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ESC Guias Revascularización miocárdica

ESC Guias Revascularización miocárdicaContents:

• Strategies of Diagnosis & severity of ischemia

• Optimal medical therapy

• Risk stratification. Clinical risk scores

• Procedural risk scores

• Heart Team: Multidisciplinary opinion

• Patient informed decision

• Specific recommendations

• Special Conditions

ESC Guias Revascularización miocárdica

ESC Guias Revascularización miocárdica

Optimal Medical Therapy• Antiischemic drugs• Antithrombotic treatment• Secondary prevention • Rehabilitation

ESC Guias Revascularización miocárdica

www.umassmed.edu/outcomes/grace

Scores to calculate Patient Risk

ESC Guias Revascularización miocárdicaScores to calculate Risk of PCI & CABG

ESC Guias Revascularización miocárdica

Patient information Patient active role in decissions•Objective, •Unbiased, •Patient-oriented, •Evidence-based, •Up-to-date, reliable, •Understandable, •Accessible, •Relevant,•Consistent with legal requirements

ESC Guias Revascularización miocárdicaPatient information (Apendix in guidelines)

ESC Guias Revascularización miocárdicaPatient information (Apendix in guidelines)

ESC Guias Revascularización miocárdicaPatient information (Apendix in guidelines)

ESC Guias Revascularización miocárdicaPatient information (Apendix in guidelines)

ESC Guias Revascularización miocárdicaMultidisciplinary Decision Pathways, Patient Info/consent & Timing of Intervention

The Heart Team

ESC Guias Revascularización miocárdicaMultidisciplinary Decision Pathways, Patient Info/consent & Timing of Intervention

ESC Guias Revascularización miocárdica

RevascularizationInSTE-ACS

ESC Guias Revascularización miocárdica

RevascularizationinNon STE-ACS

Risk Stratification in NSTE-ACS: Risk Stratification in NSTE-ACS:

0

500

1,000

1,500

2,000

2,500

3,000

3,500

GRACE risk score intervals

Patie

nts

(n)

0

5

10

15

20

25

30

35

40

Inho

spita

l mor

talit

y (%

)Troponin −Troponin +Mortality

0

500

1,000

1,500

2,000

2,500

3,000

3,500

GRACE risk score intervals

Patie

nts

(n)

0

5

10

15

20

25

30

35

40

Inho

spita

l mor

talit

y (%

)Troponin −Troponin +Mortality

<51

56 66 76 85 95 105 115 125 135 145 155 165 175 185 195 205 214 225 >226

N = 27,406 non-STE ACS patients

High < 140Low < 108

ESC Guias Revascularización miocárdica

PCI vs GABGStable patients

ESC Guias Revascularización miocárdica

RevascularizationinStable patients

Indications for Revascularisation in Stable Angina or Silent Ischaemia

* with documented ischaemia or FFR <0.80 for

angiographic diameter stenoses 50-90%

ESC Guias Revascularización miocárdica

Subset of CAD by anatomy Favours CABG Favours PCI

1VD or 2VD – non proximal LAD IIa C I C 1VD or 2VD – proximal LAD I A IIa B 3VD simple lesions, full functional revascularisation achievable with PCI,SYNTAX SCORE <22

I A IIa B

3VD complex lesions, incomplete revascularisation achievable with PCI,SYNTAX SCORE > 22

I A III A

Left Main (Isolated or 1VD, ostium/shaft) I A IIa B Left Main (Isolated or 1VD, distal bifurcation) I A IIb B Left Main + 2/3VD SYNTAX SCORE <33 I A IIb B Left Main + 2/3VD SYNTAX SCORE>33 I A III B

Indications for CABG vs PCI in candidates for revasc. in stable angina or silent ischaemia with lesions suitable for both procedures & low surgical mortality

ESC Guias Revascularización miocárdicaEuropean Society of Cardiology: 53 countries