COMPLETE REVASCULARIZATION IN ELDERLY - When it’s contraindicated Giuseppe Biondi-Zoccai S. Giovanni Battista “Molinette” Hospital University of Turin 3rd International Interventional Forum – Turin, 18 January 2008 (h 12.20-12.40)

Learning goals How do you define complete revascularization (MVD)? What is the risk-benefit balance of culprit vs multivessel PCI in stable MVD? What is the risk-benefit balance of culprit vs multivessel PCI in acute MVD? When is complete revascularization contraindicated in the elderly?

To achieve a greater understanding, let us begin with an example from a related field…

Is it safer to target one only?

Is it safer to target one only?

Or all of them at once?

Learning goals How do you define complete revascularization (MVD)?

Defining revascularization Anatomically complete: PCI of every occluded or stenotic epicardial vessel Functionally complete: PCI of every occluded or stenotic epicardial vessel of adequate size and supplying a zone of viable myocardium Incomplete (culprit only): PCI of occluded or stenotic epicardial vessel identified by comprehensive clinical judgement as responsible for signs/symptoms of ischemia Incomplete (truly): everything else

Defining revascularization Anatomically complete: PCI of every occluded or stenotic epicardial vessel Functionally complete: PCI of every occluded or stenotic epicardial vessel of adequate size and supplying a zone of viable myocardium Incomplete (culprit only): PCI of occluded or stenotic epicardial vessel identified by comprehensive clinical judgement as responsible for signs/symptoms of ischemia Incomplete (truly): everything else

Scope of the problem ALL P<0.05 % Wiemer et al, AHJ 2004

Hazards of MVD stenting

Hazards of MVD stenting

Hazards of MVD stenting Orlic et al, JACC 2004

Learning goals What is the risk-benefit balance of culprit vs multivessel PCI in stable MVD?

TIME trial supports PCI in elderly Pfisterer et al, JAMA 2003

TIME trial Pfisterer et al, JAMA 2003

Yet PCI based on oculostenotic reflex is not always justified in stable MVD

Boden et al, NEJM 2007

Boden et al, NEJM 2007

Symptomatic benefits in the COURAGE trial Boden et al, NEJM 2007

Evidence in non-randomized trials

Ijsselmuiden et al, AHJ 2004

Learning goals What is the risk-benefit balance of culprit vs multivessel PCI in acute MVD?

Early invasive management in elderly with ACS: TACTICS Study Brener et al, Am J Cardiol 2002

Yet PCI based only on oculostenotic reflex is also not justified in acute MVD Hirsch et al, Lancet 2007

Hirsch et al, Lancet 2007

Hirsch et al, Lancet 2007

What about complete PCI in STEMI? Single vs multivessel treatment during primary angioplasty: results of the multicentre randomised HEpacoat for cuLPrit or multivessel stenting for Acute Myocardial Infarction (HELP AMI) Study. Di Mario C, Sansa M, Airoldi F, Sheiban I, Manari A, Petronio A, Piccaluga E, De Servi S, Ramondo A, Colusso S, Formosa A, Cernigliaro C, Colombo A, Monzini N, Bonardi MA. Int J Cardiovasc Intervent. 2004;6(3-4):128-33.

Di Mario et al, Int J Cardiovasc Intervent 2004 % 53 vs 69 minutes, p<0.05 22,330€ vs 20,382€, p=NS 0 vs 4%, p=NS 35% vs 17% p=NS Di Mario et al, Int J Cardiovasc Intervent 2004

Learning goals When is complete revascularization contraindicated in the elderly?

Learning goals When is complete revascularization contraindicated in the elderly? Mainly when its expected benefits do not overwhelm the expected risks

Lack of symptoms/signs of myocardial ischemia

COURAGE Nuclear Substudy P=0.037 Risk of death or MI (%) Shaw et al, AHA 2007

Extremely diffuse disease or challenging lesions

Extremely diffuse disease or challenging lesions Sianos et al, EI 2005

SYNTAX score Sianos et al, EI 2005

Risk of renal failure

Risk of renal failure Mehran et al, JACC 2004

Risk of renal failure Mehran et al, JACC 2004

Increased bleeding risk

Increased bleeding risk Nikolsky et al, EHJ 2007

Increased bleeding risk Nikolsky et al, EHJ 2007

Poor compliance or life expectancy

Take home messages

Take home messages Current data disCOURAGE from extensive multivessel PCI based only on angiographic assessment in stable MVD No definite benefits have been shown from multivessel PCI in patients with acute CAD and MVD According to evidence available to date, PCI of non-culprit vessels cannot thus be recommended routinely

Take home messages Thus, major contraindications to complete revascularization in elderly are: Lack of clear-cut signs/symptoms of ischemia Extremely diffuse disease or challenging lesions Increased bleeding or renal failure risk Lack of compliance or poor life expectancy Individualized clinical decision making is pivotal to maximize benefit and minimize risks

For further slides on these topics please feel free to visit the metcardio.org website: http://www.metcardio.org/slides.html