Khi nào nong động mạch vành trên bệnh nhân đau ngực ổn định với tổn thương...

Khi nào nong động mạch vành Khi nào nong động mạch vành trên bệnh nhân đau ngực ổn định trên bệnh nhân đau ngực ổn định

với tổn thương hẹp lớn hơn 70% ?với tổn thương hẹp lớn hơn 70% ?

BSCK II HUỲNH NGỌC LONGBSCK II HUỲNH NGỌC LONG

VIỆN TIM TP.HCMVIỆN TIM TP.HCM

NONG MẠCH VÀNH DỰA VÀONONG MẠCH VÀNH DỰA VÀO

1-Đau ngực1-Đau ngực

2-Test chức năng (+) không xâm lấn.2-Test chức năng (+) không xâm lấn.

3-Số nhánh hẹp 3-Số nhánh hẹp

4-Anatomy thích hợp nong ( Syntax score).4-Anatomy thích hợp nong ( Syntax score).

TRƯỜNG HỢP 1: ĐIỂN HÌNHTRƯỜNG HỢP 1: ĐIỂN HÌNH1-Đau ngực 2-Test không xâm lấn (+) 1-Đau ngực 2-Test không xâm lấn (+)

3.Hẹp ≥70% 4-Syntax ≤ 22 3.Hẹp ≥70% 4-Syntax ≤ 22 NONGNONG

TEST TEST KHÔNG KHÔNG

XÂM LẤNXÂM LẤN

LÚC NGHĨLÚC NGHĨ GẮNG GẮNG SỨCSỨC

1-ECG1-ECG

2-Siêu âm2-Siêu âm

3-Scinti3-Scinti

COURAGE: Study designCOURAGE: Study design

Boden WE et al. Am Heart J. 2006;151:1173-9. Boden WE et al. N Engl J Med. 2007;356:1503-16.

Optimal medical therapy* + PCI (n = 1149)

Optimal medical therapy*(n = 1138)

AHA/ACC Class I/II indications for PCI, suitable coronary artery anatomy + ≥70% stenosis in ≥1 proximal epicardial vessel + objective evidence of ischemia

(or ≥80% stenosis + CCS class III angina without provocation testing)

Primary outcomes: All-cause mortality, nonfatal MI

Follow-up: Median 4.6 years

Randomized

*Intensive pharmacologic therapy + lifestyle interventionCCS = Canadian Cardiovascular Society

Secondary outcomes: Death, MI, stroke; ACS hospitalization

Freedom from Angina in COURAGE

Weintraub, et al. New Engl J Med 2008;359:677-687.

TRƯỜNG HỢP 2: KHÔNG ĐAU NGỰCTRƯỜNG HỢP 2: KHÔNG ĐAU NGỰC2-Test chức năng (+) 2-Test chức năng (+)

3.Hẹp ≥70% 4-Syntax ≤ 22 3.Hẹp ≥70% 4-Syntax ≤ 22

CÓ NÊN NONG KHÔNG ?CÓ NÊN NONG KHÔNG ?

DUKE TREADMILL SCOREDUKE TREADMILL SCORE

DTSDTSDuke treadmill Duke treadmill

1-score1-score >=+5 Low>=+5 Low

2-Score +4 to -10 Moderate2-Score +4 to -10 Moderate

3-Score <= -11 High risk3-Score <= -11 High risk

DUKE TREAMILL SCOREDUKE TREAMILL SCORETIÊN LƯỢNG TỬ VONGTIÊN LƯỢNG TỬ VONG

DTS Risk Category

1-Yr Mortality No Stenosis >=75%

1 VD >=75% 2 VD >=75% 3VD >=75% or LM >=75%

Men

Low

0.9% 52.6% 22.4% 13.6% 11.4%

Mod

2.9% 17.8% 15.6% 27.9% 38.7%

High 8.3% 1.8% 9.1% 17.5% 71.5%

Women

Low

0.5% 80.9% 9.4% 6.2% 3.5%

Mod

1.1% 65.1% 14.2% 8.3% 12.4%

High 1.8% 10.8% 18.9% 24.3% 46%

VD = Vessel Disease; LM = Left Main

ACIP: Study designACIP: Study design

Angiographic CAD (≥50% stenosis in ≥1 major vessel or branch) suitable for revascularization + ischemia during exercise or pharmacologic stress

testing and ≥1 asymptomatic episode during 48-hr AECG

Angina-guided strategy(n = 183)

