Complete or partial revascularization in patients with chronic stable angina: why and how? Peter M Pollak MD ©2011 MFMER | 3138928-1 Disclosure Relevant Financial Relationship(s) • None Off Label Usage • None ©2012 MFMER | 3208595-2 Revascularization, Ischemia, & Completeness… • Challenges in defining complete revascularization • Presence & degree of ischemia is associated with adverse outcomes • Relief of ischemia associated with improved outcomes • More complete revascularization is associated with improved outcomes • Surgical revascularization appears more durable than percutaneous revascularization ©2011 MFMER | 3138928-3 Challenges in assessing complete revascularization • There has been no universal definition • Anatomic criteria using stenosis >50% have been common • Fails to describe physiology • Fails to account for viability • Jeopardy score & Functional SYNTAX may be better • Factors associated with IR are known predictors of adverse outcome • CTO, Calcific disease, poor EF, DM, CKD, prior MI ©2011 MFMER | 3138928-4 Angiographic stenosis ≠ functional stenosis 60% 20% Gössl M et al Circ Cardiovasc Interv 2012;5:597-604 WHY REVASCULARIZE? ©2011 MFMER | 3138928-6 Ischemic Burden Treated Medically Cardiac death (%) Cardiac Death at 1.9 Years 0% – 5% (n = 7,119) (n = 1,331) – 10% (n = 716) 11 – 20% (n = 545) > 20% (n = 252) Total myocardial ischemia (%) myocardial ischemia cardiac death Hachamovitch R, et al Circulation 2003;107:2900-2907 Ischemia Reduction in COURAGE Survival Stratified by Residual Ischemia Event-free survival 100 80 0% < 5% – 10% > 10% 60 40 20 More Residual ischemia more events Shaw LJ, et al Circulation 2008;117:1283-1291 Revascularization vs Medical Therapy in Stable CAD: A Network Meta-Analysis 100 RCTs – 93,553 patients randomized Follow-up of 262,090 patient-years Pts randomized Follow-up 6,846 30,628 PY Med Rx Pts randomized CABG Follow-up 8,920 38,709 PY PTCA Pts randomized Follow-up Pts randomized Follow-up 14,802 25,096 PY EES 6,920 17,678 PY BMS Pts randomized Follow-up Pts randomized Follow-up 2,035 3,134 PY Pts randomized Follow-up R-ZES 9,187 27,384 PY 15,787 45,467 PY PES Pts randomized Follow-up 12,457 28,828 PY E-ZES SES Pts randomized Follow-up 19,391 45,679 PY The European Myocardial Revascularization Collaboration: BMJ, 2014 Revascularization vs Medical Therapy in Stable CAD: A Network Meta-Analysis Primary Endpoint: All-Cause Mortality 100 RCTs – 93,553 patients randomized 262,090 patient-years of follow-up 5,346 events for analysis Surgery CABG Early PCI techniques PTCA BMS Early-generation DES PES SES E-ZES New-generation DES R-ZES EES Rate ratio (95% CI) 0.80 (0.70, 0.91) 0.85 (0.68, 1.04) 0.92 (0.79, 1.05) 0.92 (0.75, 1.12) 0.91 (0.75, 1.10) 0.88 (0.69, 1.10) 0.65 (0.42, 1.00) 0.75 (0.59, 0.96) 0.3 Favors revascularization Favors medical therapy The European Myocardial Revascularization Collaboration: BMJ, 2014 Subsequent CABG Study, year Events/subgroup CR n/N IR n/N Risk ratio (95% CI) Mariani, 2001 1/44 2/147 1.67 (0.15-17.9) Kloeter, 2001 1/101 6/149 0.24 (0.03-2.01) van den Brand, 2002 8/406 17/170 0.19 (0.08-0.44) Ijsselmuiden, 2004 10/104 12/109 0.87 (0.39-1.93) Hannan, 2006 443/6817 1115/15,128 0.88 (0.79-0.98) Srinivas, 2007 15/135 77/1466 0.90 (0.52-1.55) Tamburino, 2008 3/212 9/296 0.46 (0.12-1.69) 56/3499 164/7795 0.76 (0.56-1.02) Hannan, 2009 Pooled 0.70 (0.52-0.95) 0.01 0.1 CR 10 100 IR P (heterogeneity)=0.03 I2=55.4 Aggarwal et al: EuroIntervention 7:1095, 2012 Repeat PCI Study, year Events/subgroup CR n/N IR n/N Risk ratio (95% CI) Mariani, 2001 5/44 14/147 1.19 (0.45-3.12) Kloeter, 2001 33/101 29/149 1.67 (1.09-2.58) van den Brand, 2002 53/406 17/170 1.30 (0.77-2.18) – – 0.94 (0.64-1.38) 22/104 34/109 0.67 (0.42-1.07) Srinivas, 2007 Ijsselmuiden, 2004 Hannan, 2006 Tamburino, 2008 Hannan, 2009 1602/6817 3372/13,807 0.96 (0.91-1.01) 34/212 93/296 0.51 (0.35-0.72) 472/3499 1617/7795 0.65 (0.59-0.71) Pooled 0.87 (0.69-1.11) 0.01 0.1 CR 10 100 IR P (heterogeneity)