OBJECTIVES. New Twist To Old Disease: Cardiovascular Update /9/2017. Prevention Pre-operative Coronary Artery Disease

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1 New Twist To Old Disease: Cardiovascular Update 2017 Sridevi R Pitta, M.D.,MBA, F.S.C.A.I., R.P.V.I Medical Director for STEMI, Medical Director for CV Quality Council, Interventional Cardiologist & Endovascular Medicine, Cox Health OBJECTIVES Prevention Pre-operative Coronary Artery Disease 1

2 Adults age >21yr and a candidate for statin therapy Definition for high and moderate intensity statin yes No Clinical ASCVD No LDL>190 mg/dl yes yes Age <75yrs High intensity statin (Moderate inensity if not candidate for high) Age >75yr or not candidate for high Intensity statin Moderate intensity statin High intensity statin (Moderate intensity if not candidate for high High >50% Moderate 30 to <50% Less clear other groups use Additional factors Diabetes Type Ior 2 Age 40-75yr No Estimate 10yr ASCVD Risk with Pooled cohort equations No >7.5%Estimated 10yrASCVD risk and age 40-75yr yes yes Moderate intensity statin Estimate 10yr ASCVD risk >7.5% High intensity statin Moderate to high intensity statin IMPROVE IT: Primary Endpoint 2

3 Secondary Prevention: Is the Lower, the Better for LDL-C What is the Future of LDL-Lowering Therapy? Is 10yr-year NNT for ASCVD Morbidity/Mortality a valuable tool for patient discussion? (Individual vs Public Health Considerations) 3

4 Major Recommendations for ASCVD Statin therapy Heart Healthy lifestyle habits: Foundation Should be the beginning of the discussion, not end of the discussion AHA/ACC Guidelines 2013: Primary Prevention PCSK9 INHIBITORS 4

5 Calculated LDL Cholesterol Levels over Time Robinson JG et al. N Engl J Med 2015;372: Cumulative Incidence of Cardiovascular Events Sabatine MS et al. N Engl J Med 2015;372:

6 PCKS9 Inhibitors Dramatic drops in LDL cholesterol Long term data Cost effectiveness OBJECTIVES Prevention Pre-operative Coronary Artery Disease 6

7 Timing of First DAPT Interruption and ST Through 1 year Palmerini et al. EuroPCR 2012 Restoration of Vasomotor function Free of late stent thrombosis Antiplatelet Circulation, 2000 Lancet,2009 7

8 OBJECTIVES Prevention Pre-operative Coronary Artery Disease Case Discussion 8

9 Major advances in health care occur not from results of randomized clinical trials or real world registries, but from the application of those results to complex healthcare systems which requires the successful interaction of healthcare workers and their patients. Tim Henry, MD Circulation,2012 ACC/AHA: 2013 Case Discussion 9

10 Mortality From Cardiogenic Shock according to age (<75yrs vs >75yrs) IABP IMPELLA Case Discussion 10

11 Platelet -Mediated Thrombosis Targets Meadows et al.circulation Res 2007 P2Y12 Receptor Antagonists Agent Class IPA Time to peak onset Reversiblit y Ticlopidine 250mg po bid Clopidogrel 300mg LD 600mg LD 75mg qd 150mg qd Prasugrel 60mg LD Prasugrel 10mg po qd Prasugrel 5mg po qd Thienopyridine (Prodrug) Thienopyridine (Prodrug) Thienopyridine (Prodrug) 25% 48hrs Non-reversible 5days 30-40% 35%-50% 30-35% 45%-50% 80% 60% 40% 12hrs 6hrs hrs - - Non-reversible 5days Non-reversible 7days Ticagrelor 180mg LD Ticagrelor 90mg po bid Cyclo-pentyl triazolopyrimidine 80% 70% 1-2hrs Reversible 2-5days 11

12 Treatment Algorithm for Duration of P2Y12 Inhibitor Therapy in Patients Treated with PCI Case Discussion 12

13 MAR2010 Page 37 of 53 13

14 LEG: BLEEDING COMPLICATIONS 14

15 ACUITY Study Showed TRI Had Reduced Access Bleeding P = 0.78 P = 0.18 P = 0.03 Event Rate N=11,989 N=798 Net clinical outcome was defined as composite ischemia or major bleeding Hamon M, et al. Choice of Arterial Access site and outcomes in patients with acute coronary syndromes managed with an early invasive strategy: The ACUITY trial. Eurointervention. 2009; 5: pp TRI can reduce Hospital Charges Postprocedure length of stay, days Total hospital length of stay, days Femoral N=77 Radial N=68 P Value P < P < 0.01 Total hospital charge, $ $23,389 $20,476 P < 0.01 Mann JT, et al. Stenting in acute coronary syndromes: a comparison of radial versus femoral access sites. Journal of the American College of Cardiology. 1998;32: TRI can Reduce Nurse Workload Nurse workload after invasive procedures according to the arterial access used Cathlab Ward/CCU 1000 Nurse Workload (min) P < 0.01 P < Radial Femoral Radial Femoral The transradial approach results in a significant reduction (P < 0.01) in nurse workload Amoroso G, et al. Overview of the transradial approach in percutaneous coronary intervention. J Cardiovasc Med (Hagerstown) 2007;8:

16 Patients Prefer TRI Histogram of patient preference for catheterization method rated on visual analog scale 120 Number of Patients P < Strongly Prefer Radial No Preference Strongly Prefer Femoral Cooper CJ, et al. Effect of transradial access on quality of life and cost of cardiac catheterization: a randomized comparison. American Heart Journal. 1999;138: SAME DAY DISCHARGE Amin AP et al. 16

17 DRIVE THROUGH Translational Science /Systems Applications 17

18 Case Discussion 18

19 Underutilization of Coronary Revascularization (PCI or CABG) in CAD Patients CAD CAD + CHF % of CAD pts NOT revascularize d %of CAD + CHF pts NOT revascularized Patients Diagnosed w/ Patients undergoing CA Revascularization D (PCI or CABG) - Patients Diagnosed w/ CAD & CHF Patients undergoing Revascularization (PCI or CABG) >75,000,000 patient record database analysis Commercial Payers & Medicare data, 1/2010 4/2014 Truven Health Analytics MarketScan Comercial and Medicare Supplemental Databases (01/01/2010-4/30/2014) IC AB JUN2017 CTO Prevalence and Treatment Patients with Coronary Artery Disease N = 14,439 CTO 18.4% Treatment of Patients with CTOs N = 1,697 Medical Therapy 44% CABG 26% Non-CTO PCI 20% Attempted CTO-PCI 10% Fefer et al. JACC IC AB JUN2017 Medical Therapy May Not be Enough Higher Ischemic Burden Correlated to Mortality 40% p= % p=0.023 p= Death or MI Rate 20% 10% 15 0% 0 0% (n=23) 1%-4.9% (n=141) 5%-9.9% (n=88) >10% (n=62) Ischemic Burden Shaw et al,circulation 2008;117 IC AB JUN

20 CTO Impact on Non-CTO Vessel AMI Mortality Higher 1-year Mortality Rate w/ CTO CTO is an independent predictor of mortality Vander SchaffRJ etal. Am J Cardiol2006. IC AB JUN2015 Lessons of the Heart -- Cardiovascular Disease: A Mind, Body, and Spirit Approach "the heart is not just a pump, but a home to the soul" Sridevi R Pitta, M.D.,MBA, F.S.C.A.I., R.P.V.I 3800 S National Ave Wheeler Heart Center 4th Floor Springfield, MO Office number: Fax number: