Management Strategies for Post-Intervention in Patients with CAD VBWG

Target lesion Nontarget lesion Target lesion Nontarget lesion Cutlip DE et al. Circulation. 2004;110: *Non-drug eluting stents Average event rate, years 2– % Year CV event rate 0 Disease progression in nonstented lesions causes most CV events N = 1228 in 2nd-generation coronary stent trials* VBWG

Glaser R et al. Circulation. 2005;111; NHLBI Dynamic Registry: N = 3747 for PCI Adjusted odds ratio P 0 Female gender0.05 Three-vessel disease (vs 1)<0.001 Two-vessel disease (vs 1)0.005 Prior coronary intervention<0.001 Age <65 years0.003 Diabetes 1.0 Hypertension 0.84 Predictors of nontarget lesion PCI for progression of disease VBWG

Improving long-term outcomes after PCI Restenosis is less of a problem in drug-eluting stent era A significant number of patients return to cath lab with new lesions Patients with more extensive CAD have increased risk Glaser R et al. Circulation. 2005;111: Vetrovec GW. Circulation. 2005;111: Aggressive post-PCI risk factor management offers the greatest opportunity to improve long-term outcomes VBWG

CRUSADE: Discharge care for CABG vs PCI Dyke CK et al. Circulation. 2004;110 (suppl):III % 88% 65% 87% 73% 72% 79% 51% 86% 68% 72% 44% 83% 92% AspirinBeta- blockers ACE inhibitors StatinsSmoking- cessation counseling Cardiac rehab Diet- modification counseling PCI (n = 25,653) CABG (n = 7663) Discharge therapy (%) VBWG

CRUSADE: Hospital variations in quality of care vs outcome Peterson ED et al. J Am Coll Cardiol. 2004;43(suppl):406A ACC/AHA class I indications Lagging hospitals (bottom 25%) Leading hospitals (top 25%) *Relative to total care opportunities BB ASAHeparin GP llb/IIIa ACEI Statin BB Treat- ment* (%) <24 hours Discharge ASA Clopidogrel In- hospital mortality (%) VBWG

Mukherjee D et al. Circulation. 2004;109: N = 1358 *Number of evidence-based medications used (aspirin, ACE inhibitor,  -blocker, statin) vs number indicated Lower mortalityHigher mortality IV III II I 0.10 (0.03–0.42) 0.17 (0.04–0.75) 0.18 (0.04–0.77) 0.36 (0.08–1.75) Appropriateness level* Odds ratio (95% CI) Greater use of evidence-based medications lowers 6-month mortality in ACS patients n VBWG

Medication class RRR (%) 5-Year CV-event risk (%) None020.0 Aspirin  -Blocker ACE inhibitor Lipid lowering Cumulative risk reduction if all 4 medication classes are used: ~70% NNT to prevent 1 major CV event in 5 years: 7 Fonarow GC. Rev Cardiovasc Med. 2003;4(suppl 3):S Potential long-term risk reduction with cardioprotective medications in post-MI patients VBWG