AHA: CAD Flashcards
coronary artery stenosis threshold for intervention (as primary procedure/culprit lesion)
70% stenosis in non-LM vessel
50% stenosis in Lmain
coronary artery stenosis threshold for intervention (as secondary/concomitant procedure or secondary/bystander lesion)
50% stenosis in non-LM vessel (at least for CABG)
adjunct testing for intermediate/indeterminate coronary artery stenosis
FFR≤0.8
iFR≤0.89
fractional flow reserve & instantaneous wave-free ratio
UpToDate
postop CABG meds (at discharge) in normal EF
β-blocker
statin
anti-platelet
minimum CAD lesion severity for radial artery use
RCA >90%
L-sided (LCx) >70%
recommendation for risk-stratification before coronary revasc
STS risk score
(1)
factors increasing complexity of CAD
Lmain or pLAD
CTO
trifurc lesion
complex bifurc lesion
heavy calcification
severe tortuosity
ostial (Ao)
diffusely diseased & narrowed segments distal to lesion
thrombotic lesion
lesion length >2cm
FFR threshold for clinically-relevant/intervenable coronary artery stenosis
functional flow reserve
≤0.80
UpToDate
iFR threshold for clinically-relevant/intervenable coronary artery stenosis
instantaneous wave-free ratio
≤0.89
UpToDate
mgmt of STEMI, tsx<24h
PCI <12h ⇒ ￪OS (1)
PCI 12-24h ⇒ ￪clinical outcomes (2a)
“1. In patients with STEMI and ischemic symptoms for <12 hours, PCI should be performed to improve survival.” (1)
“6. In patients with STEMI who are stable and presenting 12 to 24 hours after symptom onset, PCI is reasonable to improve clinical outcomes.” (2a)
mgmt of STEMI, stable, tsx>24h
delayed???
“9. In asymptomatic stable patients with STEMI who have a totally occluded infarct artery >24 hours after symptom onset and are without evidence of severe ischemia, PCI should not be performed.” (3)
mgmt of STEMI, stable, with total occlusion in infarct artery, tsx>24h
NO PCI
3: HARM
“9. In asymptomatic stable patients with STEMI who have a totally occluded infarct artery >24 hours after symptom onset and are without evidence of severe ischemia, PCI should not be performed.” (3)
preferred mgmt of STEMI, tsx<12h
PCI ⇒ ￪OS (1)
“1. In patients with STEMI and ischemic symptoms for <12 hours, PCI should be performed to improve survival.” (1)
mgmt of STEMI, stable, tsx=12-24h
PCI ⇒ ￪clinical outcomes (2a)
“6. In patients with STEMI who are stable and presenting 12 to 24 hours after symptom onset, PCI is reasonable to improve clinical outcomes.” (2a)
mgmt of STEMI, unstable, tsx>12h
i.e. c/b ongoing ischemia, acute severe HF, life-threatening arrhythmia
PCI ⇒ ￪clinical outcomes (2a)
“8. In patients with STEMI complicated by ongoing ischemia, acute severe heart failure, or lifethreatening arrhythmia, PCI can be beneficial to improve clinical outcomes, irrespective of time delay from MI onset.” (2a)
mgmt of STEMI s/p failed thrombolysis
angio @ 3-24h to verify reperfusion (2a)
PCI ⇒ ￪clinical outcomes (1)
angio @ 3-24h to verify reperfusion (2a)
“4. In patients with STEMI and evidence of failed reperfusion after fibrinolytic therapy, rescue PCI of the infarct artery should be performed to improve clinical outcomes.” (1)
“5. In patients with STEMI who are treated with fibrinolytic therapy, angiography within 3 to 24 hours with the intent to perform PCI is reasonable to improve clinical outcomes.” (2a)
mgmt of STEMI, unstable, tsx=any
i.e. cardiogenic shock, hemodynamic instability
PCI (or CABG if not feasible) ⇒ ￪OS (1)
“2. In patients with STEMI and cardiogenic shock or hemodynamic instability, PCI or CABG (when PCI is not feasible) is indicated to improve survival, irrespective of the time delay from MI onset.” (1)
mgmt of STEMI with mechanical complications
(e.g. VSD, acute MR 2/2 pap muscle infarct/rupture, free wall rupture)
CABG @ time of surgical rx ⇒ ￪OS (1)
“3. In patients with STEMI who have mechanical complications (eg, ventricular septal rupture, mitral valve insufficiency because of papillary muscle infarction or rupture, or free wall rupture), CABG is recommended at the time of surgery, with the goal of improving survival.” (1)
mgmt of STEMI, with PCI failed or infeasible, with lg area of at-risk myocardium
CABG ⇒ ￪clinical outcomes (2a)
“7. In patients with STEMI in whom PCI is not feasible or successful, with a large area of myocardium at risk, emergency or urgent CABG can be effective as a reperfusion modality to improve clinical outcomes.” (2a)
contraindications to CABG in STEMI s/p failed PCI
- no ongoing ischemia
- only small area of at-risk myocardium
- surgical revasc infeasible d/t no-reflow state or poor distal targets
“10. In patients with STEMI, emergency CABG should not be performed after failed primary PCI:
* In the absence of ischemia or a large area of
myocardium at risk, or
* If surgical revascularization is not feasible because of a no-reflow state or poor distal targets.”