Ischemia-guided strategy(n = 183)

Revascularization strategy(n = 192)

Primary outcome: Absence of ischemia at 12 weeksSecondary outcomes: Death, MI, recurrent hospitalization for cardiac

disease, nonprotocol revascularization at 1 and 2 years

Pepine CJ et al. J Am Coll Cardiol. 1994:24:1-10.Davies RF et al. Circulation. 1997;95:2037-43. Asymptomatic Cardiac Ischemia Pilot

Davies et al, Circulation, 1997

0 4 8 12 16 20 24 mos0 4 8 12 16 20 24 mos00

22

44

66

8 8 %%

6.6%Cumulative MortalityCumulative Mortality

1.1%

Revascularization

4.1%

Medical treatment

No treatment

558 patients , functionally significant stenosis without symptoms: randomization in 3 treatments strategies

ACIP: Two-year cumulative all-ACIP: Two-year cumulative all-cause mortality ratescause mortality rates

P < 0.05

SWISSI II: Study designSWISSI II: Study design

Erne P et al. JAMA. 2007;297:1985-91.

PCI (n = 96)Anti-ischemic therapy*

(n = 105)

Recent first MI with asymptomatic myocardial ischemia on exercise testing and 1- or 2-vessel coronary disease suitable for PCI

Primary outcomes: Cardiac death, nonfatal MI, symptom-driven revascularization

Follow-up: 10.2 years (mean)

Randomized, unblinded

*Nitrates, β-blockers, CCBsAll patients also received aspirin and statinSwiss Interventional Study on Silent Ischemia Type II

SWISSI II: Baseline SWISSI II: Baseline characteristicscharacteristics

PCIPCI Anti-ischemic Anti-ischemic therapytherapy

Age (years)Age (years) 54.454.4 56.256.2

Female (%)Female (%) 11.511.5 13.313.3

Diabetes (%)Diabetes (%) 9.49.4 13.313.3

Hypertension (%)Hypertension (%) 44.844.8 44.844.8

Dyslipidemia (%)Dyslipidemia (%) 75.075.0 58.158.1

Family history of CAD Family history of CAD (%)(%)

44.844.8 40.040.0

Smoking (%)Smoking (%) 72.972.9 74.374.3

Erne P et al. JAMA. 2007;297:1985-91.

SWISSI II: THEO DÕI 15 NĂMSWISSI II: THEO DÕI 15 NĂM

Erne P et al. JAMA. 2007;297:1985-91.*Log-rank

1.00

0.25

0.50

0.75

0

PCI

Drug therapy

P < 0.001*

0 5 10 15Time from randomization (years)

Event-free survival

ACIP, SWISSI II: Summary ACIP, SWISSI II: Summary and implications and implications

1-ACIP: In patients with documented CAD + 1-ACIP: In patients with documented CAD + symptomatic and asymptomatic ischemiasymptomatic and asymptomatic ischemia, PCI , PCI compared with anti-ischemic or antianginal compared with anti-ischemic or antianginal therapy reduced 2-year risk of major CV eventstherapy reduced 2-year risk of major CV events

2-SWISSI II extended these finding to 2-SWISSI II extended these finding to post-MI post-MI patients with asymptomatic ischemiapatients with asymptomatic ischemia and a and a longer 10-year follow-uplonger 10-year follow-up

Davies RF et al. Circulation. 1997;95:2037-43. Erne P et al. JAMA. 2007;297:1985-91.

TRƯỜNG HỢP 2: KHÔNG ĐAU NGỰCTRƯỜNG HỢP 2: KHÔNG ĐAU NGỰC2-Test chức năng (+) 2-Test chức năng (+)

3.Hẹp ≥70% 4-Syntax ≤ 22 3.Hẹp ≥70% 4-Syntax ≤ 22

NÊN NONGNÊN NONG

TRƯỜNG HỢP 3:TRƯỜNG HỢP 3:

1-Có đau ngực1-Có đau ngực

2-Có test chức năng (+)2-Có test chức năng (+)

3-Giải phẩu thích hợp, syntax score ≤22.3-Giải phẩu thích hợp, syntax score ≤22.

4-Nhưng tổn thương hẹp trung bình 50-70%4-Nhưng tổn thương hẹp trung bình 50-70%

CÓ NÊN NONG KHÔNG ?CÓ NÊN NONG KHÔNG ?

