复杂的亚组患者中的血运重建术葛均波英文版

RevascularizationinComplexPatientSubsets:AReportfromtheACC.09andi2Summit2021ModifiedfromRobertA.Harrington’sACCpresentation葛均波复旦大学中山医院上海市心血管病研究所RevascularizationinComplexPatientSubsetsTheveryelderly(C.Grines)ComplexCADanddiabetes(V.Fuster)Chronickidneydisease(N.Lepor)PoorLVfunction(J.Bax)Vascularcomplicationsandwomen(B.Ahmed)Revascularization

InTheVeryElderlyCindyL.Grines,M.D.,F.A.C.C.WilliamBeaumontHospitalRoyalOak,Michigan,U.S.A.In-HospitalComplicationsAfterPCI:

EffectofAgeBachelor,JACC2000;36:723Complications*AfterElectivePCI

inOctogenariansDeathMIQ-waveStrokeDeath/MI/CVARenalfailureVascularcomplicationsBachelor.JACC2000;36:723*p<.001forallcomplications******

SafetyConcernsinACSCare:

TheElderlyBleedMoreYangetalJAmCollCardiol2005;46:1490-505101520<5555-6465-74≥75Agegroup(years)BloodTransfusion(%)<5555-6465-74≥75Agegroup(years)#ofAnti-platelet/coagulantsUsed*1AgentUsed2AgentsUsed≥3AgentsUsed*Aspirin,Clopidogrel,UFH,LMWH,GPIIb/IIIaInhibitorAcuteCoronarySyndromeRegistriesElderlypatientsVaguesymptomsMoreco-morbiditiesLesslikelytoreceivemedicaltreatmentsofprovenbenefitLesslikelytoreceivecathorrevascularizationWorseoutcomesPRAIS-UK,AgeandAging2005;34:61-66CRUSADE,JAMA2004;292:2096-104GRACE,AmHeartJ2005;149:67-73TACTICS-TIMI18:ElderlyACSPatientsBenefittheMostFromEarlyInvasiveStrategyAnnInternMed2004;141:186-195AMIintheElderlyAdvancedagestrongestdeterminantofearlyandlatemortality80%ofalldeathsareinpatients>60yearsoldriskofintracranialbleedingMinorityreceivelytictherapy(10%ofpatients>65yearsold)<75yrs(n=2580)75yrs(n=452)p<.001p=.01p<.001p<.001p<.001p<.001DeGeare.AJC2000;86:30PCIrestoredTIMI3flowin92%ofyoung,85%ofelderly(p=.001)OutcomeofPAMIPatientsBasedonAgeSeniorPAMI:30-DayOutcome

BasedonAgeStratifiedRandomizationPCI LyticDeathDeath/CVAD/CVA/reMIDeathDeath/CVAD/CVA/reMIAge70-80yrs(n=351)Age>80yrs(n=130)Percent(%)38%↓p=.1736%↓p=.1855%↓p=.0093p=.72p=.57p=.96EventrateNodiabetes/CVD(+)RR=1.71(1.41–2.06)Nodiabetes/CVD(−)RR=1.00Diabetes/CVD(+)RR=2.85(2.30–3.53)Diabetes/CVD(−)RR=1.71(1.25–2.33)3691215182124Diabetes+CVD0.000.050.100.150.20MonthsNodiabetes+CVDDiabetes+noCVDNodiabetes+noCVD3)RiskofCardiovascularMortality:

OASISRegistry(n=8,013)MalmbergK,etal.Circulation.2000;102:1014-1019.MortalityinPatientsAssignedtoCABGorPCIAccordingtoDiabetesStatus10Trials,7812pts,Angiopl6Trials&BMS4TrialsFU6yrsMAHlatkyet.al.Lancet2021;373:March20th2)BARI-2D:EvaluatingTreatmentOptionsforCADandDMinType2DMInclusionCriteria

Type2DM StableCADExclusionCriteriaMandatoryCABG–UnstableCAD–CADextent–LVfunctionBARI-2Committee:K.Detre,R.Frye,T.Orchard,D.Kelley,R.Nesto,B.Sobel,S.Genuth,B.ChaitmanRevascularization

ofChoice&MedicalRxRevascularization

ofChoice&MedicalRxMedicalRxMedicalRx2x2FactorialDesign(n=2300)CATHInsulin

ProvidingInsulin

SensitizingCABG(n=897)DES(n=903)All-causeMIStrokeDeath/MI/Stroke

Revasc

MACCE

Interv!!CTS!!!!!!!death%

MainResultsat1-Year

2)SYNTAXTrial(TAXUSDES)3.54.33.24.82.20.67.77.6P=0.37P=0.11P=0.003P=0.98

P<0.0001P=0.00155.913.712.117.8SerruysPetal.NEJM2021;360:961-SYNTAXhighScoreFavorsCABG2)SYNTAXTrialConclusions:

(victoryforbothcamps)

SurgicalViewpoint:

PCIwasinferiortoCABGandfailed

tomeetit’sprimaryendpoint

PCIViewpoint:

