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Current management of stable coronary artery disease. diagnosis, medical treatment and options for revascularisation

ESC webinar

18/02/2015 00:00 18/02/2015 00:00 Europe/Paris Current management of stable coronary artery disease. diagnosis, medical treatment and options for revascularisation

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European Society of Cardiology DD/MM/YYYY
Coronary Artery Disease (Chronic)

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By attending this webinar you will understand:

  • current evidence regarding the role of revascularization in stable coronary artery disease.
  • the role of clinical and angiographic scores to determine the mode of revascularization in patients with stable coronary artery disease
  • the role of invasive techniques to better define the coronary lesions that merit being revascularized.

Manel Sabate and Filippo Crea

The ESC Webinars are designed to help you improve your daily practice!

The format includes a case based presentation, online assessment and live discussions with the 2 key opinion leaders who will give you some useful tips for your daily clinical practice.



Manel Sabate answers your questions

Your questions Comments from M. Sabate
What are the options for the management of patients with chronic stable coronary disease and associated chronic decompensated liver disease During elective PCI, the choice of BMS implantation has to be considered and dual antiplatelet therapy with aspirin and clopidogrel has to be maintained for a short period (1-3 months). In this context, platelet function testing could be considered in order to change the treatment strategy. Moreover, patients with decompensated liver disease require caution in prescribing and monitoring medical treatment. In particular,  in patients with active liver disease or persistent unexplained elevations in serum transaminases to above 3 times the upper limit of normal, the use of statins is contraindicated as they may worsen liver function. Regarding ACE-inhibitors, usual dose with frequent monitoring is recommended. Again, Ivabradine and idrolazine are contraindicated.
The Role of CAC score in Low-risk patients In patients with low risk of CAD, CAC can be a starting tool; in particular, if CAC score is 0, other causes of chest pain have to be considered, if CAC score is from 1- to 400, CT coronary angiography can be performed; is CAC is grated than 400, coronary angiography can be considered.
Why you need to spect test when history is typical and to go for angio directly SPECT is suggested as a useful method of no-invasive risk stratification (e.g. patients with stress-induced reversible perfusion deficits >10% of the total LV myocardium represent a high-risk subset). Moreover, SPECT information is also important to evaluate the functional impact of eventually intermediate lesions or to define where ischemia comes from in a patient with multivessel disease. 
Don`t you think this is unstable angina?
Patient was with exercise angina since 5-6 months without any episode at rest. Although he indiceted some progression of symptoms it was difficult to confirm by clinical history. 
What do you think about SYNTAX Score II assessment in this patients?  Would 4-year mortality prediction after PCI and CABG by SYNTAX Score II help in decision-making? The Syntax score II has been showed to be better able to predict long-term mortality in patients with complex CAD than the angiographic Syntax score. However, while promising, further validation of this new score is needed before we recommed its use (Syntax II trial). 
What is the SYNTAX score on this patient?  
The SYTAX score was 26 (presneted at the end).  
Believe that the simultaneous epicardial ablation for atrial fibrillation along with CABG may be beneficial for this patient. What is your opinion?  The prospective randomized clinical trials of surgical AF ablation performed in conjunction with other cardiac surgical procedures showed a higher rates of sinus rythm in the patients undergoing AF surgery in the absence or presence of antiarrhythmic medications vs. controls. However, many of these studies are not statistically powered to determine a difference in survival between the two groups (These data are mainly from studies on mitral surgery).
Is SPECT mandatory before PCI in any patient SPECT in these patients can be judged an useful method to stratify prognosis (amount of ischemia) and to guide revascularization in patients with multivessel disease and with intermediate lesions (mainly for the ability to quantify and localize areas of ischemia). 
If the patient didn't had diabetes will the decision of cabg changed? In diabetic and no diabetic patients, the decision to use either PCI or CABG as preferred mode of revascularization should be based on anatomical factors, together with clinical factors and other logistical or local features. PCI is recommended in patients with single-vessel disease, CABG should be performed in those presenting multivessel disease but both strategies may be performed; however, in this latter case, a discussion in the heart team appears crucial expecially for diabetic patients with double-vessel disease or without LAD involvement wehere FREEDOM trial does not draw definite conclusions. Is PCI is decided upon, the use of DES has been demonstrated to be more efficacious in diabetic patients, as compared with BMS, in preventing re-stenosis. 
Is there a greater risk of revascularization syndrome using PCIs vs. CABG surgeries? There are only small size studies about this issue; however, myocardial reperfusion syndrome seems like to be more frequent among patients underwent CABG compared to those underwent PCI. Maybe, the use of off-pum surtgery can improve the final results.
Thanks for the interesting report. Male  60 years old  underwent six months ago myocardial infarction bottom wall. Performed coronary angiography revealed occlusion of the right coronary artery in the proximal segment  the remaining vessels intact. Ischemia no. Do you need to myocardial revascularization?