HẸP 50% LAD, NÊN NONG HẸP 50% LAD, NÊN NONG KHÔNG ?KHÔNG ?

1-Nam 56 Tuổi1-Nam 56 Tuổi

2-Đau ngực điển hình2-Đau ngực điển hình

3-Duke score= -23-Duke score= -2

4-Nguy cơ trung bình, 4-Nguy cơ trung bình, nguy cơ tử vong 1 nguy cơ tử vong 1 năm=2,9%năm=2,9%

158 vb38/interm.RCA/Buddem (1)

• female, 58-y-old• underwent PCI of severe LCX lesion a minute before • 50 % stenosis in mid RCA

Should this lesion be stented ??

TƯƠNG TỰ CÁCH ĐẶT VẤN ĐỀ CỦA DEPER STUDY

The DEFER Study: DesignThe DEFER Study: Design

prospective randomized multicentric trial prospective randomized multicentric trial (14 centers) in 325 patients with stable (14 centers) in 325 patients with stable chest pain and an intermediate stenosis chest pain and an intermediate stenosis without objective evidence of ischemiawithout objective evidence of ischemia

AalstAmsterdamEindhoven Essen Gothenborg Hamburg Liège

Maastricht Madrid Osaka Rotterdam Seoul Utrecht Zwolle

data collection & analysis: Jan Willem Bech, MD, PhDPepijn van Schaardenburgh, MD

DEFER Group

REFERENCE Group PERFORM Group

The DEFER Study: Flow Chart

Patients scheduled for PCI without Proof of Ischemia

(n=325)

performance of PTCA (158)

deferral of PTCA (167)

FFR 0.75 (91)

No PTCA

FFR 0.75(90)

PTCA

FFR < 0.75(76)

PTCA

FFR < 0.75(68)

PTCA

RandomizationRandomization

THE DEFER STUDY: RANDOMIZATION

1 : 1 randomization

deferral of PCI

performance of PCI

If FFR < 0.75 performance anyway reference group

If FFR > 0.75 randomization followed

defer PCI perform PCI

The DEFER Study: The DEFER Study: CatheterizationCatheterization

• 6 or 7 F guiding catheter for measurement of aortic pressure ( Pa)

• QCA from 2 orthogonal views

• Coronary pressure measurement (Pd ) by 0.014” pressure wire (Radi Medical Systems)

• Maximum hyperemia by i.v. adenosine (140 ug/kg/min)

• Calculation of Fractional Flow Reserve by:

FFR = Pd / Pa

The DEFER Study: Base line data

Randomized to Randomized to Deferral of PTCA Performance of

PTCA N=167 N=158

Diabetes (%) 13 12Hypertension (%) 41 35Hyperlipidemia (%) 47 48Current Smoker (%) 30 25Family History CAD (%) 50 49

Age, (yr) 629 6310Female sex (%) 29 29Ejection Fraction (%) 6710 689

The DEFER Study: Baseline QCA and FFR

Ref. diam. (mm) 2.960.63 2.980.57

MLD (mm) 1.420.40

DS (%) 5210

1.420.38 5211

Randomized to Randomized to Deferral of PTCA Performance of PTCA

N=167 N=158

FFR 0.720.19 0.730.19

All baseline characteristics were identical between both groups

72 %72 % 58 %58 %68 %68 %Pts free of angina(%)Pts free of angina(%)

52 (39 %)52 (39 %)24 (27 %)24 (27 %)19 (21 %)19 (21 %)Patients ≥1 event (%)Patients ≥1 event (%)

707029292121Total eventsTotal events

2 (1.5)2 (1.5)1 (1.1)1 (1.1)00Other (%)Other (%)

11 (8.2)11 (8.2)6 (6.8)6 (6.8)6 (6.7)6 (6.7)Non-TLR(%)Non-TLR(%)

14 (10.4)14 (10.4)4 (4.5)4 (4.5)1 (1.1) 1 (1.1) CABG(%)CABG(%)

7 (5.2)7 (5.2)1 (1.1)1 (1.1)00Non-Q wave MI(%)Non-Q wave MI(%)

6 (4.5)6 (4.5)4 (4.5)4 (4.5)00Q wave MI (%)Q wave MI (%)

4 (3.0)4 (3.0)3 (3.4)3 (3.4)3 (3.3)3 (3.3)Non Cardiac Death(%)Non Cardiac Death(%)

