diabetes & coronary revascularisation esc guidelines ... · esc guidelines - clinical cases...
TRANSCRIPT
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Diabetes & Coronary RevascularisationESC Guidelines - Clinical Cases
Lampros K. Michalis, MD, FRCP, FESC
Professor of Cardiology, University of Ioannina
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ESC GuidelinesOverall Statement for
Revascularization in Diabetics
ESC 2018 Myocardial Revascularisation Guidelines
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Aspects to be
considered by the
Heart Team
ESC 2018 Myocardial RevascularisationGuidelines
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Key Messages in GuidelinesDiabetes
ESC 2018 Myocardial Revascularisation Guidelines
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Recommendations for Revascularisation (SCAD)Diabetes vs No Diabetes
ESC 2018 Myocardial Revascularisation Guidelines
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Changes compared to previous ESC Guidelines
ESC 2014 ESC 2018
ESC 2018 Myocardial Revascularisation Guidelines
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Scores for Surgical Risk & CAD Complexity
ESC 2018 Myocardial Revascularisation Guidelines
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How much is low predicted surgical mortality ?
ESC 2018 Myocardial Revascularisation Guidelines
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Recommendations for Revascularization Strategy in NSTEMI
ESC 2018 Myocardial Revascularisation Guidelines
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Recommendations for Revascularization Strategy in STEMI
ESC 2018 Myocardial Revascularisation Guidelines
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Case #1
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Case #1 – Clinical Data
• 69-yr old Male patient
• Medical History– Diabetes, Hypertension, Dyslipidaemia
• Clinical PresentationStable coronary artery disease
• Echocardiogram: EF 40-45%
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Case #1 – LCA AngiogramSevere LAD/Diagonal disease and non-significant LCx disease
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Case #1 – RCA AngiogramSubtotal RCA occlusion
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SYNTAX scoreIntermediate Syntax score I
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SYNTAX score II
ESC 2018 Myocardial Revascularisation Guidelines
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SYNTAX score II
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STS score
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Euroscore II
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Euroscore IFor comparison purposes to Trials
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Heart Team & Patient Information
Heart Team
Recommendation for CABG
Patient Preference: Declined CABG
Decision for PCI
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PCI RCA
Pre-PCI PCI result
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Staged PCI LAD
Pre-PCI PCI result
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Case #2
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Case #2 – Clinical Data
• 65-yr old Male patient
• Medical History– Diabetes, Smoking, Hypertension, Family Hx of early CAD
– Thyroid disease
• Clinical PresentationNon-ST segment Elevation Myocardial Infarction (NSTEMI)
• Echocardiogram: EF 50%
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Case #2 – LCA AngiogramSignificant LAD disease (proximal and middle)
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Case #2 – LCA AngiogramSignificant LCx and IM disease
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Case #2 – RCA AngiogramSignificant RCA disease
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SYNTAX score
Intermediate Syntax score I
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SYNTAX score II
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STS score
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Euroscore II
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Decision Making
Review of patient by Cardio-Thoracic team on an urgent basis
Recommendation for CABG
Patient Preference: Accepted recommendation
Decision for CABG
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Case #3
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Case #3 – Clinical Data
• 61-yr old Male patient
• Medical History– Diabetes, Ex-smoker
– Known coronary artery disease with recent NSTEMI without revascularisation
– Recent SPECT(Thallium): viable in all myocardial walls
– Tuberculosis
• Clinical PresentationNon-ST segment Elevation Myocardial Infarction (NSTEMI) with recurrent symptoms and ongoing Troponin increase (2000 to 6000 pg/ml) within 48 hours
• Echocardiogram: EF 35%
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Case #3 – LCA AngiogramSignificant LAD/Diagonal disease (with thrombus burden)
and significant LCx disease
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Case #3 – RCA AngiogramSignificant RCA disease
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How would you proceed
• PCI
• CABG
• I need to estimate the different scores
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SYNTAX score
HighSyntax score I
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SYNTAX score II
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STS score
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Euroscore II
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Euroscore IFor comparison purposes to Trials
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How would you proceed ?
Syntax score I: 36 (High)
Syntax score II: High mortality for PCI vs CABG
Surgical Risk
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Decision Making
Decision for PCI
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PCI LADPCI result
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Staged PCI RCAPCI result
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Case #4
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Case #4 – Clinical Data
• 83-yr old Male patient
• Medical History– Diabetes, Ex-smoker
– Known coronary artery disease with PCI mid LAD (unstable angina)
– Surgical revascularisation of carotid disease
– Prostate Cancer under radiotherapy
• Clinical PresentationUnstable angina – Positive Stress Echo
• Echocardiogram: EF 50%
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Case #4 – LCA AngiogramSignificant LM bifurcation/LAD/LCx disease
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Case #4 – RCA Angiogram
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SYNTAX score
IntermediateSyntax score I
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SYNTAX score II
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STS score
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Euroscore II
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Decision Making
Heart Team
Recommendation for PCI
- Porcelain aorta
- Favorable Syntax II score for PCI
Patient Preference: Accepted decision for PCI
Decision for PCI
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PCI LADPCI result
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