CORONARY ARTERY

DISEASE: WHY TREAT

DIFFERENTLY
Dr Ainol Sahar, MD
Consultant Interventional Cardiologist, ICL Unit Head
Serdang Hospital
Malaysia
Serdang Hospital
Why treat differently?
Treatment is different based on:

• Clinical scenario
– Stable CAD
– NSTEACS
– STEMI
• Timing of presentation

• Lesion
• Modes of treatment available
Clinical scenario: Stable CAD
Level of
Indication evidence Studies
Objective large ischaemia Parisi, Folland,
IA Hartigan 98, Pepine
94
Chronic total
occlusion(CTO) IIa C Morrison et al 99
High surgical risk
(EF<35%) IIa B
Multivessel
disease/diabetics IIb C
Clinical scenario: Stable CAD
Level of
Indication evidence Studies
Parisi, Folland,
Unprotected left main IIb C Hartigan 98, Pepine
(LM) stenosis in the 94
absence of other
revascularisation options
Routine stenting of de
novo lesions IA Surreys et al 94,
Fishman et al 94
Routine stenting of de
novo lesions in venous IA Savage et al 97,
bypass grafts Hanekamp et al
2003
Key points: Stable CAD
PCI in stable CAD: PCI offered if

1. Stable CAD with symptoms,

objective evidence of ischaemia

2. Use with reservation in

– Diabetics with multivessel disease
– Unprotected left main stenosis
Clinical scenario: NSTEACS
PCI within 48 hours
Who and which patients to choose?

The Ones at
• at high acute, thrombotic risk for rapid
progression to myocardial infarction or
death

• How do you identify?

Clinical scenario: NSTEACS

NSTEACS : High risk

• Recurrent resting pain

• Dynamic ST-segment changes:

– ST- segment depression >0.1 mV or
– transient (<30 min) ST-segment elevation >0.1/ mV

• Elevated Troponin-I, Troponin-T, or CK-MB levels

Clinical scenario: NSTEACS
Criteria (cont)

• Haemodynamic instability within the observation

period
• Major arrhythmias (ventricular tachycardia,
ventricular fibrillation)

• Early post-infarction unstable angina

• Diabetes mellitus
NSTEACS: Timing of PCI
Level of Studies
Procedure Indication evidence
Early PCI High-risk "Invasive
(<48h) compared with
NSTE-ACS IA non-invasive,"
1999; Cannon
et al., 2001;
Fox et al., 2002
Immediate High-risk Neumann et al.,
PCI (<2.5 h) NSTE-ACS 2003
IIa B
Routine
stenting in de All NSTE-ACS
novo lesions IC
Clinical scenario: STEACS

• Treatment of choice in STEMI where

facility is available
• Superiority over thrombolysis is between 3
-12 hours after onset of chest pain

• Within the first 3 hours both reperfusion

strategies are equally effective
• No evidence for facilitated PCI
Clinical scenario: STEACS
Level of Studies
Procedure Indication evidence
Patients Grines et al.,
presenting <12 1993; "A clinical
Primary PCI hours after onset IA trial," 1997;
of chest Aversano et al.,
pain/other sx and 2002; Widimsky
preferably up to et al., 2000;
90 minutes after Widimsky et al.,
first contact. 2003; Andersen
et al., 2003
When
thrombolysis is
Primary PCI contraindicated 1C
Clinical scenario: STEACS
Level of Studies
Procedure Indication evidence
for patients Grines et al.,
presenting 1993; "A clinical
Primary PCI IC trial," 1997;
within >3 hours
Aversano et al.,
and <12 hours
2002; Widimsky
after onset of et al., 2000;
chest Widimsky et al.,
pain/other 2003; Andersen
symptoms et al., 2003
Primary Routine Suryapranata et
stenting during al., 1998; Grines
Stenting 1A et al., 1999;
primary PCI Stone et al., 2002
Clinical scenario: STEACS
Level of Studies
Procedure Indication evidence
If thrombolysis
Gershlick et al 2005
failed within 45-
Rescue PCI 60 minutes after 1b
starting the
infusion
Cardiogenic shock
in association
Emergency with an intra- IC
(multi-vessel) aortic balloon
pump (IABP)
PCI even >12 to <36
hrs
Clinical scenario: STEACS
Level of Studies
Procedure Indication evidence
Routine post- Up to 24 hours Scheller et al.,
thrombolysis after 2003;
1A
coronary thrombolysis, Fernandez-
independent of Aviles et al.,
angiography
angina and/or 2004; Le May
and PCI, if
ischaemia et al., 2005
applicable
Ischaemia- Pre-discharge Madsen, 1997
guided PCI angina and/or
1B
after ischaemia after
(first) STEMI
successful
treated with
thrombolysis
thrombolysis
 Treatment based on lesion
• Single vessel disease
• Multivessel disease
• Long lesions, small vessel
• Bifurcation lesions
Treatment: Single vessel disease

