GRAND ROUNDSJoshua Kanik, MD

NEIMEF12/4/13

Revascularization strategy in Diabetic Pts

with Multivessel disease

Case: S.H.Admitted to Allen 11/4/12

• 57y.o. male transferred from Independence.

• He had been at Independence for Pneumonia.

• Treated with Levaquin & Azithromycin

• After several hours of sudden onset retrosternal CP, SOB, nausea and diaphoresis, cardiac enzymes were found to be elevated.

PMH

Social History

• Married with children

• Denies EtOH abuse

• ex-smoker (stopped 2 years ago)

• Unemployed on disability

Family History

• Siblings have CAD

• Father had esophageal cancer

• Both parents were alcoholics

R.O.S.

Constitutional: Negative for fever, chills, weight loss, malaise/fatigue and diaphoresis.

HENT: Negative for hearing loss and neck pain.

Eyes: Negative for blurred vision, double vision, photophobia, pain and discharge.

Respiratory: Positive for cough and shortness of breath (chronic). Negative for hemoptysis, sputum production and wheezing.

Cardiovascular: Positive for chest pain and leg swelling. Negative for palpitations, orthopnea and claudication.

Gastrointestinal: Positive for nausea. Negative for heartburn, vomiting, abdominal pain, diarrhea and constipation.

Genitourinary: Negative for dysuria, urgency and frequency.

Musculoskeletal: Positive for back pain and joint pain. Negative for myalgias.

Skin: Negative for itching and rash.

Neurological: Negative for dizziness, tingling, tremors and headaches.

Endo/Heme/Allergies: Negative for environmental allergies. Does not bruise/bleed easily.

Psychiatric/Behavioral: Negative for depression, suicidal ideas, hallucinations and substance abuse. The patient has insomnia.

Physical Exam

• BP 106/58

• Pulse 70

• Resp rate 20

• Temp 97.3

• SaO2 94% (2L O2)

Physical Exam

Constitutional: He appears well-developed and well-nourished. Morbid obesity

HENT:

Head: Normocephalic and atraumatic. Right Ear: External ear normal. Left Ear: External ear normal.

Mouth/Throat: Oropharynx is clear and moist. No oropharyngeal exudate.

Eyes: Conjunctivae and EOM are normal. Pupils are equal, round, and reactive to light.

Neck: Normal range of motion. Neck supple. No JVD present. No tracheal deviation present. No thyromegaly present.

Cardiovascular: Normal rate, regular rhythm and intact distal pulses. Exam reveals no gallop and no friction rub.

Murmur (3/6 systolic murmur) heard.

Pulmonary/Chest: Effort normal and breath sounds normal. No stridor, respiratory distress, wheezes, rales. He exhibits no tenderness.

Abdominal: Soft. Bowel sounds are normal. He exhibits no distension. There is no tenderness. There is no rebound and no guarding. Midline umbilical large reducible hernia Musculoskeletal: Normal range of motion. He exhibits edema (2+ worse on L). He exhibits no tenderness. Lymphadenopathy: He has no cervical adenopathy. Neurological: He is alert and oriented to person, place, and time. He has normal reflexes. No cranial nerve deficit. Coordination normal.

Skin: Skin is warm and dry. No rash noted. No erythema. No pallor. Psychiatric: He has a normal mood and affect. His behavior is normal. Judgment and thought content normal.

Lab results

WBC 15.1

Hgb 11.0

MCV 95

Plt 320

Na 136

K 4.3

Cl 96

CO2 31

BUN 40

Cr 1.1

Chol 97

HDL 31

LDL 45

Trig 103

Lab Results

CKMB 48.8

Trop13.62

Blood cx from Independence returned positive for strep Viridians.

Other studies• EKG: NSR, no ST changes

• CXR: Elevated Right Hemidiaphragm, bibasal linear densities.

• Echo: EF 50%, severe aortic stenosis, normal systolic fxn

• Lexiscan: There is a large perfusion abnormality involving the distal anteroseptal and inferior wall as well as the cardiac apex that may reflect large area of myocardial scar or resting myocardial ischemia.

Due to blood culture from Independence, cardiac catheterization was postponed pending follow up blood culture.

Pt placed on Rocephin until blood culture returned negative.

Treatment

• While waiting for cath pt was placed on:

• Rocephin

• Heparin, Plavix, ASA

• Home regimen for chronic medical conditions

Cardiac Catheterization

Performed 11/8/12• Mid LAD completely occluded. Distal LAD has

faint collaterals from RCA.

• RCA has diffuse disease.

• LCX has minimal disease.

• Recommendation: Medical management.

• Pt discharged to SNF from Allen 11/12/12

Follow-up

• He had 3rd NSTEMI 12/31/12

• Remains SOB at rest. O2 increased to 3-4L.

• Bld glu improved. Range 150-200.

-Advanced Directive & Living Will

Pt is interested in second opinion concerning his CAD.

CABG vs PCIRevascularization strategies for diabetics with

multi vessel disease.

Strategies for Multivessel Revascularization in Patients with

Diabetes

• The BARI (Bypass Angioplasty Revascularization Investigation) trial in the 90’s lead to the recommendation that Diabetics with multi vessel disease undergo a CABG rather than PCI.

• However, clinical practice did not change.

Strategies for Multivessel Revascularization in Patients with

Diabetes• BARI 2D

• ARTS (Arterial Revascularization Therapies Study)

• CARDia (Coronary Artery Revascularization in Diabetes)

• SYNTAX (SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery)

FREEDOM Trial

FREEDOM Trial

Farkouh ME, Dangas G, Leon MB, et al. Design of the Future REvasculariza- tion Evaluation in patients with Diabetes mellitus: Optimal management of Multi- vessel disease (FREEDOM) Trial. Am Heart J 2008;155:215-23.

Strategies for Multivessel Revascularization in Patients with

Diabetes• FREEDOM trial Methods

• Enrolled Diabetics with confirmed multi vessel CAD with stenosis of >70%

• Followed 1900 pt for up to 6.75 yrs (2 yr min)

• NIH Stroke Scale & Rankin scale used to screen pts during each follow up visit.

• Pts randomized to either CABG or PCI group

• PCI utilized DES only with dual anti platelet therapy for 12 months

Strategies for Multivessel Revascularization in Patients with

Diabetes

•Arterial revascularization was encouraged for the CABG group.

• Both groups had goal of:

LDL <70

BP <130/80

A1c <7%

Strategies for Multivessel Revascularization in Patients with

Diabetes

• Outcomes:

• Death, all cause

• Nonfatal myocardial infarction

• Nonfatal stroke

Strategies for Multivessel Revascularization in Patients with

DiabetesPopulation

Strategies for Multivessel Revascularization in Patients with

Diabetes

• Results:

• Primary outcome occurred in 352/1900.

• 205 PCI group 147 CABG group

• Divergence of the curves began at yr 2

• At 30 days: 26 PCI group 42 CABG group

Strategies for Multivessel Revascularization in Patients with

Diabetes

Strategies for Multivessel Revascularization in Patients with

Diabetes

Strategies for Multivessel Revascularization in Patients with

Diabetes

Pt S.H.

• Pt referred to cardiology

• Cardiologist questions prognosis and believes that pt will be fine after PCI.

• PCI scheduled by cardiologist

Pt S.H.

• Following day, notified that pt passed away during PCI.