1. 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 )

2. 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?

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

4. Is it safer to target one only?

5. Is it safer to target one only?

6. Or all of them at once?

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

8. 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

9. 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

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

11. Hazards of MVD stenting

12. Hazards of MVD stenting

13. Hazards of MVD stenting
Orlic et al, JACC 2004

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

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

16. TIME trial
Pfisterer et al, JAMA 2003

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

18. Boden et al, NEJM 2007

19. Boden et al, NEJM 2007

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

21. Evidence in non-randomized trials

23. Ijsselmuiden et al, AHJ 2004

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

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

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

27. Hirsch et al, Lancet 2007

28. Hirsch et al, Lancet 2007

29. 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):

30. 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

31. Learning goals
When is complete revascularization contraindicated in the elderly?

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

33. Lack of symptoms/signs of myocardial ischemia

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

35. Extremely diffuse disease or challenging lesions

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

37. SYNTAX score
Sianos et al, EI 2005

38. Risk of renal failure

39. Risk of renal failure
Mehran et al, JACC 2004

40. Risk of renal failure
Mehran et al, JACC 2004

41. Increased bleeding risk

42. Increased bleeding risk
Nikolsky et al, EHJ 2007

43. Increased bleeding risk
Nikolsky et al, EHJ 2007

44. Poor compliance or life expectancy

45. Take home messages

46. 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

47. 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

48. For further slides on these topics please feel free to visit the metcardio.org website: