Controversies in Cardiology: Stable CAD & COURAGE Pro: Optimal Medical Therapy vs. PCI SYED ZAHID JAMAL MD ASSOC PROF NICVD.

Slides:



Advertisements
Similar presentations
Examining the Science Underlying Myocardial Ischemia.
Advertisements

British Cardiac Intervention Society Risk Assessment In Acute Coronary Syndromes Dr David Newby BHF Senior Lecturer in Cardiology Associate Director of.
A few basics of cardiac surgery…. Brett Sheridan, MD Assistant Professor Department of Surgery.
ICD FOR PRIMARY PREVENTION EVIDENCE REVIEW
CABG GUIDELINES SANJAY DRAVID, M.D.. INTRODUCTION ACC/AHA GUIDELINE UPDATE FOR CORONARY ARTERY BYPASS GRAFT SURGERY (JACC 2004; 44: AND CIRCULATION.
Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery 2007 ACC/AHA and 2009 ESC GUIDELINES.
Clinical Trial Results. org Pexelizumab for Acute ST-Elevation Myocardial Infarction in Patients Undergoing Primary Percutaneous Coronary Intervention.
University Medical Center Groningen Thrombus aspiration during primary PCI FZ Thrombus Aspiration during Percutaneous coronary intervention in Acute.
Basel Stent Cost-effectiveness Trial-Late Thrombotic Events (BASKET LATE) Trial Basel Stent Cost-effectiveness Trial-Late Thrombotic Events (BASKET LATE)
The AiMI Trial Arshad Ali, MD, David Cox, MD, Nabil Dib, MD, Bruce Brodie, MD, Daniel Berman, MD, Navin Gupta, MD, Kevin Browne, MD, Robert Iwaoka, MD,
COURAGE: Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation Purpose To compare the efficacy of optimal medical therapy (OMT)
Arthur Stillman, M.D., Ph.D., PI Pamela Woodard, M.D., Study Co-chair Randomized Evaluation of Patients with Stable Angina Comparing Utilization of Diagnostic.
European guidelines on the management of stable coronary artery disease Key points & new position for Ivabradine and Trimetazidine ESC 2013 Montalescot.
Published in Circulation 2005 Percutaneous Coronary Intervention Versus Conservative Therapy in Nonacute Coronary Artery Disease: A Meta-Analysis Demosthenes.
Amr Hassan Mostafa, MD, FSCAI A. Professor of Cardiology Cairo University Cairo, Egypt Egypt Combat MI, March 24-25, Cairo Sheraton.
VBWG CHARISMA Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management, and Avoidance trial.
Presenter Conflict Disclosure Name:William E. Boden, MD, FACC Within the past 12 months, the presenter or their spouse/partner have had the financial interest/arrangement.
VBWG OASIS-5 The Fifth Organization to Assess Strategies in Acute Ischemic Syndromes trial.
REVASCULARIZATION Vs MEDICAL THERAPY IN STABLE CAD
Management of Chronic Stable Angina AIMGP Seminar Series Mirek Otremba 2007.
Ischemic heart disease Basic Science 3/15/06. All of the following concerning coronary artery anatomy are correct except: The left main coronary artery.
Redefining Treatment Strategies for Optimal Medical Care in CAD COURAGE and MERLIN-TIMI 36.
10 Points to Remember on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in AdultsTreatment of Blood Cholesterol to Reduce.
BARI 2D Trial BARI 2D Trial Presented at the American Diabetes Association (ADA) Annual Scientific Sessions 2009 in New Orleans The Bypass Angioplasty.
Prasugrel vs. Clopidogrel for Acute Coronary Syndromes Patients Managed without Revascularization — the TRILOGY ACS trial On behalf of the TRILOGY ACS.
RITA-3 Is this a benign lesion in a benign condition? Who Needs Angioplasty in 2008? Stable Angina Stable Angina Keith A A Fox Professor of Cardiology.
Incremental Decrease in Clinical Endpoints Through Aggressive Lipid Lowering (IDEAL) Trial IDEAL Trial Presented at The American Heart Association Scientific.
Ongoing Trials in Managing Myocardial Ischemia. MERLIN-TIMI 36: Study design IV/oral ranolazinePlacebo Patients with non-ST elevation ACS treated with.
Cardiac Rehabilitation 2011 Update for Primary Care Providers Douglass A Morrison, MD, PhD Cardiac Rehabilitation, Medical Director Yakima Regional and.
The Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery: The SYNTAX Study One Year Results of the PCI and CABG Registries.
Which Early ST-Elevation Myocardial Infarction Therapy (WEST) Trial Paul W. Armstrong, WEST Steering Committee Published in The European Heart Journal.
Occluded Artery Trial (OAT) Presented at The American Heart Association Scientific Session 2006 Presented by Dr. Judith S. Hochman OAT Trial.
Journal Club Jeffrey P Schaefer, MD April 16, 2007.
TACTICS- TIMI 18 Treat Angina with Aggrastat TM and Determine Cost of Therapy with an Invasive or Conservative Strategy.
COURAGE. 15 US VA 19 US Non-VA Hospitals 1,355 patients 16 Canadian Hospitals 932 patients 50 Hospitals 2,287 patients enrolled between 6/99-1/04 A North.
Treatment strategies for “stable” CAD patients: COURAGE, OAT, SWISSI II, VIAMI in perspective Pierfrancesco Agostoni, MD Antwerp Cardiovascular Institute.
Bangalore S, et al. β-Blocker use and clinical outcomes in stable outpatients with and without coronary artery disease. JAMA. 2012;308(13): ?
Is the Decision-Making after Failure of CTO Angioplasty Same? Infarct Related CTO or Non- Infarct Related CTO (Continue the Procedure in Other Vessel or.
Atorvastatin Versus Revascularization Treatments (AVERT) Trial Presented at The American Heart Association Scientific Sessions 1998 Presented by Dr. Bertram.
FRagmin® and Fast Revascularization during InStablity in Coronary artery disease FRISC II.
Late Open Artery Hypothesis Jason S. Finkelstein, M.D. Tulane University Medical Center 2/24/03.
Perindopril Remodeling in Elderly with Acute Myocardial Infarction PREAMIPREAMI Presented at The European Society of Cardiology Hot Line Session, September.
VBWG OASIS-6 The Sixth Organization to Assess Strategies in Acute Ischemic Syndromes trial.
Gregg W. Stone MD for the ACUITY Investigators Gregg W. Stone MD for the ACUITY Investigators A Prospective, Randomized Trial of Bivalirudin in Acute Coronary.
Gregg W. Stone MD for the ACUITY Investigators A Prospective, Randomized Trial of Bivalirudin in Acute Coronary Syndromes Final One-Year Results from the.
Ten Year Outcome of Coronary Artery Bypass Graft Surgery Versus Medical Therapy in Patients with Ischemic Cardiomyopathy Results of the Surgical Treatment.
Management Strategies for Post-Intervention in Patients with CAD VBWG.
Date of download: 6/25/2016 Copyright © The American College of Cardiology. All rights reserved. From: Medical Therapy With Versus Without Revascularization.
Occluded Artery Trial: 1° Hypothesis and Design 1° Hypothesis: Late PCI to open occluded IRA will ↓ death/reinfarction/class IV CHF by 25% compared to.
Trial to Assess the Use of the Cypher Stent in Acute Myocardial Infarction Treated with Balloon Angioplasty (TYPHOON) Trial Presented at The American College.
Survival Benefits in Higher Risk Patients Coronary Revascularization has Revolutionized the Therapy of Ischemic Heart Disease Acute coronary syndromes.
Prof. Dr. Sigmund Silber, FESC, FACC On behalf of the RESOLUTE
Total Occlusion Study of Canada (TOSCA-2) Trial
William E. Boden, MD, FACC, FAHA
Revascularization in Patients With Left Ventricular Dysfunction:
The European Society of Cardiology Presented by Dr. Bo Lagerqvist
Clinical need for determination of vulnerable plaques
The Hidden Cost of Underutilizing PCI for Chronic Total Occlusions
Section 5: Intervention and drug therapy
American College of Cardiology Presented by Dr. Stephan Windecker
Preventive Angioplasty in Myocardial Infarction Trial
The Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery: The SYNTAX Study One Year Results of the PCI and CABG Registries.
TIMI IIIA Protocol Design 391 Patients with Unstable Angina / NQWMI
The European Society of Cardiology Presented by RJ De Winter
American College of Cardiology Presented by Dr. Michel R. Le May
O.L.Reuchlin gebruik van CT binnen de cardiogie
The Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery: The SYNTAX Study One Year Results of the PCI and CABG Registries.
ARISE Trial Aggressive Reduction of Inflammation Stops Events
TYPHOON Trial Trial to Assess the Use of the Cypher Stent in Acute Myocardial Infarction Treated with Balloon Angioplasty (TYPHOON) Trial Presented at.
Cardiovascular Epidemiology and Epidemiological Modelling
Presentation transcript:

