Dr. Miguel Quinones
The main theme of this joint ESC-ACC session was a review of current evidence to guide the use of revascularization techniques in patients with mutivessel coronary artery disease (CAD).Dr. Valentin Fuster and Dr. Fausto Pinto put the findings of the FREEDOM and SYNTAX trials into perspective.Both trials indicated superiority, in terms of long-term reduction of coronary events, of coronary artery bypass graft surgery (CABG) over coronary stents (PCI) in patients with ≥2 vessel disease and either diabetes (FREEDOM) or high angiographic SYNTAX scores.Dr. Fuster emphasized the need for longer follow up of the FREEDOM population (currently in place) and brought up a few unresolved issues, such as the finding of increased incidence of stroke with CABG, the fact that the majority of patients randomized had 3-vessel disease (thus, data available to guide decision-making in patients with 2-vessel disease is limited), and importantly, the suboptimal medical management observed in both groups (only 20% had their blood pressure, LDL and HbA1c levels at recommended targets). He emphasized the need for optimal secondary prevention in these patients and suggested a role in the future for a once-a-day “polypill” that combines a statin, an ACE inhibitor and aspirin. Dr. Pinto presented data from SYNTAX showing that patients with residual lesions that were not revascularized had more long-term events, regardless of their SYNTAX score or method of revascularization. He also suggested that diabetic patients with low risk scores may do well with PCI. Dr. Pim Tonino discussed FAME, a randomized trial in patients presenting to the catheterization laboratory for PCI, where a reduction in long-term coronary events was observed in the group randomized to PCI guided by an abnormal fractional flow reserve versus the angiographic severity, and suggested that a functional score may be superior to the SYNTAX score in predicting risk, thus resurfacing the long-term controversy of anatomy versus function. Dr. Laura Mauri discussed the ASCERT study, a large (>180,000) patient database from ACC and STS registries, where CABG resulted in lower long-term mortality in all patients regardless of subgroups (i.e. including non-diabetics and those with lower SYNTAX score) as compared to PCI. She quickly pointed out the importance of confounding factors that bias decisions by physicians and patients towards PCI or CABG, and the impossibility of deciphering them in a registry analysis.All speakers emphasized the value of a Heart Team (cardiologist and surgeon) in evaluating patients based on angiographic/functional data and clinical risk, and balancing mortality predictions with the impact of the treatment modality on quality of life, thus allowing patients to make a rational decision.
Together at last: individualising treatment in patients with multivessel coronary artery disease
Our mission: To reduce the burden of cardiovascular disease
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