1. September 18th 2012 Case #3: KA, 70 yr M
Presentation:
Presented on 9/11/2012 with new onset CCS class II angina and
a stress MPI moderate apical and mild inferior ischemia. Cath revealed 3 V+LM CAD and normal LV function
Prior History:
Hyperlipidemia, Hypertension- uncontrolled, Asthma, GI upset
Medications: All once daily dosage
Candesartan/HCTZ 32/12.5mg, ISMN 60mg, Atorvastatin 20mg, Clopidogrel 75mg, Amlodipine 10mg, Ezetimibe 10mg, Inhalers 1

2. Case# 3: cont… Syntax score 34 Cardiac Cath 09/11/2012:
3 Vessel + LM CAD with LVEF 65%
Left Main: 80%
LAD: 80% prox and 80% D1 bifurcation lesion (1,1,1)
LCx: 50% prox and 90% multiple lesions in LPL1
RCA: 80% prox and 70% lesion in mid RCA
Subsequent Course:
- Pt was taken out of the cath lab for Heart Team consultation and CABG recommended for high Syntax score. Pt refused CABG due to personal belief and asthma. Pt was given 162mg enteric coated aspirin and underwent 2 CoCr EES & did well
Plan Today:
- PCI of LM/LAD-D1 bifurcation/LCx lesions (5 lesions) with FFR 2

3. Appropriateness Criteria for Coronary Revascularization

4. Issues Involving The Case
Complex CAD: PCI vs. CABG;
SYNTAX Trial- 5 Year F/U
Non-Complex CAD: PCI vs. (O,R)MMT
FAME II Trial

5. Issues Involving The Case
Complex CAD: PCI vs. CABG;
SYNTAX Trial- 5 Year F/U
Non-Complex CAD: PCI vs. (O,R)MMT
FAME II Trial

6. SYNTAX Trial: Study Design & Patient Disposition
62 EU Sites +
23 US Sites
De novo 3VD and/or LM (isolated, +1,2,3 VD)
Heart Team (Surgeon & Interventional Cardiologist) Review Randomized if suitable for either CABG or PCI or Enrolled in nested registry if not equally suitable
CABG Reg.
n=649*
CABG RCT
n=897
PCI RCT
n=903
PCI Registry
n=198
Enrolled
CABG
n=644**
From SYNTAX_CSR_randomized_Unblinded_2008Oct10.doc Exhibit 5
SYNTAX 5-Year Report_Randomized_15JUN12.doc Exhibit 4 (evaluable for 5-year MACCE)
SYNTAX 5-Year Report_Registry_22JUN12.doc Exhibits 4 and 8
CABG
849 (94.6%)
PCI
891 (98.7%)
PCI
n=192**
Primary Endpoint 1 Year Follow-up
CABG
610 (94.7%)
CABG
805 (89.7%)
Completed Study
5 Year Follow-up
PCI
871 (96.5%)
PCI
188 (97.9%)
*N=649 followed for 5 years, N=1077 enrolled, **CABG N=644, PCI N=192 treated per protocol. PCI performed with TAXUS Express

7. SYNTAX Trial: All-Cause Death to 5 Years
PES (N=903)
CABG (N=897)
Before 1 year*
3.5% vs 4.4%
P=0.37
1-2 years*
1.5% vs 1.9%
P=0.53
2-3 years*
1.9% vs 2.6%
P=0.32
3-4 years*
2.2% vs 3.2%
P=0.22
4-5 years*
3.1% vs 2.3%
P=0.34 25 50
P=0.10
P=0.10
Cumulative Event Rate (%)
1 yr data From SYNTAX_CSR_randomized_Unblinded_2008Oct10.doc exhibit 1
2-Year_Randomized_ doc Exhibit 2 (binary interval rate)
SYNTAX 3-Year Report_Randomized_12JUL10.doc Exhibit 2 (binary interval rate)
SYNTAX 4-Year Report_Randomized_15JUN11.doc exhibits 1 (KM rate on right sidea) and exhibit 2 (binary interval rate in white box)
13.9%
11.4% 12 60 24 36 48
Months Since Allocation
ESC 2012
Cumulative KM Event Rate ± 1.5 SE; log-rank P value;*Binary rates
ITT population 7

