PCI v CABG Dr Rod Stables The Cardiothoracic Centre Liverpool UK.

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Presentation transcript:

PCI v CABG Dr Rod Stables The Cardiothoracic Centre Liverpool UK

CABG is Alive and Well in Liverpool

Liverpool Family Life

Presentation Outline Undisputed current facts PCI improves access to revascularisation Availability

Access to Revascularisation - Availability Existing immediate capacity Dominant method for revascularisation UK PCI growth rate - 16% per annum UK CABG growth rate - static or negative Revascularisation event ratio trend > 2 : 1 Immediate ability to grow capacity favours PCI NSF targets - and beyond New indications

UK Activity: PCI v Isolated CABG

Presentation Outline Undisputed current facts PCI improves access to revascularisation Availability Patients with co-morbidity Patients with acute presentations Acute coronary syndromes Primary PCI for ST  MI Cardiogenic shock

Improved Cardiac Provision Favours PCI Better primary prevention Earlier investigation and treatment of CAD Aggressive early approach to occlusion Primary PCI for AMI Early PCI for non-ST elevation ACS Reduced incidence of Advanced ‘surgical’ disease’

Presentation Outline Undisputed current facts PCI improves access to revascularisation PCI is cost saving

SoS Trial - Total Costs at 1 Year £0 £1,000 £2,000 £3,000 £4,000 £5,000 £6,000 £7,000 £8,000 £9,000 £10,000 PCICABG Follow-up Initial hosp  Cost = £2,609 (95% CI: £1,769 to £3,314) £3,884 £2,412 £7,321 £1,518 Costs

Presentation Outline Undisputed current facts PCI improves access to revascularisation PCI is cost saving PCI is popular with patients

PCI - Appeal to Patients Experience from consent attempts in RCTs Shorter hospital stay

SoS Trial: Length of Stay - Index Procedure Median 3 daysMedian 10 days

PCI - Appeal to Patients Experience from consent attempts in RCTs Shorter hospital stay Reduced immediate procedural morbidity Avoids GA, scars etc Rapid rehabilitation CABG option remains (short or long term)

Presentation Outline Undisputed current facts PCI improves access to revascularisation PCI is cost saving PCI is popular with patients PCI is improving at a rapid pace

PCI Evolution Rate of new product registration Techniques and application Adjunctive medication schedules Imaging equipment Devices / equipment Stents and drug eluting stents Improving clinical results

Stenting and Emergency CABG

Stenting and Restenosis Procedures

Presentation Outline Undisputed current facts Historic trials favour CABG Reduced repeat revascularisation

SoS Trial: Repeat Revascularisation Hazard ratio 3.90 (2.58 to 5.91)

SoS Trial: Death or Non-Fatal Q Wave MI Hazard ratio 0.95 (0.63 to 1.43)

Mortality to 1 Year

Presentation Outline Undisputed current facts Historic trials favour CABG Reduced repeat revascularisation Emerging clinical data - favours PCI

PCI v CABG: The Current Picture Non - MACCE adverse events SoS data Hospitalisation events after index revasc Non - MACCE : Never reported CABG 351 (0.7 per patient) PCI 156 (0.3 per patient) MACCE: PCI - superior safety and efficacy

Latest Trials From TCT 2004 ARTS 2 Registry n = 607 MV revasc by DES More diabetes than ARTS 1 (26% v 18%) More 3 VD (54% v 28%) More stents (3.7 [73mm] v 2.8 [48mm]) 6 month freedom from MACCE ARTS % ARTS 1: PCI % CABG %

ARTS II - MACCE Free Survival

‘Armies can be resisted but not an idea whose time has come.’ Victor Hugo