy
Hyperglycemia
Age & sex
Unexplained dyspnea
Multiple cardiac risk
factors
ADA (2007)
Bax et al Diabetes Care 2007;30:2729-36
6. Exercise ECG to
screen high-risk
patients
Ischemia imaging
as initial strategy
only in patients with
abnormal resting
ECGs
ADA (1998)
Bax et al Diabetes Care 2007;30:2729-36
7. Cardiac CT*
using electron beam or multislice
technology
If medical goals
cannot be met
Those with strong
clinical suspicion of
very-high-risk CAD
Bax et al Diabetes Care 2007;30:2729-36
ADA (2007)
* AHA Class IIB recommendation
for intermediate risk
8. Further testing if
coronary calcium
score >400 considering
age and renal function
Bax et al Diabetes Care 2007;30:2729-36
Calcium score
1-10 minimal CAD
11-100 mild
101-400 moderate
>400 extensive
ADA (2007)
9. First CHD events and stroke
Median follow-up: 4 years
Coronary artery calcium score (CACS)
+ risk factors (lipoprotein, apolipoprotein,
homocysteine, CRP, HOMA-IR, UAC ratio)
589 T2DM with no history of CVD
O:
I:
P:
PREDICT
RCT
Elkeles et al Eu Heart J 2008;29:2244-51
10. e 2 Primary endpoint event rates in successive categories of coronary artery calcification score. Each unit increase in log2 (CACSþ1)
ents a doubling in CACS. The calcification score categories 0–10, 11–100, 101–400, 401–1000, and 1001–10000 include log-
rmed CACS categories 1–4, 4–7, 7–9, 9–10, and 11, respectively. Dotted lines show 95% confidence intervals.
DICT study 224
CACS
Independent Predictor of CHD/stroke
66 CV events (10 strokes)
Elkeles et al Eu Heart J 2008;29:2244-51
Doubling of CACS = 29% risk
PREDICT
11. Further testing if
coronary calcium
score >400 considering
age and renal function
SPECT: myocardial perfusion
Stress echocardiography:
ischemic wall motion
abnormalities
Bax et al Diabetes Care 2007;30:2729-36
ADA (2007)
12. Cardiac death or nonfatal MI
No screening vs adenosine-stress
radionuclide myocardial perfusion
imaging (MPI)
1123 T2DM and no symptoms of CAD
O:
I:
P:
DIAD
Young LH et al JAMA 2009;301(15):1547-55
RCT
13. Young LH et al JAMA 2009;301(15):1547-55
DIAD
HR 0.88; 95%CI (0.44,1.80)
p=0.73
15 events
17 events
Cumulative Incidence of Cardiac Events
Low event rate
2.9% over 5 y
(0.6%/yr)
14. NPV
normal MPI 98%
PPV
Any abnormality 6%
Mod/large defects 12%
Cumulative
Incidence of
Cardiac Events
by Screening
Group
Young LH et al JAMA 2009;301(15):1547-55
15. Routine screening for inducible
ischemia in asymptomatic T2DM
not advocated
Low yield of detecting significant
inducible ischemia
Low overall cardiac event rate
Routine screening does not appear
to affect overall outcome
Prohibitively expensive
Young LH et al JAMA 2009;301(15):1547-55
16. Further testing if
coronary calcium
score >400 considering
age and renal function
SPECT: myocardial perfusion
Stress echocardiography:
ischemic wall motion
abnormalities
Bax et al Diabetes Care 2007;30:2729-36
Stress echo?