8. SYNTAX Trial: Myocardial Infarction to 5 Yrs
PES (N=903)
CABG (N=897)
Before 1 year*
3.3% vs 4.8%
P=0.11
1-2 years*
0.1% vs 1.2%
P=0.008
2-3 years*
0.3% vs 1.2%
P=0.03
3-4 years*
0.3% vs 1.5%
P=0.01
4-5 years*
0% vs 1.2%
P=0.004 25 50
P=0.001
P<0.001
Cumulative Event Rate (%)
1 yr data From SYNTAX_CSR_randomized_Unblinded_2008Oct10.doc exhibit 1
2-Year_Randomized_ doc Exhibit 2 (binary interval rate)
SYNTAX 3-Year Report_Randomized_12JUL10.doc Exhibit 2 (binary interval rate)
SYNTAX 4-Year Report_Randomized_15JUN11.doc exhibits 1 (KM rate on right sidea) and exhibit 2 (binary interval rate in white box)
9.7%
3.8% 12 60 24 36 48
Months Since Allocation
Cumulative KM Event Rate ± 1.5 SE; log-rank P value;*Binary rates
ITT population 8

9. SYNTAX Trial: CVA to 5 Years
PES (N=903)
CABG (N=897)
Before 1 year*
2.2% vs 0.6%
P=0.003
1-2 years*
0.6% vs 0.7%
P=0.82
2-3 years*
0.5% vs 0.6%
P=1.00
3-4 years*
0.4% vs 0.2%
P=0.68
3-4 years*
0% vs 0.1%
P=1.00 25 50
P=0.09
P=0.09
Cumulative Event Rate (%)
1 yr data From SYNTAX_CSR_randomized_Unblinded_2008Oct10.doc exhibit 1
2-Year_Randomized_ doc Exhibit 2 (binary interval rate)
SYNTAX 3-Year Report_Randomized_12JUL10.doc Exhibit 2 (binary interval rate)
SYNTAX 4-Year Report_Randomized_15JUN11.doc exhibits 1 (KM rate on right sidea) and exhibit 2 (binary interval rate in white box)
3.7%
2.4% 12 60 24 36 48
Months Since Allocation
Cumulative KM Event Rate ± 1.5 SE; log-rank P value;*Binary rates 9

10. SYNTAX Trial: All Death/CVA/MI to 5 Yrs
PES (N=903)
CABG (N=897)
Before 1 year*
7.7% vs 7.6%
P=0.98
1-2 years*
2.2% vs 3.5%
P=0.11
2-3 years*
2.5% vs 3.8%
P=0.14
3-4 years*
2.7% vs 4.6%
P=0.05
4-5 years*
3.1% vs 3.1%
P=0.98 25 50
P=0.03
P=0.03
Cumulative Event Rate (%)
20.8%
1 yr data From SYNTAX_CSR_randomized_Unblinded_2008Oct10.doc exhibit 1
2-Year_Randomized_ doc Exhibit 2 (binary interval rate)
SYNTAX 3-Year Report_Randomized_12JUL10.doc Exhibit 2 (binary interval rate)
SYNTAX 4-Year Report_Randomized_15JUN11.doc exhibits 1 (KM rate on right sidea) and exhibit 2 (binary interval rate in white box)
16.7% 12 60 24 36 48
Months Since Allocation
Cumulative KM Event Rate ± 1.5 SE; log-rank P value;*Binary rates 10

11. SYNTAX Trial: Repeat Revasc to 5 Years
PES (N=903)
CABG (N=897)
Before 1 year*
5.9% vs 13.5%
P<0.001
1-2 years*
3.7% vs 5.6%
P=0.06
2-3 years*
2.5% vs 3.4%
P=0.33
3-4 years*
1.6% vs 4.2%
P=0.002
4-5 years*
1.9% vs 4.3%
P=0.008 25 50
P<0.001
P<0.001
25.9%
Cumulative Event Rate (%)
1 yr data From SYNTAX_CSR_randomized_Unblinded_2008Oct10.doc exhibit 1
2-Year_Randomized_ doc Exhibit 2 (binary interval rate)
SYNTAX 3-Year Report_Randomized_12JUL10.doc Exhibit 2 (binary interval rate)
SYNTAX 4-Year Report_Randomized_15JUN11.doc exhibits 1 (KM rate on right sidea) and exhibit 2 (binary interval rate in white box)
13.7% 12 60 24 36 48
Months Since Allocation
Cumulative KM Event Rate ± 1.5 SE; log-rank P value;*Binary rates 11