(3: HARM)
“The no-reflow phenomenon refers to unsuccessful microvascular reperfusion even in the presence of a widely patent epicardial coronary artery. This usually occurs with reperfusion in the setting of PCI for the treatment of STEMI, after prolonged myocardial ischemia, or with a large thrombus burden.”
goal door to PCI time
<2h (120min)
incl transfer
mgmt options for non-infarct/bystander vessels with primary PCI of infarct/culprit vessel, STEMI, stable
low-risk pt (low burden comorbid dz) AND:
1. non-infarct/bystander vessels supplying a lg area of at-risk myocardium AND low-complexity: staged PCI ⇒ ￬MI,death (1)
2. non-infarct/bystander vessels supplying a lg area of at-risk myocardium AND higher complexity: elective CABG ⇒ ￬MACE (2a)
3. +v low-complexity dz (regardless of at-risk territory?): concurrent PCI ⇒ ￬MACE (2b)
else: GDMT (any but low-risk, low-complexity, lg at-risk area)
“1. In selected hemodynamically stable patients with STEMI and multivessel disease, after successful primary PCI, staged PCI of a significant non-infarct artery stenosis is recommended to reduce the risk of death or MI.” (1)
“2. In selected patients with STEMI with complex multivessel non-infarct artery disease, after successful primary PCI, elective CABG is reasonable to reduce the risk of cardiac events.” (2a)
“3. In selected hemodynamically stable patients with STEMI and low-complexity multivessel disease, PCI of a non-infarct artery stenosis may be considered at the time of primary PCI to reduce cardiac event rates.” (2b)
“4. In patients with STEMI complicated by cardiogenic shock, routine PCI of a non-infarct artery at the time of primary PCI should not be performed because of the higher risk of death or renal failure.” (3: HARM)
Figure 4. Revascularization of Noninfarct-Related Coronary Artery Lesions in Patients With STEMI.
only place it mentions “non-culprit artery(ies) supplying a large area of myocardium at risk and absence of multiple comorbidities” as a pre-requisite to considering more than GDMT
https://drive.google.com/file/d/11uFUQLvHNoHt2gx8g8HFe1VT0HjSuNLA/view
indication(s) for thrombolysis in mgmt of STEMI
(instead of PCI)
PCI unavailable & door to PCI time incl transfer >2h (120min)
tx of bystander/non-infarct lesions in STEMI during PCI of culprit/infarct lesion
only if stable & low-complexity: PCI ⇒ ￬MACE (2b)
tx of bystander/non-infarct lesions in STEMI after PCI of culprit/infarct lesion
GDMT
OR if non-infarct/bystander vessels supplying a lg area of at-risk myocardium AND low-risk pt (low burden comorbid dz), consider:
1. staged PCI ⇒ ￬MI,death (1)
2. elective CABG ⇒ ￬MACE (2a)
“1. In selected hemodynamically stable patients with STEMI and multivessel disease, after successful primary PCI, staged PCI of a significant non-infarct artery stenosis is recommended to reduce the risk of death or MI.” (1)
“2. In selected patients with STEMI with complex multivessel non-infarct artery disease, after successful primary PCI, elective CABG is reasonable to reduce the risk of cardiac events.” (2a)
“3. In selected hemodynamically stable patients with STEMI and low-complexity multivessel disease, PCI of a non-infarct artery stenosis may be considered at the time of primary PCI to reduce cardiac event rates.” (2b)
“4. In patients with STEMI complicated by cardiogenic shock, routine PCI of a non-infarct artery at the time of primary PCI should not be performed because of the higher risk of death or renal failure.” (3: HARM)
Figure 4. Revascularization of Noninfarct-Related Coronary Artery Lesions in Patients With STEMI.