ADA (2007)
17. Non-fatal MI, late myocardial
revascularization and cardiac death
Symptom-limited treadmill exercise
testing (Bruce protocol) + 2-D echo at
rest and immediately after exercise
193 T2DM with suspected or known CAD
referred for EE
O:
I:
Prognostic Value of Exercise Echo (EE)
P:
Oliveira JLM et al Cardiovascular Ultrasound 2009;7:24
Retrospective
18. Oliveira JLM et al Cardiovascular Ultrasound 2009;7:24
Survival Free of Cardiac Events
Kaplan-Meier curves
Normal
Abnormal
RR 3.63, 95%CI (1.09-6.02) p=0.03
Cardiac events
+ EE 20.6%
- EE 7%
19. Serial testing?
Low cardiac event rate
within 2 years after
normal stress
myocardial perfusion
or echo studies
Bax et al Diabetes Care 2007;30:2729-36
progressive
atherosclerosis
Warranty
22. Suspect CAD
Mild to moderate
symptoms
CCS Class I, II
Normal or single
segment abnormal
OMT
Asymptomatic
Selective
ischemia
assessment
Myocardial
perfusion imaging
Optimal
medical therapy
BP <130/80
LDL <70
HbA1c <7%
Fuster V & Farkouh ME. Circulation 2010;121:2540-52
23. Suspect CAD
Mild to moderate
symptoms
CCS Class I, II
Normal or single
segment abnormal
Multisegmental
abnormalities
OMT
Coronary
angiography
Asymptomatic
Selective
ischemia
assessment
Myocardial
perfusion imaging
Optimal
medical therapy
BP <130/80
LDL <70
HbA1c <7%
Fuster V & Farkouh ME. Circulation 2010;121:2540-52
24. Suspect CAD
Mild to moderate
symptoms
CCS Class I, II
Significant symptoms
CCS Class III, IV
Normal or single
segment abnormal
Multisegmental
abnormalities
OMT
Coronary
angiography
Asymptomatic
Selective
ischemia
assessment
Myocardial
perfusion imaging
Optimal
medical therapy
BP <130/80
LDL <70
HbA1c <7%
Fuster V & Farkouh ME. Circulation 2010;121:2540-52
25. When does CABG offer
benefits over PCI?
When can
revascularization be
offered to patients on
medical therapy?
Who should be screened
for CAD?
26. Primary - all-cause mortality
Secondary - composite of death, MI or
stroke
Prompt revascularization with intensive
medical therapy vs intensive medical
therapy alone
2368 T2DM with heart disease
BARI 2D
O:
I:
P:
RCT
BARI 2D Study Group. NEJM 2009;11:360(24):2503-15
30. Medical therapy
for all patients
HbA1c <7%
LDL <100 mg/dL
BP <130/80 mm Hg
Counseling on smoking cessation,
weight loss and regular exercise
Feedback on risk factor control
Follow-up monthly for first 6 months
then q3 months thereafter
BARI 2D Study Group. NEJM 2009;360(24):2503-15
33. BARI 2D Study Group. NEJM 2009;360(24):2503-15
Non-fatal MI
Revascularization grp 7.4%
Medical therapy 14.6%
34. Myocardial Jeopardy Index (MJI)
percentage of myocardial segments supplied by
significantly diseased coronary arteries or their branches
35. Coronary
angiography
Fuster V & Farkouh ME. Circulation 2010;121:2540-52
Mild to moderate
symptoms
CCS Class I, II
Significant symptoms
CCS Class III, IV
MJI = Myocardial Jeopardy Index
36. Coronary
angiography
Fuster V & Farkouh ME. Circulation 2010;121:2540-52
Normal or
non-obstructive
Mild to moderate
symptoms
CCS Class I, II
Significant symptoms
CCS Class III, IV
OMT
Optimal
medical therapy
BP <130/80
LDL <70
HbA1c <7%
MJI = Myocardial Jeopardy Index
37. Coronary
angiography
Fuster V & Farkouh ME. Circulation 2010;121:2540-52
Normal or
non-obstructive
Mild to moderate
symptoms
CCS Class I, II
Significant symptoms
CCS Class III, IV
Non-
obstructive
OMT
Optimal
medical therapy
BP <130/80
LDL <70
HbA1c <7%
MJI = Myocardial Jeopardy Index
38. Coronary
angiography
Fuster V & Farkouh ME. Circulation 2010;121:2540-52
Normal or
non-obstructive
Mild to moderate
symptoms
CCS Class I, II
Significant symptoms
CCS Class III, IV
Obstructive
AND low MJI
Deferred
revascularization
+ OMT
Non-
obstructive
OMT
Optimal
medical therapy
BP <130/80
LDL <70
HbA1c <7%
MJI = Myocardial Jeopardy Index
39. Coronary
angiography
Fuster V & Farkouh ME. Circulation 2010;121:2540-52
Normal or
non-obstructive
Mild to moderate
symptoms
CCS Class I, II
Significant symptoms
CCS Class III, IV
Obstructive
AND low MJI
Obstructive
AND high MJI
Deferred
revascularization
+ OMT
Prompt
revascularization
+ OMT
Obstructive
Non-
obstructive
OMT
Optimal
medical therapy
BP <130/80
LDL <70
HbA1c <7%
MJI = Myocardial Jeopardy Index
40. When does CABG offer
benefits over PCI?
