Προσδιορισµός του ασθενή που θα ωφεληθεί από στεφανιαία επαναγγείωση

Transcription

1 Προσδιορισµός του ασθενή που θα ωφεληθεί από στεφανιαία επαναγγείωση Dr Γεώργιος Καζινάκης Καρδιολόγος, Διευθυντής ΕΣΥ, Α Πανεπιστηµιακή Καρδιολογική Κλινική ΠΓΝΘ ΑΧΕΠΑ

2

3

4 Revascularization for stable coronary artery disease

5 Rationale for revascularization S. ANGINA Angina is associated with impaired quality of life, reduced physical endurance, mental depression, and recurrent hospitalizations and outpatient visits Revascularization by PCI or CABG more effectively relieves angina, reduces the use of anti-angina drugs, and improves exercise capacity and quality of life, compared with a strategy of medical therapy alone

6 Rationale for revascularization S. ANGINA Ischaemia is of prognostic importance in patients with SCAD, particularly when occurring at low workload Revascularization relieves myocardial ischaemia more effectively than medical treatment alone. The extent, location, and severity of coronary artery obstruction as assessed by coronary angiography or coronary computed tomography (CT) angiography are important prognostic factors in addition to ischaemia and left ventricular function Eur Heart J 2011;32(8): Eur Heart J 2005;26(14):

7 Evidence basis for revascularization

8

9

10

11

12

13 Freedom from death and MI Overall survival

14 Freedom from MI Freedom from revasculatization

15

16 COURAGE

17 BARI 3D

18

19

20

21

22

23

24

25 FAME 2

26

27

28

29

30

31

32

33

34 ISCHEMIA TRIAL

35

36

37 Revascularization in non-st-segment elevation acute coronary syndromes

38 The key objectives of coronary angiography and subsequent revascularization are symptom relief and improvement of prognosis

39 NONSTEMI Non-ST-segment elevation acute coronary syndrome (NSTE- ACS) is the most frequent manifestation of ACS, and mortality and morbidity remain high and equivalent to those of patients with STEMI during long-term follow-up.. The key objectives of coronary angiography and subsequent revascularization are symptom relief and improvement of prognosis. Overall quality of life, length of hospital stay, and potential risks associated with invasive and pharmacological treatments must also be considered when deciding on a treatment strategy

40 Early risk stratification is important, in order to identify patients at high- immediate- and long-term risk for death and cardiovascular events

41

42 early invasive vs. conservative approach META-ANALYSIS meta-analysis, covering seven trials with more up-to-date adjunctive medication, showed a significant reduction in risk for all cause mortality (RR Ό 0.75; 95%CI ; P, 0.001) and myocardial infarction (RR Ό 0.83; 95% CI ; P Ό 0.012), for an early invasive vs. conservative approach at 2 years without excess of death and myocardial infarction at 1 month. J Am Coll Cardiol 2006;48(7): A further meta-analysis of eight RCTs showed a significant lower incidence of death, myocardial infarction, or rehospitalization for ACS (OR Ό 0.78; 95% CI ) for the invasive strategy at 1 year. JAMA 2008;300(1):71 80.

43 From: Benefit of Early Invasive Therapy in Acute Coronary Syndromes: A Meta-Analysis of Contemporary Randomized Clinical Trials J Am Coll Cardiol. 2006;48(7): doi: /j.jacc Figure Legend: Relative risk of all-cause mortality for early invasive therapy compared with conservative therapy at a mean follow-up of 2 years. The results show a long-term survival benefit from early invasive therapy. CI = confidence interval; FRISC-II = Fragmin and Fast Revascularization During Instability in Coronary Disease; ICTUS = Invasive Versus Conservative Treatment in Unstable Coronary Syndromes Investigators; ISAR-COOL = Intracoronary Stenting With Antithrombotic Regimen Cooling Off; RITA-3 = Randomized Intervention Trial of Unstable Angina; RR = relative risk; TIMI-18 = Thrombolysis In Myocardial Infarction-18; TRUCS = Treatment of Refractory Unstable Angina in Geographically Isolated Areas Without Cardiac Surgery; VINO = Value of First Day Coronary Angiography/Angioplasty in Evolving Non ST-Segment Elevation Myocardial Infarction. Date of download: 5/23/2015 Copyright The American College of Cardiology. All rights reserved.

