CCS/CAIC/CSCS Position Statement on Revascularization Multi-vessel CAD. Teo et al, Canadian Journal of Cardiology 2014;30:

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1 CCS/CAIC/CSCS Position Statement on Revascularization Multi-vessel CAD Teo et al, Canadian Journal of Cardiology 2014;30:

2 Parallel Paper: Canadian Cardiovascular Society Guidelines for the Diagnosis and Management of Stable Ischemic Heart Disease Mancini GBJ, et al Canadian Journal of Cardiology 2014;30: PURE STUDY: UNPUBLISHED DATA

3 Revascularization in multi-vessel CAD To improve prognosis or enhance quality of life or both Decision to perform revascularization either by CABG or PCI is with the understanding that the anatomy, and functional lesion assessment when applicable, is suited to effective revascularization by either technique Pursued in concert with long-term comprehensive secondary prevention therapies and durable supervised lifestyle interventions.

4 Recommendations ACS STEMI: early culprit lesion revascularization with PCI, with minimal delay. (Strong recommendation, high quality evidence) ACS other than STEMI - early culprit lesion revascularization with PCI or early complete revascularization with CABG in most patients, depending on relative stability and anatomy. (Strong recommendation, moderate quality evidence)

5 PURE STUDY: UNPUBLISHED DATA

6 Recommendations Non-ACS (being considered for revascularization) CABG or PCI in low and moderate complexity multivessel CAD, preserved LV function, particularly in patients without diabetes. (Strong recommendation, high quality evidence) CABG in patients, acceptable surgical candidates, with multi-vessel CAD and diabetes, or with complex multi-vessel CAD (Strong recommendation, high quality evidence) suggest multi-vessel PCI or CABG for symptom relief, when survival benefit uncertain, in selected patients (Conditional recommendation, low quality evidence)

7 Patients with Co-morbidities* LV dysfunction & CHF Revascularization, typically with CABG, may be considered in patients with multi-vessel CAD, severe LV dysfunction and CHF with evidence of ischemia or hibernating myocardium. PCI considered in patients with severe angina and not candidates for CABG. Chronic renal failure (CRF) PCI or CABG following individualized assessments taking into consideration comorbid conditions and impact on renal viability. COPD Patients being evaluated for CABG should undergo assessment for surgical complications and have individualized management plans formulated. *Conditions commonly encountered; low levels of evidence available for decision making. Special care and considerations required.

8 Other considerations in decision making Multiple co-morbid conditions LV dysfunction & CHF Chronic renal failure COPD Left main CAD Repeat revascularization Frailty Social factors

9 Aids to Decision Making Risk scores Society of Thoracic Surgeons (STS) score EuroSCORE SYNTAX II score Heart Team non-invasive cardiologists, interventional cardiologists, cardiac surgeons, referring/treating cardiologists/internists, and other specialists depending on co-morbidity.

10 Case History JJC (d.o.b. Jan 9, 1937) 78 yr old man, first seen March 2000, with unexplained SOB and atypical CP. Evaluations: positive ECG changes during ETT but no CP, MIBI scan: small area of ischemia in inferior wall, plan for regular MIBIs but no angiography unless symptoms changed. Remained active, no restrictions in activities. Risk factors: dyslipidemia, hypertension, quit smoking in 1985 Suboptimal compliance to medications, muscle aches and pains due to statins, intolerant to some BP meds; but seemed to be careful with diet; meds on May 7, 2015: atenolol, telmisartan, triazide, nifedipine, Vit B12 and allopurinol (no statin). Comorbidity: overall the years, developed PVD, abdominal aortic aneurysm, chronic renal impairment, also depression and chronic stable myeloma.

11 Recent Developments Routine assessment by vascular surgery in May 2015 (decision to operate): enlarging AAA, and symptomatic PVD. May 26, 2015, open repair of AAA and repair of bilateral iliac arteries. Post-op in ICU, severe retro peritoneal bleeding, severe hypotension requiring intubation, inotropic support and multiple transfusions. Situation unstable, decided not to re-operate but to stabilize first. Labs: Creatinine: May 26 (pre-op): 167, May 30: 242; Hb: May 26: 111, May 29: 65, May 30: 61 (transfusions), levels gradually stabilized with transfusions to around 90. Troponin I: May 26: 10, May 27: 203, 7608, May 28: 23099, June 1: Cardiac cath: May 26 diagnostic cath severe triple vessel disease. Approach?

12 Ventriculogram

13 RCA PURE STUDY: UNPUBLISHED DATA

14 RCA PURE STUDY: UNPUBLISHED DATA

15 Left system PURE STUDY: UNPUBLISHED DATA

16 Decisions on revascularization Final decision at cardiac catheterization lab: Two drug eluting stents + one bare metal stent to LAD with good results PTCA to first Diagonal branch Attempted PCI to small second Diagonal branch but had dissection not proceeded Complex disease to RCA and Circumflex medical therapy,? Intervention in future. PURE STUDY: UNPUBLISHED DATA

17 Follow-up When seen on August 20, 2015, symptomatically stable, no chest pain or claudication, resumed normal activities. Meds: Nifedipine ER 30 mg BID, allopurinol 300 mg daily, telmisartan 40 mg daily, Clopedogrel 75 mg daily, ECASA 81 mg daily, bisoprolol 5 mg daily, Atorvastatin 80 mg daily. August 26: Creatinine 103; Hb 111. Echo: June 08: LVEF 41%, apical LV, mid antero-lateral and anteroseptal walls akinetic, inferior walls hypokinetic July 27: LVEF 59%, apical & basal inferior walls akinetic, mid antero-septal wall hypokinetic Should he undergo further revascularization?

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