only place it mentions “non-culprit artery(ies) supplying a large area of myocardium at risk and absence of multiple comorbidities” as a pre-requisite to considering more than GDMT
https://drive.google.com/file/d/11uFUQLvHNoHt2gx8g8HFe1VT0HjSuNLA/view
mgmt of NSTEMI with “elevated” risk of recurrent ischemic events
“invasive strategy” (PCI???) ⇒ ￬MACE (1)
“elevated biomarkers or other higher-risk findings”
mgmt of NSTEMI, with cardiogenic shock
“emergency revasc”(/”immediate invasive strategy”) (<2h) ⇒ ￬death (1)
SHOCK trial:
randomized pts to medical tx or emergency revasc
of revasc, 2/3=PCI & 1/3=CABG
revasc better than med tx for 6mo mortality
PCI v CABG no difference in mortality
mgmt of NSTEMI, unstable
i.e. refractory angina, hemodynamic instability, electrical instability
“immediate invasive strategy” (PCI???) ⇒ ￪outcomes (1)
mgmt of NSTEMI, initially stabilized, with high risk of clinical events
GRACE score >140 = high-risk of “clinical events”
“early invasive strategy” (<24h) (PCI???) ⇒ ￪outcomes (2a)
↓recurr isch, ↓urgent revasc, ↓LOS
mgmt of NSTEMI, initially stabilized, with low or intermediate risk of clinical events
GRACE score >140 = high-risk of “clinical events”
“delayed invasive strategy” (PCI???) before discharge ⇒ ￪outcomes (2a)
mgmt of NSTEMI s/p failed PCI, unstable
i.e. ongoing ischemia, hemodynamic compromise, lg at-risk area
“ongoing ischemia, hemodynamic compromise, or threatened occlusion of an artery with substantial myocardium at risk”
emergency CABG (2a)
“In patients with NSTE-ACS who have failed PCI and have ongoing ischemia, hemodynamic compromise, or threatened occlusion of an artery with substantial myocardium at risk, who are appropriate candidates for CABG, emergency CABG is reasonable.” (2a)
1st decision branch-point for initial mgmt of STEMI
timing:
tsx<24h=PCI
>24h=???
2nd decision branch-point for initial mgmt of STEMI (after tsx)
stability:
unstable=PCI>CABG
stable=see timing
1st decision branch-point for initial mgmt of NSTEMI
stability:
- unstable ⇒ “immediate invasive strategy”/”emergent revasc”
- stable ⇒ dependent on clinical risk (GRACE score)
2nd decision branch-point for initial mgmt of NSTEMI (after stability)
- high-risk ⇒ revasc <24h
- low-risk ⇒ revasc before discharge
risk of clinical events (GRACE score):
>140=”early invasive strategy” (<24h)
<140=”delayed invasive strategy” (before discharge)
mgmt of multivessel (3v) SIHD with EF=55%
CABG (2b) OR PCI (2b) for OS
- multivessel (3+) dz (with EF=WNL) ⇒ ￪OS (2b)
mgmt of multivessel SIHD with EF=25%
CABG (1) for OS
- multivessel dz + EF<35% ⇒ ￪OS (1)
mgmt of multivessel SIHD with EF=45%
CABG (2a) for OS
- multivessel dz + EF=35-50% (with LIMA-LAD) ⇒ ￪OS (2a)
mgmt of multivessel SIHD with Lmain dz
CABG (1) for OS
- L main dz ⇒ ￪OS (1)
specific indication(s) for CABG in stable ischemic heart dz (SIHD)
- refrx angina on GDMT ⇒ ￬sx (1)
- L main dz ⇒ ￪OS (1)
- multivessel dz + EF<35% ⇒ ￪OS (1)
- multivessel dz + EF=35-50% (with LIMA-LAD) ⇒ ￪OS (2a)
- multivessel (3+) dz (with EF=WNL) ⇒ ￪OS (2b)
- [pLAD dz (with EF=WNL) “revasc” ⇒ “uncertain” survival benefit (2b)]
big picture/broad category indications for CABG in stable ischemic heart dz (SIHD)
all for ￪OS:
- Lmain dz
- multivessel dz + LV dysfxn (￬EF)
- multivessel (3+) dz (with EF=WNL)
- [pLAD dz (“uncertain”)]
for sx relief:
- refrx angina on GDMT
indication(s) for PCI in stable ischemic heart dz (SIHD)
- refrx angina on GDMT ⇒ ￬sx (1)
- Lmain dz with tx equipoise/equivalency ⇒ ￪OS (2a)
- [multivessel (3+) dz (with EF=WNL) ⇒ “uncertain” survival benefit (2b)]
- [pLAD dz (with EF=WNL) “revasc” ⇒ “uncertain” survival benefit (2b)]
Generally, should stable ischemic heart dz (SIHD) be treated with CABG or PCI?