Controversies in Cardiology: Stable CAD & COURAGE Pro: Optimal Medical Therapy vs. PCI SYED ZAHID JAMAL MD ASSOC PROF NICVD

Ha ha ha ha !

Varying Degrees of CAD Lesion Severity in a Single Coronary Artery Highly variable degrees of: plaque formation luminal obstruction inflammation likelihood of rupture

Is this a benign lesion in a benign condition? Stable Angina

What are you lookin at?

Nature of the Problem: Severe Obstruction (Angina, No Rupture) vs Mild Obstruction (No Angina, Likely to Rupture) Revascularization; Anti-anginal Rx Exertional Angina, (+) ETT Severe Fibrotic Plaque Severe obstruction, No lipid, Fibrosis, Ca ++ Pharmacologic Stabilization; ? Early Identification of High-risk Plaque Rupture Acute MI, Unstable Angina, Sudden death Vulnerable Plaque Minor obstruction, Eccentric plaque, Lipid pool, Thin cap Courtesy of P. Stone, 2007

The Differing Fates of Coronary Stenoses of Varying Severity Clinical manifestations of coronary lesions behave differently based on the degree of luminal obstruction and morphology: –Lesions > 50-75% obstruction Angina; positive stress test; positive calcium score –Lesions < 50% obstruction Rupture, superimposed thrombus ACS/Death Both types of lesions are inevitably present within the same stable CAD patient at any point in time

Goals of Therapy in CAD Management 1.Improve anginal symptoms by optimizing myocardial O 2 supply:demand balance Medication: Reduce HR, BP, contractility, preload β-blockers Ca ++ blockers Nitrates Enhance myocardial O 2 supply Ca ++ blockers & ? Ranolazine Revascularization (PCI or CABG) 2.Reduce/stabilize atherosclerotic plaque, reducing likelihood of rupture ACS/Cardiac death –Aggressive statin therapy –ACE inhibitors –Aspirin ± Clopidogrel –β-blockers –Lifestyle modifications (Courtesy of P. Stone, 2007)

* Med Management (MM), Percutaneous Coronary Intervention (PCI), Coronary Artery Bypass Grafting (CABG) Increased Mortality with Medical Management for UA/NSTEMI Patients : Patients with Significant CAD on Cath in the SYNERGY Trial Chan M, JACC Cardiovasc Int 2008

A Different Story in Stable CAD: Contrasting 1 Year Death/MI Rates: ACS, Stable Angina, “Primary Prevention” Wallentin L et al. Lancet 2000;356:9–16 Juul-Moller S et al. Lancet 1992;340:1421–1425 Shepherd J et al. N Engl J Med 1995;333:1301–1307 Poole-Wilson et al ACTION Lancet 2004;364: Death/ MI (%) Months of follow up Unstable angina/non Q wave MI (FRISC II) Stable angina (SAPAT) Primary Prevention (WOSCOPS) ACTION trial (stable CAD) Approx 1.5% Stable CAD COURAGE 3.8%

THE PROBLEM: Major Cardiac Events Occur in Non-Target Lesions Following Successful PCI Hazard Rate (%) (Cutlip, et al. Circulation 2004;110:1226) Substantial number of cardiac events could be prevented if we knew how to identify them 5 year Followup of 1228 Patients Treated with Bare Metal Stents Non-Target Lesion Event Rates: 12.4% Year % Year 1-5

Classification of Natural History of Early Atherosclerotic Plaques Plaque Trajectory Histo- pathology Progression Rate Vascular Remodeling Proclivity to Rupture Clinical Manifestations Quiescent Plaque Small lipid core/thick cap Minimal Compensatory LowAsymptomatic High-risk vulnerable plaque Large lipid core/ thin,inflamed cap Increased Excessive expansive High Acute Coronary Syndrome Stenotic Plaque Small lipid core/very thick cap GradualConstrictiveLowStable Angina (Chatzizisis, et al. JACC 2007;49:2379)

Relative Risk of Recurrent Cardiac Events with PTCA vs Medical Therapy Meta-analysis of 6 randomized trials (n=1904) (Bucher, et al. BMJ 2000;321:73)

Stable CAD: PCI vs Conservative Medical Management Meta-analysis of 11 randomized trials; N = 2950 Death Cardiac death or MI Nonfatal MI CABG PCI Katritsis DG et al. Circulation. 2005;111: P Risk ratio (95% Cl) Favors PCIFavors Medical Management

Long-Term Clinical Outcome: PTCA vs Medical Management in RITA-2 (Henderson, et al. JACC 2003;42:1161) P=NS No difference in outcome over median of 7 years RITA-2, 1018 patients (504 PTCA, 514 medical management) Death Death or MI

In Patients with Chronic Angina and Stable CAD: We know that PCI improves angina and short-term exercise capacity, so if we don’t “fix what we see”: 1.Will we expose patients to increased risk of death/MI? 2.Will angina and quality of life be worse? 3.Will residual ischemia be less well treated? 4.Will patients feel they did not receive “best care”? 5.What about high-risk patients—3V CAD; ↓ EF? What Is The Concern Of Leaving Coronary Stenoses Alone?

Evidence Prior to COURAGE of Leaving Coronary Stenoses Alone (Henderson, et al. JACC 2003;42:1161) P=NS No difference in outcome over median of 7 years RITA-2, 1018 patients (504 PTCA, 514 medical management) Death Death or MI

Stable CAD: PCI vs. Medical Management Pre-COURAGE Meta-analysis of 11 randomized trials; N = 2950 Death Cardiac death or MI Nonfatal MI CABG PCI Katritsis DG et al. Circulation. 2005;111: P Risk ratio (95% Cl) Favors PCIFavors Medical Management

COURAGE Primary EP: Survival Free of Death or MI Years PCI + OMT Optimal Medical Therapy (OMT) Hazard ratio: % CI ( ) P = ,287 Pts. Randomized to PCI + OMT vs. OMT Intensive, Guideline-Driven Medical Therapy & Lifestyle Intervention In Both Groups Source: Boden et al. N Engl J Med. 2007; 356:

Optimal Medical Therapy Pharmacologic Anti-platelet: aspirin; clopidogrel (c/w with established practice standards) Statin: simvastatin ± ezetimibe or extended-release niacin ACE Inhibitor or ARB: lisinopril or losartan Beta-blocker: long-acting metoprolol (Toprol XL®) Calcium channel blocker: amlodipine Nitrate: isosorbide 5-mononitrate Lifestyle Smoking cessation Exercise program Nutrition counseling Weight control Applied to Both Arms by Protocol and Case-Managed

Value of Optimal Medical Therapy: The COURAGE Trial Death/MIDeath New ACSNew MI Compared with Optimal Medical Therapy Alone, PCI provided no incremental benefit on Death, MI, New ACS (Boden, et al. NEJM 2007;356:1503)

Value of Optimal Medical Therapy: The COURAGE Trial (Boden, et al. NEJM 2007;356:1503) Percent With Angina Baseline 1 Year 3 Year 5 Year Compared with Optimal Medical Therapy alone, PCI is associated with a reduction in angina, but not after 5 yrs pNS P<0.001 P=0.02 pNS PCI + Optimal Rx Optimal Rx alone