 If anginal symptoms refractory to medical therapy are referred and a proof of viability is provided, revascularization can be considered.
Does Bioresorbable Vascular Scaffold have a place for new guideline in CAD revascularization?   Althought further evidences will be provided by ongoing studies, BVS could be teorically implanted in patients with young age and multivessel or diffuse coronary disease. Of note, a recent study demonstrated that BVS may also decrease the angina, maybe by reducing fixed and dynamic restenosis and by improving vasomotor responses; in this context, the use of BVS can be considered also in  case of anginal symptoms refractory to OMT.
How long should we wait till we decide if patient is failing OMT?  Persistent anginal symptom? OMT should be considered a synergistic approach to revascularization. It should be emphasized that the success, or lack of the success, of an initial trial of OMT should be manifest within a relatively short period of time, thus avoiding a prolonged process of drugs are ineffective or not tolerated. Considering symptoms (change of CCS), drug side effects or limited quality of life, re-valuation of the patients and change of strategy of treatment have to be considered.  
Show the patíent Take the beta Blocker the Day of the stress echo? or not? As diagnostic test, better not take it to get better response
Do yo think that all young patient with angina and positive ergometry need a catetherism? In this context, the stratification of risk has to be taken in account, according to cardiovascular risk factors and Duke Treadmill Score. If the risk is jugded intermediate or high, the coronary angiography has to be performed. 
Did you perform the stenting in the first patient in a single session? I performed stent of RCA and OM in one session and LAD and assessment of RI in a second staged procedure
Did you perform the stenting in the first patient in a single session? I performed stent of RCA and OM in one session and LAD and assessment of RI in a second staged procedure
What do you think after first PCI (RCA and OM) was it necessary to see ischemia in LAD teritory? From the angiographic point of view LAD lesion was long and severe. As the concept is to achieve complete revascularization (once decided) I would not leave LAD untreated.
Bioabsorbable stent are approved internationally like FDA BVS is not yet approved by FDA (hopefully in the 2015)
What is the role of the use of external counerpulsation in Stable coronary disease? In my view, it has no role in stable patient. Maybe for last remaining vessel and poor EF, but such a case would not be stable... 
Appendage clossure has an effectiveness rate between 30-70% CAn we trust that? Whether surgical LAA obliteration (which does not employ a prosthesis in direct contact with the blood, thus potentially obviating the need for prolonged antiplatelet/anticoagulation therapy) reduces stroke risk has not yet been investigated in randomized, prospective studies. Currently, concomitant surgical LAA obliteration may be considered to reduce stroke risk in CABG patients with a history of AF, but randomized studies are needed to further clarify this issue. Indeed, the current data on LAA occlusion at the time of concomitant cardiac surgery reveal a lack of clear consensus because of the inconsistency of techniques used for surgical excision, the highly variable rates of successful LAA occlusion, and the unknown impact of LAA occlusion on future thromboembolic events.
Can we stop anti vit K after LAA closure although LA is dilated If needed (no tolerance to AVK), you can probably do it after a period of 2-3 months (endothelialization process complete). 
At 6 months was he in Sinus rhythm ? or did AF recur? The patient persisted in SR
How was the follow up for atrial fibrillation recurrence?  In this patient, no AF recurrence occurred so far.
Is the patient still on anticoagulation ? No, we stopped AVK 3 months after surgery
Do you stop anti-K vitamin therapy prior the CABG and for how long after the surgery?  For most types of surgery, vitamin K antagonist therapy can be resumed on the evening of or the day after surgery, once postoperative bleeding has been controlled and oral intake has resumed. For patients undergoing a surgical procedure associated with a high risk of postoperative bleeding, anticoagulant therapy can be delayed for a day or 2 before being restarted. 
How to measure FFR when multiple lesions are there in one artery When multiple lesions are present in the same artery, FFR for the entire segment has to be performed first to assess the ischemia of the entire segment. Then under hyperaemia you have to perform a pullback of the pressure wire in order to detect the place of the largest pressure step-up. Then you treat this segment and repeat the process.
How do you approach patients with stable CAD and no significant epicardial stenoses?  In patients with no significant epicardial stenosis, an FFR assessment can be performed in order to exclude the haemodynamic relevance of obvious coronary plaque—yet without the appearance of stenosis—by FFR may be helpful in selected patients before making a diagnosis of microvascular disease as the cause of the patient’s symptoms. In this context, patients have to be treated with nitrates, beta-blockers, ACE-inhibitors, statins, Xhantine derivates (aminophylline, bamifylline) and recently ranolazine and ivabradine. In the case of suspected vasospastic angina, diagnosis can be confirmed by no-invasive ECG, (ergonovine test, Holter ECG) or invasive provocative tests ( Ergonovine or Ach intra-coronary tests). Calcium antagonists and nitrates have to be prescribed in these patients.
What time should be spent after previous surgery as PCI to decide do next revascularization?  For patients with severe symptoms (CCS 3) and for those with high–risk anatomy (left main disease or equivalent, three-vessel disease or proximal LAD or depressed ventricular function), revascularization (PCI or CABG) should be performed within 2 weeks. For all other patients with SCAD, revascularization (PCI or CABG) should be performed within 6 weeks.
What patients should we send directly to cath lab? Unstable (ACS) patients.