12. SYNTAX Trial: MACCE to 5 Years
PES (N=903)
CABG (N=897)
Before 1 year*
12.4% vs 17.8%
P=0.002
1-2 years*
5.7% vs 8.3%
P=0.03
2-3 years*
4.8% vs 6.7%
P=0.10
3-4 years*
4.2% vs 7.9%
P=0.002
4-5 years*
5.0% vs 6.3%
P=0.27 25 50
P<0.001
P<0.001
37.3%
Cumulative Event Rate (%)
26.9%
1 yr data From SYNTAX_CSR_randomized_Unblinded_2008Oct10.doc exhibit 1
2-Year_Randomized_ doc Exhibit 2 (binary interval rate)
SYNTAX 3-Year Report_Randomized_12JUL10.doc Exhibit 2 (binary interval rate)
SYNTAX 4-Year Report_Randomized_15JUN11.doc exhibits 1 (KM rate on right sidea) and exhibit 2 (binary interval rate in white box) 12 60 24 36 48
Months Since Allocation
Cumulative KM Event Rate ± 1.5 SE; log-rank P value;*Binary rates
ITT population 12

13. SYNTAX Trial: PP Graft Occlusion or Stent Thrombosis to 5 Years
(Per Patient Binary Rates) 7
CABG
PCI
Patients (%) 7
SYNTAX 5-Year Report_Randomized_22JUN12.doc Exhibit 9
Acute
≤1d
Subacute
2-30d
Late
31-365d
Very Late d d d
Total
5 year d
Days Postprocedure 13

14. SYNTAX score is purely High >32 an anatomic score of the
extent of CAD (>50%) in a pt
Each lesion is assigned a
numerical number and then
sum of all lesions score
for a patient is
calculated to come up
with the final numerical
Syntax score
Pt are divided in 3 groups:
Low <22
Intermediate 23-32
High >32
Serruys P et al. NEJM 2009;360:961.

15. SYNTAX Trial: MACCE vs. SYNTAX Score
*P= 0.03 vs PCI with SYNTAX score ≤22
†P= vs PCI with SYNTAX score 23-32
Trend for PCI: P=0.006
P < 0.001
CABG (n= 897)
PES DES (n= 903)
23.4*†
16.7
14.7
13.6
12.0
MACCE at 12 Months (%)
10.9
In patients with a SYNTAX score of 22 or less (meaning less complicated disease), there was no significant difference between CABG and PCI in rates of major adverse cardiac and cerebrovascular events.
In patients with moderately complicated disease (represented by a SYNTAX score of 23 to 32) a trend toward better outcomes with CABG was seen, although the difference did not reach statistical significance.
In patients with very complicated disease (represented by a SYNTAX score of 33 or more), CABG had significantly better outcomes than PCI (P<.001).
The rate of MACCE in the high-score PCI group was statistically significantly higher than in the other PCI groups; the trend for all 3 PCI groups was statistically significant as well.
These results provide evidence for current practices in which patients with complex, multivessel disease receive CABG while patients with less complex disease are treated with PCI.
≤22
23-32
≥33
SYNTAX Score
Serruys P et al. NEJM 2009;360:961.
Serruys PW, Mohr FW. Presented at: Transcatheter Cardiovascular Therapeutics 2008; October 12-17, 2008; Washington, DC.

16. MACCE to 5 Years by SYNTAX Score Tercile
Low Scores (0-22)
PES (N=299)
CABG (N=275)
CABG
PCI
P value
Death
10.1%
8.9%
0.64
CVA
4.0%
1.8%
0.11 MI
4.2%
7.8%
Death, CVA or MI
14.9%
16.1%
0.81
Revasc.
16.9%
23.0%
0.06
Overall 50
32.1%
P=0.43
Cumulative Event Rate (%) 25
28.6%
SYNTAX 5-Year Report_Randomized_15JUN12.doc exhibit 53 12 24 36 48 60
Months Since Allocation
Cumulative KM Event Rate ± 1.5 SE; log-rank P value

