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Revascularization in Complex Patient Subsets:A Report from the ACC.09 and i2 Summit 2009Modified from Robert A.Harringtons ACC presentation葛均波葛均波复旦大学中山医院复旦大学中山医院 上海市心血管病研究所上海市心血管病研究所Revascularization in Complex Patient SubsetsThe very elderly(C.Grines)Complex CAD and diabetes(V.Fuster)Chronic kidney disease(N.Lepor)Poor LV function(J.Bax)Vascular complications and women(B.Ahmed)Revascularization In The Very ElderlyCindy L.Cindy L.GrinesGrines,M.D.,F.A.C.C.,M.D.,F.A.C.C.William Beaumont HospitalWilliam Beaumont HospitalRoyal Oak,Michigan,U.S.A.Royal Oak,Michigan,U.S.A.In-Hospital Complications After PCI:Effect of AgeBachelor,JACC 2000;36:723Bachelor,JACC 2000;36:723Complications*After Elective PCIin OctogenariansDeathDeathMIMIQ-waveQ-waveStrokeStrokeDeath/MI/Death/MI/CVACVARenalRenalfailurefailureVascularVascularcomplicationscomplicationsBachelor.JACC 2000;36:723Bachelor.JACC 2000;36:723*p .001 for all complicationsp .001 for all complications*Safety Concerns in ACS Care:Safety Concerns in ACS Care:The Elderly Bleed MoreThe Elderly Bleed MoreYang et al Yang et al J Am Coll CardiolJ Am Coll Cardiol 2005;46:1490-5 2005;46:1490-50 05 5101015152020555 555-55-646465-65-7474 7 75 5Age group(years)Age group(years)Blood Transfusion(%)Blood Transfusion(%)55 60 years old80%of all deaths are in patients 60 years old risk of risk of intracranialintracranial bleeding bleedingMinority receive Minority receive lyticlytic therapy(10%of patients therapy(10%of patients 65 years old)65 years old)75 yrs(n=2580)75 yrs(n=2580)75 yrs(n=452)75 yrs(n=452)p .001p .001p=.01p=.01p .001p .001p .001p .001p .001p .001p .001p 80 yrs(n=130)Age 80 yrs(n=130)Percent(%)Percent(%)38%38%p=.17p=.1736%36%p=.18p=.1855%55%p=.0093p=.0093p=.72p=.72p=.57p=.57p=.96p=.96CABG(n=897)DES(n=903)All-cause MI Stroke Death/MI/Stroke Revasc MACCE Interv!CTS!death%Main Results at 1-Year 2)SYNTAX Trial(TAXUS DES)3.54.33.24.82.20.67.77.6P=0.37P=0.11P=0.003P=0.98 P 0.0001P=0.00155.913.712.117.8Serruys P et al.NEJM 2009;360:961 -SYNTAX high Score Favors CABG 2)SYNTAX Trial Conclusions:(victory for both camps)Surgical Viewpoint:PCI was inferior to CABG and failedto meet its primary endpoint PCI Viewpoint:PCI was equal to CABG in hard endpoints of death&MI(even in LM)and Any pt will trade re-PCI(+8%)to CVA Aggressive background therapy for CAD and diabetesContemporary Contemporary PCI PCI with DESwith DESn=1,000n=1,000Patients:DM and Patients:DM and multiveselmultivesel CAD eligible CAD eligible for PCI or CABGfor PCI or CABGContemporary Contemporary CABGCABGwith or without CPBwith or without CPBn=1,000n=1,000Randomized 1:1 Randomized 1:1 3)FREEDOM (NHLBI)3)FREEDOM Recruitment:1532 patients20052006200720081408150312981532as of 1/28/0920091.US:Mount Sinai Medical Center2.Canada Vancouver Hosp and Health Sciences Center3.Canada Montreal Heart Institute4.South America InCor Heart Institute5.South America Institute Dante Pazzanese CABG is superior to PCI with regards to the need CABG is superior to PCI with regards to the need for repeat for repeat revascularizationrevascularization;DES-PCI is closing the DES-PCI is closing the gapgapWell-powered trials of at least 3-years Well-powered trials of at least 3-years duration duration are required before definitive conclusions on the are required before definitive conclusions on the cluster of death/MI/Stroke can be drawncluster of death/MI/Stroke can be drawn The SYNTAX ScoreThe SYNTAX Score can help guide therapy;more can help guide therapy;more complex disease benefits from CABG while complex disease benefits from CABG while others achieve equal results with PCIothers achieve equal results with PCIMajor emphasis should be put on Major emphasis should be put on intensive CV intensive CV risk factor management.risk factor management.It is critical that both It is critical that both arms achieve optimal control of risk factorsarms achieve optimal control of risk factorsTAKE HOME MESSAGECoronary Artery Revascularization in Patients with Chronic Kidney Disease.Norman E.Lepor MD FACCCedars-Sinai Heart InstituteAssociate Clinical Professor of MedicineGeffen School of Medicine-UCLAWestside Medical Associates of Los AngelesCONTRAST-INDUCED NEPHROPATHY IN-HOSPITAL MORTALITYProfound increase in in-hospital mortality in patients developing acute Profound increase in in-hospital mortality in patients developing acute renal failure(ARF),particularly in diabetic patientsrenal failure(ARF),particularly in diabetic patients%IN-HOSPITAL DEATHP BMS)in patients with mild to moderate CKDSurgical revascularization may be best in those with ESRDSignificantly Improved Vascular Complications Among Women Undergoing PCI:From the Northern New England PCI RegistryBina Ahmed*,Winthrop D.Piper,David Malenka,Peter VerLee,John Robb,Merle Kellet,Thomas Ryan,Michael Herne,William Phillips and Harold L.Dauerman*University of Vermont College of MedicineVascular Complications Decreasing After PCI:Is This True for Both Women and Men?Dartmouth-Dartmouth-Hitchcock Hitchcock Medical Medical CenterCenterFletcher Allen Fletcher Allen Health CareHealth CareEastern Maine Eastern Maine Medical CenterMedical CenterCatholic Catholic Medical CenterMedical CenterMaine Medical CenterMaine Medical CenterPortsmouth Regional Hospital-Portsmouth Regional Hospital-Affiliates Affiliates York Hospital and Wentworth York Hospital and Wentworth Douglass Hospital Douglass HospitalConcord HospitalConcord HospitalCentral Maine Central Maine Medical CenterMedical CenterNorthern New England Northern New England Cardiovascular Disease Cardiovascular Disease Study GroupStudy GroupMethodsVascular Complications Among Women are Linearly Related to AgeVascular Complications in Women Have Decreased DramaticallyOutcomes Following Coronary Stenting in a Linked NCDR and CMS Database:A National Study of Long-Term,Real-World Outcomes of Bare-Metal and Drug-Eluting Stents650 sites;262,700 patients 65 yearsDES 217,675;BMS 45,025.UnadjustedFollow up from Medicare claims data at 3 yearsDESBMSDeath12.917.9Non fatal MI7.310.0Revasc23.424.5We thought so:patients treated with DES do better.-Slide courtesy of DR Holmes
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