CAD: Treatment of Stable CAD Flashcards
Limitations of trials comparing CABG to OMT
Predates ACEI, statins
ASA not used rot timely postop
3 subgroups of pt’s that had mortality benefit from CABG
3VD/LM or pLAD (esp w/ LV Dysfunction)
2VD w/ pLAD
Pt’s w/ greatest clinical risk: HTN, MI, bad angina, ST dep at rest
Class I indications for CABG in stable angina
LM LM Equiv (pLAD and pLCX) 3VD 2VD w/ pLAD AND ischemia or EF<50% 1VD w/ high risk stress or large area of viability Disabling angina on OMT
3 types of success post PCI
Angiographic ( 3x ULN)
Clinical (procedural + relief of si/sxs of ischemia)
Is post PCI restenosis a complication of PCI
No (normal vascular response to injury)
What % of PCI’s have a trop bump?
70%
Criteria for post PCI MI
2 of 3: bio markers, sxs, Q waves
On meta analysis, what were the benefits of PCI vs OMT?
Angina relief
What did BARI trial show in terms of angina?
CABG > PCI
What have trials shows for in hospital MI for PCI vs. CABG?
Higher In-hospital mortality with CABG
What is the difference in Late mortality in PCI vs CABG trials
No difference
What was difference b/w PCI and CABG for Late MI and Mortality?
No difference
What is the benefit for diabetics treated initially with CABG?
Decreased Mortality and MI
Why do diabetics have decreased mortality with CABG?
Less recurrent MI’s with IMA
What are the only 2 benefits of stents over POBA?
Reduce restenosis 50%
Reduce revascularization 40%
Was there a difference b/w PTCS and Stenting for death/MI/Emergent CABG?
No
What did ERACI-II trial show for CABG vs stent?
Functional revascularization was same
What did he ARTS, ERACI-II, and SOS trials show for stent vs. CABG?
Same death and MI
More revascularization w/ PCI
In a Meta-analysis if RCTs, what age group had the most mortality benefit from CABG over PCI?
> 65 yo
Class I indications for PCI in chronic stable angina
None
What percent of COURAGE subjects received DES?
2%
Inclusion criteria for COURAGE
> =1V w/ 70% + ischemia (ECG or stress)
Or
80% stenosis + angina
Exclusion criteria for COURAGE
CCS class IV
>50% LMCA
EF<30%
Refractory CHF
COURAGE results
Mortality/MI- no difference
Angina free: PCI> OMT until 36 OM’s
In what ways are DES superior to BMS?
Less late stent thrombosis
Less late MI (sirolimus< paclitaxel< BMS)
Is there a difference b/w DES and BMS for mortality or emergent CABG?
No
In pt’s w/ LM or 3VD, what was worse witCABG?
Stroke
SYNTAX trial PICO and results
In pt’s w/ LMCA or 3VD, CABG had less MACCE than DES (Taxus). The MACCE was due to repeat revasc, as there was no difference in death or MI.
Note: nonsig trend towards lower all-cause mortality w/ CABG.
Class I for cholesterol intake in chronic stable angina
Reduce saturated fats (<200mg/d cholesterol.
Which beta receptor decreases HR?
B1
Which beta receptor decreases afterload?
B2
Why is carvedilol a good antihypertensive?
It blocks alpha 1 receptors
Which beta receptors decrease contractility?
Beta 1 and 3
After MI, how long should BB be cont’d if pt has Nl LVEF?
3 yrs
BB that v an be used for CHF
Bisoprolol
Metoprolol succinate
Cavedilol
Class I indications to improve survival with CABG
LM > 50%
sig stenosis in ANY 3V
Sig stenosis in pLAD and one other vessel
Rate of vascular complications post PCI?
<1%
In what case is angioplasty superior to OMT for stable CAD?
Angina relief
Meds used in COURAGE
ASA or Plavix
Metoprolol, norvasc, +/- nitrates
Lisinopril or losartan
Simvastatin +/- ezetimibe
BARI 2D conclusions
Overall mortality between OMT and CABG arms for DM and CAD pt’s was same. Lower CV events in CABG arm.
Which has higher restenosis rates: paclitaxel or everolimus stents?
Paclitaxel
At what syntax score do pt’s do better with cabg?
> 22
FREEDOM trial results
In pt’s with DM and MV-CAD, CABG had lower mortality c/w DES
3 findings of STICH trial
- CABG does not reduce mortality in pt’s with stable CAD and LVEF<35% (but CABG had less death and CV hospitalization)
- viability not helpful
- LV reconstruction (SAVER) not helpful
What class indication is it to give steroids or Benadryl pre cath for someone with shellfish allergy?
Class III
Who should get ACEI in SIHD (class I)?
DM (HOPE trial)
HTN
CKD
EF< 40%
~5yr mortality for pt’s w/ EF<35%
65%