17. MACCE to 5 Years by SYNTAX Score Tercile
Intermediate Scores (23-32)
PES (N=310)
CABG (N=300)
CABG
PCI
P value
Death
12.7%
13.8%
0.68
CVA
3.6%
2.0%
0.25 MI
11.2%
<0.001
Death, CVA or MI
18.0%
20.7%
0.42
Revasc.
24.1%
Overall 50
36.0%
P=0.008
Cumulative Event Rate (%) 25
SYNTAX 5-Year Report_Randomized_15JUN12.doc exhibit 55
25.8% 12 24 36 48 60
Months Since Allocation
Cumulative KM Event Rate ± 1.5 SE; log-rank P value

18. MACCE to 5 Years by SYNTAX Score Tercile
High Scores (33)
PES (N=290)
CABG (N=315)
CABG
PCI
P value
Death
11.4%
19.2%
0.005
CVA
3.7%
3.5%
0.80 MI
3.9%
10.1%
0.004
Death, CVA or MI
17.1%
26.1%
0.007
Revasc.
12.1%
30.9%
<0.001
Overall 50
P<0.001
44.0%
Cumulative Event Rate (%) 25
26.8%
SYNTAX 5-Year Report_Randomized_15JUN12.doc exhibit 57 12 24 36 48 60
Months Since Allocation
Cumulative KM Event Rate ± 1.5 SE; log-rank P value

19. MACCE to 5-Years Based on Syntax Score Tercile: 3 V CAD
CABG
PES DES
Death, MI or CVA
0-22
11.6
p=0.06
23-32
>33
18.8
8.4
18.2
21.1
10.5
p=0.004
p=0.006
171
155
166
181
208
207
Revascularization
p=0.007
26.1
p=0.81
p=0.42
20.7
18.0
17.1
16.1
14.9 % %
171
181
208
207
166
155
0-22
23-32
>33
Serruys et al, ESC 2012

20. ACC/AHA/SCAI Guidelines: Revascularization to Improve Survival in Complex CAD
Revasc Method
COR
LOE
CABG I B
PCI
IIaFor SIHD when low risk of PCI complications and high likelihood of good long-term outcome (e.g., SYNTAX score of ≤22, ostial or trunk left main CAD), and a signficantly increased CABG risk (e.g., STS-predicted risk of operative mortality ≥5%)
IIbFor SIHD when low to intermediate risk of PCI complications and intermediate to high likelihood of good long-term outcome (e.g., SYNTAX score of <33, bifurcation left main CAD) and increased CABG risk (e.g., moderate-severe COPD, disability from prior stroke, prior cardiac surgery, STS-predicted operative mortality >2%)
III: HarmFor SIHD in patients (versus performing CABG) with unfavorable anatomy for PCI and who are good candidates for CABG
IIaFor UA/NSTEMI if not a CABG candidate
IIaFor STEMI when distal coronary flow is <TIMI grade 3 and PCI can be performed more rapidly and safely than CABG C
GNL 2011

21. Appropriate Use Criteria 2012
Method of Revascularization of Multi-vessel CAD
CABG
PCI
Two-vessel CAD with proximal LAD stenosis A
Three Vessel CAD with low CAD burden (i.e., three
focal stenosis, low SYNTAX score)
Three-vessel CAD with intermediate to high CAD burden (i.e., multiple diffuse lesions, presence of CTO, or high SYNTAX score). U
Isolated left main stenosis
Left main stenosis and additional CAD with low CAD burden (i.e., one to two vessel additional involvement, low SYNTAX score)
Left main stenosis and additional CAD with intermediate to high
CAD burden (i.e., three vessel involvement, presence of CTO, or high SYNTAX score) I
Patel et al., JACC 2012; 59:0000 21

22. Heart Team Approach to UPLM or Complex CAD
Anatomic Setting
COR
LOE
UPLM or Complex CAD
I – Heart Team Approach C
IIa – Calculation of the STS and SYNTAX scores B
GNL 2011