44 From: Benefit of Early Invasive Therapy in Acute Coronary Syndromes: A Meta-Analysis of Contemporary Randomized Clinical Trials J Am Coll Cardiol. 2006;48(7): doi: /j.jacc Figure Legend: Relative risk of all-cause mortality for early invasive therapy compared with conservative therapy as a function of time. The results show a long-term survival benefit from early invasive therapy without an increase in early adverse events. Date of download: 5/23/2015 Copyright The American College of Cardiology. All rights reserved.

45 From: Benefit of Early Invasive Therapy in Acute Coronary Syndromes: A Meta-Analysis of Contemporary Randomized Clinical Trials J Am Coll Cardiol. 2006;48(7): doi: /j.jacc Figure Legend: Relative risk of recurrent nonfatal myocardial infarction for early invasive therapy compared with conservative therapy at a mean follow-up of 2 years. The results show a long-term reduction in myocardial infarction from early invasive therapy. Abbreviations as in Figure 1. Date of download: 5/23/2015 Copyright The American College of Cardiology. All rights reserved.

46 From: Benefit of Early Invasive Therapy in Acute Coronary Syndromes: A Meta-Analysis of Contemporary Randomized Clinical Trials J Am Coll Cardiol. 2006;48(7): doi: /j.jacc Figure Legend: Relative risk of recurrent unstable angina resulting in rehospitalization for early invasive therapy compared with conservative therapy at a mean follow-up of 13 months. The results show a long-term reduction in recurrent unstable angina from early invasive therapy. Abbreviations as in Figure 1. Date of download: 5/23/2015 Copyright The American College of Cardiology. All rights reserved.

47 In a gender-specific analysis a similar benefit was found in biomarkerpositive women, compared with biomarker-positive men. Importantly, biomarker negative women tended to have a higher event rate with an early invasive strategy, suggesting that early invasive procedures should be avoided in low-risk, troponin-negative, female patients

48 Timing of angiography and intervention

49 From: Optimal Timing of Coronary Invasive Strategy in Non ST-Segment Elevation Acute Coronary Syndromes: A Systematic Review and Meta-analysis Ann Intern Med. 2013;158(4): doi: / Figure Legend: Summary of evidence search and selection. RCT = randomized, controlled trial. Date of download: 5/24/2015 Copyright American College of Physicians. All rights reserved.

50 From: Optimal Timing of Coronary Invasive Strategy in Non ST-Segment Elevation Acute Coronary Syndromes: A Systematic Review and Meta-analysis Ann Intern Med. 2013;158(4): doi: / Figure Legend: Individual and summary ORs for mortality in randomized trials and observational studies comparing early versus delayed intervention. ABOARD = Angioplasty to Blunt the Rise of Troponin in Acute Coronary Syndromes Randomized for an Immediate or Delayed Intervention; ACUITY = Acute Catheterization and Urgent Intervention Triage Strategy; CRUSADE = Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the American College of Cardiology/American Heart Association Guidelines; D-L = DerSimonian and Laird; ELISA Date = Early of or download: Late Intervention 5/24/2015 in Unstable Angina; GRACE = Copyright Global Registry American of Acute College Coronary of Physicians. Events; ISAR-COOL All rights = Intracoronary reserved. Stenting With Antithrombotic Regimen Cooling Off; LIPSIA-NSTEMI = Leipzig Immediate Versus Early and Late Percutaneous Coronary Intervention Trial in Non ST-

51 From: Optimal Timing of Coronary Invasive Strategy in Non ST-Segment Elevation Acute Coronary Syndromes: A Systematic Review and Meta-analysis Figure Legend: Individual and summary ORs for myocardial infarction in randomized trials and observational studies comparing early versus delayed intervention. Date of download: 5/24/2015 Ann Intern Med. 2013;158(4): doi: / Copyright American College of Physicians. All rights reserved.

