COX HEART SUMMIT 2017 11 [Read-Only] · (Individual vs Public Health Considerations) ... Robinson JG et al. N Engl J Med 2015;372:1489-1499. ... CA D Patients Diagnosed w ...

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New Twist To Old Disease :Cardiovascular Update 2017

Sridevi R Pitta, M.D.,MBA, F.S.C.A.I., R.P.V.IMedical Director for STEMI,

Medical Director for CV Quality Council,Interventional Cardiologist & Endovascular Medicine ,

Cox Health

OBJECTIVES

� Prevention� Pre-operative � Coronary Artery Disease

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Less clear other

groups use

Additional factors

Clinical

ASCVD

Age >75yr or not candidate

for high Intensity statin

Moderate intensity statin

Age <75yrs High intensity statin

(Moderate inensity if not

candidate for high)Adults age >21yr

and a candidate for

statin therapy

yesyes

LDL>190

mg/dlHigh intensity statin

(Moderate intensity if not

candidate for high

High

>50%

Definition for high

and moderate

intensity statin

Moderate

30 to

<50%

No

yes

Estimate 10yr ASCVD risk

>7.5%

High intensity statin

Diabetes

Age 40 75yr

Diabetes Type Ior 2

Age 40-75yr

Moderate intensity statin

yes

No

Moderate to high

intensity statinyes

>7.5%Estimated

10yrASCVD

risk and age 40-

75yr

Estimate 10yr ASCVD

Risk with Pooled cohort

equations

No

No

IMPROVE – IT: Primary Endpoint

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Secondary Prevention: Is the Lower, the Better for LDL-C

What is the Future of LDL-Lowering Therapy?

Is 10yr-year NNT for ASCVD Morbidity/Mortality a valuable tool for patient

discussion? (Individual vs Public Health Considerations)

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Major Recommendations for

ASCVD Statin therapy

Major Recommendations for

ASCVD Statin therapy

Heart Healthy lifestyle

habits: Foundation

“Should be the beginning of the discussion,

not end of the discussion”

AHA/ACC Guidelines 2013: Primary Prevention

PCSK9 INHIBITORS

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Robinson JG et al. N Engl J Med 2015;372:1489-1499.

Calculated LDL Cholesterol Levels over Time

Cumulative Incidence of Cardiovascular Events

Sabatine MS et al. N Engl J Med 2015;372:1500-1509.

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PCKS9 Inhibitors

• Dramatic drops in LDL cholesterol

• Long term data

• Cost effectiveness

OBJECTIVES

� Prevention� Pre-operative � Coronary Artery Disease

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Palmerini et al. EuroPCR 2012

Timing of First DAPT Interruption and ST Through 1 year

Circulation, 2000

Lancet,2009

• Restoration of

Vasomotor

function

• Free of late

stent thrombosis

• Antiplatelet

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OBJECTIVES

� Prevention� Pre-operative � Coronary Artery Disease

Case Discussion

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“ Major advances in health care occur not from results of randomized clinical trials or real world registries, but from the application of those results to complex healthcare systems which requires the successful

interaction of healthcare workers and their patients”.

Tim Henry, MD

Circulation,2012

ACC/AHA: 2013

Case Discussion

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Mortality From Cardiogenic Shock according to age (<75yrs vs >75yrs)

IABP IMPELLA

Case Discussion

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Platelet -Mediated Thrombosis

Targets

Meadows et al.Circulation Res 2007

P2Y12 Receptor Antagonists

Agent Class IPA Time to

peak

onset

Reversiblit

y

Ticlopidine

250mg po bid

Thienopyridine

(Prodrug)

25% 48hrs Non-reversible

5days

Clopidogrel

300mg LD

600mg LD

75mg qd

150mg qd

Thienopyridine

(Prodrug)

30-40%

35%-50%

30-35%

45%-50%

12hrs

6hrs

-

-

Non-reversible

5days

Prasugrel 60mg LD

Prasugrel 10mg po qd

Prasugrel 5mg po qd

Thienopyridine

(Prodrug)

80%

60%

40%

1-2hrs

-

-

Non-reversible

7days

Ticagrelor 180mg LD

Ticagrelor 90mg po

bid

Cyclo-pentyl

triazolo-

pyrimidine

80%

70%

1-2hrs Reversible

2-5days

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Treatment Algorithm for Duration of P2Y12 Inhibitor Therapy in Patients Treated with PCI

Case Discussion

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90582785 MAR2010 Page 37 of 53

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LEG: BLEEDING COMPLICATIONS

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ACUITY Study Showed TRI Had Reduced Access Bleeding

Hamon M, et al. Choice of Arterial Access site and outcomes in patients with acute coronary syndromes managed with an early invasive strategy: The ACUITY trial. Eurointervention. 2009; 5: pp 115-120.

