Exploring the Landscape: Choices and Decisions in IHD Mustafa Toma, MD SM FRCPC ABIM June 11 th , 2016
Jan 21, 2018
Exploring the Landscape: Choices and Decisions in
IHD
Mustafa Toma, MD SM FRCPC ABIM
June 11th, 2016
Disclosures
• Honoraria: Pfizer, Servier, AstraZeneca
• Advisory Board: Novartis, Servier
• Clinical Trials: Novartis, Servier
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
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
Case
• 50 yo male with CCS class II stable angina
– HTN
– Dyslipidemia
– Smoker
– Positive family history CAD
• Positive stress test
Case 1: Angiogram shows:
Single vessel disease
Multi-vessel disease
Non-obstructive CAD
Options for treatment of CAD
• Medical Rx
• PCI
• CABG
Medical Rx
• ASA
• Statin
• Ace inhibitor
• Beta blocker
• Anti-anginals:
– Nitrates
– Amlodipine
– Ranolazine
PCI
CABG
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
Coronary disease Lesion Types
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
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”
Decision Making
• Coronary anatomy is the gateway to decision making
– Coronary angiogram
– CCTA
• Fix what we know to be broken
• If it ain’t broke, don’t fix it!
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: [email protected]
“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
Informed Consent
• Cardiologists and surgeons provide different information
– Alternate revascularization strategy not discussed in:
• 68% of patients undergoing PCI
• 59% of patients undergoing CABG
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)
Those with indication for CABG
53%34%
12%
1%
CABG PCI Medial Rx no Rx
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: [email protected]
The ‘Heart team’
The ‘Heart team’ – Why not
• ‘novelty’
• Lack of experience
• Lack of proven benefit
• Logistic issues
• Turf protection
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
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
Stable angina: COURAGE
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
Multi-Vessel disease: PCI vs. CABGSYNTAX Trial
Serruys PW et al. N Engl J Med 2009;360:961-972
Rates of Outcomes among the Study Patients, According to Treatment Group.
Serruys PW et al. N Engl J Med 2009;360:961-972
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
Farkouh ME et al. N Engl J Med 2012;367:2375-2384
Multi-Vessel disease in Diabetics: PCI vs. CABGFreedom Trial
Case 3: STEMI
• Time is muscle
• Revascularization crucial:
– Fibrinolytics: ‘lytics’
– Primary PCI
• Urgent coronary angiogram
Case 3
• 50 yo male, acute chest pain
• ECG shows anterior STEMI
• Emergent cath:
– Occluded LAD
• PCI with stenting of LAD
Case 4
• 50 yo male, acute chest pain
• ECG shows anterior STEMI
• Emergent cath:
– Occluded LAD
– 80% LCx
– 80% RCA
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
90-day Mortality:
Non-culprit vs Culprit-only
15.0
10.0
5.0
0.0
300 60 90
Days to follow-up
Cu
mu
lati
ve M
ort
ality
, %
NIRA-PCI (n=238)
13.1%
IRA-only PCI
(n=5135) 4.0%
p(log-rank)<0.001
Toma et al. EHJ 2010
PRAMI Results
Wald DS et al. N Engl J Med 2013;369:1115-1123
PRAMI - Prespecified Clinical Outcomes.
Wald DS et al. N Engl J Med 2013;369:1115-1123
Case 5
• 50 yo male, Chronic shortness of breath
• No history of angina
• Echo: LVEF 30%
• cath:
– 90% LAD
– 80% LCx
– 70% RCA
Case 5
• What would you do?
– Medical Rx
– Multi-vessel PCI
– CABG
Long-term benefit of revascularization
Velazquez EJ et al. N Engl J Med 2016;374:1511-1520
STICH long-term follow upMed 9.8 years
CABG associated with reduced all causemortality, CV mortality, death or CV hospitalization
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
Thank you!