8 (6.0)8 (6.0)2 (2.3)2 (2.3)3 (3.3)3 (3.3)Cardiac Death(%)Cardiac Death(%)

14414490909191Number of patientsNumber of patients

ReferenceReferencePerformPerformDeferDefer

FFR<0.75FFR<0.75FFR ≥0.75FFR ≥0.75

18 (13.4)18 (13.4)8 (9.1)8 (9.1)8 (8.9)8 (8.9)TLR(%)TLR(%)

DEFER: Clinical Outcome at 5 YearsDEFER: Clinical Outcome at 5 Years

Lost to follow-up 1 2 10Lost to follow-up 1 2 10

0%

20%

40%

60%

80%

100%

baseline 1month 1 year 2 year 5 year

Defer group Perform group Reference group

freedom from chest pain

FFR > 0.75 FFR > 0.75 FFR < 0.75

* *

* *

* **

*

Cardiac Death And Acute MI After 5 YearsCardiac Death And Acute MI After 5 Years

3.3

7.9

15.7

0

5

10

15

20 %

P=0.20

P< 0.03

P< 0.005

DEFER PERFORM REFERENCE

FFR > 0.75 FFR < 0.75

Cardiac Death And Acute MI After 5 Years

3.3

7.9

15.7

0

5

10

15

20 %

P=0.20

P< 0.03

P< 0.005

DEFER PERFORM REFERENCE

FFR > 0.75 FFR < 0.75

889096103105135FFR < 0.75

136138143154162178FFR = 0.75

No. at risk

75.8

64.4

0 1 2 3 4 50

25

50

75

100

FFR 0.75

FFR < 0.75p=0.03

Years of Follow-up

event – free survival (%)

7.47.4

0.60.600

11

22

33

44

55

66

77

88

12000 Patients12000 Patients( 2 x 6000)( 2 x 6000)

similar stenosissimilar stenosisseverity byseverity bycoronary angiocoronary angio

The risk for death or acute myocardial infarction in the next five years is 20 times higher for an ischemic lesion compared to a non-ischemic lesion !!!

Iskander S, Iskandrian A E JACC 1998

% d

eath

or

Acu

te M

I

no ischemia ischemia

FFR LÀ TEST CHỨC NĂNG FFR LÀ TEST CHỨC NĂNG XÂM LẤN QUAN TRONGXÂM LẤN QUAN TRONG

1-Một nhánh, hẹp trung bình 50-70%1-Một nhánh, hẹp trung bình 50-70%


3-Không có test không xâm lấn3-Không có test không xâm lấn

Nhưng bù lại, có FFR ≤ 0.75Nhưng bù lại, có FFR ≤ 0.75

NÊN NONG NÊN NONG

HẸP 50% LADHẸP 50% LAD

1-Nam 56 Tuổi1-Nam 56 Tuổi

2-Đau ngực điển hình2-Đau ngực điển hình

3-Duke score= -23-Duke score= -2

4-Nguy cơ tử vong 1 4-Nguy cơ tử vong 1 năm=2,9%.năm=2,9%.

Làm thêm FFR ≤ 0.75 Làm thêm FFR ≤ 0.75 NongNong

FFR >0.75FFR >0.75Nguy cơ Nguy cơ tử vong < 1%/nămtử vong < 1%/năm

TRƯỜNG HỢP 3:TRƯỜNG HỢP 3:


2-Hẹp trung bình 50-70%.2-Hẹp trung bình 50-70%.

3-FFR ≤ 0.75 test chức năng xâm lấn3-FFR ≤ 0.75 test chức năng xâm lấn

NÊN NONGNÊN NONG

FFR LÀ GÌ ?FFR LÀ GÌ ?Fractional Flow ReserveFractional Flow Reserve

THIẾU MÁU CƠ TIM ?THIẾU MÁU CƠ TIM ?