Tertiary Outcomes: Cardiac Death/MI/ACS Years PCI + OMT OMT Hazard ratio: 1.07 CI 95% (0.91, 1.27) P = % 22.6% 10% 20% 30%

“COURAGE Enrolled Low-Risk Patients”… Huh??? Diabetes: 34% Dyslipidemia: 71 % HTN: 67% Smokers: 29% Prior MI: 39% Prior Revasc: 26% Angina at BL: 88% Angina Duration: 26 mo Angina Freq.: 6 episodes/wk Multivessel CAD: 70% LAD disease: 68% Inducible Ischemia: 85% Stress MPI: Multiple defects 67% Death/MI Event Rate: 4.3%/year

COURAGE Patient Randomized to OMT Alone

Need for Subsequent Revascularization: 7 Years of F/U* PCI + OMTOMT Overall Need for Revascularization 21%33% Subsequent CABGN=77N=81 Median Time to Revascularization † 10 months; 10.5% 10.8 months; 16.5% *Median 4.6 years of follow-up † Median time to Repeat or 1 st Revascularization After ~ 11 mo, the avg. X-over from OMT to PCI was 2.8%/year over years 1-7

Freedom from CCS Angina During Follow-up & NNT to Improve Sx Characteristic: CCS Class 0 PCI + OMTOMT NNT to improve angina in 1 pt with PCI CLINICAL Angina free – no. Baseline12%13%--- 1 Yr*66%58% Yr*72%67%20 5 Yr74%72%50 * The comparison between the PCI group and the medical-therapy group was significant at 1 year ( P<0.001) and 3 years (P=0.02) but not at baseline or 5 years.

SAQ Mean QOL Scores During Follow-up & NNT to Improve Sx CharacteristicPCI + OMTOMT NNT to improve SAQ QOL in 1 pt with PCI Mean SAQ QOL Score: Scale Baseline Mo* Mo* Yr* Yr *P < between groups

COURAGE QOL Editorial Commentary

Nuclear Substudy (n=314) Source: Shaw et al. J Nucl Cardiol 2006 Sep;13(5): Rest/Stress Myocardial Perfusion SPECT (MPS) Pre-Rx Pre-Rx Following 6-18m Randomized Rx (mean 374 ± 50 days) Following 6-18m Randomized Rx (mean 374 ± 50 days) Documented Pre-Rx Ischemia Pre-RxTc-99m sestamibi MPS Pre-RxTc-99m PCI + OMT (n=159) (n=159)OMT(n=155)OMT(n=155) Repeat MPS at 6-18m Repeat MPS at 6-18m Hypothesis: Reduction in Ischemia will be greater for Pts. Randomized to PCI+OMT than for those Randomized to OMT as Measured By Changes in Ischemic Burden by MPS at Baseline & 6- 18m after Randomization

Patient Expectations About Elective PCI for Stable CAD 52 consecutive patients scheduled for first elective PCI completed semi-structured questionnaire prospectively Holmboe et al. J Gen Intern Med 2000;15:632. Do you think the angioplasty will prevent a heart attack? Yes75% Do you think the angioplasty will help you live longer? Yes71%

Recent Mid-America Heart Institute Patient PCI Survey One million PCI procedures per year Majority elective Prospective survey of 350 elective PCI patients with stable MAHI between 1/06-10/07 Focus: are pt. perspectives of PCI benefit aligned with current evidence? John H. Lee, MD et al: 2008 AHA Scientific Sessions, November 12, 2008

Patient Perceived Benefits of Elective PCI

Alternate Therapies Offered

Stenosis Severity prior to AMI: What Drives Late Events is CAD Progression in Non-Flow- Limiting Lesions → New Plaque Rupture

