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Appropriteness Criteria for Coronary Revascularization
- 1. Appropriateness Criteria for Revascularization – Making sense of the recommendations Dr. Lalit Kapoor Chief Cardiac Surgeon Apollo Hospital, Ranchi www.heartsurgery.in
- 2. Left Main Left Main Equivalent TVD DVD with LAD
- 3. Which procedure is best?
- 6. 8% 0 1 2 3 4 5 6 7 8 9 Aspirin Aspirin -bloq Aspirin -bloq Statin Aspirin -bloq Statin ACEI None 6% 4,5% 3% 2,3% RRR 25% RRR 30% RRR 25% RRR 25% SECONDARY PREVENTION Event rate* (2 years) Impact of pharmacological treatment * CV death, AMI or stroke Yusuf S. Lancet 2002;360:2 Statin ACEI -bloq Aspirin 25 40 60 70
- 7. Medical Treatment - Outcomes Califf RM, Armstrong PW, Carver JR, et al. Task Force 5. Stratification of patients into high-, medium-, and low-risk subgroups for purposes of risk factor management. J Am Coll Cardiol. 1996;27:964–1047 (4).
- 8. Comparison of medical therapy, CABG and PTCA
- 9. Results from Duke trial
- 10. Main results from SYNTAX randomized trial Serruys PW et al. European Society of Cardiology Congress 2008; September 1, 2008; Munich, Germany. Dr Friedrich W Mohr (University of Leipzig, Germany), pointed out, almost one-third of patients considered for randomization in SYNTAX were deemed ineligible for PCI, primarily due to complex disease or anatomy Serruys PW, et al. N Engl J Med 2009;360:961-72 End point CABG (%) DES (%) p MACCE 12.1 17.8 0.0015 Death/MI/stroke 7.7 7.6 0.98 Revascularization 5.9 13.7 <0.0001 Stroke 2.2 0.6 0.003 MI 3.2 4.8 0.11 All-cause death 3.5 4.3 0.37
- 11. Main results from SYNTAX randomized trial End point CABG (%) DES (%) p Angina Free (1mth) 61.6 64.4 Angina Free (6mth) 72.0 68.5 Angina Free (12mth) 76.3 71.6 <0.05 Cost $33,254 $27,560 Additional Cost (1yr) $2,500 Cost in India 150000 550000 Additional Cost (1yr) 125000
- 13. Appropriateness Criteria for Coronary Revascularization ACCF/SCAI/STS/AATS/AHA/ASNC 2009 Appropriateness Criteria for Coronary Revascularization A Report by the American College of Cardiology Foundation Appropriateness Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, and the American Society of Nuclear Cardiology Endorsed by the American Society of Echocardiography, the Heart Failure Society of America, and the Society of Cardiovascular Computed Tomography J Am Coll Cardiol, 2009; 53:530-553
- 19. Copyright ©2009 American College of Cardiology Foundation. Restrictions may apply. Patel, M. R. et al. J Am Coll Cardiol 2009;53:530-553 Appropriateness Ratings by Risk Findings on Noninvasive Imaging Study and Symptom Status
- 20. Copyright ©2009 American College of Cardiology Foundation. Restrictions may apply. Patel, M. R. et al. J Am Coll Cardiol 2009;53:530-553 Appropriateness Ratings by High-Risk Findings on Noninvasive Imaging Study and CCS Class III or IV Angina (Patients Without Prior Bypass Surgery) ` `
- 21. Copyright ©2009 American College of Cardiology Foundation. Restrictions may apply. Patel, M. R. et al. J Am Coll Cardiol 2009;53:530-553 Appropriateness Ratings by Intermediate-Risk Findings on Noninvasive Imaging Study and CCS Class I or II Angina (Patients Without Prior Bypass Surgery) ` `
- 22. Copyright ©2009 American College of Cardiology Foundation. Restrictions may apply. Patel, M. R. et al. J Am Coll Cardiol 2009;53:530-553 Appropriateness Ratings by Low-Risk Findings on Noninvasive Imaging Study and Asymptomatic (Patients Without Prior Bypass Surgery) ` `
- 23. Copyright ©2009 American College of Cardiology Foundation. Restrictions may apply. Patel, M. R. et al. J Am Coll Cardiol 2009;53:530-553 Method of Revascularization of Advanced Coronary Artery Disease SYNTAX
- 24. Copyright ©2009 American College of Cardiology Foundation. Restrictions may apply. Patel, M. R. et al. J Am Coll Cardiol 2009;53:530-553 Acute Coronary Syndromes*
- 29. For copies of this presentation please send a request to drlalitkapoor@gmail.com
Notas del editor
- Single vsl disease patients esp in the RCA almost always need angioplasty Extensive triple vessle or LM disease get surgery. The question of the comparative effectiveness is relevant for those folks in whom the disease is neither too limited or too extensive, both procedures are technically feasible: SVD of prox LAD, double vsl disease, and less severe 3vsl disease patients.
- Figure 10-34. The Duke database provided information for evaluating the appropriateness of treatment modalities. They compared medical therapy, coronary artery bypass grafting (CABG), and percutaneous transluminal coronary angioplasty (PTCA). When appropriately adjusted for risk, CABG patients with three-vessel disease had significantly improved survival at 10 years than did individuals treated medically or with PTCA [27], [28].
- Figure 10-35. Results from the Duke trial comparing percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG). The preferred method of therapy depends on the extent and severity of coronary disease. PTCA seems to be superior in patients with less extensive disease, whereas CABG is more advantageous for patients with more extensive coronary disease [27], [28].