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PCI for multi-vessel CAD
when & how?
Dinh Duc Huy, MD, FSCAI
Tam Duc Heart Hospital
2 Very
different
ways to treat
1 disease
Gersh and Frye.
New Engl J Med
2005;352:2235
PCI versus CABG: ASCERT Registry
189,000 stable patients =65 years old treated with either PCI or CABG
Weintraub, et al. New Engl J Med 2012;366:1457-76
Meta-Analysis of 10 randomized CABG vs. PCI
trials- 7000 patients
Impact of diabetes
Impact of age
Hlatky, et al. Lancet 2009;373:1190-97
SYNTAX study- 5 year outcomes
1800 patients with 3 vessel CAD randomized to PCI with Paclitaxel DES or CABG
Mortality
MI
MACCE
Stroke
Mohr, et al. Lancet 2013;381:629-38
Impact of Syntax Score
Serruys, et al. N Engl J Med 2009;360:961-72
Freedom trial- long term outcomes
1900 diabetics enrolled from 140 centers with mostly 1st generation DES
Farkouh, et al. N Engl J Med 2012;367:2375-84
Backgrounds- Most trials comparing PCI with CABG have not made
use of 2nd -generation drug-eluting stents.
The primary end point =
composite of death, MI, or TVR at 2 years after randomization
Park S J. N Engl J Med 2015;372:1204-12
BEST studymain results
• 27 centers in East Asia
• 880 patients
• 438 in PCI group
• 442 in CABG group
• MACEs was higher
among those who had
undergone PCI with the
use of Everolimus-DES
than among those who
had undergone CABG
Park S J. N Engl J Med 2015;372:1204-12
Longterm
clinical
outcomes
end
points
Park S J. N Engl J Med 2015;
372:1204-12
Subgroup analysis- Impact of
Diabetes, Syntax score, EuroSCORE
Park S J. N Engl J Med 2015;372:1204-12
PCI for multi-vessel CAD
1st message:
PCI is good in patients with young age, less complex
CAD (low Syntax score), and non-diabetic.
Same data from New York State registryEverolimus-eluting stent or bypass surgery for multi vessel coronary disease?
Bangalore S. N Engl J Med 2015;372:1213-22
Complete versus Incomplete Revascularization
from New York Registry
PCI
CABG
HR (95%CI)
P value
Complete Revascularization
N=1911
N=1911
Death at 3 year
2.54%
2.5%
1.08 (0.82-1.42)
0.58
Myocardial infarction
1.43%
1.37%
1.02 (0.71-1.47)
0.93
Stroke
0.42%
0.84%
0.43 (0.24-0.75)
0.003
Revascularization
5.46%
3.4%
1.55 (1.26-1.9)
<0.001
Incomplete Revascularization N=7312
N=7312
Death
3.25%
2.96%
1.03 (0.91-1.17)
0.63
Myocardial infarction
1.98%
1.07%
1.66 (1.39-1.98)
<0.001
Stroke
0.80%
1.01%
0.66 (0.52-0.83)
0.0004
Revascularization
7.70%
3.03%
2.59 (2.34-2.88)
<0.001
Complete versus Incomplete Revascularization
from BEST study
PCI
CABG
HR (95%CI)
P value
Complete Revascularization
N=215
N=295
Death at 5year
7.0%
4.4%
1.50 (0.71-3.15)
0.29
Myocardial infarction
2.3%
3.1%
0.75 (0.25-2.24)
0.60
Death , MI or Stroke
11.6%
9.5%
1.18 (0.69-2.02)
0.55
Any repeat revascularization
6.5%
3.4%
1.89 (0.84-4.25)
0.13
MACE
16.7%
12.2%
1.34 (0.84-2.13)
0.22
Incomplete Revascularization N=215
N=122
Death
6.5%
5.7%
1.22 (0.49-3.02)
0.68
Myocardial infarction
7.4%
1.6%
4.85(1.11-21.1)
0.036
Death , MI or Stroke
12.6%
9.0%
1.52(0.75-3.07)
0.24
Any repeat revascularization
15.8%
10.7%
1.58 (0.83-3.00)
0.16
MACE
23.7%
16.4%
1.59 (0.94-2.66)
0.08
PCI for multi-vessel CAD
2nd message:
Complete Revascularization is important practical issue.
FAME Study: Angio-guided verus FFR-guided PCI
1005 patients with 2-3 vessel CAD randomized to Angio or FFR-guided PCI
Fearon W. New Engl J Med 2009;360:213-24
Functional SYNTAX ScoreReclassifies > 30% of cases
Without FFR
With FFR
Nam CW, et al. J Am Coll Cardiol 2011;58:1211-8
FFR- guided PCI versus CABG- FAME 3 study
Is FFR-guided PCI with the 2nd -generation Resolute DES non-inferior to CABG
in patients with multi vessel CAD?
PCI for multi-vessel CAD
3rd message:
Ischemic-guided (by FFR) PCI may lead to better outcomes
ESC Guidelines 2014
Elective PCI for 3 Vessel Disease
CABG
Recommendation
Class
According to extent of CAD
PCI
Level
Class
Level
3 VD with SYNTAX score ≤ 22
I
A
I
B
3 VD with SYNTAX score 23-32
I
A
III
B
3 VD with SYNTAX score > 32
I
A
III
B
Thank you for your attention!