For Patients Undergoing Elective Coronary Angiography for Chronic Angina: 13 RCTs in 7,605 patients (including BARI-2D) show no difference in death, MI, stroke or other “hard” endpoints between PCI and OMT An initial course of OMT preserves the option for PCI if medical therapy fails (only 16.5% of COURAGE OMT patients “crossed over” to PCI within 1 year) Over a full 7-year follow-up period, 2/3 of all OMT patients never required even a 1 st PCI procedure Why The Evidence Supports OMT as the Initial Approach to Stable CAD Management

In Patients with Chronic Angina and Stable CAD: There is better angina relief with PCI over 1-3 years There is better QOL with PCI over 1-2 years The subsequent need for revascularization in the 1 st year is lower in PCI than OMT patients OMT is a safe & viable option for most patients, and for those who may not be good candidates for PCI (frailty; CKD; multiple co-morbidities; treacherous anatomy, etc.) OMT as an initial approach preserves PCI as a subsequent option for symptom/QOL relief, if needed Where Does COURAGE Give Us Clarity of Management?

In Patients with Chronic Angina and Stable CAD: Is OMT as good as PCI + OMT in patients with impaired LV systolic function (EF < 40%)? Do patients with high-grade 3-vessel CAD fare as well with OMT vs. PCI + OMT, esp. with EF < 40%? Does stenosis severity (≥ 90% vs. 70%-80%) alter PCI vs. OMT outcomes, and does defining coronary anatomy in all patients aid clinical decision-making? Is it important to delineate the presence or absence of high- risk inducible ischemia in all patients? Where Do the Results of COURAGE Still Leave Uncertainty?

CAD manifestations in an individual patient are due both to: –Flow-limiting obstructions (angina, + stress test, + Ca ++ score) –Minor obstructions with high-risk vulnerable plaque (ACS, death) –Catheter-based treatment directed only at flow-limiting obstructions will do little to reduce the burden of CAD events precipitated by olaque rupture of non-flow- limiting stenoses Selective Management Strategies Focusing on Obstructive and Non-Obstructive CAD Summary and Conclusions

Non-obstructive high-risk plaque: –Difficult to identify/predict natural history at this time –Aggressive systemic pharmacologic therapy stabilizes vulnerable plaque and thereby reduces mortality and morbidity Statins, ACE-inhibitors, ? Niacin –Ultimately, risk stratification (and local intervention) of individual lesions may be possible Selective Management Strategies Focusing on Obstructive and Non-Obstructive CAD Summary and Conclusions

Flow-limiting Obstructive CAD: –Optimal Medical Therapy is a viable & defendable initial management strategy and is supported by existing ACC/AHA Clinical Practice Guidelines –Revascularization is appropriate in patients with severe angina symptoms (or who have failed medical Rx), or in those who have substantial ischemic jeopardy –Revascularization may be more effective than medications to: reduce angina increase exercise capacity decrease subsequent revascularization procedures but not to improve mortality, reduce MI, or other CV events. Selective Management Strategies Focusing on Obstructive and Non-Obstructive CAD Summary and Conclusions

Occluded Artery Trial (OAT) Presented at The American Heart Association Scientific Session 2006 OAT Trial

OAT Trial: Background The goal of the trial was to evaluate percutaneous coronary intervention (PCI) compared with medical therapy among stable, high-risk patients with persistent total occlusion of the infarct-related artery post-myocardial infarction (MI).The goal of the trial was to evaluate percutaneous coronary intervention (PCI) compared with medical therapy among stable, high-risk patients with persistent total occlusion of the infarct-related artery post-myocardial infarction (MI). Presented at AHA 2006

OAT Trial: Hypothesis A strategy of routine PCI for total occlusion of the infarct-related artery 3-28 days after acute MI would reduce the occurrence of the composite of death, reinfarction, or New York Heart Association (NYHA) class IV heart failure.A strategy of routine PCI for total occlusion of the infarct-related artery 3-28 days after acute MI would reduce the occurrence of the composite of death, reinfarction, or New York Heart Association (NYHA) class IV heart failure. Presented at AHA 2006

