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1 PCI with DES versus CABG & syntax score Dr. Mohamed Sobhy, MD, FACC, FESC Professor of Cardiology, Alexandria University, Egypt Head of Cardiology Department President of Egyptian Society of Cardiology

2 Agenda Decision by heart team Syntax Score Syntax Trial Other new scores Appropriate Criteria 2012 Recommendation for revascularization in NSTE ACS Vascular Access Coronary stents

3 Agenda Decision by heart team Syntax Score Syntax Trial Other new scores Appropriate Criteria 2012 Recommendation for revascularization in NSTE ACS Vascular Access Coronary stents

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8 Agenda Decision by heart team Syntax Score Syntax Trial Other new scores Appropriate Criteria 2012 Recommendation for revascularization in NSTE ACS Vascular Access Coronary stents

9 How to calculate and usethe SYNTAX score - Capodanno Optimizing PCI Outcomes New Orleans,April 02,2011 Slide 5 Calculating the SYNTAX score Ferrarotto Hospital University ofcatania

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12 How to calculate and usethe SYNTAX score - Capodanno Optimizing PCI Outcomes New Orleans,April 02,2011 Slide 6 1. Select dominance coronary system Ferrarotto Hospital University ofcatania

13 How to calculate and usethe SYNTAX score - Capodanno Optimizing PCI Outcomes New Orleans, April 02, 2011 Slide 7 2. Specify diseased segments Ferrarotto Hospital University ofcatania

14 How to calculate and usethe SYNTAX score - Capodanno 3. Characterize lesion complexity Optimizing PCI Outcomes New Orleans, April 02, 2011 Slide 8 Ferrarotto Hospital University ofcatania

15 How to calculate and usethe SYNTAX score - Capodanno Optimizing PCI Outcomes New Orleans,April 02,2011 Slide 9 4. Add another lesion / Calculate the score Ferrarotto Hospital University ofcatania

16 Agenda Decision by heart team Syntax Score Syntax Trial Other new scores Appropriate Criteria 2012 Recommendation for revascularization in NSTE ACS Vascular Access Coronary stents

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25 MACCE to 4 Years by SYNTAX Score Tercile Low Scores (0-22) Cumulative Event Rate (%) 0 0 CABG (N=275) TAXUS (N=299) P=0.57 Overall 28.6% 26.1% Death CVA MI Months Since Allocation Death, CVA or MI CABG 8.9% 4.0% 4.2% 48 PCI 8.3% 1.4% 6.6% P value % 14.4% 0.87 Revasc. 13.6% 20.0% 0.04 Cumulative KM Event Rate 1.5 SE; log-rank P value SYNTAX Overall RCT 4-year Outcomes November 8th, 2011 TCT San Francisco, CA Slide 5 Site-reported Data; ITT population

26 MACCE to 4 Years by SYNTAX Score Tercile Intermediate Scores (23-32) Cumulative Event Rate (%) CABG (N=300) TAXUS (N=310) P=0.006 Overall 32.0% Death CVA MI 21.5% Death, CVA or MI CABG 9.3% 3.6% 3.6% 14.9% PCI 11.1% 2.0% 9.0% 17.3% P value Months Since Allocation 48 Revasc. 10.9% 20.7% Cumulative KM Event Rate 1.5 SE; log-rank P value SYNTAX Overall RCT 4-year Outcomes November 8th, 2011 TCT San Francisco, CA Slide 6 Site-reported Data; ITT population

27 MACCE to 4 Years by SYNTAX Score Tercile High Scores ( 33) Cumulative Event Rate (%) 0 0 CABG (N=315) TAXUS (N=290) P< Months Since Allocation Overall % 23.6% Death CVA MI Death, CVA or MI CABG 8.4% 3.7% 3.9% PCI 16.1% 3.5% 9.3% P value % 22.7% 0.01 Revasc. 11.4% 28.8% <0.001 Cumulative KM Event Rate 1.5 SE; log-rank P value SYNTAX Overall RCT 4-year Outcomes November 8th, 2011 TCT San Francisco, CA Slide 7 Site-reported Data; ITT population

28 MACCE to 4 Years CABG (N=897) TAXUS (N=903) Before 1 year * 12.4% vs 17.8% P=0.002 Cumulative Event Rate (%) 1-2 years* 5.7% vs 8.3% P=0.03 P< years* 4.8% vs 6.7% P= years* 4.2% vs 7.9% P= % 23.6% Months Since Allocation Cumulative KM Event Rate 1.5 SE; log-rank P value;*binary rates ITT population SYNTAX Overall RCT 4-year Outcomes November 8th, 2011 TCT San Francisco, CA Slide 4

29 Agenda Decision by heart team Syntax Score Syntax Trial Other new scores Appropriate Criteria 2012 Recommendation for revascularization in NSTE ACS Vascular Access Coronary stents

30 How to calculate and usethe SYNTAX score - Capodanno Optimizing PCI Outcomes New Orleans,April 02,2011 Slide 16 Why do we need both clinical and angiographic variables? <19 SYNTAX score >27 5% 10% 8% % 18% 17% 3-6 EuroSCORE 11% 8% 5% >6 Clinical and angiographic scores summarize very different information in 255 patients with unprotected LM Low Spearman rank correlation coefficient between SYNTAX score and EuroSCORE (RS=0.204, p = 0.001) The frequency of patients for each cross-tabulation cell is shown within a rectangle that is proportional in size to the frequency Ferrarotto Hospital University ofcatania Capodanno et al, Am Heart J 2010:159:103-9

