ESC Guias Revascularizaci贸n mioc谩rdica
ESC Guias Revascularización miocárdica Contents: • Strategies of Diagnosis & severity of ischemia • Optimal medical therapy • Risk stratification. Clinical risk scores • Procedural risk scores • Heart Team: Multidisciplinary opinion • Patient informed decision • Specific recommendations • Special Conditions
ESC Guias Revascularizaci贸n mioc谩rdica
ESC Guias Revascularización miocárdica Optimal Medical Therapy • Antiischemic drugs • Antithrombotic treatment • Secondary prevention • Rehabilitation
ESC Guias Revascularizaci贸n mioc谩rdica Scores to calculate
Patient Risk
www.umassmed.edu/ outcomes/grace
ESC Guias Revascularizaci贸n mioc谩rdica Scores to calculate Risk of PCI & CABG
ESC Guias Revascularización miocárdica Patient information Æ Patient active role in decissions •Objective, •Unbiased, •Patient-oriented, •Evidence-based, •Up-to-date, reliable, •Understandable, •Accessible, •Relevant, •Consistent with legal requirements
ESC Guias Revascularizaci贸n mioc谩rdica Patient information (Apendix in guidelines)
ESC Guias Revascularizaci贸n mioc谩rdica Patient information (Apendix in guidelines)
ESC Guias Revascularizaci贸n mioc谩rdica Patient information (Apendix in guidelines)
ESC Guias Revascularizaci贸n mioc谩rdica Patient information (Apendix in guidelines)
ESC Guias Revascularizaci贸n mioc谩rdica Multidisciplinary Decision Pathways, Patient Info/consent & Timing of Intervention
The Heart Team
ESC Guias Revascularizaci贸n mioc谩rdica Multidisciplinary Decision Pathways, Patient Info/consent & Timing of Intervention
ESC Guias Revascularizaci贸n mioc谩rdica Revascularization In STE-ACS
ESC Guias Revascularizaci贸n mioc谩rdica Revascularization in Non STE-ACS
Risk Stratification in NSTE-ACS: Low < 108
3,500
High < 140 Troponin â&#x2C6;&#x2019; Troponin + Mortality
2,500 2,000
30 25 20
1,500
15
1,000
10
500 0
5 < 51
56
66
76
85
95
105 115 125 135 145 155 165 175 185 195 205 214 225 > 226
GRACE risk score intervals
N = 27,406 non-STE ACS patients
0
Inhospital mortality (%)
35
3,000
Patients (n)
40
ESC Guias Revascularizaci贸n mioc谩rdica PCI vs GABG Stable patients
ESC Guias Revascularizaci贸n mioc谩rdica Revascularization in Stable patients Indications for Revascularisation in Stable Angina or Silent Ischaemia * with documented ischaemia or FFR <0.80 for angiographic diameter stenoses 50-90%
ESC Guias Revascularización miocárdica Indications for CABG vs PCI in candidates for revasc. in stable angina or silent ischaemia with lesions suitable for both procedures & low surgical mortality Favours CABG
Favours PCI
IIa C
IC
1VD or 2VD – proximal LAD
IA
IIa B
3VD simple lesions, full functional revascularisation achievable with PCI, SYNTAX SCORE <22
IA
IIa B
3VD complex lesions, incomplete revascularisation achievable with PCI, SYNTAX SCORE > 22
IA
III A
Left Main (Isolated or 1VD, ostium/shaft)
IA
IIa B
Left Main (Isolated or 1VD, distal bifurcation)
IA
IIb B
Left Main + 2/3VD SYNTAX SCORE <33
IA
IIb B
Left Main + 2/3VD SYNTAX SCORE>33
IA
III B
Subset of CAD by anatomy 1VD or 2VD – non proximal LAD
ESC Guias Revascularizaci贸n mioc谩rdica
European Society of Cardiology: 53 countries