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O papel da intervenção coronária percutânea no tratamento da angina estável e isquemia silenciosa Marcelo J C Cantarelli, MD, PhD, FACC, FSCAI H. Bandeirantes H. Leforte H. Rede D’Or São Luiz Anália Franco Grupo AngioCardio

O papel da intervenção coronária percutânea no tratamento da

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O papel da intervenção coronária percutânea no tratamento da angina

estável e isquemia silenciosa

Marcelo J C Cantarelli, MD, PhD, FACC, FSCAI H. Bandeirantes – H. Leforte

H. Rede D’Or São Luiz Anália Franco

Grupo AngioCardio

50 anos de revascularização miocárdica - Trials

0

Roger VL, Go AS, Lloyd-Jones DM, et al. Heart Disease and Stroke Statistics—2011 update: a

report From the American Heart Association. Circulation 2011;1231.)

Incidence of stable angina pectoris from the Framingham Heart Study (1980–2002/2003)

stratified by age and sex.

Dificuldades para mensurar evidências

• Heterogeneidade clínica - assintomáticos, sintomáticos, diabéticos, já revascularizados

• Heterogeneidade funcional - diferentes cargas de isquemia documentada em testes não invasivos

• Heterogeneidade angiográfica – uni e multiarteriais, lesões difusas e oclusões totais

• Ausência muitas vezes da interrelação entre elas • Rápido avanço dos materiais e técnicas

intervencionistas e aparecimento de novos fármacos

Objetivos do tratamento

• Melhorar a sobrevida

• Aliviar sintomas

• Prevenir IAM, ICC e isquemia maligna (TV, FV, Morte súbita)

Metanálise de 11 estudos: ICP ou tratamento clínico – 1992 – 2001

Katritsis DG, Ioannidis JPA. Percutaneous coronary intervention versus conservative therapy in nonacute

coronary artery disease: a meta-analysis. Circulation 2005;111(22):2906–2912.)

Morte qq causa

Morte cardíaca e IAM

Kastrati, A et al - J Am Coll

Cardiol 2008;52(11):894–904

17 trials ICP ou TCO follow-up 51 meses

17 trials ICP ou TCO follow-up 51 meses

Kastrati, A et al - J Am Coll

Cardiol 2008;52(11):894–904

17 trials ICP ou TCO follow-up 51 meses

Kastrati, A et al - J Am Coll

Cardiol 2008;52(11):894–904

Comparative outcomes for patients who do and do not undergo percutaneous coronary intervention for stable coronary artery

disease in New York (2003-2008)

Mortalidade/IAM

Sobrevida

Hannan E L et al. Circulation 2012; 125: 1870-1879

Comparative outcomes for patients who do and do not undergo percutaneous coronary intervention for stable coronary artery

disease in New York (2003-2008)

IAM

Nova revascularização

Hannan E L et al. Circulation 2012; 125: 1870-1879

Sem diferenças: pacientes ≤ 65 anos e p uniarteriais

Isquemia Silenciosa

Davies RF, Goldberg AD, Forman S, et al. Asymptomatic Cardiac Ischemia Pilot (ACIP) study two-year follow-up: outcomes of patients randomized to initial strategies of medical therapy versus revascularization. Circulation 1997;95(8):2037–2043

Dea

th o

r M

I

Smith PK, Califf RM, Tuttle RH, et al. Selection of surgical or percutaneous coronary intervention provides

differential longevity benefit. Ann Thorac Surg 2006;82(4):1420–1429.)

Figure 2. Observed cardiac death rates over the follow-up period in patients undergoing revascularization (Revasc) vs medical therapy (Medical Rx) as a function of the amount of

inducible ischemia.

Hachamovitch R et al. Circulation. 2003;107:2900-2907

Copyright © American Heart Association, Inc. All rights reserved.

Figure 4. Log hazard ratio for revascularization (Revasc) vs medical therapy (Medical Rx) as a function of % myocardium ischemic based on final Cox proportional hazards model.

Hachamovitch R et al. Circulation. 2003;107:2900-2907

Copyright © American Heart Association, Inc. All rights reserved.

Figure 3. Kaplan–Meier survival for the subset of 105 patients with moderate to severe pretreatment ischemia including a comparison of patients with ≥5% reduction in ischemic myocardium compared with those without a significant reduction in ischemia after 6 to 18

months of PCI+OMT or OMT. Overall event-free survival was 83.8% vs 66.0% for patients with vs without significant ischemia reduction (P=0.001).

Shaw L J et al. Circulation. 2008;117:1283-1291 Copyright © American Heart Association, Inc. All rights reserved.