1- ECG gắng sức, Siêu âm 1- ECG gắng sức, Siêu âm

dobutamin, Scintigraphidobutamin, Scintigraphi

“ “mất cân bằng cung/cầu”mất cân bằng cung/cầu”

2-FFR 2-FFR Giảm lưu lượng trong mạch vành thủ phạmGiảm lưu lượng trong mạch vành thủ phạm

LƯU LƯỢNG MÁU TRONG LƯU LƯỢNG MÁU TRONG MẠCH VÀNH MẠCH VÀNH

1-Tương tự định luật Ohm trong dòng điện: 1-Tương tự định luật Ohm trong dòng điện:

U=R.I U=R.I I= U/RI= U/R

2-Lưu lượng mạch máu Q= 2-Lưu lượng mạch máu Q= Pressure/ResistancePressure/Resistance

TỈ LỆ LƯU LƯỢNG MÁU SAU TỈ LỆ LƯU LƯỢNG MÁU SAU

VÀ TRƯỚC CHỖ HẸPVÀ TRƯỚC CHỖ HẸP

3-Q sau/Q trước= Psau/P trước=FFR3-Q sau/Q trước= Psau/P trước=FFR

CÁCH THỰC HIỆN FFRCÁCH THỰC HIỆN FFR

1-Đo trạng thái bình thường1-Đo trạng thái bình thường

2-Đo sau khi chích adenosin2-Đo sau khi chích adenosin (140 ug/kg/min) vào mạch vành. vào mạch vành.

3-FFR ≤ 0.80 3-FFR ≤ 0.80 Lưu lượng máu sau chỗ Lưu lượng máu sau chỗ hẹp đã giảm 20%.hẹp đã giảm 20%.

4-FFR ≤ 0.754-FFR ≤ 0.75 Lưu lượng máu sau chỗ Lưu lượng máu sau chỗ hẹp đã giảm 25%.hẹp đã giảm 25%.

FFR =TRƯỚC + BÀNG HỆ + FFR =TRƯỚC + BÀNG HỆ + VI TUẦN HOÀNVI TUẦN HOÀN

FFRFFR ESC GUIDELLINE 2008 ESC GUIDELLINE 2008

Class I A Class I A

TRƯỜNG HỢP 4:TRƯỜNG HỢP 4:Hẹp nhiều nhánh và lan tỏaHẹp nhiều nhánh và lan tỏa

ECG GẮNG SỨC, SIÊU ÂM ECG GẮNG SỨC, SIÊU ÂM DOBUTAMIN, SCINTIGRAPHIDOBUTAMIN, SCINTIGRAPHI

KHÓ XÁC ĐỊNH:KHÓ XÁC ĐỊNH:

1-Mạch nào thủ phạm1-Mạch nào thủ phạm

2-Đoạn nào cần nong2-Đoạn nào cần nong

NÊN DÙNG FFRNÊN DÙNG FFR

FAME 2 STUDYFAME 2 STUDY Fractional Flow Reserve (FFR) Fractional Flow Reserve (FFR) vs. Angiography in Multivessel vs. Angiography in Multivessel

EvaluationEvaluation

FAME 2: FFR-Guided PCI versus Medical Therapy in Stable CADFAME 2: FFR-Guided PCI versus Medical Therapy in Stable CAD

Available on-line on Aug 28, 2012 on www.nejm.org

BackgroundBackground1-The FAME 2 trial, multicenter, international, 1-The FAME 2 trial, multicenter, international,

randomized study comparing fractional flow randomized study comparing fractional flow reserve (FFR)-guided percutaneous coronary reserve (FFR)-guided percutaneous coronary intervention (PCI) to best medical therapy intervention (PCI) to best medical therapy (MT) in patients with stable coronary disease.(MT) in patients with stable coronary disease.

2-The study was stopped early because of a 2-The study was stopped early because of a significantly higher rate of the composite significantly higher rate of the composite endpoint of death, MI and urgent endpoint of death, MI and urgent revascularization in patients assigned to MT. revascularization in patients assigned to MT.

Primary Endpoint: Death, MI, Urgent Revascularization at 2 years

Trial DesignTrial DesignStable patients with 1, 2, or 3 vessel CAD evaluated for PCI with DES

n=1220

FFR in all target lesions

At least 1 stenosis with FFR ≤ 0.80 (n=888)

Randomization 1:1

PCI + MT MT

Randomized Trial

All FFR > 0.80(n=322)

