PCI v CABG Dr Rod Stables The Cardiothoracic Centre Liverpool UK.

PCI v CABG

Dr Rod Stables

The Cardiothoracic Centre

Liverpool UK

CABG is Alive and Well in Liverpool

CABG is Alive and Well in Liverpool

Liverpool Family Life

Liverpool Family Life

Presentation Outline

• Undisputed current facts

• PCI improves access to revascularisation

• Availability

Access to Revascularisation - Availability

• Existing immediate capacity

• Dominant method for revascularisation

• UK PCI growth rate - 16% per annum

• UK CABG growth rate - static or negative

• Revascularisation event ratio trend > 2 : 1

• Immediate ability to grow capacity favours PCI

• NSF targets - and beyond

• New indications

UK Activity: PCI v Isolated CABG

0

10000

20000

30000

40000

50000

60000

'91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03

BCISSCTS

Presentation Outline

• Undisputed current facts

• PCI improves access to revascularisation

• Availability

• Patients with co-morbidity

• Patients with acute presentations

• Acute coronary syndromes

• Primary PCI for ST MI

• Cardiogenic shock

Improved Cardiac Provision Favours PCI

• Better primary prevention

• Earlier investigation and treatment of CAD

• Aggressive early approach to occlusion

• Primary PCI for AMI

• Early PCI for non-ST elevation ACS

• Reduced incidence of

• Advanced ‘surgical’ disease’

Presentation Outline

• Undisputed current facts

• PCI improves access to revascularisation

• PCI is cost saving

SoS Trial - Total Costs at 1 Year

£0£1,000£2,000£3,000£4,000£5,000£6,000£7,000£8,000£9,000

£10,000

PCI CABG

Follow-up

Initial hosp

Cost = £2,609 (95% CI: £1,769 to £3,314)

£3,884

£2,412

£7,321

£1,518

Co

sts

Presentation Outline

• Undisputed current facts

• PCI improves access to revascularisation

• PCI is cost saving

• PCI is popular with patients

PCI - Appeal to Patients

• Experience from consent attempts in RCTs

• Shorter hospital stay

SoS Trial: Length of Stay - Index Procedure

S urgery

Days in hospital1 8 15 22 29 36+

0

25

50

75

100

125

150PC I

Days in hospital1 8 15 22 29 36+

0

25

50

75

100

125

150

Median 3 days Median 10 days

PCI - Appeal to Patients

• Experience from consent attempts in RCTs

• Shorter hospital stay

• Reduced immediate procedural morbidity

• Avoids GA, scars etc

• Rapid rehabilitation

• CABG option remains (short or long term)

Presentation Outline

• Undisputed current facts

• PCI improves access to revascularisation

• PCI is cost saving

• PCI is popular with patients

• PCI is improving at a rapid pace

PCI Evolution

• Rate of new product registration

• Techniques and application

• Adjunctive medication schedules

• Imaging equipment

• Devices / equipment

• Stents and drug eluting stents

• Improving clinical results

Stenting and Emergency CABG

0

10

20

30

40

50

60

70

80

90

100

'92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03

Year

% s

ten

t

0

0.5

1

1.5

2

2.5

% E

m C

AB

G

% Stent

% Em.CABG

Stenting and Restenosis Procedures

0

10

20

30

40

50

60

70

80

90

100

'92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03

Year

%

0

2

4

6

8

10

12

14

%

% Stent

% Restenosis

Presentation Outline

• Undisputed current facts

• Historic trials favour CABG

• Reduced repeat revascularisation

Cu

mu

lativ

e p

erc

en

tag

e

T im e since random isation (years)0 1 2 3

0

5

10

15

20

25

30

P C Ip<0.001

S u rg ery

SoS Trial: Repeat Revascularisation

Hazard ratio 3.90 (2.58 to 5.91)

Cu

mu

lativ

e p

erc

en

tag

e

T im e since random isa tion (years)0 1 2 3

0

2

4

6

8

10

12

14

p=0.81

P C I

S urgery

SoS Trial: Death or Non-Fatal Q Wave MI

Hazard ratio 0.95 (0.63 to 1.43)

Mortality to 1 Year

Su

rviv

al p

rob

ab

ility

T im e since random isa tion (m onths)0 3 6 9 12

0

.1

.2

.3

.4

.5

.6

.7

.8

.9

1

p=0.050P C I

S u rg ery

Presentation Outline

• Undisputed current facts

• Historic trials favour CABG

• Reduced repeat revascularisation

• Emerging clinical data - favours PCI

PCI v CABG: The Current Picture

• Non - MACCE adverse events

• SoS data

• Hospitalisation events after index revasc

• Non - MACCE : Never reported

• CABG 351 (0.7 per patient)

• PCI 156 (0.3 per patient)

• MACCE: PCI - superior safety and efficacy

Latest Trials From TCT 2004

• ARTS 2

• Registry n = 607 MV revasc by DES

• More diabetes than ARTS 1 (26% v 18%)

• More 3 VD (54% v 28%)

• More stents (3.7 [73mm] v 2.8 [48mm])

• 6 month freedom from MACCE

• ARTS 2 - 93.6 %

• ARTS 1: PCI - 84.7% CABG - 94.5%

ARTS II - MACCE Free Survival

‘Armies can be resisted but not an idea whose time has come.’

Victor Hugo