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Complete or partial
revascularization in patients with
chronic stable angina: why and
how?
Peter M. Pollak MD

©2011 MFMER | 3138928-1


Disclosure
Relevant Financial Relationship(s)
• None
Off Label Usage
• None

©2012 MFMER | 3208595-2


Revascularization, Ischemia, &
Completeness…
• Challenges in defining complete
revascularization
• Presence & degree of ischemia is associated
with adverse outcomes
• Relief of ischemia associated with improved
outcomes
• More complete revascularization is associated
with improved outcomes
• Surgical revascularization appears more
durable than percutaneous revascularization
©2011 MFMER | 3138928-3

Challenges in assessing complete
revascularization
• There has been no universal definition
• Anatomic criteria using stenosis >50% have
been common
• Fails to describe physiology
• Fails to account for viability
• Jeopardy score & Functional SYNTAX may
be better
• Factors associated with IR are known
predictors of adverse outcome
• CTO, Calcific disease, poor EF, DM, CKD,
prior MI
©2011 MFMER | 3138928-4


Angiographic stenosis ≠ functional stenosis
60%

20%

Gössl M et al. Circ Cardiovasc Interv. 2012;5:597-604


WHY REVASCULARIZE?

©2011 MFMER | 3138928-6

Ischemic Burden Treated Medically
Cardiac death (%)

Cardiac Death at 1.9 Years
8
7
6
5
4
3
2
1
0
0%
1 – 5%
(n = 7,119) (n = 1,331)

5 – 10%
(n = 716)

11 – 20%
(n = 545)

> 20%
(n = 252)

Total myocardial ischemia (%)

myocardial ischemia  cardiac death

Hachamovitch R, et al. Circulation. 2003;107:2900-2907.


Ischemia Reduction in COURAGE
Survival Stratified by Residual Ischemia

Event-free survival

100
80

0%
< 5%
5 – 10%
> 10%

60
40
20
0

More Residual ischemia  more events
Shaw LJ, et al. Circulation. 2008;117:1283-1291.


Revascularization vs Medical Therapy in
Stable CAD: A Network Meta-Analysis
100 RCTs – 93,553 patients randomized
Follow-up of 262,090 patient-years

Pts randomized
Follow-up

6,846
30,628 PY Med Rx

Pts randomized
CABG Follow-up

8,920
38,709 PY

PTCA
Pts randomized
Follow-up

Pts randomized
Follow-up

14,802
25,096 PY EES

6,920
17,678 PY

BMS
Pts randomized
Follow-up

Pts randomized

Follow-up

2,035
3,134 PY

Pts randomized
Follow-up

R-ZES

9,187
27,384 PY

15,787
45,467 PY

PES
Pts randomized
Follow-up

12,457
28,828 PY

E-ZES
SES Pts randomized
Follow-up

19,391
45,679 PY

The European Myocardial Revascularization Collaboration: BMJ, 2014


Revascularization vs Medical Therapy in
Stable CAD: A Network Meta-Analysis
Primary Endpoint: All-Cause Mortality
100 RCTs – 93,553 patients randomized
262,090 patient-years of follow-up
5,346 events for analysis
Surgery
CABG
Early PCI techniques
PTCA
BMS
Early-generation DES
PES
SES
E-ZES
New-generation DES
R-ZES
EES

Rate ratio (95% CI)
0.80 (0.70, 0.91)
0.85 (0.68, 1.04)
0.92 (0.79, 1.05)
0.92 (0.75, 1.12)
0.91 (0.75, 1.10)
0.88 (0.69, 1.10)
0.65 (0.42, 1.00)

0.75 (0.59, 0.96)

0.3
1
3
Favors revascularization Favors medical therapy

The European Myocardial Revascularization Collaboration: BMJ, 2014


Revascularization vs Medical Therapy in
Stable CAD: A Network Meta-Analysis
Rate ratio (95% Crl)

Rate ratio (95% CrI)

Myocardial infarction
(92 trials; 90,472 patients)
CABG vs medical treatment

0.79 (0.63-0.99)

PTCA vs medical treatment

0.88 (0.70-1.11)

BMS vs medical treatment

1.04 (0.84-1.27)

PES vs medical treatment

1.18 (0.88-1.54)

SES vs medical treatment

0.94 (0.71-1.22)

E-ZES vs medical treatment

0.80 (0.56-1.10)

R-ZES vs medical treatment

0.82 (0.52-1.26)

EES vs medical treatment

0.75 (0.55-1.01)

0.1
0.3
Favors revascularization

1
3
Favors medical therapy

Windecker et al: BMJ 348, 2014

Revascularization vs Medical Therapy in
Stable CAD: A Network Meta-Analysis
Secondary Endpoint: Repeat Revascularization
90,282 patients randomized
234,693 patient-years of follow-up
11,619 events for analysis
Surgery
CABG
Early PCI techniques
PTCA
BMS
Early-generation DES
PES
SES
E-ZES
New-generation DES
R-ZES
EES
0.1

Rate ratio (95% CI)
0.16 (0.13, 0.20)
0.97 (0.82, 1.16)
0.69 (0.59, 0.82)
0.44 (0.35, 0.55)
0.29 (0.24, 0.36)
0.38 (0.29, 0.51)
0.26 (0.17, 0.40)
0.27 (0.21, 0.35)

0.3
1
3
Favors revascularization Favors medical therapy

The European Myocardial Revascularization Collaboration: BMJ, 2014, ahead of print


Conclusion: Among patients with stable coronary
artery disease, coronary artery bypass grafting reduces
the risk of death, myocardial infarction, and
subsequent revascularisation compared with medical
treatment. All stent based coronary revascularisation
technologies reduce the need for revascularisation to a
variable degree. Our results provide evidence for
improved survival with new generation drug eluting
stents but no other percutaneous revascularisation
technology compared with medical treatment.