MT

Registry

50% randomly assigned to follow-up

Angio-Angio-GuidedGuidedn = 496 n = 496

FFR- FFR- GuidedGuidedn = 509n = 509

P P ValueValue

Age, mean Age, mean ±SD±SD 6464±10±10 6565±10±10 0.470.47

Male, %Male, % 7373 7575 0.300.30

Diabetes, %Diabetes, % 2525 2424 0.650.65

Hypertension, %Hypertension, % 6666 6161 0.100.10

Current smoker, %Current smoker, % 3232 2727 0.120.12

Hyperlipidemia, %Hyperlipidemia, % 7373 7272 0.620.62

Previous MI, %Previous MI, % 3636 3737 0.840.84

NSTE ACS, %NSTE ACS, % 3636 2929 0.110.11

Previous PCI , %Previous PCI , % 2626 2929 0.340.34

LVEF, mean LVEF, mean ±SD±SD 5757±12±12 5757±11±11 0.920.92

LVEF < 50% , %LVEF < 50% , % 2727 2929 0.470.47

Baseline CharacteristicsBaseline Characteristics

ANGIO-ANGIO-groupgroup

N=496N=496

FFR-groupFFR-group

N=509N=509P-valueP-value

# indicated lesions per # indicated lesions per patientpatient

2.7 2.7 ± 0.9± 0.9 2.8 2.8 ± 1.0± 1.0 0.340.34

FFR resultsFFR results

Lesions succesfully measured, Lesions succesfully measured, No No (%)(%)

-- 1329 (98%)1329 (98%) --

Lesions with FFR ≤ 0.80 ,Lesions with FFR ≤ 0.80 ,No (%)No (%) -- 874 (63%)874 (63%) --

Lesions with FFR > 0.80 ,Lesions with FFR > 0.80 ,No (%)No (%) -- 513 (37%)513 (37%) --

FFR in ischemic lesionsFFR in ischemic lesions -- 0.60 0.60 ± 0.14± 0.14 --

FFR in non-ischemic lesionsFFR in non-ischemic lesions -- 0.88 0.88 ± 0.05± 0.05 --

FAME study: FAME study: Procedural Results (1)Procedural Results (1)

FAME study: FAME study: Procedural Results (2)Procedural Results (2)


N=496N=496

FFR-groupFFR-group


Procedure time (min)Procedure time (min) 70 ± 4470 ± 44 71 ± 4371 ± 43 0.510.51

Contrast agent used (ml)Contrast agent used (ml) 302 ± 127302 ± 127 272 ± 133272 ± 133 <0.001<0.001

Materials used at procedure Materials used at procedure

(US $)(US $)

60076007 53325332 <0.001<0.001


FFR- GuidedFFR- Guidedn = 509n = 509 P ValueP Value

Indicated lesions / patientIndicated lesions / patient 2.72.7±0.9±0.9 2.82.8±1.0±1.0 0.340.34

Stents / patientStents / patient 2.7 ± 1.22.7 ± 1.2 1.9 ± 1.31.9 ± 1.3 <0.001<0.001

Procedural CharacteristicsProcedural Characteristics

Trial ResultsTrial Results

De Bruyne, et al. New Engl J Med 2012;367:991-1001.

FFR-Guided FFR-Guided PCIPCI

(n=447)(n=447)MTMT

(n=441)(n=441)P-P-

ValueValue

Primary EndpointPrimary Endpoint 4.34.3 12.712.7 <0.001<0.001

DeathDeath 0.20.2 0.70.7 0.310.31

Myocardial InfarctionMyocardial Infarction 3.43.4 3.23.2 0.890.89

Urgent RevascularizationUrgent Revascularization 1.61.6 11.111.1 <0.001<0.001

Free from AnginaFree from Angina (1 month) (1 month) 7171 4848 <0.001<0.001

%


N=496N=496

FFR-groupFFR-group


Events at 1 year, No (%)Events at 1 year, No (%)

Death, MI, CABG, or repeat-PCIDeath, MI, CABG, or repeat-PCI 91 (18.4)91 (18.4) 67 (13.2)67 (13.2) 0.020.02

DeathDeath 15 (3.0)15 (3.0) 9 (1.8)9 (1.8) 0.190.19

Death or myocardial infarctionDeath or myocardial infarction 55 (11.1)55 (11.1) 37 (7.3)37 (7.3) 0.040.04

CABG or repeat PCICABG or repeat PCI 47 (9.5)47 (9.5) 33 (6.5)33 (6.5) 0.080.08

Total no. of MACETotal no. of MACE 113113 7676 0.020.02

Myocardial infarction, specifiedMyocardial infarction, specified

All myocardial infarctionsAll myocardial infarctions 43 (8.7)43 (8.7) 29 (5.7)29 (5.7) 0.070.07

