Wednesday, October 7, 2015

Stable Ischemic Heart Disease Guidelines: Summary

Stable Ischemic Heart Disease Guidelines: Summary

 

Revascularization to improve mortality:

Left Main >50% (CABG Class I, PCI Class IIa)- CASS, VA Co-op Study, MASS II
3 vessel disease or pLAD and one other (CABG, Class I)- CASS, VA Co-op Study, MASS II
2 major coronary arteries with significant ischemia (CABG, Class IIa)
LVSD 35-50% EF when viable myocardium present (Class IIa)
SCD in presumed ischemia related VT (CABG/PCI, Class I)

Revascularization options:

CABG vs BMS
No difference at 5 years, single or multi-vessel disease
Procedural stroke CABG>PCI
Angina relief CABG>PCI
Repeat revascularization PCI>CABG

 

CABG vs DES
MACE and mortality: PCI>CABG at 3 years in higher syntax scores >22 (<22, no difference)

Special groups

Left main (selected patients- ostium or trunk)
Mortality, MI and stroke at 1 and 2 years, PCI=CABG (syntax >33, higher mortality)
TVR at 1, 2 and 3 years, PCI>CABG
PLAD
(PCI =CABG) >medical therapy
LV systolic dysfunction
LVEF <35%, CABG = GDMT at 5 years- STICH
Diabetes
Survival: CABG >PCI – BARI, FREEDOM
Revascularization: PCI>CABG - SYNTAX

Medical therapy of angina:

Beta blockers
For patients with PAD/ Prinzmetal’s angina: labetalol/carvedilol (alpha adrenergic blocking) or nebivolol (direct vasodilator)
CCBs: verapamil or diltiazem
Long acting nitrates
Ranolazine: contraindicated in significant hepatic impairment. 500mg BID max dose with diltiazem and verapamil. Increases plasma concentration of simvastatin 2 fold.

 

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