PCI: Indications & Future Directions
S. Chiu Wong MD, FACC Associate Professor of Medicine Weill Medical College of Cornell University Director, Cardiac Catheterization Laboratories The New York Presbyterian Hospital-Cornell Campus
ACC Symposium: Cardiology Update 2004
Great Wall International Congress of Cardiology
October 17, 2004 Beijing China
History and Current Status of PCI
Indications of Percutaneous Coronary Intervention
Future Development
Novel Drug Eluting Stents
Expanding Beyond Coronary Vasculature
Newer Imaging Technologies
Cellular Approach: Angiogenesis and Myogenesis
PCI: Indications & Future Directions Summary
History and Current Status of PCI
Indications of Percutaneous Coronary Intervention
Future Development
Novel Drug Eluting Stents
Expanding Beyond Coronary Vasculature
Newer Imaging Technologies
Cellular Approach: Angiogenesis and Myogenesis
PCI: Indications & Future Directions
PCI: Indications & Future Directions Milestones of PTCA
1939-1985
Balloon Angioplasty NHLBI Registry 1977-81 PTCA Results
Angiographic Success –88%
Procedural Mortality – 1%
Non-fatal MI – 4.3%
Emergency CABG – 3.4%
New Device Angioplasty How Good is Balloon PTCA?
(N=458)
1985-86
(N=140)
1992-93
(N=500)
1991-92
(N=202)
1991-93
(N=1399)
1991-92
Balloon Angiographic Success
PCI: Indications & Future Directions Restenosis Following PTCA
An Achilles' heel for interventional cardiology……
PCI: Indications & Future Directions How Good is Balloon PTCA?
Balloon PTCA Restenosis Rate
I+II
SVG’s
New Device Angioplasty Two Major Goals
1. Increase Procedure Success
2. Reduce Restenosis
Angiographic Success
complications
New Device Angioplasty How Good is New Device Angioplasty?
Angiographic Success
Overall
(N=2267)
Registry
(N=215)
DCA
(N=512)
Stent
(N=259)
PCI: Indications & Future Directions Restenosis Post Stent Vs. Balloon
Restenosis (%)
**
*
*P=0.046,**P=0.02
NEJM 1994
25%
31%
U.S. Percutaneous Intervention Volume Total PTCA and Stents Cases
(21%)
(37%)
(42%)
(44%)
(70%)
(80%)
(80%)
(80%)
(83.4%)
Impact of New Device Interventions NHLBI 1985-1986 Vs. Dynamic Registry 1997-1998
Williams et al, Circ 2000;102:2945-2951
P<0.001
P<0.001
P<0.001
P<0.001
P<0.001
Impact of New Device Interventions NHLBI 1985-1986 Vs. Dynamic Registry 1997-1998
Williams et al, Circ 2000;102:2945-2951
P<0.001
P<0.001
P=0.001
Landmark in Interventional Cardiology
Circa 2003/4
Circa 1808
Circa 1886
PCI: Indications & Future Directions SIRIUS: Key Clinical Findings
Dramatic Reduction in late loss
83%
Marked Reduction in TVF
69%
9-month Event Free Survival in the Cypher Group
92.7%
PCI: Indications & Future Directions
Current Treatment Options In Coronary Artery Disease
At 5, 7, and 10 years, 10.2%, 15.8%, and 26.4% of patients, respectively, assigned to CABG had died, compared with 15.8%, 21.7%, and 30.5% of their medically assigned counterparts. Risk reductions (RR) were significant at all 3 time points (RR=0.61, 0.68, 0.83).
Yusuf S et al. Lancet. 1994; 344: 563–570
PCI: Indications & Future Directions
Medical Vs. CABG in the Treatment of CAD
In meta-analysis of 7 randomized trial, 1324 patients were assigned to CABG and 1325 to medical therapy between 1972 and 1984
Mortality
* Tertiles of risk determined by a stepwise risk score incorporating both clinical (age, angina, MI, diabetes, hypertension) and angiographic (ejection fraction, lesion location) variables.
Yusuf S et al. Lancet. 1994; 344: 563–570
PCI: Indications & Future Directions
Medical Vs. CABG in the Treatment of CAD
Pooled risk ratios for various end points from 6 randomized trials comparing PTCA with medical treatment in pts with stable non-acute CAD ( N=953 for PTCA and N=951 for medical treatment) published between 1979-1998
PCI: Indications & Future Directions
PTCA Vs. Medical Therapy in the Treatment of Non-Acute CAD
Bucher HC, et al. BMJ. 2000; 321: 73–77
Thus, PTCA results in greater angina relief but at the cost of more CABG
Summary estimate: RR = 0.80, 95% CI 0.63 to 1.03.
Bavry AA et al, Am J Cardiol. 2004; 93:830-5.
PCI: Indications & Future Directions
Mortality up to 12 months for invasive versus conservative strategies
Meta-analysis on 5 studies on 6,766 UA/NSTEMI pts (3,371 invasive and 3,385 conservative) enrolled from 6/96 to 3/20 with contemporary use of both IIbIIIa inhibitors and stents in most cases
Meta-analysis of 13 Randomized trials comparing bypass surgery with PCI on 7964 pts enrolled from 1987 to 2002.
Hoffman SN et al, JACC 2003;41:1293-1304
PCI: Indications & Future Directions
All-cause mortality for 1, 3, 5, and 8 years post-initial revascularization.
All trials
multivessel coronary artery disease
1.5% absolute survival advantage at 5 years
Risk difference for all-cause mortality for years 4 and 6.5 post-initial revascularization comparing coronary artery bypass graft surgery (CABG) to PTCA for diabetic and non-diabetic patients.
Hoffman SN et al, JACC 2003;41:1293-1304
PCI: Indications & Future Directions
CABG Vs. PTCA in the Treatment of CAD
History of Percutaneous Coronary Intervention
Indications of Percutaneous Coronary Intervention
Current Status of Percutaneous Coronary Intervention
Future Development
Novel Drug Eluting Stents
Expanding Beyond Coronary Vasculature
Newer Imaging Technologies
Cellular Approach: Angiogenesis and Myogenesis
PCI: Indications & Future Directions
Patients who do not have treated diabetes with asymptomatic ischemia or mild angina with 1 or more significant lesions in 1 or 2 coronary arteries suitable for PCI with a high likelihood of success and a low risk of morbidity and mortality. The vessels to be dilated must subtend a large area of viable myocardium (Level of Evidence B)
PCI: Indications & Future Directions
Recommendation in Asymptomatic or Class I Angina
Class I Recommendation:
Smith et al. ACC/AHA PCI guidelines JACC 2001;37:2239i
The same clinical and anatomic requirements for Class I, except the myocardial area at risk is of moderate size or the patient has treated diabetes. (Level of Evidence B)
PCI: Indications & Future Directions
Recommendation in Asymptomatic or Class I Angina
Class IIa Recommendation:
Smith et al. ACC/AHA PCI guidelines JACC 2001;37:2239i
Patients with asymptomatic ischemia or mild angina with ≥2 coronary arteries suitable for PCI with a high likelihood of success and a low risk of morbidity and mortality. The target vessels must subtend at least a moderate area of viable myocardium.
(Level of Evidence: B)
PCI: Indications & Future Directions
Recommendation in Asymptomatic