• Single-vessel disease with chronic stable

angina

– No difference in survival between medical and

surgical treatment of patients.

– PCI has been shown to improve symptoms and

quality of life in patients with single-vessel
disease and severe symptoms.
Treatment: Single vessel disease

• Single-vessel disease with chronic stable

angina

– Medical therapy may be preferred in patients

with mild or no symptoms
– Improvement in survival and prevention of
future events are not established.
– Multiple PTCA procedures or subsequent
surgical treatment may be necessary.
Treatment: Single vessel disease
• Single-vessel disease with chronic stable
angina

– obtain laboratory evidence of ischemia before

the procedure

– Stenoses that may lead to future coronary

events cannot be accurately identified by
angiography without evidence of ischemia or
symptoms.
Multivessel disease
(BARI) trial
• survival benefit among diabetics with multiple-
vessel disease treated with bypass surgery in
comparison with balloon angioplasty.

• Indications for contemporary CABG—

– double or triple vessel disease including high grade
proximal left anterior descending coronary artery
stenosis
– triple vessel disease in diabetic patients
– triple vessel disease in the setting of left ventricular
dysfunction
– left main disease and intractable angina after failure of
other therapies.
Indication for CABG
class I A

• the presence of significant left main stenosis

• presence of 2-vessel disease with

– significant proximal left anterior descending

(LAD) artery stenosis and either abnormal left
ventricular (LV) function (ejection fraction
<50%) or ischemia on noninvasive testing.
Indication for CABG
Class I B

• 1- or 2-vessel disease without left anterior

descending artery stenosis but with a large area
of viable myocardium and high-risk criteria on
noninvasive testing

• Unsuccessfully treated medically who have an

acceptable risk for CABG.
Indication for CABG
Other recommendations:

• patients with 1- or 2-vessel disease without

significant LAD CAD who survived sudden death
(Class I C)
• have a moderate area of viable myocardium and
documented ischemia (Class IIa B)

• 1-vessel disease with significant LAD artery

stenosis (Class IIa B)
• The last 2 indications are shared with PTCA.
CABG and PTCA
are not recommended (Class III C)
• 1- vessel disease or 2-vessel disease without LAD
CAD and mild symptoms, who have
– nondemonstrable ischemia or a small area of
viable myocardium,
– or have received inappropriate medical
treatment

• borderline stenoses and no demonstrable

ischemia
• patients with stenoses <50%.
Multivessel stenting versus CABG
What they (surgeons) say…….
BARI and [ARTS]

• PCI accomplished less complete revascularization

but did not diminish early to mid-term survival.

• These findings, coupled with the diminishment of

in-stent re-stenosis achieved with DES, have
encouraged the current practice of ischemia-
directed revascularization in patients with
multivessel coronary disease.
.
Multivessel stenting versus CABG
What they (surgeons) say…….
Surgery or Stent trial

• on bare metal stents versus CABG

• showed a 1-year and 5-year survival benefit for
CABG versus PCI, although this result has largely
been overlooked

DES versus CABG?

