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