When can
revascularization be
offered to patients on
medical therapy?
Who should be screened
for CAD?
41.
42. Tempting but
incorrect to conclude
from BARI 2D
... for type 2 DM with
severe angiographic
CAD, CABG is better
than PCI
Rutter MK & Nesto RW. Heart 2010;96:1436-40
43. Rutter MK & Nesto RW. Heart 2010;96:1436-40
Evidence-based appropriate therapy for CAD in diabetes
by symptom and/or disease severity
44. original BARI study
Diabetes subgroup
CABG with significantly better 5-year (80%
vs 67%) and 10-year (58% vs 46%, p=0.025)
survival when compared to balloon PCI
CABG vs PCI
1829 patients (most had unstable angina
and multivessel disease)
O:
I:
P:
BARI Investigators. NEJM 1996;335:217-25
RCT
45. Coronary Artery Revascularization
in Diabetes (CARDia)
Underpowered to compare individual outcomes
Composite (death, stroke or MI) similar
for CABG and PCI-treated (10.5% vs 13%,
p=0.39); More repeat procedures with PCI
CABG or PCI with abciximab and
stenting
510 diabetics with multivessel or complex
single-vessel CAD
O:
I:
P:
RCT
Kapur A et al. J Am Coll Cardiol 2010;55:432-40
46. SYNergy between PCI with TAXus
and cardiac surgery (SYNTAX)
More major cardiac and cerebrovascular
events with PCI (26% vs 14%, p=0.003)
PCI mortality higher for highly complex
lesions (13.5% vs 4.1%, p=0.003)
CABG vs PCI (paclitaxel-eluting stents)
Post hoc data for those with diabetes
1800 patients with complex left main or
three-vessel disease (452 with diabetes)
O:
I:
P:
RCT
one-year data
Banning AP et al. J Am Coll Cardiol 2010;55:1067-75
47. Future REvascularization Evaluation in Patients
with Diabetes: Optimal Management of
Multivessel Disease (FREEDOM)
Total and CVD mortality at 1-5 years
Quality of life and cost-effectiveness
CABG vs DES stent PCI in the setting
of optimal medical therapy
~2058 patients with diabetes and
multivessel disease
O:
I:
P:
Farkouh et al. Am Heart J 2008;155:215-23
RCT
48. JNJhealth “Coronary Stent Animation” 3 Sept 2008,
http://www.youtube.com/watch?v=9FPapBbbS4o&feature=channel. Accessed 25 Oct 2010
Coronary grafts bypass proximal segments of vessels
taking many atheromatous lesions out of play
Stents leave behind substantial coronary plaque
49. Summary
Type 2 diabetes
CABG best for
multivessel CAD and/or
LV systolic dysfunction
PCI with DES is
equivalent to CABG in
single-vessel disease
and normal LV systolic
function
Page BJ et al. Curr Diab Rep 2010;10:10-15
50. When does CABG offer
benefits over PCI?
When can
revascularization be
offered to patients on
medical therapy?
Who should be screened
for CAD?