52 From: Optimal Timing of Coronary Invasive Strategy in Non ST-Segment Elevation Acute Coronary Syndromes: A Systematic Review and Meta-analysis Ann Intern Med. 2013;158(4): doi: / Figure Legend: Individual and summary ORs for major bleeding complications in randomized trials and observational studies comparing early versus delayed intervention. ABOARD = Angioplasty to Blunt the Rise of Troponin in Acute Coronary Syndromes Randomized for an Immediate or Delayed Intervention; ACUITY = Acute Catheterization and Urgent Intervention Triage Strategy; D-L = DerSimonian and Laird; ELISA = Early or Late Intervention in Unstable Angina; GRACE = Global Registry of Acute Coronary Events; ISAR-COOL = Intracoronary Stenting With Antithrombotic Regimen Cooling Off; LIPSIA-NSTEMI = Leipzig Immediate Versus Early and Late Percutaneous Coronary Intervention Date Trial of in download: Non ST-Segment 5/24/2015 Elevation Myocardial Infarction; Copyright OR = odds American ratio; SYNERGY= College Superior of Physicians. Yield of All the rights New Strategy reserved. of Enoxaparin, Revascularization and Glycoprotein IIb/IIIa Inhibitors; TIMACS = Timing of Intervention in Acute Coronary Syndromes.

53 From: Optimal Timing of Coronary Invasive Strategy in Non ST-Segment Elevation Acute Coronary Syndromes: A Systematic Review and Meta-analysis Ann Intern Med. 2013;158(4): doi: / Figure Legend: Individual and summary ORs for refractory ischemia and repeated revascularization in patients treated with early versus delayed intervention. Date of download: 5/24/2015 Copyright American College of Physicians. All rights reserved.

54 Optimal Timing of Coronary Invasive Strategy in Non ST-Segment Elevation Acute Coronary Syndromes: A Systematic Review and Meta-analysis Eliano P. Navarese, MD, PhD; Paul A. Gurbel, MD; Felicita Andreotti, MD, PhD; Udaya Tantry, PhD; Young-Hoon Jeong, MD, PhD; Marek Kozinski, MD, PhD; Thomas Engstrøm, MD; Giuseppe Di Pasquale, MD; Waclaw Kochman, MD; Diego Ardissino, MD; Elvin Kedhi, MD; Gregg W. Stone, MD; and Jacek Kubica, MD, PhD Data Synthesis: Seven RCTs (5370 patients) and 4 observational studies ( patients) were included. Early intervention was less than 20 hours after hospitalization or randomization for RCTs and 24 hours or less for observational studies. Meta-analysis of the RCTs was inconclusive for a survival benefit associated with the early invasive strategy (odds ratio, 0.83 [95% CI, 0.64 to 1.09]; P = 0.180); a similar result emerged from the observational studies. With early versus late intervention, the odds ratios in the RCTs were 1.15 (CI, 0.65 to 2.01; P = 0.63) and 0.76 (CI, 0.56 to 1.04; P = 0.090) for myocardial infarction and major bleeding during follow-up, respectively. Limitation: Current evidence from RCTs is limited by the small overall sample size, low numbers of events in some trials, and heterogeneity in the timing of intervention and in patient risk profiles. Conclusion: At present, there is insufficient evidence either in favor of or against an early invasive approach in the NSTE-ACS population. A more definitive RCT is warranted to guide clinical practice.

55

56 In summary, the timing of angiography and revascularization should be based on patient risk profile. Patients at very high risk (as defined above) should be considered for urgent coronary angiography (in less than 2 hours). In patients at high risk, with at least one primary high-risk criterion, an early invasive strategy within 24 hours appears to be the reasonable timescale. In lower-risk subsets, with a GRACE risk score of <140 but with at least one secondary high-risk criterion (Table 7), the invasive evaluation can be delayed without increased risk but should be performed during the same hospital stay, preferably within 72 hours of admission. In other low-risk patients without recurrent symptoms, a noninvasive assessment of inducible ischaemia should be performed before hospital discharge.

57

58 Revascularization in patients with diabetes

59 Evidence for myocardial revascularization -Stable coronary artery disease

60

61 BARI 2D trial Survival, however, was not significantly different, which may reflect a power issue or the fact that patients with more extensive myocardial perfusion abnormalities or LV function impairment were more likely to receive revascularization over time in the medical therapy group. Compared with medical therapy, the revascularization strategy at the 3-year follow-up had : a lower rate of worsening angina (8% vs. 13%, respectively; P, 0.001), new angina (37% vs. 51%, respectively; P, 0.001), and subsequent coronary revascularizations (18% vs. 33%, respectively; P, 0.001), and a higher rate of angina-free status (66% vs. 58%, respectively; P 0.003). trial. Journal of Nuclear Cardiology 2012;19(4):

