B P5 C41 Percutaneous Coronary Intervention Flashcards
(166 cards)
The major value of percutaneous or surgical coronary revascularization is _____.
Relief of the symptoms and signs of ischemic CAD
Greater than ____% improvement in the ischemic burden is achieved more often with PCI, and the magnitude of the residual ischemia correlates with less frequent death and MI.
> 5%
_____ was the first randomized study comparing PTCA with conventional medical therapy to be published, where PTCA resulted in an improvement in exercise duration and freedom from angina.
ACME (Angioplasty Compared to Medicine)
Identify the Trial in SIHD and PCI
2287 patients with objective evidence of ischemia and proximal angiographic CAD (≥70% visual stenosis) were randomized to optimal medical therapy (OMT) with or without PCI.
Main study findings indicated that as an initial management strategy in patients with SIHD,PCI did not reduce death,MI,or other major cardiovascular events when added to OMT
COURAGE (Clinical Outcomes Utilization Revascularization and Aggressive DruG Evaluation) trial
Primary endpoint (death or MI) was similar in the two treatment groups for the subsets with either no to mild ischemia (18% and 19%, respectively, P = 0.92) or moderate to severe ischemia (19% and 22%, respectively, P = 0.53, interaction P value = 0.65).
Identify the trial in SIHD and PCI
Stable patients with angiographic evidence of coronary artery disease (CAD) were included.
If FFR was ≤0.80, they were randomized to either PCI along with OMT or OMT alone. If FFR was greater than 0.80, they were excluded
The primary MACE endpoint of death/MI/urgent revascularization was significantly lower in the PCI + OMT arm compared with the OMT arm (4.3% vs. 12.7%, p < 0.001)
FAME-2 Trial
This was driven predominantly by a significant reduction in the need for urgent revascularization (1.6% vs. 11.1%, p < 0.001); rates of death (0.2% vs. 0.7%, p = 0.31) and MI (3.4% vs. 3.2%, p = 0.89)
Identify the trial in SIHD and PCI
230 patients with stable angina and evidence of significant single-vessel stenosis were randomized to PCI with a current-generation DES or a placebo procedure after six weeks of medical therapy optimization
No significant difference between the PCI and medical therapy groups in the primary endpoint of exercise time increment
ORBITA (Objective Randomised Blinded Investigation with optimal medical Therapy of Angioplasty in stable angina)
Relief from ischemia appeared to be greater among the PCI patients: on DSE peak stress wall motion score index improved more with PCI
Identify the trial in SIHD and PCI
5179 patients with stable angina and stress testing showed moderate or severe reversible ischemia on imaging tests (or severe ischemia on exercise tests without imaging) and no evidence of significant left main disease or nonobstructive CAD on CTA
Randomized to angiography + revascularization when feasible + medical therapy, or initial conservative strategy of medical therapy alone
At 5 years (median 3.2 years), the primary composite outcome (death, MI, unstable angina, heart failure or resuscitated cardiac arrest) was similar between the revascularization and medical therapy groups (16.4% vs. 18.2%; difference, −1.8 percentage points; 95% CI, −4.7 to 1.0).
ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial
CABG is associated with a late mortality benefit in certain high-risk medical and anatomic subsets such as ____.
Left main disease
Three-vessel CAD
Extensive markers of higher anatomic risk for PCI (high SYNTAX)
Diabetes and significant multivessel disease
These benefits are manifested beyond 1 year after treatment and for up to 5 years of follow-up
Early periprocedural risks, particularly for stroke, are higher with CABG, and patients have a longer in-hospital recovery period.
Asymptomatic patients or those who have only mild symptoms are generally best treated with medical therapy unless _____.
(1) One or more high-grade lesions subtend a moderate to large area of viable myocardium
(2) The patient prefers to maintain a very active lifestyle or has a high-risk occupation
(3) The procedure can be performed with a high chance of success and low likelihood of complications.
Patients who are minimally symptomatic or asymptomatic should not undergo coronary revascularization if _____.
(1) Only a small area of myocardium is at risk
(2) No objective evidence of ischemia can be detected
(3) Likelihood of success is low or the chance of complications is high
The 2014 ACC/AHA guidelines suggest an important role for the patient’s functional capacity to help with decision making (Preoperative considerations). For _____, pharmacological stress testing is indicated.
Higher risk patients (mortality >1%) + poor or unclear exercise tolerance (<4 METs)
If positive, coronary angiography and revascularization where appropriate may be indicated.
Assessment of the potential risks and benefits of PCI must address five fundamental patient-specific risk factors: _____.
(1) Extent of jeopardized myocardium
(2) Baseline lesion morphology
(3) Underlying cardiac function (e.g., LV function, rhythm stability, coexisting valvular heart disease)
(4) Presence of renal dysfunction
(5) Preexisting medical comorbid conditions that may place the patient at higher risk for PCI
The _____ subtended by the treated coronary artery is the principal consideration in assessing the acute risk associated with the PCI procedure.
