PCI v CABG Dr Rod Stables The Cardiothoracic Centre Liverpool UK.
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Transcript of PCI v CABG Dr Rod Stables The Cardiothoracic Centre Liverpool UK.
![Page 1: PCI v CABG Dr Rod Stables The Cardiothoracic Centre Liverpool UK.](https://reader036.fdocuments.net/reader036/viewer/2022062519/5697bffc1a28abf838cc1a57/html5/thumbnails/1.jpg)
PCI v CABG
Dr Rod Stables
The Cardiothoracic Centre
Liverpool UK
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CABG is Alive and Well in Liverpool
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CABG is Alive and Well in Liverpool
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Liverpool Family Life
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Liverpool Family Life
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Presentation Outline
• Undisputed current facts
• PCI improves access to revascularisation
• Availability
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Access to Revascularisation - Availability
• Existing immediate capacity
• Dominant method for revascularisation
• UK PCI growth rate - 16% per annum
• UK CABG growth rate - static or negative
• Revascularisation event ratio trend > 2 : 1
• Immediate ability to grow capacity favours PCI
• NSF targets - and beyond
• New indications
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UK Activity: PCI v Isolated CABG
0
10000
20000
30000
40000
50000
60000
'91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03
BCISSCTS
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Presentation Outline
• Undisputed current facts
• PCI improves access to revascularisation
• Availability
• Patients with co-morbidity
• Patients with acute presentations
• Acute coronary syndromes
• Primary PCI for ST MI
• Cardiogenic shock
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Improved Cardiac Provision Favours PCI
• Better primary prevention
• Earlier investigation and treatment of CAD
• Aggressive early approach to occlusion
• Primary PCI for AMI
• Early PCI for non-ST elevation ACS
• Reduced incidence of
• Advanced ‘surgical’ disease’
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Presentation Outline
• Undisputed current facts
• PCI improves access to revascularisation
• PCI is cost saving
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SoS Trial - Total Costs at 1 Year
£0£1,000£2,000£3,000£4,000£5,000£6,000£7,000£8,000£9,000
£10,000
PCI CABG
Follow-up
Initial hosp
Cost = £2,609 (95% CI: £1,769 to £3,314)
£3,884
£2,412
£7,321
£1,518
Co
sts
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Presentation Outline
• Undisputed current facts
• PCI improves access to revascularisation
• PCI is cost saving
• PCI is popular with patients
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PCI - Appeal to Patients
• Experience from consent attempts in RCTs
• Shorter hospital stay
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SoS Trial: Length of Stay - Index Procedure
S urgery
Days in hospital1 8 15 22 29 36+
0
25
50
75
100
125
150PC I
Days in hospital1 8 15 22 29 36+
0
25
50
75
100
125
150
Median 3 days Median 10 days
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PCI - Appeal to Patients
• Experience from consent attempts in RCTs
• Shorter hospital stay
• Reduced immediate procedural morbidity
• Avoids GA, scars etc
• Rapid rehabilitation
• CABG option remains (short or long term)
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Presentation Outline
• Undisputed current facts
• PCI improves access to revascularisation
• PCI is cost saving
• PCI is popular with patients
• PCI is improving at a rapid pace
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PCI Evolution
• Rate of new product registration
• Techniques and application
• Adjunctive medication schedules
• Imaging equipment
• Devices / equipment
• Stents and drug eluting stents
• Improving clinical results
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Stenting and Emergency CABG
0
10
20
30
40
50
60
70
80
90
100
'92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03
Year
% s
ten
t
0
0.5
1
1.5
2
2.5
% E
m C
AB
G
% Stent
% Em.CABG
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Stenting and Restenosis Procedures
0
10
20
30
40
50
60
70
80
90
100
'92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03
Year
%
0
2
4
6
8
10
12
14
%
% Stent
% Restenosis
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Presentation Outline
• Undisputed current facts
• Historic trials favour CABG
• Reduced repeat revascularisation
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Cu
mu
lativ
e p
erc
en
tag
e
T im e since random isation (years)0 1 2 3
0
5
10
15
20
25
30
P C Ip<0.001
S u rg ery
SoS Trial: Repeat Revascularisation
Hazard ratio 3.90 (2.58 to 5.91)
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Cu
mu
lativ
e p
erc
en
tag
e
T im e since random isa tion (years)0 1 2 3
0
2
4
6
8
10
12
14
p=0.81
P C I
S urgery
SoS Trial: Death or Non-Fatal Q Wave MI
Hazard ratio 0.95 (0.63 to 1.43)
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Mortality to 1 Year
Su
rviv
al p
rob
ab
ility
T im e since random isa tion (m onths)0 3 6 9 12
0
.1
.2
.3
.4
.5
.6
.7
.8
.9
1
p=0.050P C I
S u rg ery
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Presentation Outline
• Undisputed current facts
• Historic trials favour CABG
• Reduced repeat revascularisation
• Emerging clinical data - favours PCI
![Page 27: PCI v CABG Dr Rod Stables The Cardiothoracic Centre Liverpool UK.](https://reader036.fdocuments.net/reader036/viewer/2022062519/5697bffc1a28abf838cc1a57/html5/thumbnails/27.jpg)
PCI v CABG: The Current Picture
• Non - MACCE adverse events
• SoS data
• Hospitalisation events after index revasc
• Non - MACCE : Never reported
• CABG 351 (0.7 per patient)
• PCI 156 (0.3 per patient)
• MACCE: PCI - superior safety and efficacy
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Latest Trials From TCT 2004
• ARTS 2
• Registry n = 607 MV revasc by DES
• More diabetes than ARTS 1 (26% v 18%)
• More 3 VD (54% v 28%)
• More stents (3.7 [73mm] v 2.8 [48mm])
• 6 month freedom from MACCE
• ARTS 2 - 93.6 %
• ARTS 1: PCI - 84.7% CABG - 94.5%
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‘Armies can be resisted but not an idea whose time has come.’
Victor Hugo