Eve

nt R

ate

P = 0.78 P = 0.18 P = 0.03

N=798N=11,989

Net clinical outcome was defined as composite ischemia or major bleeding

TRI can reduce Hospital Charges

FemoralN=77

RadialN=68

P Value

Postprocedure length of stay, days

2.3 1.4 P < 0.01

Total hospital length of stay, days

4.5 3.0 P < 0.01

Total hospital charge, $ $23,389 $20,476 P < 0.01

Mann JT, et al. Stenting in acute coronary syndromes: a comparison of radial versus femoral access sites. Journal of the American College of Cardiology. 1998;32:572-576.

TRI can Reduce Nurse Workload

Amoroso G, et al. Overview of the transradial approach in percutaneous coronary intervention. J Cardiovasc Med (Hagerstown) 2007;8:230-7.

Nurse workload after invasive procedures according to the arterial access used

The transradial approach results in a significant reduction (P < 0.01) in nurse workload

P < 0.01

P < 0.01

Cathlab Ward/CCU

1000

750

500

250

0

Nur

se W

orkl

oad

(min

)

Radial Femoral Radial Femoral

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Patients Prefer TRIHistogram of patient preference for catheterization method rated on visual analog scale

Cooper CJ, et al. Effect of transradial access on quality of life and cost of cardiac catheterization: a randomized comparison. American Heart Journal.1999;138:430-436.

0

20

40

60

80

100

120

Strongly Prefer Radial

No Preference Strongly Prefer

Femoral

Num

ber

of P

atie

nts

P < 0.0001

Amin AP et al.

SAME DAY DISCHARGE

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DRIVE THROUGH

Translational Science /Systems Applications

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Case Discussion

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IC-460115-AB JUN2017

0

50

100

150

200

250

300

350

CAD

Patients Diagnosed w/ Patients undergoing Revascularization

(PCI or CABG)

Underutilization of Coronary Revascularization (PCI or CABG) in CAD Patients

>75,000,000 patient record database analysis Commercial Payers & Medicare data, 1/2010 –

4/2014

Truven Health Analytics MarketScan Comercial and Medicare Supplemental Databases (01/01/2010 - 4/30/2014)

CAD

52% of CADpts NOT revascularized

CAD + CHF

-

10

20

30

40

50

60

70

80

Patients Diagnosed w/CAD

& CHF

Patients undergoing Revascularization (PCI or CABG)

56%of CAD +CHF pts NOTrevascularized

CTO Prevalence and Treatment

CTO 18.4%

Patients with CoronaryArtery Disease

N = 14,439

Attempted

CTO-PCI

10%Non-CTO PCI

20%

Medical

Therapy

44%

CABG

26%

Treatment of Patientswith CTOs

N = 1,697

Fefer et al. JACC 2012. IC-460115-AB JUN2017

IC-308913-AB JUN2015

0

15

22

0%

10%

20%

30%

40%

Medical Therapy May Not be EnoughHigher Ischemic Burden Correlated to Mortality

Dea

thor

MI

Rat

e

Shaw et al, Circulation 2008;117

p=0.063

p=0.023

p=0.002

39

>10%(n=62)

5%-9.9%(n=88)

0%(n=23)

1%-4.9%

(n=141)

Ischemic Burden

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IC-308913-AB JUN2015

CTO Impact on Non-CTO Vessel AMI MortalityHigher 1-year Mortality Rate w/ CTO

Van der Schaff RJ et al. Am J Cardiol 2006.

CTO is an

independent

predictor of

mortality

Lessons of the Heart -- Cardiovascular Disease: A Mind, Body, and Spirit Approach

"the heart is not just a pump, but a home to the soul"

Sridevi R Pitta, M.D.,MBA, F.S.C.A.I., R.P.V.I3800 S National Ave Wheeler Heart Center 4th Floor

Springfield, MO 65807

Office number: 417-875-2628

Fax number: 417-875-3718