• Arterial Revascularization Therapies Study
(ARTS)-II trial (ACC March 05)
Multivessel DES versus CABG
(ARTS II)

607 patients :sirolimus stents

• non-randomized registry
• The outcomes of these patients were compared
to :the CABG (n = 602) and BMS arms (n = 600)
of ARTS-I

In the ARTS-II trial

• patients were more frequently diabetic (26.2%
vs. 18.2%),
• had more three-vessel CAD (54% vs. 28%),
• and had more C-type lesions (13.9% vs. 7.5%)
compared to the ARTS-I trial.
Multivessel stenting versus CABG
What they (surgeons) say…….
• There was no difference in the major
cardiovascular events at one year between the

– ARTS-II DES trial registry patients and

– CABG randomized patients in the ARTS-I trial
(10.4% vs. 11.6%)

• This study is widely interpreted as suggesting

that current generation DES have similar
outcomes as CABG; however,

– its non-randomized nature and the comparison

is with a non-concurrent CABG group
What the surgeons say…
Taggart in the 2006 Thomas B. Ferguson lecture
to The Society of Thoracic Surgeons

• these trials systematically enrolled patients

– with limited disease burden
• who had little plausible survival benefit from
surgery versus medical therapy.

• More than 90% of screened patients were

excluded from randomization, frequently due to
anatomic complexity of the coronary lesions
deeming ineligibility for entry into the PCI arm.
What the surgeons say…
• Many patients randomized in these studies did
not have left anterior descending coronary artery
disease.

• In other words, these investigations only

represented a small portion of the spectrum of
multivessel disease, but their results were used
to justify PCI in much more anatomically complex
patients.
What the surgeons say…
• Evidence from total population-based studies
such as the New York State registry indicate that
when all patients are considered

– CABG provides superior survival in the setting

of all patients with left anterior descending
coronary artery disease and at least one other
diseased vessel

• Importantly, this survival benefit is evident in a

2-year to 3-year time span.
Multivessel stenting versus CABG
What they (surgeons) say…….
• Yang et al :CABG versus PCI in the DES era
– not randomized
– clear differences in the anatomic complexity
and medical comorbidities between the
patients.

• Patients who underwent CABG

– unstable angina,
– poorer ejection fraction,
– more left anterior descending coronary artery and triple-
vessel disease, and
– a higher incidence of diabetes, which is generally
associated with more diffuse and distal coronary disease.
Multivessel stenting versus CABG
What they (surgeons) say…….
• Patients who underwent CABG achieved more
complete revascularization

– more than 95% of patients received multiple

arterial grafting.

• The almost exclusive use of multiple arterial

grafting in the surgical group and DES in the PCI
group enable evaluation of state-of-the-art
techniques with both modalities.
Multivessel stenting versus CABG
What they (surgeons) say…….
PCI in multivessel disease

• increased repeat revascularization

• increased myocardial infarction within the first
year after revascularization compared with CABG
patients, although the sample sizes were small.

• As seen in the ARTS and BARI trials, the diabetic

patients particularly benefited from surgical
revascularization.
Multivessel stenting versus CABG

CABG
• lower mortality rates than does treatment with
drug-eluting stents
• associated with lower rates of death or
myocardial infarction and repeat
revascularization.

Ischaemia driven revascularization /"incomplete

revascularization," is an inferior strategy in
patients with true multiple vessel coronary
disease.
Multivessel stenting versus CABG
What they (surgeons) say…….
• New York State registry have convincingly shown
that incomplete revascularization was highly
associated with early and late cardiac mortality.

¾ In the current discussion of surgery versus

stents, one critical question has largely been
ignored:

¾ Does re-stenosis cause recurrent cardiac events

in PCI patients?
Multivessel stenting versus CABG
What they (surgeons) say…….
Although larger observational studies and clinical
trials will continue to attempt to clarify the role of
PCI, CABG and medical therapy in multivessel
coronary disease….

• careful, stratified recruitment of specific anatomic

subsets, and pre-specified subgroup comparisons
will be required to provide definitive guidance.

• In the meantime, cardiovascular practitioners

must distill, out of the data currently available,
an optimal revascularization strategy
individualized for each patient.
Why treat differently?
Treatment is different based on:

• Clinical scenario
– Stable CAD
– NSTEACS
– STEMI
• Timing of presentation

• Lesion
• Modes of treatment available
Thank you