23. Incorporation of intermediate-high SYNTAX Score (23-32, 33+) for revascularization choice in pts with 3V CAD: 4-Yr Data of SYNTAX Trial
As you all know, since Jan 2010, we have incorporated Syntax score in stratifying patients for revascularization choices (PCI or CABG) for advanced CAD and pts with Syntax score 33 who are not high-surgical risk, being preferentially referred for CABG.
Recent presentation of 4-year data of Syntax Trial at TCT 2011, revealed CABG arm having significantly lower individual endpoint of death or MI or revascularization compared to Taxus DES PCI, even in the intermediate Syntax score (23-32) patients with 3V CAD. This observation was noted in both diabetic and non-diabetic pts. Outcomes of pts with low Syntax score (<23) was comparable in both groups. Hence as per evidence-based guidelines, optimal coronary revascularization for intermediate Syntax scores (23-32) pts as well as high scores (>33) pts, should be CABG. Therefore, patients with SYNTAX Score 23 and not having absolute contraindications to CABG (included below), should be taken out of the cath room for discussion with Heart Team regarding choices of revascularization. As a rule, these 3V CAD patients (SYNTAX Score 23) should be categorically recommended for CABG because of survival & MI advantage over PCI. Consultation with of a cardiac surgeon will be required if PCI is contemplated in these pts. Only exception to this rule (taking the pt out of the cath room for discussion) could be, if the referring MD (who has to be different then the Interventionalist) is physically present in the cath lab and expresses strong desire against CABG (because of his/her own belief or known wishes of the patient).
Patients with 3V CAD and SYNTAX Score 23 but following situations and co-morbidities could be excluded from routine CT surgery consultations:
1) Acute MI (STEMI or Non-STEMI)
2) Age >85 years old
4) Prior CVA/recent TIA
5) Severe COPD (FEV1 <50% predicted) and on chronic bronchodilator therapy
6) BMI >50
7) Participation in IRB approved trial of PCI
Also patient’s firm refusal for CABG should be entertained only after the CT surgery consultation outside the cath room in the holding area or the telemetry unit. We will monitor and report the data of this system process going forward by analyzing the triage of all 3V CAD pts with Syntax score of (23).

24. Various Risk Classifications for Revascularization in CAD24

25. Garg et al., Circ. Cardiovasc. Interv 2010;3; 31725

26. Kaplan Meier Curves for MACCE
Garg et al., Circ. Cardiovasc. Interv 2010;3; 317

27. Global Risk Classification (GRC) for CAD
Capodanno et al, Am Heart J 2010; 159:103

28. Features considered score calculation
Score name
Ref.
Score Range
Features considered score calculation
Comments
SRS (SYNTAX risk score)
Serruys and co workers
0 to ~ 75
Exclusively based on coronary anatomy.
Can be complex to calculate; usually requires online assistance or dedicated software.
CSS (Clinical SYNTAX score)
Garg et al
0 to ~ 500
Based on both coronary and clinical features.
Calculated by multiplying the SRS with the ACEFmod scores.
NYSRS (New York State Risk Score)
Wu et al
0 to 40
Age, gender, hemodynamic state, LVEF, pre-procedure MI, PAD, CHF, renal failure, LM CAD.
8 of 9 elements are clinical co-morbidities, with only 1 coronary anatomical feature (LM disease).
ACEF (Age, Creatinine, Ejection Fraction score)
Ranucci et al
1 to ~10
Considers only age, creatinine and ejection fraction.
= [Age (yrs)/LVEF (%)] + 1 if creatinine ≥ 2.0 mg/dL. Originally derived in cardiac surgery patients.
ACEFmod (Modified ACEF score)
1 to ~14
Considers only age, creatinine clearance and ejection fraction.
= [Age (yrs)/LVEF (%)] + 1 point for every 10 mL/min reduction in CrCl below 60 mL/min per 1.73 m2 (up to a maximum of 6 points).
NCDR (National Cardiovascular Data Registry score)
Peterson et al
0 to 100
Age, prior CHF, shock, PAD, lung disease, GFR, NYHA class IV, PCI urgency.
Does not consider coronary anatomy.
Other risk scores: EuroSCORE, Society of Thoracic Surgeons (STS), Global Risk Classification (GRC) score (= EuroSCORE + SRS), FFR-based SYNTAX, NYSRS for patients >65 years of age, Northern New England, Michigan Consortium, William Beaumont Hospital, Mayo Clinic.