Is the 0.8 cut of level in FFR is agreed upon Initial studies suggested that the cut-off figure of 0.75 was reliable for identifying ischaemia-producing lesions, but subsequently the 0.80 criterion has gained widespread acceptance and its clinical role has been validated in outcome studies (N Engl J Med. 2009 Jan 15;360(3):213-24; J Am Coll Cardiol 2007;49:2105–2111.)
Any role of echocardiographic assessment of coronary flow reserve? CRF using transthoracic echocardiography can be employed to objective evidence of microvascular disease by measuring diastolic coronary blood flow in the LAD at peak vasodilatation (following intravenous adenosine) and at rest. In particular, a CFR  of 2.0 strongly suggests coronary microvascular disease. However, CFR may be preserved in mild forms of coronary microvascular disease.
Do you have institutional data about the complexity of surgical revascularisation and use of BIMA at your hospital?   (as base for heart-team decision): the employment BIMA technique is rather low (10-20%) but increasing in our Center in recent years.
What antiplatelet treatment did you use after PCI In stable patients: aspirin and clopidogrel. Exception: complex PCI with many stents or complex treatment (bifurcation with 2 stent for example)
How do you assess FFR with multiple sequential stenosis? FFR with pullback has to be performed in order to detect the the largest pressure step-up. (see answer above)
I suppose the left atrium was large and the risk of recurrence of atrial fibrillation is still high: beeing provocative don't you think that the ablation procedure could be considered in some way not so useful ?   Recent studies have tried to assess whether AF is an independent risk for death. In particular, late survival was reduced as determined from propensity-matched studies and mutivariable analysis in patients undergoing CABG. Therefore, AF may not be just a marker for high-risk patients, but it may be an indepedent risk factor for increased long term morbidity and mortality. Assuming this, AF ablation may improve survival or reduce late adverse cardiac events. 
What about if the patient has ventricular arrhythmia but is relatively stable under OMT? This patient is not probably stable anymore. Revascularization exhibits a protective effect on ventricular arrhytmia; according with the recent evidences, independently from the medical treatment, patients with ischaemic LV dysfunction (LVEF<35%) who are considered for primary preventive ICP implantation, should be evaluated for residual ischaemia and for potential revascularization targets (an adjusted increased risk of VT or VF of 5% or 8%, respectively, was observed with every 1-year increment of time elapsed for revascularization, irrespectively of the mode of revascularization, potentially related to a gradual preogression of CAD).
What antiplatelet treatment did you use after PCI in the first case? We used aspirin and clopidogrel as it was stable CAD patient.
How about combining NOAC and dual antiplatet therapy in your center? We follow the Woest regimen (AVK+clopidogrel) in high risk patients. 
How to perform the stress test? (with Beta-blockers and nitrates or after withholding this medication)

Beta blockers and nitrates should be withheld for 48 hours prior to stress testing performed for the diagnosis of CAD. However, if exercise testing is performed to evaluate the effectiveness of therapy in patients with known CAD, treatment should be continued.