What do the guidelines say?

Transcription

1 Percutaneous coronary intervention in 3-vessel disease and main stem What do the guidelines say? Nothing to disclose Dariusz Dudek Institute of Cardiology, Jagiellonian University Krakow, Poland The European Association of Percutaneous Cardiovascular Interventions (EAPCI) The Chair of the Scientific Programme Commitee

2 Eur Heart J. 2010;31(20): ESC Guidelines on myocardial revascularization 2010 Indications for revascularization in stable angina or silent ischaemia Subset of CAD by anatomy Class Level For prognosis Left main >50%* I A Any proximal LAD >50%* I A 2VD or 3VD with impaired LV function I B Proven large area of ischaemia (>10% LV)* I B Single remaining patent vessel >50% stenosis I C 1VD without proximal LAD and without >10% ischaemia III A For symptoms Any stenosis >50% with limiting angina or angina equivalent, unresponsive to OMT I A Dyspnoea/CHF and >10% LV ischaemia/viability supplied by >50% stenotic artery Ila B No limiting symptoms with OMT III C * with documented ischaemia or FFR <0.80 for angiographic diameter stenoses 50 90%.

3 ESC Guidelines on myocardial revascularization 2010 Indications for CABG vs. PCI in stable patients with lesions suitable for both procedures & low predicted surgical mortality Subset of CAD by anatomy Favours CABG Favours PCI 1VD or 2VD - non-proximal LAD IIb C I C 1VD or 2VD - proximal LAD I A IIa B 3VD simple lesions, full functional revascularization achievable with PCI, SYNTAX score <22 I A IIa B 3VD complex lesions, incomplete revascularization achievable with PCI, SYNTAX score >22 I A III A Left main (isolated or 1VD, ostium/shaft) I A IIa B Left main (isolated or 1VD, distal bifurcation) I A IIb B Left main + 2VD or 3VD, SYNTAX score <32 I A IIb B Left main + 2VD or 3VD, SYNTAX score 33 I A III B Eur Heart J. 2010;31(20):

4 ESC Guidelines on myocardial revascularization 2010 Revascularization in stable angina Potential indications for ad hoc PCI vs. revascularization at an interval ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J. 2010;31(20):

5 ACC/AHA PCI Guidelines Focused Updates Recommendations for PCI for Unprotected Left Main Coronary Artery Disease PCI of the LMCA with stents as an alternative to CABG may be considered in patients with anatomic conditions that are associated with a low risk of PCI procedural complications and clinical conditions that predict an increased risk of adverse surgical outcomes (IIb, B) J. Am. Coll. Cardiol. 2009;54;

6 Eur Heart J. 2010;31(20): ESC Guidelines on myocardial revascularization Clear information 2010 Multidisciplinary decision making (Heart Team) how to establish the Heart Team The creation of a Heart Team serves the purpose of a balanced multidisciplinary decision process (clinical/non-invasive cardiologist, cardiac surgeon, and interventional cardiologist). Additional input may be needed from general practitioners, anaesthesiologists, geriatricians, or intensivists. Consensus on the optimal revascularization treatment should be documented.

7 Eur Heart J. 2010;31(20): ESC Guidelines on myocardial revascularization 2010 Multidisciplinary In ACS (STEMI, decision making (Heart Team) NSTEMI) culprit lesion should be Global indication for Heart Team consultation treated with no delay for Heart Team opinion Other ACS refers to Unstable Angina

8 Eur Heart J. 2010;31(20): ESC Guidelines on myocardial revascularization 2010 Multidisciplinary decision making (Heart Team) How to provide Heart Team consultation for PCI center without on-site cardiac surgery? Hospital teams without a cardiac surgical unit or with interventional cardiologists working in an ambulatory setting should refer to standard evidence-based protocols designed in collaboration with an expert interventional cardiologist and a cardiac surgeon, or seek their opinion for complex cases.

9 Eur Heart J. 2010;31(20): ESC Guidelines on myocardial revascularization 2010 Multidisciplinary decision making (Heart Team) Ad hoc PCI or revascularization after Heart Team discussion? Standard protocols compatible with the current Guidelines may be used to avoid the need for systematic case-by-case review of all diagnostic angiograms.

10 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J. 2010;31(20): Revascularization in ST-segment elevation myocardial infarction (ESC Guidelines) Potential indications for ad hoc PCI vs. revascularization at an interval

11 Revascularization in ST-segment elevation myocardial infarction (ESC Guidelines) With the exception of cardiogenic shock, PCI (whether primary, rescue, or post-fibrinolysis) should be limited to the culprit stenosis (IIa, B) 1 Except for patients in cardiogenic shock, only the culprit lesion should be dilated in the acute setting. Complete revascularization of the non-culprit lesions may be performed at a later time point depending on the remaining ischaemia 2 1. ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J. 2010;31(20): ESC STEMI Guidelines. Eur Heart J Dec;29(23):

12 Heart Team after MR Guidelines 2010 When to stop after coronary angiography? STEMI &NSTEMI: non culprit lesion(s) after culprit lesion treatment unless hemodynamicaly unstable. UA: when stable clinical status and: proximal LAD, ostial Cx, MVD and LM Stable angina: 3VD, 2VD with prox LAD and/or ostial Cx, 1VD in prox LAD, LM stenosis. Eur Heart J. 2010;31(20):

13 Revascularization in NSTEACS New NSTE ACS Guidelines 2011 Recommendations Class Level The revascularization strategy (ad-hoc culprit lesion PCI/ multivessel PCI/CABG) should be based on the clinical status as well as the disease severity, i.e. distribution and angiographic lesion characteristics (e.g. SYNTAX score), according to the local Heart Team protocol. I C In patients stabilized after an episode of ACS, the choice of revascularization modality can be made as in stable CAD. In multivessel disease the decision is more complex and the choice has to be made between culprit lesion PCI, multivessel PCI, CABG, or a combined (hybrid) revascularization in some cases. The revascularization strategy should be based on the clinical status as well as the severity and distribution of the CAD and the lesion characteristics ESC Guidelines for the management of ACS in patients presenting without persistent ST-segment elevation, ESC Congress 2011

14 Revascularization in NSTEACS New NSTE ACS Guidelines 2011 Recommendations Class Level The revascularization strategy (ad-hoc culprit lesion PCI/ multivessel PCI/CABG) should be based on the clinical status as well as the disease severity, i.e. distribution and angiographic lesion characteristics (e.g. SYNTAX score), according to the local Heart Team protocol. I C However, protocols based on the SYNTAX score should be designed by the Heart Team at each institution, defining specific anatomical criteria and clinical subsets that can be treated ad hoc or transferred directly to CABG. After culprit lesion PCI, patients with scores in the two higher terciles of the SYNTAX score should be discussed within the Heart Team, in light of functional evaluation of the remaining lesions. This also includes the assessment of comorbidities and individual characteristics. ESC Guidelines for the management of ACS in patients presenting without persistent ST-segment elevation, ESC Congress 2011

15 ESC Guidelines for the management of ACS in patients presenting without persistent ST-segment elevation, ESC Congress 2011 New NSTEACS ESC Guidelines Coronary artery bypass surgery The proportion of patients with NSTE-ACS undergoing bypass surgery during initial hospitalization is 10%. The general consensus is to wait for h in patients who had culprit lesion PCI and have additional severe CAD. Surgery should be performed during the same hospital stay in patients with LMCA or three-vessel disease involving the proximal LAD.

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