OAT Trial: Study Design  Primary Endpoints: Death, MI, or NYHA class IV heart failure PCI with stenting n=1082 n=1082 Medical Therapy n=1084 n= patients with angiography on day 3-28 post-MI with evidence of total occlusion of the infarct- related artery with poor or absent antegrade flow (TIMI flow grade 0 or 1); and met a criterion for increased risk, defined as ejection fraction <50%, proximal occlusion of a major epicardial vessel with a large risk region, or both Exclusions: NYHA class III or IV heart failure, shock, serum creatinine concentration >2.5 mg/dl, angiographically significant left main or three-vessel coronary artery disease, angina at rest, or severe ischemia on stress testing. Randomized. 22% female, mean age 59 years, mean follow-up 3 years, mean EF 48% at baseline Concomitant medications: Aspirin, anticoagulation if indicated, ACE inhibitors, beta-blockers, and lipid-lowering therapy, unless contraindicated 2166 patients with angiography on day 3-28 post-MI with evidence of total occlusion of the infarct- related artery with poor or absent antegrade flow (TIMI flow grade 0 or 1); and met a criterion for increased risk, defined as ejection fraction <50%, proximal occlusion of a major epicardial vessel with a large risk region, or both Exclusions: NYHA class III or IV heart failure, shock, serum creatinine concentration >2.5 mg/dl, angiographically significant left main or three-vessel coronary artery disease, angina at rest, or severe ischemia on stress testing. Randomized. 22% female, mean age 59 years, mean follow-up 3 years, mean EF 48% at baseline Concomitant medications: Aspirin, anticoagulation if indicated, ACE inhibitors, beta-blockers, and lipid-lowering therapy, unless contraindicated Presented at AHA 2006

OAT Trial: Primary Endpoint The primary endpoint of death, reinfarction, or NYHA class IV heart failure occurred in 17.2% of the PCI group and 15.6% of the medical therapy group ([HR] 1.16, p=0.20).The primary endpoint of death, reinfarction, or NYHA class IV heart failure occurred in 17.2% of the PCI group and 15.6% of the medical therapy group ([HR] 1.16, p=0.20). Primary Endpoint of death, reinfarction, NYHA class IV heart failure (% patients) Hazard Ratio 1.16, p=0.20 Presented at AHA 2006

OAT Trial: Primary Component Endpoints Total reinfarction trended higher in the PCI group (7.0% vs. 5.3%, HR 1.36, p=0.13), as did nonfatal reinfarction (6.9% vs. 5.0%, HR 1.44, p=0.08).Total reinfarction trended higher in the PCI group (7.0% vs. 5.3%, HR 1.36, p=0.13), as did nonfatal reinfarction (6.9% vs. 5.0%, HR 1.44, p=0.08). Repeated elevation of cardiac biomarkers within 48 hours of randomization occurred significantly more frequently in the PCI group (10.0% vs. 3.3%, p<0.001).Repeated elevation of cardiac biomarkers within 48 hours of randomization occurred significantly more frequently in the PCI group (10.0% vs. 3.3%, p<0.001). There was no difference in the individual endpoints of death (9.1% for PCI vs. 9.4% for medical therapy, p=0.83) or NYHA class IV heart failure (4.4% vs. 4.5%, p=0.92) between the treatment groups.There was no difference in the individual endpoints of death (9.1% for PCI vs. 9.4% for medical therapy, p=0.83) or NYHA class IV heart failure (4.4% vs. 4.5%, p=0.92) between the treatment groups. Primary Component Endpoints (% patients) TotalReinfarction Presented at AHA 2006 % patients NonfatalReinfarctionDeath Repeated ↑ of Cardiac Biomarkers NYHA Class IV Heart Failure p=0.13p=0.13 p=0.08p=0.08 p<0.001p<0.001 p=0.83p=0.83 p=0.92p=0.92