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33 How to calculate and usethe SYNTAX score - Capodanno Optimizing PCI Outcomes New Orleans,April 02,2011 Slide 17 The Global Risk Classification (GRC) EuroSCORE >6 SYNTAX score < >27 L L I L L I * log rank test; n = 255 LM patients undergoing PCI Cardiac death free survival (%) Cardiac death free survival (%) I I H P = 0.004* LOW MIDDLE HIGH SYNTAX score 96.1% 94.6% 78.1% Time (months) P < 0.001* LOW MIDDLE HIGH 0 12 Time (months) GRC 98.4% 84.0% 68.6% 24 Ferrarotto Hospital University ofcatania Capodanno et al, Am Heart J 2010:159:103-9

34 How to calculate and usethe SYNTAX score - Capodanno Optimizing PCI Outcomes New Orleans,April 02,2011 Slide 19 Conclusions The SYNTAX score is an effective method of indicating risk in patients having PCI together with aiding the selection of revascularisation strategy. Increasing SYNTAX scores are related to increased adverse outcomes in left main PCI, whereas outcomes of CABG are independent of SYNTAX score. Adding clinical variables improves the discrimination abilityof the SYNTAX score alone. Combined risk scores such as the GRC identify a sizeable cohort of LM patients with very different outcomes following PCI. dcapodanno@gmail.com Ferrarotto Hospital University ofcatania

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37 Agenda Decision by heart team Syntax Score Syntax Trial Other new scores Appropriate Criteria 2012 Recommendation for revascularization in NSTE ACS Vascular Access Coronary stents

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41 Agenda Decision by heart team Syntax Score Syntax Trial Other new scores Appropriate Criteria 2012 Recommendation for revascularization in NSTE ACS Vascular Access Coronary stents

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44 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions American College of Cardiology Foundation and American Heart Association, Inc.

45 PCI in Specific Clinical Situations: UA/NSTEMI I IIa IIb III An early invasive strategy (i.e., diagnostic angiography with intent to perform revascularization) is indicated in UA/NSTEMI patients who have refractory angina or hemodynamic or electrical instability (without serious comorbidities or contraindications to such procedures).

46 PCI in Specific Clinical Situations: UA/NSTEMI (cont.) I IIa IIb III An early invasive strategy (i.e., diagnostic angiography with intent to perform revascularization) is indicated in initially stabilized UA/NSTEMI patients (without serious comorbidities or contraindications to such procedures) who have an elevated risk for clinical events.

47 PCI in Specific Clinical Situations: UA/NSTEMI (cont.) I IIa IIb III The selection of PCI or CABG as the means of revascularization in the patient with ACS should generally be based on the same considerations as those without ACS.

48 PCI in Specific Clinical Situations: UA/NSTEMI (cont.) I IIa IIb III No Benefit An early invasive strategy (i.e., diagnostic angiography with intent to perform revascularization) is not recommended in patients with extensive comorbidities (e.g., liver or pulmonary failure, cancer) in whom a. The risks of revascularization and comorbid conditions are likely to outweigh the benefits of revascularization, b. There is a low likelihood of ACS despite acute chest pain, or c. Consent to revascularization will not be granted regardless of the findings.

49 Agenda Decision by heart team Syntax Score Syntax Trial Other new scores Appropriate Criteria 2012 Recommendation for revascularization in NSTE ACS 2010 Vascular Access Coronary stents

50 Vascular Access I IIa IIb III The use of radial artery access can be useful to decrease access site complications.

51 Agenda Decision by heart team Syntax Score Syntax Trial Other new scores Appropriate Criteria 2012 Recommendation for revascularization in NSTE ACS 2010 Vascular Access Coronary stents

52 Coronary Stents I IIa IIb III I IIaIIb III I IIaIIb III PCI/STEMI UA/NSTEMI Before implantation of DES, the interventional cardiologist should discuss with the patient the need for and duration of DAPT and the ability of the patient to comply with and tolerate DAPT. DES is useful as an alternative to BMS to reduce the risk of restenosis in cases in which the risk of restenosis is increased and the patient is likely to be able to tolerate and comply with prolonged DAPT.

53 Coronary Stents (cont.) I IIa IIb III Balloon angioplasty or BMS should be used in patients with high bleeding risk, inability to comply with 12 months of DAPT, or with anticipated invasive or surgical procedures within the next 12 months during which time DAPT may be interrupted.

54 Coronary Stents (cont.) I IIa IIb III Harm I IIa IIb III Harm PCI with coronary stenting should not be performed if the patient is not likely to be able to tolerate and to comply with DAPT. DES should not be implanted if the patient is not likely to be able to tolerate and comply with prolonged DAPT, or this cannot be determined prior to stent implantation.

55 Conclusion Heart Team is mandatory for decision You should follow and be strict to the guidelines DES is the stent for multi vessel disease with diabetics in patients with low or intermediate syntax score CABG is indicated in high syntax score and low or intermediate Euro score.

56 See you next year! June 2012