29. Risk Score Distributions in 500 MV CAD at MSH
SRS
CSS
NYSRS
ACEF
ACEFmod
NCDR 29

30. Mortality SRS CSS NYSRS ACEF ACEFmod NCDR p = 0.006 p < 0.0001
proportion
proportion
proportion
ACEF
ACEFmod
NCDR
p <
p <
p = 0.002
proportion
proportion
proportion

31. Myocardial Infarction
SRS
CSS
NYSRS
p = 0.024
p = 0.041
p = 0.27
proportion
proportion
proportion
ACEF
ACEFmod
NCDR
p = 0.27
p = 0.26
proportion
proportion
proportion
p = 0.28

32. Target Lesion Revascularization
SRS
CSS
NYSRS
p = 0.075
proportion
proportion
proportion
p = 0.37
p = 0.89
ACEF
ACEFmod
NCDR
p = 0.24
p = 0.14
p = 0.045
proportion
proportion
proportion 32

33. Major Adverse Cardiac Events
SRS
CSS
NYSRS
p <
p = 0.027
p <
proportion
proportion
proportion
ACEF
ACEFmod
NCDR
p = 0.001
proportion
proportion
proportion
p = 0.37
p = 0.67

34. Mortality SRS NYSRS ACEFmod Reference CSS ACEF NCDR Risk Score AUC
p value vs. SRS
ACEF
0.7586
0.082
CSS
0.7550
0.019
NYSRS
0.7408
0.17
Risk Score
AUC
p value vs. SRS
ACEFmod
0.7400
0.18
NCDR
0.6789
0.78
SRS
0.6616 - 34

35. Major Adverse Cardiac Events
SRS
NYSRS
ACEFmod
Reference
CSS
ACEF
NCDR
Risk Score
AUC
p value vs. SRS
SRS
0.6282 -
CSS
0.6059
0.39
NYSRS
0.5942
0.38
Risk Score
AUC
p value vs. SRS
ACEF
0.5865
0.26
ACEFmod
0.5589
0.076
NCDR
0.5333
0.021

36. Issues Involving The Case
Complex CAD: PCI vs. CABG;
SYNTAX Trial- 5 Year F/U
Non-Complex CAD: PCI vs. (O,R)MMT
FAME II Trial

37. Page 991
Conclusions
In patients with stable coronary artery disease and functionally significant stenosis, FFR-guided PCI plus the best available medical therapy,, as compared with the best available medical therapy alone, decreased the need for urgent revascularization. In patients without ischemia, the outcome appeared to favorable with the best available medical therapy alone. (Funded by St. Jude Medical; Clinic al trials. Gov. number. NCT ) 37

38. FAME II Trial: Flow Chart
Stable patients scheduled for 1,2 or 3 vessel DES stenting
FFR in all targets lesions
Randomized Trial
Registry
At least 1 stenosis with FFR < 0.80
When all FFR >0.80
Randomization 1:1
OMT
PCI + OMT
OMT
50 % randomly assigned to FU
Follow-up after 1,6 months, 1,2,3,4 and 5 years 38

39. FAME II Trial: Cumulative Incidence of Primary End Points and Its Components
Bruyne et al., NEJM 2012:367:991

40. FAME II Trial: Revascularization Status
P<0.001
5.2% MT alone and 0.9% PCI
patients had MI or UA with ECG changes requiring TVR
(HR 0.13; P=<0.001)
P<0.001
(%)
P<0.001
Bruyne et al., NEJM 2012:367:991 40

41. FAME II Trial: Landmark Analysis of the Primary End Point and Its Components
Bruyne et al., NEJM 2012:367:991

42. FAME II Trial: Patients with Angina Class II to IV and Corresponding Relative Risk
Bruyne et al., NEJM 2012:367:991 42

43. Japanese Stable Angina Pectoris (JSAP Trial)
469 met eligibility criteria
85 declined to give permission
384 consented to participate
(82% of patients with protocol eligibility)
192 were assigned to PCI plus medical group, and underwent initial elective PCI
41 (21.4%) underwent additional elective PCI
192 were assigned to initial medical therapy only group
70 (36.5%) underwent additional elective PCI
192 were included in the primary analysis
192 were included in the primary analysis
Nishigaki et al., JACC Intv 2008;1:469 43

