Curiosare fra le raccomandazioni delle Linee Guida ESC 2014 sulla rivascolarizzazione miocardica Marco Comeglio UO Diagnostica e Interventistica Cardiovascolare Asl 3 Pistoia Curiosare fra le raccomandazioni delle Curiosare fra le raccomandazioni delle Linee Guida ESC 2014 Linee Guida ESC 2014 sulla rivascolarizzazione miocardica sulla rivascolarizzazione miocardica Marco Comeglio Marco Comeglio UO Diagnostica e Interventistica Cardiovascolare UO Diagnostica e Interventistica Cardiovascolare Asl 3 Pistoia Asl 3 Pistoia L’uomo ha un’insaziabile curiosità di conoscere og cosa, eccetto quelle che meritano di essere conosciute Oscar W L L ’ ’ uomo ha un uomo ha un ’ ’ insaziabile insaziabile curiosit curiosit à à di conoscere og di conoscere og cosa, eccetto quelle che cosa, eccetto quelle che meritano di essere meritano di essere conosciute conosciute Oscar W Oscar W
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Curiosare fra le raccomandazioni delle
Linee Guida ESC 2014
sulla rivascolarizzazione miocardica
Marco Comeglio
UO Diagnostica e Interventistica Cardiovascolare
Asl 3 Pistoia
Curiosare fra le raccomandazioni delleCuriosare fra le raccomandazioni delle
Linee Guida ESC 2014Linee Guida ESC 2014
sulla rivascolarizzazione miocardicasulla rivascolarizzazione miocardica
Marco ComeglioMarco Comeglio
UO Diagnostica e Interventistica CardiovascolareUO Diagnostica e Interventistica Cardiovascolare
Asl 3 PistoiaAsl 3 Pistoia
L’uomo ha un’insaziabile
curiosità di conoscere ogni
cosa, eccetto quelle che
meritano di essere
conosciuteOscar Wilde
LL’’uomo ha unuomo ha un’’insaziabile insaziabile
curiositcuriositàà di conoscere ogni di conoscere ogni
cosa, eccetto quelle che cosa, eccetto quelle che
meritano di essere meritano di essere
conosciuteconosciuteOscar WildeOscar Wilde
2014 ESC/EACTS Guidelines on Myocardial Revascularisation2014 ESC/EACTS Guidelines on Myocardial Revascularisation
Guidelines and recommendations Guidelines and recommendations should should helphelp healthhealth
professionalsprofessionals to make decisions in their daily to make decisions in their daily
practice; however, the practice; however, the final decisions final decisions concerning an concerning an
individual patient individual patient must be made by the must be made by the responsible responsible
health professionalhealth professional(s), in consultation with the (s), in consultation with the
patientpatient……
PreamblePreamble
1.1. Scores and risk stratification Scores and risk stratification
2.2. Process for decisionProcess for decision--making and patient informationmaking and patient information
3.3. Strategies for diagnosis: functional testing and imagingStrategies for diagnosis: functional testing and imaging
4.4. Revascularization for stable coronary artery diseaseRevascularization for stable coronary artery disease
5.5. Revascularization in nonRevascularization in non--STST--segment elevation acute coronary segment elevation acute coronary syndromessyndromes
6.6. Revascularization in STRevascularization in ST--segment elevation myocardial infarctionsegment elevation myocardial infarction
7.7. Revascularization in patients with heart failure and cardiogenicRevascularization in patients with heart failure and cardiogenic shockshock
8.8. Revascularization in patients with diabetesRevascularization in patients with diabetes
9.9. Revascularization in patients with chronic kidney diseaseRevascularization in patients with chronic kidney disease
10.10. Revascularization in patients requiring valve interventionsRevascularization in patients requiring valve interventions
AnginaAngina: : associated with associated with impaired quality of life, reduced physical endurance, mental impaired quality of life, reduced physical endurance, mental
depression, and recurrent hospitalizations and outpatient visitsdepression, and recurrent hospitalizations and outpatient visits
�� Revascularization by PCI or CABG more effectively relieves anginRevascularization by PCI or CABG more effectively relieves angina, reduces the use a, reduces the use
of antiof anti--angina drugs, and improves exercise capacity and quality of lifeangina drugs, and improves exercise capacity and quality of life, compared , compared
with a strategy of OMT alonewith a strategy of OMT alone
IschaemiaIschaemia is of prognostic importance in patients with SCAD, particularly is of prognostic importance in patients with SCAD, particularly when when
occurring at low work loadoccurring at low work load
�� Revascularization relieves myocardial ischaemia more effectivelyRevascularization relieves myocardial ischaemia more effectively than OMT alonethan OMT alone
The extent, location, and severity of CAD are important prognostThe extent, location, and severity of CAD are important prognostic factors in addition to ic factors in addition to
ischaemia and left ventricular functionischaemia and left ventricular function
Trials of Optimal Medical Therapy
with or without Revascularization
Trials of Optimal Medical Therapy
with or without Revascularization
2014 ESC/EACTS Guidelines on Myocardial Revascularisation2014 ESC/EACTS Guidelines on Myocardial Revascularisation
• Underpowered (many exclusion from initial
cohort)
• Investigator selection Bias (post-angio study)
• Low risk pts (0.4% annual cardiac death)
• End Point : all cause death - only 26.7%
confirmed Cardiac Death
• ITT … but huge cross-over
• …..etc…
Trials of Optimal Medical Therapy
with or without Revascularization
Trials of Optimal Medical Therapy
with or without Revascularization
2014 ESC/EACTS Guidelines on Myocardial Revascularisation2014 ESC/EACTS Guidelines on Myocardial Revascularisation
FAME 2: FFRFAME 2: FFR--Guided PCI versus OMT in SCADGuided PCI versus OMT in SCADNEJM 2012; 367:991
De
ath
, M
I, U
rg R
ev
with documented ischaemia or FFR < 0.80 for stenosis < 90%
Indications for Revascularization in Patients with
Stable Angina or Silent Ischaemia
Indications for Revascularization in Patients with
Stable Angina or Silent Ischaemia
2014 ESC/EACTS Guidelines on Myocardial Revascularisation2014 ESC/EACTS Guidelines on Myocardial Revascularisation
2014 ESC/EACTS Guidelines on Myocardial Revascularisation2014 ESC/EACTS Guidelines on Myocardial Revascularisation
Hybrid procedures, consecutive
or combined, in specific patients IIb
C
2014 ESC/EACTS Guidelines on Myocardial Revascularisation2014 ESC/EACTS Guidelines on Myocardial Revascularisation