SYNTAX Trial – 3 anos follow-up

Kappetein A P et al. Eur Heart J 2011; 32:2125-2134

Lesão isolada de DA proximal – RM vs ICP Mortalidade

Kappor JR et al. J Am Coll Cardiol Intv, 2008; 1:483-491

Lesão isolada de DA proximal – RM vs ICP Nova revascularização

Proximal LAD: PCI versus CABG TVR and Relief of Angina

Target Vessel Revascularization

Angina Relief

CABG PCI

1 Year

95.5%

84.6%

5 Year

84.2%

75.6%

Kapoor JR et al. J Am Coll Cardiol Intv, 2008; 1:483-491 Kappor JR et al. J Am Coll Cardiol Intv, 2008; 1:483-491

Proximal LAD: PCI versus CABG TVR and Relief of Angina

Target Vessel Revascularization

Angina Relief

CABG PCI

1 Year

95.5%

84.6%

5 Year

84.2%

75.6%

Kapoor JR et al. J Am Coll Cardiol Intv, 2008; 1:483-491

Alívio da angina

1 ano: 4% vs. 19.5% 5 anos: 7.3% vs. 33.5%) P<0,001

P=0,01

Diabetes tipo 2 e estratégias de tratamento da DAC

The BARI 2D Study Group – NEJM 2009; 360:2503-2515

Freedom Trial

Freedom Trial

Revascularização e IRC

Survival After Coronary Revascularization Among Patients With Kidney Disease (APPROACH) Hemmelgarn BR et al. Circulation 2004;110:1890-1895

Fame 2 Trial

Fame 2 Trial

COURAGE Trial

Relief of Angina: PCI versus Optimal Medical Therapy

PCI Optimal Medical Rx P value

1 year 66% 58% <0.001

3 years 72% 67% P=0.02

5 years 74% 72% NS

All PCI was with Bare metal Stents

In the OMT group 32.6% of patient crossed over

Todos receberam stents convencionais TMO 32,6% de cross-over para ICP

Alívio de Angina

Indicações para revascularização

CABG vs PCI

ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 Appropriate Use Criteria

for Coronary Revascularization Focused Update

A Report of the American College of Cardiology Foundation Appropriate Use

Criteria Task Force, Society for Cardiovascular Angiography and

Interventions, Society of Thoracic Surgeons, American Association for

Thoracic Surgery, American Heart Association, American Society of Nuclear

Cardiology, and the Society of Cardiovascular Computed Tomography

J Am Coll Cardiol, 2012; 59:857-881, doi:10.1016/j.jacc.2011.12.001

(Published online 30 January 2012).

© 2012 by the American College of Cardiology Foundation

Scope of Indications

The clinical presentation (e.g., acute coronary syndrome, stable angina)

Severity of angina (asymptomatic, Canadian Cardiovascular Society [CCS] Class

I, II, III, or IV)

Extent of ischemia on noninvasive testing and the presence or absence of other

prognostic factors, such as congestive heart failure, depressed left ventricular

function, or diabetes

Extent of medical therapy

Extent of anatomic disease (1-, 2-, 3-vessel disease, with or without proximal LAD

or left main coronary disease)

Copyright ©2012 American College of Cardiology Foundation. Restrictions may apply.

Patel, M. R. et al. J Am Coll Cardiol 2012;59:857-881

Appropriate Use Ratings by Low-Risk Findings on Noninvasive Imaging Study and

Asymptomatic (Patients Without Prior Bypass Surgery)

Copyright ©2012 American College of Cardiology Foundation. Restrictions may apply.

Patel, M. R. et al. J Am Coll Cardiol 2012;59:857-881

Appropriate Use Ratings by Intermediate-Risk Findings on Noninvasive Imaging Study

and CCS Class I or II Angina (Patients Without Prior Bypass Surgery)

Copyright ©2012 American College of Cardiology Foundation. Restrictions may apply.

Patel, M. R. et al. J Am Coll Cardiol 2012;59:857-881

Appropriate Use Ratings by High-Risk Findings on Noninvasive Imaging Study and CCS

Class III or IV Angina (Patients Without Prior Bypass Surgery)

Copyright ©2012 American College of Cardiology Foundation. Restrictions may apply.

Patel, M. R. et al. J Am Coll Cardiol 2012;59:857-881

Method of Revascularization of Multivessel Coronary Artery Disease

Pontos importantes

• A ICP, por reduzir o volume de isquemia, traz importante benefício clinico aos pacientes com doença obstrutiva com maior efeito no controle dos sintomas e aumento da tolerância ao exercício.

• Faltam evidências diretas do incremento de sobrevida e redução definitiva de eventos cardiovasculares maiores em toda a população de pacientes com DCA crônica

Pontos importantes

• Pacientes de alto risco para eventos adversos, incluindo aqueles com ICC, IRC, DM e isquemia documentada extensa, tem maior potencial de benefícios mensuráveis com a revascularização (ICP ou RM) em adição à terapêutica medicamentosa ótima