KHI NÀO CÂN NHẮC TÁI THÔNG MẠCH VÀNH TRONG HỘI CHỨNG VÀNH MẠN.pptx

Chỉ định tái thông trong hội chứng vành mạn: khi nào, cho ai và phương thức nào?

1. When to consider revascularize for obstructive CAD TAM TINH, MD

2. Case presentation

3. Optimal treatment CCS Lifestyle changes Medical therapy, and Revascularization of obstructed coronary vessels for select patients “See one, stent one” ❌

4. 2023 ACC/AHA CCD guideline - indications Virani SS et al, Circulation. 2023 Sep 26;148(13):e148

5. Summary Indication Goal For whom Mode of revasc. Symtomatic Improve symptoms Refractory angina despite OMT PCI or CABG Anatomic Improve survival LM stenosis Multivessel CAD and EF ≤ 35% CABG Reduce MACE * Multivessel CAD PCI or CABG *MACE: urgent revascularization, spontaneous MI, CV death

6. Revascularization to improve symptoms Al-Lamee RK,. BMJ. 2022;377:e067085

7. Revascularization to improve symptoms Meta analysis Panuccio G et al, Eur J Clin Invest. 2024;54(12):e14303

8. Revascularization to reduce mortality Trial data Chang AM et al, Med Clin North Am. 2024;108(3):517-538

9. Revascularization to reduce mortality Trial data Chang AM et al, Med Clin North Am. 2024;108(3):517-538

10. Revascularization to reduce mortality Trial data Chang AM et al, Med Clin North Am. 2024;108(3):517-538

11. Revascularization to reduce mortality Summary Who Left main disease (outdated trial VA Coop, ECSS 1970s) Multivessel CAD and EF ≤ 35% (CASS, STITCH, STITCHES) Mode of revascularization CABG Consideration of upfront surgical risk

12. Revascularization to reduce mortality R ecommendation 2023 ACC/AHA 2024 ESC

13. Revascularization to improve other cardiovascular outcomes Trial data Chang AM et al, Med Clin North Am. 2024;108(3):517-538

14. Revascularization to improve other cardiovascular outcomes Trial data Chang AM et al, Med Clin North Am. 2024;108(3):517-538

15. Revascularization to improve other cardiovascular outcomes Trial data Chang AM et al, Med Clin North Am. 2024;108(3):517-538

16. Revascularization to improve other cardiovascular outcomes Trial data Chang AM et al, Med Clin North Am. 2024;108(3):517-538

17. Forget Ischemia: It’s All About the Plaque

18. In summary, contemporary RCTs show no survival benefit for revascularization ( predominantly PCI ) in patients with CCD without high-risk features such as LM disease or a low EF However, some RCTs support a reduction in the frequency of urgent revascularization, spontaneous MIs, and cardiovascular mortality Therefore, the 2021 and 2023 guidelines provide a class IIa recommendation for revascularization for multivessel CAD to reduce the risk of cardiovascular (CV) events such as spontaneous MI, need for urgent revascularization, or cardiac death. However, given the only modest impact on outcomes , tempered by the uncertainty outlined above, patients should be counseled cautiously regarding their potential benefit balanced with procedural risks Revascularization to improve other cardiovascular outcomes Summary Chang AM et al, Med Clin North Am. 2024;108(3):517-538

19. Revascularization to improve other cardiovascular outcomes Recommendation 2023 ACC/AHA 2024 ESC

20. Situations in which PCI or CABG would be preferred Patients With Complex Disease Three-vessel CAD Left main disease Patients With Diabetes

21. REVASCULARIZATION STRATEGY Three-vessel CAD In the 10-year follow-up (SYNTAXES ), investigators found a persistent increase in all-cause mortality among those in the PCI group with three-vessel disease and a high syntax score Chang AM et al, Med Clin North Am. 2024;108(3):517-538

22. REVASCULARIZATION STRATEGY Three-vessel CAD Chang AM et al, Med Clin North Am. 2024;108(3):517-538

23. REVASCULARIZATION STRATEGY Left Main Disease Chang AM et al, Med Clin North Am. 2024;108(3):517-538

24. REVASCULARIZATION STRATEGY Patients with Diabetes Chang AM et al, Med Clin North Am. 2024;108(3):517-538

25. REVASCULARIZATION STRATEGY Patients with Diabetes Chang AM et al, Med Clin North Am. 2024;108(3):517-538

26. REVASCULARIZATION STRATEGY PCI vs CABG Krittanawong C et al., Curr Cardiol Rep. 2024;26(9):919-933

27. Situations in which PCI or CABG would be preferred Recommendation 2023 ACC/AHA

28. Situations in which PCI or CABG would be preferred Recommendation 2024 ESC In CCS patients with significant three-vessel disease, preserved LVEF, no diabetes , and insufficient response to GDMT, CABG is recommended over medical therapy alone to improve symptoms, survival , and other outcomes ( IA )

29. Tóm tắt khuyến cáo ACC/AHA 2023 và ESC 2024

30. Key takeaways 3 indications Symtomatic indication: after OMT Improve symtoms Anatomic indication: on top of OMT Improve survival Reduce future MACE Risk – benefit assessment Situations in which PCI or CABG would be preferred Patient with complex disease Patient with diabetes

31. CASE DECISION-MAKING AND RESOLUTION