PCIwasequaltoCABGinhardendpointsofdeath&MI(eveninLM)andAnyptwilltradere-PCI(+8%)toCVAAggressivebackgroundtherapyforCADanddiabetesContemporaryPCIwithDESn=1,000Patients:DMandmultiveselCADeligibleforPCIorCABGContemporaryCABGwithorwithoutCPBn=1,000Randomized1:13)FREEDOM(NHLBI)3)FREEDOMRecruitment:1532patients20052006200720211408150312981532asof1/28/092021US:MountSinaiMedicalCenterCanada–VancouverHospandHealthSciencesCenterCanada–MontrealHeartInstituteSouthAmerica–InCorHeartInstituteSouthAmerica–InstituteDantePazzaneseCABGissuperiortoPCIwithregardstotheneedforrepeatrevascularization;DES-PCIisclosingthegapWell-poweredtrialsofatleast3-yearsdurationarerequiredbeforedefinitiveconclusionsontheclusterofdeath/MI/Strokecanbedrawn

TheSYNTAXScore

canhelpguidetherapy;morecomplexdiseasebenefitsfromCABGwhileothersachieveequalresultswithPCIMajoremphasisshouldbeputonintensiveCVriskfactormanagement.ItiscriticalthatbotharmsachieveoptimalcontrolofriskfactorsTAKEHOMEMESSAGECoronaryArteryRevascularizationinPatientswithChronicKidneyDisease.

NormanE.LeporMDFACCCedars-SinaiHeartInstituteAssociateClinicalProfessorofMedicineGeffenSchoolofMedicine-UCLAWestsideMedicalAssociatesofLosAngelesCKDandRevascularizationPCIhigherriskowingtoincreasedincidenceofacuterenalinjury,restenosisandmortalityCABhigherriskforallcausemortalityLongerpostoperativebleedingtimesHigherpostoperativebleedingratesandtransfusionrequirementsIncreasedlengthofhospitalstaysKidneyInt.1999;55:1057-1062.CONTRAST-INDUCEDNEPHROPATHY

IN-HOSPITALMORTALITYProfoundincreaseinin-hospitalmortalityinpatientsdevelopingacute

renalfailure(ARF),particularlyindiabeticpatients%IN-HOSPITALDEATHP<.0000001NoARFARFDialysisMcCullough,etal.AmJMed.1997:103–375.1.1%7.1%35.7%IncidenceofAdverseOutcomes@6MonthsWithSTEMIReperfusion-GRACERegistryJAmCollCardiolIntv2021;2:26-33IncidenceofHospitalStrokeandMajorBleedingStratifiedbyRenalFunctioninGRACERegistryJAmCollCardiolIntv2021;2:26-33SurvivalPostPCIinEVENTRegistryJAmCollCardiolIntv2021;2:37-45SurvivalAfterRevascularizationinCKD

AlbertaProvincialProjectforOutcomesinCHD(APPROACH)

Circulation2004;110:1890-95NondialysisCKDDialysis-CKDSurvivalPostCABGinESRDJAmCollCardiol2004;44:1343-1353AlgorithmForRevascularizationinCKD

ANephrologistsPerspectiveClinJAmSocNephrol2006;1:209-220ConclusionTheCKDpatientrepresentsachallengingpatientpopulationtotreatwithrevascularizationHasuniquephysiologypredisposingbothtothedevelopmentofCADandcomplicationsofrevascularizationtherapiesNorecentrandomizedtrialexperiencetoguideselectionoftherapyDataseemstosupporttheuseofPCI(DES>BMS)inpatientswithmildtomoderateCKDSurgicalrevascularizationmaybebestinthosewithESRDRevascularization

inpoorLVfunctionJeroenJBaxDeptCardiologyLeidenUniversityMedicalCenterTheNetherlandsACC2021,OrlandoGrants:GEhealthcare,BMSmedicalimaging,EdwardsLifesciences,Biotronik,StJudeMedical,BostonScientific,MedtronicIschemicLVDysfunction

Clinicalgoal: -identifypatientswithviabletissue -withpotentialtorecoverfunction -tojustifyenhancedsurgicalriskHowtoassessviability?Metabolism(glucose,FFA’s):FDG,BMIPPIntactcellmembrane:Tl-201Intactmitochondria:Tc-99mIntactperfusion:Tl-201,Tc-99m,MCEContractilereserve:stressecho/MRIConclusionsRevascularizationinlowEFhasenhancedriskAssessmentofviabilityisimportantButalso:ScarextentLVsizeandfunctionMitralregurgitationSignificantlyImprovedVascularComplicationsAmongWomenUndergoingPCI:

FromtheNorthernNewEnglandPCIRegistryBinaAhmed*,WinthropD.Piper,DavidMalenka,PeterVerLee,JohnRobb,MerleKellet,ThomasRyan,MichaelHerne,WilliamPhillipsandHaroldL.Dauerman**UniversityofVermontCollegeofMedicineVascularComplicationsDecreasingAfterPCI:

IsThisTrueforBothWomenandMen?

Dartmouth-HitchcockMedicalCenterFletcherAllenHealthCareEasternMaineMedicalCenterCatholicMedicalCenterMaineMedicalCenterPortsmouthRegionalHospital-AffiliatesYorkHospitalandWentworthDouglassHospitalConcordHospitalCentralMaineMedicalCenterNorthernNewEnglandCardiovascularDisease

StudyGroupMethodsVascularComplicationsAmongWomenareLinearlyRelatedtoAgeVascularComplicationsinWomenHaveDecreasedDramaticallyRevascularizationinComplexPatientSubsetsTheveryelderly(C.Grines)ComplexCADanddiabetes(V.Fuster)Chronickidneydi