CABG
contraindication(s) to revasc in stable ischemic heart dz (SIHD)
- <3-vessel (1 or 2) dz NOT involving pLAD + EF=WNL (3: NO BENEFIT)
- non-anatomically/-functional significant vessel dz (3: HARM)
“8. In patients with SIHD, normal left ventricular
ejection fraction, and 1- or 2-vessel CAD not
involving the proximal LAD, coronary revascularization is not recommended to improve
survival.10,14,16,26,28,29
3: Harm B-NR
9. In patients with SIHD who have ≥1 coronary
arteries that are not anatomically or functionally significant (<70% diameter of non–left
main coronary artery stenosis, FFR >0.80),
coronary revascularization should not be
performed with the primary or sole intent to
improve survival.” (3:HARM)
timing of surgery for mechanical complications of MI
if any signs end-organ dysfxn, support with IABP or VA ECMO for 3-7???d
timing of surgery if CABG indicated for acute STEMI
>72d
SESATS: “Data from the New York State Cardiac Registries shows that CABG within 6 hours of a non-transmural myocardial infarction or within 3 days of a transmural infarction increases mortality. Therefore, CABG should be delayed for at least 6 hours after a non-transmural infarct and for at least 3 days after a transmural infarct unless other over-riding indications are present.”
timing of surgery if CABG indicated for acute NSTEMI
>6h
SESATS: “Data from the New York State Cardiac Registries shows that CABG within 6 hours of a non-transmural myocardial infarction or within 3 days of a transmural infarction increases mortality. Therefore, CABG should be delayed for at least 6 hours after a non-transmural infarct and for at least 3 days after a transmural infarct unless other over-riding indications are present.”
If performing staged CAS followed by CABG, how long do you wait / what is the time interval between procedures?
6w
SESATS: “Following carotid artery stenting, an interval of at least six weeks must be allowed before CABG is performed. This allows time for the initial two-week period of potential hyperperfusion of the ipsilateral cerebral hemisphere and the six-week requirement for glycoprotein IIb/IIIa inhibitors to pass before proceeding with CABG.”
If performing staged CEA followed by CABG, how long do you wait / what is the time interval between procedures?
2w
SESATS: “Following carotid endarterectomy, there must be a two-week interval before proceeding with CABG to allow the period of potential hyperperfusion of the ipsilateral cerebral hemisphere to resolve.”
usual timing of post-infarct VSD
3-7d post-infarct
most common location of post-infarct VSD with LAD culprit/infarct vessel
anterior:
antero-apical septum
post-infarct VSD medical mgmt mortality rate
90%
(SESATS)
post-infarct VSD emergency surgical mgmt mortality rate (all-comers)
45-55%
(SESATS)
“In a retrospective review of the Society of Thoracic Surgeons’ database, nearly 3,000 patients underwent a post-MI VSD repair between 1999 and 2010. The overall mortality rate with surgical repair was 54% if repair was undertaken within 7 days from MI, and 18.4% if undertaken more than 7 days after MI. Multivariate analysis showed an increased risk of mortality in patients with, in descending order, pre-operative need for dialysis, emergency status of case, the presence of shock, increased age, and the requirement for an intra-aortic balloon pump.”