62 BARI 2D trial The investigators speculated that the benefit of CABG over medical therapy emerged due to a preference for CABG rather than PCI among patients with more advanced CAD. This was further substantiated in a study of the impact of angiographic (BARI-2D score) risk stratification on outcomes. Among the CABG stratum patients with high-risk angiographic scores, the 5-year risk of death, myocardial infarction or stroke was significantly lower and amplified for those assigned to revascularization, when compared with medical therapy (24.8% vs. 36.8%, respectively; P Ό 0.005). J Am Coll Cardiol. 2013;61(7):

63 Evidence for myocardial revascularization -Acute coronary syndromes

64 acs In both the Fragmin during Instability in Coronary Artery Disease-2 (FRISC-2) and Treat angina with Aggrastat and determine Cost of Therapy with an Invasive or Conservative Strategy Thrombolysis in Myocardial Infarction 18 (TACTICS-TIMI 18) trials, an early invasive strategy in ACS patients was associated with better outcomes than with a conservative strategy; intactics-timi 18, the magnitude of the benefit to diabetic patients was greater than that to non-diabetic patients.

65 meta-analysis In a recent meta-analysis of nine RCTs with 9904 ACS patients, diabetic patients (n=1789) had a higher rate of death (9.3% vs. 3.2%; P, 0.001), nonfatal myocardial infarction (11.3% vs. 7.1%; P, 0.001), and rehospitalization with ACS (18.1% vs. 13.0%; P, 0.001) than non-diabetic patients at one year post-procedure. An early invasive strategy was associated with a similar risk reduction in death, myocardial infarction, or rehospitalization for ACS in diabetic and non-diabetic patients (RR 0.87; 95% CI vs. 0.86; 95% CI ; P for interaction 0.83).33 J Am Coll Cardiol 2012;60(2):

66 Coronary artery bypass surgery compared with percutaneous coronary interventions for multivessel disease: a collaborative analysis of individual patient data from ten randomised trials Prof Mark A Hlatky, MD Background Coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) are alternative treatments for multivessel coronary disease. Although the procedures have been compared in several randomised trials, their long-term effects on mortality in key clinical subgroups are uncertain. We undertook a collaborative analysis of data from randomised trials to assess whether the effects of the procedures on mortality are modified by patient characteristics. Methods We pooled individual patient data from ten randomised trials to compare the effectiveness of CABG with PCI according to patients' baseline clinical characteristics. We used stratified, random effects Cox proportional hazards models to test the effect on all-cause mortality of randomised treatment assignment and its interaction with clinical characteristics. All analyses were by intention to treat. Findings Ten participating trials provided data on 7812 patients. PCI was done with balloon angioplasty in six trials and with bare-metal stents in four trials. Over a median follow-up of 5 9 years (IQR ), 575 (15%) of 3889 patients assigned to CABG died compared with 628 (16%) of 3923 patients assigned to PCI (hazard ratio [HR] 0 91, 95% CI ; p=0 12). In patients with diabetes (CABG, n=615; PCI, n=618), mortality was substantially lower in the CABG group than in the PCI group (HR 0 70, ); however, mortality was similar between groups in patients without diabetes (HR 0 98, ; p=0 014 for interaction). Patient age modified the effect of treatment on mortality, with hazard ratios of 1 25 ( ) in patients younger than 55 years, 0 90 ( ) in patients aged years, and 0 82 ( ) in patients 65 years and older (p=0 002 for interaction). Treatment effect was not modified by the number of diseased vessels or other baseline characteristics. Interpretation Long-term mortality is similar after CABG and PCI in most patient subgroups with multivessel coronary artery disease, so choice of treatment should depend on patient preferences for other outcomes. CABG might be a better option for patients with diabetes and patients aged 65 years or older because we found mortality to be lower in these subgroups.

67

68

69 Revascularization in patients with chronic kidney disease

70 Influence of Renal Function on the Effects of Early Revascularization in Non-ST-Elevation Myocardial Infarction Data From the Swedish Web-System for Enhancement and Development of Evidence- Based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART) Karolina Szummer, MD; Pia Lundman, MD, PhD; Stefan H. Jacobson, MD, PhD; Staffan Schön, MD; Johan Lindbäck, MSc; Ulf Stenestrand, MD, PhD; Lars Wallentin, MD, PhD; Tomas Jernberg, MD, PhD; for SWEDEHEART registry

71 Figure 2. A, Type of revascularization across renal function groups. Karolina Szummer et al. Circulation. 2009;120: Copyright American Heart Association, Inc. All rights reserved.