Proportion of viable myocardium
PCI interrupts coronary blood flow for a period of seconds to minutes, and the ability of patients to hemodynamically tolerate a sustained coronary occlusion depends on both the _____.
(1) Extent of “downstream” viable myocardium
(2) Presence and grade of collaterals to the ischemic region
Although the risk for abrupt closure has been reduced substantially with the availability of coronary stents, when other procedural complications develop—such as a _____—rapid clinical deterioration may occur that is proportionate to the extent of jeopardized myocardium
Large side branch occlusion
Distal embolization
Perforation
No-reflow
Predictors of cardiovascular collapse with a failed PCI include the _____.
(1) Magnitude of myocardium at risk
(2) Severity of the baseline stenosis
(3) Multivessel CAD
(4) Diffuse disease
Left main coronary artery disease may be present in approximately ____% of patients who undergo coronary angiography overall, and in ____% of subjects presenting with ACS
6%
12%
LM disease is associated with a poor prognosis with medical therapy, given the large myocardial territory at risk (ranging from _____% of the myocardium depending on the coronary dominance).
75% to 100%
Revascularization is recommended by current guidelines for patients with an LM stenosis greater than or equal to _____%, regardless of symptomatic status or associated ischemic burden.
Traditionally, _____ has represented the gold standard for LM revascularization.
50%
CABG
The _____ trial randomized 1905 patients with significant LM disease and a SYNTAX score of less than 32 to CABG or PCI with a second- generation DES (Xience, Abbott Vascular, Santa Clara, CA).
At 5 years, no differences were noted for PCI versus CABG for the primary end- point (22.0% vs. 19.2%, P = 0.13).
However, all-cause mortality (13.0% vs. 9.9%), non-procedural MI (6.8% vs. 3.5%) and ID-TLR rates (16.9% vs.10%) were higher with PCI compared with CABG.
Due to violation of proportional hazards, a piecemeal hazard model analysis was used.
During the first 30 days after revascularization, PCI was associated with a lower risk of the primary endpoint (HR 0.61; 95% CI, 0.42 to 0.88), which was driven by a lower incidence of (procedural) MI (HR 0.63; 95% CI,0.42 to 0.94). Between 30 days and 1 year, the primary endpoint rates between PCI and CABG were similar (HR 1.07; 95% CI, 0.68 to 1.70), as were each of its individual components. Between 1 year and 5 years, the risk for the primary endpoint was higher in the PCI arm (HR 1.61; 95% CI, 1.23 to 2.12)
EXCEL Trial
From a PCI standpoint, _____ should be considered as standard of care for LM PCI optimization.
In addition, for distal LM lesions, a _____ strategy is superior to provisional stenting or Culotte stent- ing, with significant reductions in MACE, repeat revascularization and stent thrombosis.
IVUS and OCT
Double Kiss (DK) crush 2-stent strategy
In patients with multivessel CAD, an assessment of CAD complexity, such as the _______ score, may be useful to guide revascularization (IIB, ACC AHA 2021 Revasc Guidelines)
SYNTAX score
SYNTAX score remains the most widely used and validated risk score to guide the choice of revascularization in patients with multivessel disease.
Angiographic Features Contributing to Increasing Complexity of CAD:
Multivessel disease
Left main or proximal LAD artery lesion
Chronic total occlusion
Trifurcation lesion
Complex bifurcation lesion
Heavy calcification
Severe tortuosity
Aorto-ostial stenosis
Diffusely diseased and narrowed segments distal to the lesion
Thrombotic lesion
Lesion length >20 mm
Class I indications for Revascularization of the Infarct Artery in Patients With STEMI
STEMI and ischemic symptoms for _____________
STEMI and _______________ or hemodynamic instability
STEMI who have ______________ complications
STEMI and evidence of failed reperfusion after fibrinolytic therapy, _________________ of the infarct artery
ACC AHA 2021 Revascularization Guidelines
In patients with STEMI and ischemic symptoms for <12 hours, PCI should be performed to improve survival
In patients with STEMI and cardiogenic shock or hemodynamic instability, PCI or CABG (when PCI is not feasible) is indicated to improve survival, irrespective of the time delay from MI onset
In patients with STEMI who have mechanical complications (e.g., ventricular septal rupture, mitral valve insufficiency because of papillary muscle infarction or rupture, or free wall rupture), CABG is recommended at the time of surgery, with the goal of improving survival
In patients with STEMI and evidence of failed reperfusion after fibrinolytic therapy, rescue PCI of the infarct artery should be performed to improve clinical outcomes
Identify the trial in PCI in STEMI (ICP > 12hrs <48hrs)
Examined the benefits of PCI in reducing infarct size in asymptomatic patients with STEMI and symptom onset >12 hours but <48 hours before presentation
In this small study, an invasive strategy of coronary stenting was associated with a reduction in left ventricular infarct size (primary endpoint) compared with a conservative strategy
ACC AHA 2021 Revascularization Guidelines
BRAVE - 2 (Beyond 12 Hours Reperfusion Alternative Evaluation-2) trial
An invasive strategy was associated with a reduction in adjusted 4-year mortality rate