post-infarct VSD emergency surgical mgmt mortality rate with multi-organ system dysfxn/failure
>70%
(SESATS)
criteria/requirements for transcatheter device rx of a post-infarct VSD
defect <1.5cm diameter
≥10-14d post-infarct (to allow sufficient scarring of the rim tissue to anchor device)
recommendation(s) for CABG over PCI
- Lmain dz + high-complexity dz ⇒ ￪OS (1)
- complex (SYNTAX>33) or diffuse multivessel CAD ⇒ ￪OS (2a)
- multivessel CAD incl LAD + DM ⇒ ￪OS & ￬repeat revasc (1)
- multivessel CAD + Lmain
- prior CABG + sxs attributable to LAD dz with plan for LIMA-LAD in redo (2a)
- pts who cannot or won’t take DAPT (2a)
indication(s) for PCI over CABG
- acute STEMI (1)
- prior CABG with patent LIMA-LAD (2a)
SYNTAX score threshold for high-complexity dz
≥33
SYNTAX score threshold for moderate-complexity dz
22-33
SYNTAX score threshold for low-complexity dz
≤22
mgmt of spontaneous coronary artery dissxn (SCAD)
- medical/conservative mgmt i.e. NO routine revasc (3: HARM)
- may consider revasc if hemodynamic instability or ongoing ischemia (2b)
“Unlike other forms of ACS, routine revascularization for patients with SCAD may not confer the same benefit. PCI wires may propagate the dissection, and balloons and stents can extend the hematoma and lead to vessel occlusion. CABG onto a dissected vessel or one with a propensity to dissect is challenging, and as many as 30% of patients have acute graft closure.”
mgmt of severe, proximal, discrete coronary lesions in cardiac allograft vasculopathy
PCI (2a)
periop medical mgmt for CABG
- cont ASA ⇒ ￬ischemic events (1)
- do NOT start new ASA <24h before elective CABG (3: NO BENEFIT)
- postop (<6h) ASA300 🠆 QD ⇒ ￬SVG closure & ￬MACE (1)
- if acute MI (ACS): DAPT (ASA+ticag or ASA+Plavix) x1y ⇒ ￬SVG closure (2b)
- d/c Plavix ≥24h (1) & ideally 5d ⇒ ￬major bleeding/transfusion (2a)
- preop β-blocker ⇒ ￬postop afib (2a) & ￬mortality in-hosp & 30d (2b)
- postop (ASAP) β-blocker ⇒ ￬postop afib (1)
- ± preop amio ⇒ ￬postop afib (2a)
- insulin drip for Glc<180 intraop & early postop ⇒ ￬SWI (1)
- “comprehensive approach to ￬SWI” (1):
- mupirocin nares for + S. aureus nasal swab preop
- vanc paste to sternal edges @ open & close
- skeletonize BIMA if using
- ppx abx <48h postop
postop medical/Rx mgmt for CABG
- cont ASA ⇒ ￬ischemic events (1)
- postop (<6h) ASA300 🠆 QD ⇒ ￬SVG closure & ￬MACE (1)
- if acute MI (ACS): DAPT (ASA+ticag or ASA+Plavix) x1y ⇒ ￬SVG closure (2b)
- postop (ASAP) β-blocker ⇒ ￬postop afib (1)
- insulin drip for Glc<180 intraop & early postop ⇒ ￬SWI (1)
- ppx abx <48h postop
timing of postop ASA after CABG
<6h
mgmt of post-infarct ventricular free wall rupture
- pericardiocentesis drain
- IABP
- femoral cannulation for CPB before sternotomy
- surgery: debride ventricle & patch closure???
(BTK)
Is an anterior or posterior post-infarct VSD more common?
anterior 2/2 LAD occlusion
(posterior would be 2/2 dominant RCA or dominant LCx)
mgmt of post-infarct VSD
- distal bypass anastomoses
- ventriculotomy through infarct
- debride necrotic myocardium
- patch closure of VSD (bovine pericardium + 3-0 prolene mattress sutures) + underlying ventricular closure
- proximal anastomoses
