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COMPLETE REVASCULARIZATION IN ELDERLY - When it’s contraindicated. Giuseppe Biondi-Zoccai S. Giovanni Battista “Molinette” Hospital University of Turin. 3rd International Interventional Forum – Turin, 18 January 2008 (h 12.20-12.40). Learning goals.
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COMPLETE REVASCULARIZATION IN ELDERLY - When it’s contraindicated Giuseppe Biondi-Zoccai S. Giovanni Battista “Molinette” Hospital University of Turin 3rd International Interventional Forum – Turin, 18 January 2008 (h 12.20-12.40)
Learning goals • How do you define complete revascularization (MVD)? • What is the risk-benefit balance of culprit vs multivessel PCI in stable MVD? • What is the risk-benefit balance of culprit vs multivessel PCI in acute MVD? • When is complete revascularization contraindicated in the elderly?
To achieve a greater understanding, let us begin with an example from a related field…
Learning goals • How do you define complete revascularization (MVD)?
Defining revascularization • Anatomically complete: PCI of every occluded or stenotic epicardial vessel • Functionally complete: PCI of every occluded or stenotic epicardial vessel of adequate size and supplying a zone of viable myocardium • Incomplete (culprit only): PCI of occluded or stenotic epicardial vessel identified by comprehensive clinical judgement as responsible for signs/symptoms of ischemia • Incomplete (truly): everything else
Defining revascularization • Anatomically complete: PCI of every occluded or stenotic epicardial vessel • Functionally complete: PCI of every occluded or stenotic epicardial vessel of adequate size and supplying a zone of viable myocardium • Incomplete (culprit only): PCI of occluded or stenotic epicardial vessel identified by comprehensive clinical judgement as responsible for signs/symptoms of ischemia • Incomplete (truly): everything else
Scope of the problem ALL P<0.05 % Wiemer et al, AHJ 2004
Hazards of MVD stenting Orlic et al, JACC 2004
Learning goals • What is the risk-benefit balance of culprit vs multivessel PCI in stable MVD?
TIME trial supports PCI in elderly Pfisterer et al, JAMA 2003
TIME trial Pfisterer et al, JAMA 2003
Yet PCI based on oculostenotic reflex is not always justified in stable MVD
Symptomatic benefits in the COURAGE trial Boden et al, NEJM 2007
Learning goals • What is the risk-benefit balance of culprit vs multivessel PCI in acute MVD?
Early invasive management in elderly with ACS: TACTICS Study Brener et al, Am J Cardiol 2002
Yet PCI based only on oculostenotic reflex is also not justified in acute MVD Hirsch et al, Lancet 2007
What about complete PCI in STEMI? Single vs multivessel treatment during primary angioplasty: results of the multicentre randomised HEpacoat for cuLPrit or multivessel stenting for Acute Myocardial Infarction (HELP AMI) Study.Di Mario C, Sansa M, Airoldi F, Sheiban I, Manari A, Petronio A, Piccaluga E, De Servi S, Ramondo A, Colusso S, Formosa A, Cernigliaro C, Colombo A, Monzini N, Bonardi MA. Int J Cardiovasc Intervent. 2004;6(3-4):128-33.
% 53 vs 69 minutes, p<0.05 22,330€ vs 20,382€, p=NS 35% vs 17% p=NS 0 vs 4%, p=NS Di Mario et al, Int J Cardiovasc Intervent 2004
Learning goals • When is complete revascularization contraindicated in the elderly?
Learning goals • When is complete revascularization contraindicated in the elderly? • Mainly when its expected benefits do not overwhelm the expected risks
COURAGE Nuclear Substudy P=0.037 Risk of death or MI (%) Shaw et al, AHA 2007
Extremely diffuse disease or challenging lesions Sianos et al, EI 2005
SYNTAX score Sianos et al, EI 2005
Risk of renal failure Mehran et al, JACC 2004
Risk of renal failure Mehran et al, JACC 2004
Increased bleeding risk Nikolsky et al, EHJ 2007
Increased bleeding risk Nikolsky et al, EHJ 2007
Take home messages • Current data disCOURAGE from extensive multivessel PCI based only on angiographic assessment in stable MVD • No definite benefits have been shown from multivessel PCI in patients with acute CAD and MVD • According to evidence available to date, PCI of non-culprit vessels cannot thus be recommended routinely
Take home messages • Thus, major contraindications to complete revascularization in elderly are: • Lack of clear-cut signs/symptoms of ischemia • Extremely diffuse disease or challenging lesions • Increased bleeding or renal failure risk • Lack of compliance or poor life expectancy • Individualized clinical decision making is pivotal to maximize benefit and minimize risks
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