72 Figure 4. Estimated hazard ratio for mortality at 1 year for patients treated either medically or with early revascularization(1416 had missing covariate). Karolina Szummer et al. Circulation. 2009;120: Copyright American Heart Association, Inc. All rights reserved.

73 Figure 3. Kaplan-Meier curve for 1-year survival according to renal function stage (pooled log-rank P<0.001). Karolina Szummer et al. Circulation. 2009;120: Copyright American Heart Association, Inc. All rights reserved.

74 Conclusionsfor SWEDEHEART registry Early invasive therapy is associated with greater 1-year survival in patients with non ST-elevation myocardial infarction and mild-to-moderate renal insufficiency, but the benefit declines with lower renal function, and is less certain in those with renal failure or on dialysis. (Circulation. 2009;120: )

75 Arterial Revascularization Therapies Study (ARTS) trial In the post hoc analysis of patients with CKD (25% of 1205 patients) in the randomized Arterial Revascularization Therapies Study (ARTS) trial, which compared CABG against multivessel PCI with the use of BMS, no difference was observed in the primary endpoint of death, myocardial infarction, or stroke (19% vs. 17%; HR 0.93; 95% CI ; P Ό 0.80) as well as mortality after 3 years of follow-up; however, the risk of repeat revascularization was reduced in favour of CABG (25% vs. 8%; HR 0.28; 95% CI ; P Ό 0.01).

76 Patients with severe chronic kidney disease and end-stage renal disease or in haemodialysis

77 US Renal Data System In the absence of data from RCTs, results from a large cohort of patients with end-stage renal disease (data from US Renal Data System) with poor 5-year survival (22 25%) suggest that CABG should be preferred over PCI for multivessel coronary revascularization in appropriately selected patients on maintenance dialysis. Compared with PCI, CABG was associated with significantly lower risks for both death and the composite of death or myocardial infarction. Selection of the most appropriate revascularization strategy must therefore account for the general condition and life expectancy of the patient, the least invasive approach being more appropriate in the most fragile and compromised patients. Chang TI,, Kazi DS,.Multivessel coronary artery bypass grafting vs. percutaneous coronary intervention in ESRD. J Am Soc Nephrol 2012;23(12):

78 Candidates for renal transplantation Candidates for renal transplantation must be screened for myocardial ischaemia, and those with significant CAD should not be denied the potential benefit of myocardial revascularization. Renal transplant recipients have been reported to have similar long-term survival after CABG and PCI Herzog CA,. Long-term outcome of renal transplant recipients in the United States after coronary revascularization procedures. Circulation 2004; 109(23):

79

80

81 arrhythmia

82 arrhythmia REVASCULARIZATION FOR TREATMENT OF ELECTRICAL STORM

83 Revascularization for treatment of electrical storm Electrical storm is a life-threatening syndrome related to incessant ventricular arrhythmias, which is most frequently observed in patients with: ischaemic heart disease, advanced systolic heart failure, valve disease, corrected congenital heart disease, and genetic disorders such as (Brugada syndrome, early repolarisation and long-qt syndromes)

84 Revascularization for treatment of electrical storm Urgent coronary angiography and revascularization should be part of the management of patients with electrical storm, as well as antiarrhythmic drug therapy and/or ablation of ventricular tachycardia.

85 arrhythmia REVASCULARIZATION AFTER OUT-OF- HOSPITAL CARDIAC ARREST

86 Immediate Percutaneous Coronary Intervention Is Associated With Better Survival After Out-of-Hospital Cardiac ArrestClinical Perspective by Florence Dumas, Alain Cariou, Stéphane Manzo-Silberman, David Grimaldi, Benoît Vivien, Julien Rosencher, Jean-Philippe Empana, Pierre Carli, Jean-Paul Mira, Xavier Jouven, and Christian Spaulding Circ Cardiovasc IntervVolume 3(3): June 15, 2010 Copyright American Heart Association, Inc. All rights reserved.

87 Patients post-rosc admitted to the intensive care unit. Florence Dumas et al. Circ Cardiovasc Interv. 2010;3: Copyright American Heart Association, Inc. All rights reserved.

88 Survival rates according to the performance and outcome of PCI. ns indicates not significant. Florence Dumas et al. Circ Cardiovasc Interv. 2010;3: Copyright American Heart Association, Inc. All rights reserved.