Small periprocedural CK-MB 3-5 x Small periprocedural CK-MB 3-5 x NN

1616 1212

Other infarctions (“late or large”)Other infarctions (“late or large”) 2727 1717

FAME study: FAME study: Adverse Events at 1 yearAdverse Events at 1 year

1 Year Event-Free Survival1 Year Event-Free Survival

FFR-guided

30 days2.9% 90 days

3.8% 180 days4.9% 360 days

5.1%

Angio-guided

Absolute Difference in MACE-Free Survival

1 Year Economic Evaluation1 Year Economic Evaluation

Angio Better FFR Better

FFR Less Costly

Angio Less Costly

QALY

US

D

Bootstrap SimulationBootstrap Simulation

Adverse Events at 2 YearsAdverse Events at 2 Years



P P ValueValue

Total no. of MACETotal no. of MACE 139139 105105

Individual EndpointsIndividual Endpoints

DeathDeath 19 (3.8)19 (3.8) 13 (2.6)13 (2.6) 0.250.25

Myocardial InfarctionMyocardial Infarction 48 (9.7)48 (9.7) 31 (6.1)31 (6.1) 0.030.03

CABG or repeat PCICABG or repeat PCI 61 61 (12.3)(12.3)

53 53 (10.4)(10.4) 0.350.35

Composite EndpointsComposite Endpoints

Death or Myocardial Death or Myocardial InfarctionInfarction

63 63 (12.7)(12.7) 43 (8.4)43 (8.4) 0.030.03

Death, MI, CABG, or Death, MI, CABG, or re-PCIre-PCI

110 110 (22.2)(22.2)

90 90 (17.7)(17.7) 0.070.07

2 Year Survival Free of 2 Year Survival Free of MACEMACE

FFR-GuidedFFR-Guided

Angio-GuidedAngio-Guided

730 days730 days4.5%4.5%

2 Year Survival Free of 2 Year Survival Free of Repeat RevascularizationRepeat Revascularization


Angio-GuidedAngio-Guided

730 days730 days1.9%1.9%

2 Year Survival Free of MI2 Year Survival Free of MI


Angio-GuidedAngio-Guided 730 days730 days3.6%3.6%

2 Year Survival Free of 2 Year Survival Free of Death/MIDeath/MI


Angio-GuidedAngio-Guided730 days730 days

4.3%4.3%

Other 2 Year OutcomesOther 2 Year Outcomes



P P ValueValue

Follow-up (%)Follow-up (%) 92.792.7 94.594.5 0.310.31

Anti-anginal Anti-anginal Medications, No.Medications, No. 1.2 ±0.81.2 ±0.8 1.2 ±0.71.2 ±0.7 0.660.66

Dual Antiplatelet Dual Antiplatelet Therapy (%)Therapy (%) 33.633.6 31.431.4 0.490.49

Freedom from Freedom from Angina, (%)Angina, (%) 75.875.8 79.979.9 0.140.14

FAME study: FAME study: CONCLUSIONS (1)CONCLUSIONS (1)

Routine measurement of FFR during PCI with DES Routine measurement of FFR during PCI with DES in patients with multivessel disease, when in patients with multivessel disease, when compared to current angiography guided strategy,compared to current angiography guided strategy,furthermore:furthermore:

• is cost-saving and does not prolong the procedureis cost-saving and does not prolong the procedure

• reduces the number of stents usedreduces the number of stents used

• decreases the amount of contrast agent useddecreases the amount of contrast agent used

FAME study: FAME study: CONCLUSIONS (2)CONCLUSIONS (2)

Routine measurement of FFR during PCI with DES Routine measurement of FFR during PCI with DES in patients with multivessel disease, when in patients with multivessel disease, when compared to current angiography guided strategycompared to current angiography guided strategy

• reduces the rate of the composite endpoint of reduces the rate of the composite endpoint of

death, myocardial infarction, re-PCI and CABG death, myocardial infarction, re-PCI and CABG

at 1 year by at 1 year by ~ ~ 30% và kêt quả được duy trì đến 2 30% và kêt quả được duy trì đến 2

nămnăm• reduces mortality and myocardial infarction at reduces mortality and myocardial infarction at

1 year by 1 year by ~ ~ 35 %35 %

Outcome of Deferred Outcome of Deferred LesionsLesions513 Deferred Lesions in513 Deferred Lesions in