44. JSAP Trial: PCI + MT for Low Risk CAD
Nishigaki et al., JACC Intv 2008;1:469

45. JSAP Trial: PCI + MT for Low Risk CAD
MT (n= 182)
PCI (n= 183) %
Nishigaki et al., JACC Intv 2008;1:469 45

46. COURAGE Trial: 5-year death/MI
Subgroup Analysis based on the Regional Practices
OMT Group (n=1138)
PCI Group (n=1149)
P ≈ 0.02 22 22 21 17 15
Death/MI (%) at 4.6 years 14
27%↑ 
29%↓
Canada
932 pts
US VA
968 pts
US non-VA
387 pts
Boden et al. N Engl J Med 2007;356:1503 46 46

47. PCI vs. RMT in Stable CAD: NY State Database
4-Year Adverse Outcomes
for Propensity-Matched PCI vs. Medical Therapy
Overall survival
Freedom from MI
No at Risk
0.0
1.0
2.0
3.0
4.0
5.0
RMT
933
870
675
458
310
145
PCI
865
648
429
291
140
No at Risk
0.0
1.0
2.0
3.0
4.0
5.0
RMT
933
873
700
445
298
169
PCI
890
726
480
332
182
Hannan et al, Circulation 2012;125:1870 47

48. PCI vs. RMT in Stable CAD: NY State Database
4-Year Adverse Outcomes
for Propensity-Matched PCI vs. Medical Therapy
P = 0.005
P = 0.02
P = 0.007 %
Hannan et al, Circulation 2012;125:1870 48

49. PCI vs. RMT in Stable CAD: NY State Database
Hannan et al, Circulation 2012;125:1870

50. COURAGE Trial type Cases (N=265,184)
Pattern and Intensity of Optimal Medical Therapy (OMT) during PCI: Impact of COURAGE Trial: Data from ACC-NCDR CathPCI Registry
PRE- COURAGE (n=173,416)
Post- COURAGE (n=293,795)
66.0
63.5
64.3
61.8 %
43.5
44.7
40.0
41.1
OMT Pre-PCI
OMT Post-PCI
OMT Pre-PCI
OMT Post-PCI
All Cases (N=467,211)
COURAGE Trial type Cases (N=265,184)
W Borden et al. JAMA 2011;305:1882

51. Pattern and Intensity of Optimal Medical Therapy (OMT) during PCI: Impact of COURAGE Trial: Data fro ACC-NCDR CathPCI Registry
PRE- COURAGE (n=173,416)
Post- COURAGE (n=293,795)
66.0
63.5
64.3
61.8 %
43.5
44.7
40.0
41.1
Implications: There is a large practice gap in medical care of PCI pts.
Important opportunity to develop innovative and aggressive strategies
to increase OMT in PCI pts, both before PCI (by referring MDs)
and
after PCI (by the Interventional team)
OMT Pre-PCI
OMT Post-PCI
OMT Pre-PCI
OMT Post-PCI
All Cases (N=467,211)
COURAGE Trial type Cases (N=265,184)
W Borden et al. JAMA 2011;305:1882

52. Take Home Message: Incorporation of SYTAX and FAME II Trials in Coronary Revascularization
Long-term data of coronary revascularization for complex extensive CAD (Syntax score >23), clearly favors CABG over 1st generation DES PCI and should become the default therapy by guidelines. FREEDOM Trial will be presented as the LBT in AHA 2012
Appropriate revascularization of obstructive lesions guided by physiological FFR (<0.8) during PCI, has shown to achieve excellent long-term results and is superior to MMT alone

53. Question # 1
5-Year f/u of SYNTAX Trial has shown CABG to be superior to DES PCI on following components except:
All cause mortality
Repeat revascularization
CVA
Myocardial infarction C

54. Question # 2
Appropriate dose of IV adenosine for hyperemic FFR evaluation is:
140 mcg/kg/min
160 mcg/kg/min
120 mcg/kg/min
10 mcg IC bolus A

55. Question # 3
FAME II Trial showed the following outcome in the FFR guided PCI vs. medical therapy;
Higher readmission
More angina class
Reduced Mortality
Lower TLR D

56. Question # 4
In the SYNTAX trial of DES vs CABG which drug eluting stent was used?
Sirolimus eluting stent
Paclitaxel eluting stent
Everolimus eluting stent
Zotarolimus eluting stent B

57. Question # 5
Following are the risk score for assessment of revascularization status except;
Grace score
Syntax score
Global risk score
EuroScore
NY State risk score A