Management Strategies for Post-Intervention in Patients with CAD

1
VBWG
Management Strategies forPost-Intervention in
Patientswith CAD
2
Disease progression in nonstented lesions causes
most CV events
VBWG
N 1228 in 2nd-generation coronary stent trials
Average event rate, years 25
CV event rate
25
6.7
20
7
18.3
Target lesion
Nontarget lesion
15
5

12.4
10
3
7.0
6.7
5.6
5.7
1.7
5
2.3
1
1.5
1.6
1.3
0
Target lesion
Nontarget lesion
1
2
3
4
5
0
Year
Non-drug eluting stents
Cutlip DE et al. Circulation. 20041101226-30.
3
Predictors of nontarget lesion PCI for
progression of disease
VBWG
NHLBI Dynamic Registry N 3747 for PCI
P
Three-vessel disease (vs 1)
lt0.001
Two-vessel disease (vs 1)
0.005
Prior coronary intervention
lt0.001
Age lt65 years
0.003
Female gender
0.05
Diabetes
1.0
Hypertension
0.84
1
5
2
4
3
0
Adjusted odds ratio
Glaser R et al. Circulation. 2005111143-9.
4
Improving long-term outcomes after PCI
VBWG

• Restenosis is less of a problem in drug-eluting
  stent era
• A significant number of patients return to cath
  lab with new lesions
• Patients with more extensive CAD have increased
  risk

Aggressive post-PCI risk factor management offers
the greatest opportunity to improve long-term
outcomes
Glaser R et al. Circulation. 2005111143-9. Vetro
vec GW. Circulation. 2005111125-6.
5
CRUSADE Discharge care for CABG vs PCI
VBWG
100
95
92
87
88
86
83
79
80
73
72
72
68
65
60
51
Dischargetherapy()
44
40
20
0
Cardiac rehab
Aspirin
Beta-blockers
ACEinhibitors
Statins
Smoking- cessation counseling
Diet- modification counseling
PCI (n 25,653)
CABG (n 7663)
Dyke CK et al. Circulation. 2004110
(suppl)III-420.
6
CRUSADE Hospital variations in quality of care
vs outcome
VBWG
ACC/AHA class I indications
5.95
6
In-hospital mortality ()
4.16
4
2
100
0
80
Treat-ment ()
60
40
20
0
ASA
Heparin
ASA
GP llb/IIIa
ACEI
Statin
BB
Clopidogrel
BB
Discharge
lt24 hours
Lagging hospitals (bottom 25)
Leading hospitals (top 25)
Peterson ED et al. J Am Coll Cardiol.
200443(suppl)406A. http//www.crusadeqi.com/Jul
y 2005.
Relative to total care opportunities
7
Greater use of evidence-based medications lowers
6-month mortality in ACS patients
VBWG
N 1358
Appropriateness level
n
Lower mortality
Higher mortality
IV
0.10 (0.030.42)
630
III
314
0.17 (0.040.75)
II
0.18 (0.040.77)
302
I
0.36 (0.081.75)
91
0.5
1.0
1.5
3.0
2.0
0.0
Odds ratio (95 CI)
Number of evidence-based medications used
(aspirin, ACE inhibitor, ?-blocker, statin) vs
number indicated
Mukherjee D et al. Circulation. 2004109745-9.
8
Potential long-term risk reduction with
cardioprotective medications in post-MI patients
VBWG
Medication class RRR () 5-Year CV-event risk ()
None 0 20.0
Aspirin 25 15.0
?-Blocker 25 11.3
ACE inhibitor 25 8.4
Lipid lowering 30 5.9

• Cumulative risk reduction if all 4 medication
  classes are used 70
• NNT to prevent 1 major CV event in 5 years 7

Fonarow GC. Rev Cardiovasc Med. 20034(suppl
3)S37-46.