OAT Trial: Summary Among stable, high-risk patients with persistent total occlusion of the infarct-related artery post-MI, performance of PCI 3-28 days post-MI was not associated with a difference in the composite of death, reinfarction, or NYHA class IV heart failure through a mean follow-up of 3 years compared with medical therapy.Among stable, high-risk patients with persistent total occlusion of the infarct-related artery post-MI, performance of PCI 3-28 days post-MI was not associated with a difference in the composite of death, reinfarction, or NYHA class IV heart failure through a mean follow-up of 3 years compared with medical therapy. Despite no reduction in the composite endpoint, PCI was associated with a trend toward higher rates of reinfarction compared with medication therapy.Despite no reduction in the composite endpoint, PCI was associated with a trend toward higher rates of reinfarction compared with medication therapy. Among stable, high-risk patients with persistent total occlusion of the infarct-related artery post-MI, performance of PCI 3-28 days post-MI was not associated with a difference in the composite of death, reinfarction, or NYHA class IV heart failure through a mean follow-up of 3 years compared with medical therapy.Among stable, high-risk patients with persistent total occlusion of the infarct-related artery post-MI, performance of PCI 3-28 days post-MI was not associated with a difference in the composite of death, reinfarction, or NYHA class IV heart failure through a mean follow-up of 3 years compared with medical therapy. Despite no reduction in the composite endpoint, PCI was associated with a trend toward higher rates of reinfarction compared with medication therapy.Despite no reduction in the composite endpoint, PCI was associated with a trend toward higher rates of reinfarction compared with medication therapy. Presented at AHA 2006

OAT Trial: Summary (cont.) The reinfarctions were not only procedural-related infarcts (i.e., early procedural enzymatic leaks), but true ST elevation reinfarctions that accumulated throughout follow-up.The reinfarctions were not only procedural-related infarcts (i.e., early procedural enzymatic leaks), but true ST elevation reinfarctions that accumulated throughout follow-up. One explanation for the trend toward an increase in reinfarctions with PCI may be embolization resulting in myocardial damage and impaired collateral flow.One explanation for the trend toward an increase in reinfarctions with PCI may be embolization resulting in myocardial damage and impaired collateral flow. Presence of persistent total occlusion remains a problem for a sizeable cohort of patients for whom suitable treatment is lacking.Presence of persistent total occlusion remains a problem for a sizeable cohort of patients for whom suitable treatment is lacking. The reinfarctions were not only procedural-related infarcts (i.e., early procedural enzymatic leaks), but true ST elevation reinfarctions that accumulated throughout follow-up.The reinfarctions were not only procedural-related infarcts (i.e., early procedural enzymatic leaks), but true ST elevation reinfarctions that accumulated throughout follow-up. One explanation for the trend toward an increase in reinfarctions with PCI may be embolization resulting in myocardial damage and impaired collateral flow.One explanation for the trend toward an increase in reinfarctions with PCI may be embolization resulting in myocardial damage and impaired collateral flow. Presence of persistent total occlusion remains a problem for a sizeable cohort of patients for whom suitable treatment is lacking.Presence of persistent total occlusion remains a problem for a sizeable cohort of patients for whom suitable treatment is lacking. Presented at AHA 2006

OAT Trial: Summary (cont.) Early reperfusion therapy, the goal of ST elevation MI treatment, with either primary PCI or thrombolysis, is not indicated for patients who present late, often with persistent total occlusion.Early reperfusion therapy, the goal of ST elevation MI treatment, with either primary PCI or thrombolysis, is not indicated for patients who present late, often with persistent total occlusion. The present study, the largest randomized trial to date in this population, does not support the use of late PCI for stable but persistent total occlusion.The present study, the largest randomized trial to date in this population, does not support the use of late PCI for stable but persistent total occlusion. Early reperfusion therapy, the goal of ST elevation MI treatment, with either primary PCI or thrombolysis, is not indicated for patients who present late, often with persistent total occlusion.Early reperfusion therapy, the goal of ST elevation MI treatment, with either primary PCI or thrombolysis, is not indicated for patients who present late, often with persistent total occlusion. The present study, the largest randomized trial to date in this population, does not support the use of late PCI for stable but persistent total occlusion.The present study, the largest randomized trial to date in this population, does not support the use of late PCI for stable but persistent total occlusion. Presented at AHA 2006

Dang, HE IS DRUNK