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Is this a benign lesion in a benign condition?

Who Needs Angioplasty in 2008? Stable Angina. Is this a benign lesion in a benign condition?. Keith A A Fox Professor of Cardiology University & Royal Infirmary Edinburgh. Advanced angioplasty 2008. Conflicts of interest slide. Device industry: None

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Is this a benign lesion in a benign condition?

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  1. Who Needs Angioplasty in 2008? • Stable Angina Is this a benign lesion in a benign condition? Keith A A Fox Professor of Cardiology University & Royal Infirmary Edinburgh

  2. Advanced angioplasty 2008 Conflicts of interest slide Device industry: None Grant Funding: British Heart Foundation, Wellcome Trust, Medical Research Council, ESC, Sanofi-Aventis, BMS, GSK Travel & honoraria: Sanofi-Aventis, BMS, GSK

  3. Event Rates: “Primary Prevention”; Stable Angina ; non-ST Elevation ACS. Death / MI after 12 months 16 12 8 4 0 Approx 1.5% Stable CAD Death/ MI (%) Unstable angina/non Q wave MI (FRISC II) Stable angina (SAPAT) Primary Prevention (WOSCOPS) ACTION trial (stable CAD) 0 2 4 6 8 10 12 Months of follow up Wallentin L et al. Lancet 2000;356:9–16 Juul-Moller S et al. Lancet 1992;340:1421–1425 Shepherd J et al.N Engl J Med 1995;333:1301–1307 Poole-Wilson et al ACTION Lancet 2004;364:849-57.

  4. salvage of ischaemic myocardium Stable angina Non-ST elevation ACS ST Elevation MI Concepts: Extent of salvage (infarction) proportional to clinical benefit: death or MI Extent of reversible ischaemia proportional to benefit on relief of angina

  5. BHF RITA-3 25 20 15 10 Cumulative percentage 5 0 0 1 2 3 4 5 Follow-up time (years) RITA 3, 5 yr outcome: All deaths Cardiovascular Deaths: p = 0.026 odds ratio: 0.68 95% CI 0.49 – 0.95 15.1% p = 0.054 odds ratio: 0.76 95% CI 0.58 - 1.00 Conservative Intervention 12.1% Death or MI: odds ratio 0.78, 95%CI 0.61-0.99, p= 0.04 Lancet 2005: 366; 914-20

  6. PCI vs. Conservative Therapy: Stable CAD Meta-analysis (pre-COURAGE) Stable CAD & >1 stenosis: 2950 patients from randomized trials (PCI versus conservative medical therapy) Conservative Therapy n=1474 PCI n=1476 • Primary Endpoint: Death, or nonfatal MI, CABG, and PCI during follow-up (in the target vessel or other vessel/segment). Katritsis DG et al Circulation 2005; 111:2906-2912

  7. PCI vs. Conservative Therapy: Meta-Analysis • No significant difference: death, cardiac death or MI, nonfatal MI, and need for CABG # patients Katritsis DG et al Circulation 2005; 111:2906-2912

  8. Stable CAD: PCI vs ConservativeMedical Management Meta-analysis of 11 randomized trials; N = 2,950 Favours PCI Favours Medical Management 0 1 2 Risk ratio (95% Cl) Katritsis DG et al. Circulation. 2005;111:2906-12.

  9. RITA-2: PTCA vs Medical Therapy in Stable Angina(n=1000) Lancet 1997

  10. RITA-2: Impact on Grade 2 Angina (Med v PTCA) RITA-2 Lancet 1997

  11. RITA 2: Quality of Life over 3 years of Follow-up Pocock et al. JACC 2000

  12. PCI vs. Conservative Therapy: Summary • Compared with conservative therapy, PCI does not decrease mortality or the risk of MI during follow-up in patients with chronic CAD. • A trend for increased risk of MI in patients undergoing PCI was observed. • Even when analyses were limited to studies that used stents, the meta-analysis found no evidence of superiority for the PCI strategy. • Need for more randomized trials… Katritsis DG et al Circulation 2005; 111:2906-2912

  13. 2287 patients • objective evidence of myocardial ischemia • stenosis > 70% in > one proximal coronary artery Objective myocardial ischemia: ST-segment depression or T-wave inversion on the resting ECG or inducible ischemia (exercise or vasodilator stress) or at least one coronary stenosis > 80% plus classic angina “Optimal Medical Therapy“ At 5 yrs: 70% had LDL <2.20 mmol per liter) 65% and 94% had systolic and diastolic BP < 130/85 45% of patients with diabetes had Hb A1c <7% High adherence to diet, exercise, and smoking cessation BMS not DES; all patients suitable for PCI; low event rate

  14. COURAGE: Freedom from angina Boden WE et al. N Engl J Med 2007 http://www.nejm.org.

  15. COURAGE: Cumulative event rates (4.6 yrs) Boden WE et al. N Engl J Med 2007 http://www.nejm.org.

  16. COURAGE: Cumulative event rates (4.6 yrs) Boden WE et al. N Engl J Med 2007 http://www.nejm.org.

  17. COURAGE study 2000 2003 Stress Rest Stress Rest Apex Patient randomized to medical treatment only Mid Base After optimal anti-ischemic medical therapy Before treatment Case presented at ACC 2003 by Dr. Robert O´Rourke

  18. Conclusions: 2008 • PCI in stable angina… • Event rates of death & MI approx 1.5% per annum - • on optimal medical therapy • Scope to improve rate of death or MI is very limited - • even in patients with proximal stenosis & inducible ischaemia • PCI is superior to medical therapy (at least over 3 yrs) • in relief of angina, but not longer term • Greater benefit in those with more extensive ischaemia • (>5% LV) • Role of PCI in those with angina and LV dysfunction • is unresolved

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