SHA24/075002

16 February, 2013 Saudi Heart Association

11:00-11:15

The Great Debate: All multivessel CAD in 2013 should undergo multivessel PCI: Con

Abdullah A. Alghamdi, MD, MSc, FRCSC

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Disclosure

• I have no relations with pharmaceutical or device companies • I have no conflict of interest to disclose

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Multivessel PCI Should NOT be done for all patients

• PCI should not be done for all patients with multivessel CAD due to the presence of a superior and Gold Standard treatment strategy “CABG” • Specific Reasons will be discussed below:

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Reason 1

Heart Heart Team Team Approach Approach & & Practice Practice Guidelines Guidelines

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State of the art clinical practice

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Sate of the art clinical practice

Isaac Elzevir , 1620 6

The Practice of Teamwork (Multidisciplinary Approach)

• State of art approach for best practice • Platform to offer a tailored treatment strategy for specific patient • Supported by guidelines

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Heart Team Approach

• Class Ic in American & European Guidelines • Reports have shown that survival was better in patient discussed as opposed to randomized • Syntax score and STS scores are useful measures • FAME Trial 8

Multivessel CAD

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Practice Guidelines

• Provide the best available advice for use by most practitioners • Task forces, committees • Experts in field • Balanced and scientific literature reading and synthesis • Interventional cardiologists and cardiac surgeons 10

Guidelines

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Guidelines

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Guidelines

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Guidelines

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Guidelines

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Reason 2

Failure Failure of of revascularization revascularization (need (need for for intervention) intervention) isis more more in in PCI PCI than than CABG CABG

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Failure of Revascularization

• Graft Patency: 5, 10 and 15 years • IMA: 98%, 95%, 88% • SVG: 80%, 60%, 50% Worst conduit is better than any stent, and that was before the advanced antiplatelet and statin therapy Tatoulis J, Ann Thorac Surg. 2004;77(1):93.

Sabik JF 3rd, Ann Thorac Surg. 2005;79(2):544

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Failure of Revascularization

• Observational and RCTs showed overwhelming evidence that PCI is inferior with regard to repeat revascularization (failure of initial revascularization) • PCI has high rate of failure

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Failure of Revascularization

Davide C, J Am Col Cardiol, 58-14, 2011.

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Failure of Revascularization

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Reason 3

PCI PCI results results in in more more cardiac cardiac death death than than CABG CABG

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Cardiac Death

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Reason 4

PCI PCI results results in in more more MI MI than than CABG CABG

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Myocardial Infarction

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Reason 5

CABG CABG isis the the best best strategy strategy for for diabetic diabetic patients patients

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Multivessel disease in Diabetic Patients

• Conservative figures showed at least 25% of those undergoing revascularization are diabetics

FREEDOM Trial, NEJM, 2012 26

Multivessel disease in Diabetic Patients

JACC Vol. 58, No. 24, 2011 27

Multivessel disease in Diabetic Patients

FREEDOM Trial, NEJM, 2012 28

Multivessel disease in Diabetic Patients

FREEDOM Trial, NEJM, 2012 29

Multivessel disease in Diabetic Patients

FREEDOM Trial, NEJM, 2012 30

Reason 6

Complete Complete Revascularization Revascularization

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Complete Revascularization

• CABG offers complete or near complete revascularization • PCI does not offer complete revascularization in all patients (~ 70%) • Those with incomplete revascularization had trends for higher mortality and significantly needed reinterventions Jones EL, Am J Cardiol. 1983;51:7–12.

Bell MR, J Am Coll Cardiol. 1990;16:553– 62.

Bourassa MG, Eur Heart J. 1998;19:103–11.

Faxon DP, Am Heart J. 1992;123:854 –9.

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Reason 7

PCI PCI requires requires the the use use of of DAPT: DAPT: Expensive, Expensive, Needs Needs Compliance Compliance

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DAPT use

• PCI requires the use of DAPT • Plavix is relatively expensive • Noncompliance or inability to afford results is stent thrombosis (20-45% mortality)

Grines CL, J Am Coll Cardiol.2007;6:734 –9.

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Reason 8

CABG: CABG: Real Real World World Results Results

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Real World Results

16% 21% • • • • •

>65 year ≥ 2VD Not ACS CABG=86,244 PCI=103,549

William Weintraub, NEJM, 2012 36

Reason 9

PCI PCI isis only only suitable suitable for for subgroup subgroup of of patients patients with with multivessel multivessel disease disease

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Extent of CAD

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Extent of CAD

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Extent of CAD

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Reason 10

PCI PCI isis not not suitable suitable for for all all patients patients with with multivessel multivessel CAD CAD

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Patients with multivessel CAD CABG

25% DM

Complete revascula rization

Concomitant valvular

PCI

5% LM

Issues with Plavix

Proximal LAD

Complex CAD 5% CKD

Poor LVF

Patient Choice

Patient Choice

Comrobid Less complex CAD

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Summary

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Embolic Load During Diagnostic Angiography

Emboli were detected in about 15%

Cluster of microemboli entering MCA Eur Heart J. 2005 Jul;26(13):1269-75 44

Embolic Load During Diagnostic Angiography

Int. J Cardiol 2009 45

PRECOMBAT Trial

N Engl J Med. 2011 May 5;364(18):1718-27 46

SYNTAX results in 5- year

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Surgical Approach to reduce CVA

• Neurocognitive function is comparable to PCI (BARI/SOS) • Emboli come from aorta due to manipulation (X-Clamp/Cardioplegia) • Adoption of aortic no touch techniques minimizes the risk of stroke in first year

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Surgical Approach to reduce CVA

Ann Thorac Surg. 2010 Oct;90(4):1384-90 49

Cost Effectiveness

• Cost effectiveness analysis: Quality Adjusted Life Year • Magnuson reported the cost effectiveness of CABG vs PCI in Freedom Trial • of CABG surgery was reported at $34 467 while the cost of PCI was $24 845 • At follow up CABG was cost-effective with an incremental cost-effectiveness ratio of $8132 per QALY gained Freedom Trial 50