Windecker et al: BMJ 348, 2014


COMPLETE OR INCOMPLETE
REVASCULARIZATION?

©2011 MFMER | 3138928-15


Completeness of Revascularization

• Meta-analysis of MV CAD studies

• Purpose
• Evaluate effect of completeness of revascularization on
subsequent clinical outcomes
• CR defined as no remaining lesion >50% after PCI in a
major epicardial vessel
• 9 studies
• 1 RCT
• 8 Registry studies
• 37,116 patients
• CR 31%
• IR 69%
Aggarwal et al: EuroIntervention 7:1095, 2012


All-Cause Mortality
Study, year

Events/subgroup
CR n/N
IR n/N

Risk ratio (95% CI)

Mariani, 2001

0/44

2/147

0.65 (0.03-13.4)

Kloeter, 2001

0/101

3/149

0.21 (0.01-4.0)

van den Brand, 2002

7/406

6/170

0.48 (0.16-1.43)

Nicolsky, 2004

5/94

44/258

0.31 (0.12-0.76)

Ijsselmuiden, 2004

8/104

3/109

2.79 (0.76-10.2)

Hannan, 2006

–

–

0.87 (0.77-0.98)

Srinivas, 2007

–

–

1.03 (0.56-1.89)

Hannan, 2009

–

–

0.81 (0.69-0.95)

Pooled

0.82 (0.68-0.99)

0.01

0.1

CR

1

10

100

IR
P (heterogeneity)=0.14
I2=36.1

Aggarwal et al: EuroIntervention 7:1095, 2012


Non-Fatal MI
Study, year

Events/subgroup
CR n/N
IR n/N

Risk ratio (95% CI)

Mariani, 2001

0/44

2/147

0.65 (0.03-13.4)

Kloeter, 2001

0/101

3/149

1.47 (0.09-23.3)

van den Brand, 2002

7/406

6/170

0.83 (0.40-1.75)

Nicolsky, 2004

4/94

44/258

0.36 (0.17-0.78)

Ijsselmuiden, 2004

8/104

3/109

1.44 (0.60-3.44)

Srinivas, 2007

–

–

0.76 (0.43-1.35)

Tamburino, 2008

–

–

0.93 (0.15-5.52)

Hannan, 2009

–

–

0.61 (0.45-0.83)

Pooled

0.67 (0.53-0.84)

0.01

0.1

CR

1

10

100

IR
P (heterogeneity)=0.46
I2=0.00

Aggarwal et al: EuroIntervention 7:1095, 2012


Subsequent CABG
Study, year

Events/subgroup
CR n/N
IR n/N

Risk ratio (95% CI)

Mariani, 2001

1/44

2/147

1.67 (0.15-17.9)

Kloeter, 2001

1/101

6/149

0.24 (0.03-2.01)

van den Brand, 2002

8/406

17/170

0.19 (0.08-0.44)

Ijsselmuiden, 2004

10/104

12/109

0.87 (0.39-1.93)

Hannan, 2006

443/6817 1115/15,128

0.88 (0.79-0.98)

Srinivas, 2007

15/135

77/1466

0.90 (0.52-1.55)

Tamburino, 2008

3/212

9/296

0.46 (0.12-1.69)

56/3499

164/7795

0.76 (0.56-1.02)

Hannan, 2009
Pooled

0.70 (0.52-0.95)

0.01

0.1

CR

1

10

100

IR
P (heterogeneity)=0.03
I2=55.4

Aggarwal et al: EuroIntervention 7:1095, 2012

Repeat PCI
Study, year

Events/subgroup
CR n/N
IR n/N

Risk ratio (95% CI)

Mariani, 2001

5/44

14/147

1.19 (0.45-3.12)

Kloeter, 2001

33/101

29/149

1.67 (1.09-2.58)

van den Brand, 2002

53/406

17/170

1.30 (0.77-2.18)

–

–

0.94 (0.64-1.38)

22/104

34/109

0.67 (0.42-1.07)

Srinivas, 2007
Ijsselmuiden, 2004

Hannan, 2006
Tamburino, 2008
Hannan, 2009

1602/6817 3372/13,807

0.96 (0.91-1.01)

34/212

93/296

0.51 (0.35-0.72)

472/3499

1617/7795

0.65 (0.59-0.71)

Pooled

0.87 (0.69-1.11)

0.01

0.1

CR

1

10

100

IR
P (heterogeneity)<0.01
I2=90.4

Aggarwal et al: EuroIntervention 7:1095, 2012

Conclusions: In patients with multivessel coronary
disease, complete revascularisation with PCI may be
associated with better outcomes than incomplete
revascularisation.

Aggarwal et al: EuroIntervention 7:1095, 2012


More grafts  improved survival in patients
with reduced LV function

Gössl M et al. Circ Cardiovasc Interv. 2012;5:597-604


More CABG grafts  Less Events

Gössl M et al. Circ Cardiovasc Interv. 2012;5:597-604


1924 Asian patients with MVCAD undergoing
PCI (1900) or CABG (514) over 5 yrs

MACCE

Mortality
Kim Y et al. Circulation. 2011;123:2373-2381

Arterial Revascularization Therapies Study trial

Serruys NEJM 2001


936 patients with LIMA-LAD but no graft to RCA or LCX

Risk from IR may vary by territory or myocardial jeopardy
Rastan A J et al. Circulation. 2009;120:S70-S77