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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


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


www.umassmed.edu/outcomes/grace

Scores to calculate Patient Risk

ESC Guias Revascularización miocárdicaScores to calculate Risk of PCI & CABG


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

The Heart Team

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


RevascularizationInSTE-ACS


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


PCI vs GABGStable patients


RevascularizationinStable patients

Indications for Revascularisation in Stable Angina or Silent Ischaemia

* with documented ischaemia or FFR <0.80 for

angiographic diameter stenoses 50-90%


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

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