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Multivessel vs. CABG: Advances in Coronary Artery Disease Treatment

Explore the evolving landscape of coronary artery disease treatment, from medical advancements to invasive procedures like CABG and PCI. Delve into outcomes, appropriateness criteria, and real-world practice insights. Benefit from cost considerations and the importance of a multidisciplinary team approach in managing this critical condition.

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Multivessel vs. CABG: Advances in Coronary Artery Disease Treatment

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  1. CABG VSMulti Vessel PCI Hasanat Sharif MD FRCS Chief of Cardiorthoracic Surgery Aga Khan University Hospital

  2. Multivessel • Definition • Cardiologist • Cardiac Surgeon

  3. Treatment of Coronary Artery Disease • Medical • Percutaneous Intervention • Surgical Revascularization

  4. Treatment of Coronary Artery Disease • Medical • Advances in medical treatment • Anti platelet agents • ACEI/ARB • Statins • Aggressive risk factor modification

  5. Treatment of Coronary Artery Disease • Primary percutaneous intervention • Role in evolving acute myocardial infarction • Culprit vessel addressed

  6. Intervention • Interventionalist’s procedural bias • Perception • Clinician • Referring doctors and • Patient

  7. Syntax Trial

  8. Two-year outcomes for SYNTAX Kappetein AP. European Society of Cardiology 2009 Congress; September 2, 2009: Barcelona, Spain.

  9. Approriateness criteria for coronary revascularization • Refined and extended guidance beyond that provided by evidence based guidelines • Expert panel of 17 members • Year long effort to evaluate available evidence and existing guidelines

  10. Appropriateness Criteria • Inappropriate 1-3 • Uncertain 4-6 • Appropriate 7-9 • PCI inappropriate for LM CAD • PCI uncertain for 3 VCAD • PCI appropriate for acute myocardial injury • CABG appropriate for 3VCAD and LM CAD

  11. What happens in actual practice? • Catheterization laboratory cardiologists in hospitals with PCI capability were more likely to recommend patients for PCI than • Hospitals in which only catheterization was performed

  12. Indicated CABG 13% PCI 59% Both 17% Recommended 53% (34% PCI) 94% 93% PCI 5% CABG Adherence to ACC/AHA guidelines

  13. Trials • Justification • ? Economically/industry driven • ? Extending the boundaries of care • Randomization • Multi centered • Adequate numbers • Long term follow up • End point - survival

  14. Trials • Ethics • Informed patient consent • Critical to provide complete disclosure of risks/benefits • Survival • Stent thrombosis/graft closure • Risk of re intervention/complications

  15. Trials • Enrolled only 5-10% of the eligible population • ? Generalizability of results • Real life situations

  16. Trials • Propensity analysis is not perfect • Euroscore over predicts procedural risk • Cost analysis and impact on healthcare budget

  17. Observational data • Consistently show a survival advantage for CABG over PCI • STS database • Northern New England database • Duke • New York

  18. AKU Data Fifty month data Jan 2006-March 2010 • Total CABG n=2041 • Left main n= 406 (19.9%) • 1 VCAD n= 69 (3.4%) • 2 VCAD n= 257 (12.6%) • 3 VCAD n= 1715 (84%)

  19. AKU Data • Mean age 58 years (+/-11) • Males 82% • LVEF 48% (+/-14) • IMA usage 90% • CVA n = 8 (0.4%) • Mortality n = 32 (1.6%)

  20. Cost Considerations • CABG package 225K • One bare metal stent 285K • Additional stent 32K • One DES 395K • Additional stent 139K

  21. Triple vessel and left main coronary stenosis • CABG first choice for majority of patients • Consider PCI for patients with co morbidities that preclude CABG • Advances • PCI technology and • Surgical techniques/ peri operative care • Extending the boundaries of cardiovascular care

  22. Treatment of coronary artery disease • Multidisciplinary team approach • Cardiologist • Interventionalist • Cardiac Surgeon • Separate diagnosis from treatment! • Treatment option given on cath table • Scare tactics

  23. Thank You

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