509 FFR-Guided Patients509 FFR-Guided Patients

2 Years2 Years

31 31 Myocardial InfarctionsMyocardial Infarctions2222

Peri-proceduralPeri-procedural

99Late Myocardial InfarctionsLate Myocardial Infarctions

88Due to a New Lesion Due to a New Lesion

or Stent-Relatedor Stent-Related

11Myocardial Infarction due toMyocardial Infarction due to

an Originally Deferred Lesionan Originally Deferred Lesion

Only 1/513 or 0.2% of deferred Only 1/513 or 0.2% of deferred lesions resulted in a late lesions resulted in a late

myocardial infarctionmyocardial infarction

Outcome of Deferred Outcome of Deferred LesionsLesions513 Deferred Lesions in513 Deferred Lesions in

509 FFR-Guided Patients509 FFR-Guided Patients

2 Years2 Years

5353 Repeat Revascularizations Repeat Revascularizations3737

in a New Lesion orin a New Lesion orin a Restenotic Onein a Restenotic One

1616Originally Deferred LesionsOriginally Deferred Lesions

66Without FFR or Without FFR or

Despite an FFR > 0.80Despite an FFR > 0.80

1010Originally Deferred LesionsOriginally Deferred Lesions

with Clear Progressionwith Clear Progression

Only 10/513 or 1.9% of deferred Only 10/513 or 1.9% of deferred lesions clearly progressed lesions clearly progressed

requiring repeat revascularizationrequiring repeat revascularization

TRƯỜNG HỢP 4:TRƯỜNG HỢP 4:Hẹp nhiều nhánh và lan tỏaHẹp nhiều nhánh và lan tỏa

nên dùng FFR xác định chỗ nên dùng FFR xác định chỗ cần nongcần nong

CHIẾN LƯỢC CHỌN MỔ BẮC CHIẾN LƯỢC CHỌN MỔ BẮC CẦU HAY NONG ?CẦU HAY NONG ?

3 Year MACE in Patients With 3 VD AND LM in the SYNTAX trial

Cumulative 3-Year Incidence of MACE in Patients With 3-Vessel CAD in the SYNTAX trial

Results For Each SYNTAX Tercile

GNL 2011

CHỌN MỔ BẮC CẦU HAY NONG ?CHỌN MỔ BẮC CẦU HAY NONG ?

1-Tiểu đường1-Tiểu đường

2-Bệnh thận mạn2-Bệnh thận mạn

3-Tái lưu thông hoàn toàn hay không ?3-Tái lưu thông hoàn toàn hay không ?

4-Chức năng thất trái4-Chức năng thất trái

5-Tiền sử mổ bắc cầu trước5-Tiền sử mổ bắc cầu trước

6-Khả năng uống 2 thuốc chống kết tập tiểu cầu6-Khả năng uống 2 thuốc chống kết tập tiểu cầu

7-Bệnh phổi tắc nghẽn-Tai biến mạch não7-Bệnh phổi tắc nghẽn-Tai biến mạch não

GNL 2011

Heart Team Approach to Heart Team Approach to UPLM or Complex CADUPLM or Complex CAD

GNL 2011

IVUS TƯƠNG ĐƯƠNG VỚI FFRIVUS TƯƠNG ĐƯƠNG VỚI FFR

TÓM TẮTTÓM TẮT

1-Đau ngực + Test (+) + Hẹp ≥ 70%1-Đau ngực + Test (+) + Hẹp ≥ 70%NongNong

2-Không đau ngực + Test (+) 2-Không đau ngực + Test (+) Nong.Nong.

3-Hẹp trung bình 50-70%3-Hẹp trung bình 50-70%FFR ≤0.75 (+)FFR ≤0.75 (+)

4- 3 nhánh, lan tỏa, thân chung4- 3 nhánh, lan tỏa, thân chung FFR ≤0.80 (+) FFR ≤0.80 (+) Syntax score, Euro scoreSyntax score, Euro scoreBàn luận phẩu thuật Bàn luận phẩu thuật viên và bệnh nhân để quyết địnhviên và bệnh nhân để quyết định

5-FFR, IVUS, VOLCANAL, OTC5-FFR, IVUS, VOLCANAL, OTC là test chức là test chức năng xâm lấn, giúp trong trường hợp phức tạp.năng xâm lấn, giúp trong trường hợp phức tạp.

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