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: journals.permissions@oup.com

“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: journals.permissions@oup.com

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!