89 Multivariable logistic regression analysis of early predictors of survival in patients with OHCA without obvious extracardiac causes. Florence Dumas et al. Circ Cardiovasc Interv. 2010;3: Copyright American Heart Association, Inc. All rights reserved.

90 arrhythmia Revascularization plays an important role in reducing the frequency of ventricular arrhythmias in normal and mildly reduced LV function (CASS study, European Coronary Surgery Study). Thus, revascularization significantly decreased the risk for sudden cardiac death in patients with CAD and LVEF <35% [Studies of Left Ventricular Dysfunction (SOLVD)]. Likewise, simultaneous ICD implantation during CABG did not improve survival in patients with reduced LV function (CABG Patch).

91 arrhythmia Because of the protective effect of revascularisation of ventricular arrhythmias, patients with ischaemic LV dysfunction (LVEF <35%) who are considered for primary preventive ICD implantation should be evaluated for residual ischaemia and for potential revascularization targets

92

93 Repeat percutaneous coronary intervention Restenosis <10% Disease progression ( ACCOUNT UP 50% RE- INTERVANTIONS) Stent thrombosis 1-2,5% Early graft failure 5-7%

94 Late graft failure

95

96

97

98 Hybrid procedures 1) Selected patients with single-vessel disease of the LAD, or in multivessel disease but with poor surgical targets except for the LAD territory, in whom minimally invasive direct coronary artery bypass grafting (MIDCAB) can be performed to graft the LAD using the LIMA. The remaining lesions in other vessels are subsequently treated by PCI. (2) Patients who had previous CABG and now require valve surgery, and who have at least one important patent graft (e.g. IMA to LAD) and one or two occluded grafts with a native vessel suitable for PCI. (3) Combination of revascularization with non-sternotomy valve intervention (e.g. PCI and minimally invasive mitral valve repair, or PCI and transapical aortic valve implantation). (4)Stemi for culprit lesion and complete revascularization

99

100 Revascularization in patients requiring valve interventions PRIMARY INDICATION FOR VALVE INTERVENTIONS

101 Overall, 40% of patients with valvular heart disease will have concomitant CAD. Coronary angiography is recommended in all patients with valvular heart disease requiring valve surgery, apart from young patients (men,40 years and pre-menopausal women) without risk factors for CAD or when the risks of angiography outweigh the benefits In patients undergoing AVR who also have significant CAD, the combination of CABG and aortic valve surgery reduces: the rates of perioperative myocardial infarction, perioperative mortality, late mortality, and morbidity, when compared with patients not undergoing simultaneous CABG

102 TAVI PLUS CAD a recent single-centre investigation found an increased risk of cardiovascular adverse events among patients with advanced CAD (SYNTAX score >22). PCI, among patients with CAD undergoing TAVI, does not appear to increase the short-term risks of death, myocardial infarction, or stroke, compared with patients undergoing isolated TAVI; however, its impact on long-term prognosis is not well established. The selection of lesions treated by PCI is usually based on clinical presentation and angiography, as functional methods of detecting ischaemia have not been validated among patients with severe aortic stenosis. Currently, there is no conclusive evidence as to whether PCI should be performed as a staged intervention or during the same procedure, and the decision may be made on an individual basis according to the leading clinical problem, renal failure, and complexity of the underlying CAD

103 Primary indication for coronary revascularization Many patients with CAD and reduced LV function have concomitant secondary mitral regurgitation. Observational data from the STICH trial suggest that adding mitral valve repair to CABG in patients with LV dysfunction (LVEF 35%) and moderate-tosevere mitral regurgitation offers better survival than CABG alone. Likewise, in patients undergoing CABG for the clinically leading problem of CAD, aortic valves with moderate stenosis should be replaced. Case-by-case decisions by the Heart Team are needed for patients with an indication for PCI and moderate-to-severe valve disease.

104

105 Τα όνειρα που ταξιδεύουν

106 HOME MESSAGE Η βέλτιστη φαρµακευτική αγωγή και η επαναγγείωση είναι δύο σηµαντικά εργαλεία στη καθ ηµέρα πρακτική του καρδιολόγου και το κάθε ένα θα πρέπει να χρησιµοποιείται στο µέγιστο βαθµό Καλλίτερα αποτελέσµατα έχει η συνεργασία και των δύο µεθόδων όταν η µία από µόνη της δεν καλύπτει τις ανάγκες του ασθενούς.

107 Ευχαριστώ για τη προσοχή σας Καλό καλοκαίρι Μπάλος Κρήτη