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To Stent or not to Stent?

In the wake of the ISCHEMIA trial results being published, and the media firestorm that ensued, I’ve run into some interesting scenarios, including STEMI patients saying they don’t want to be revascularized because they heard on the news that stents are useless (oh boy!). However, after a robust discussion with an intern, I decided to do a quick n dirty rundown of who does and does not need immediate revascularization, and which strategy to go with.

If there’s one thing you should know about the ISCHEMIA trial, it is that this study sought to answer the question of whether or not STABLE ischemic heart disease would benefit from an aggressive revascularization strategy vs a conservative strategy of goal-directed medical therapy. This had nothing to do with patients who had ACS. I will also add that with long-term followup, the results might change, nobody knows for certain. The reason I say this is because the PCI arm had a signal towards harm in the first 6 months after revascularization, but as they approached 4 years, the mortality curves started to separate in favor of the aggressive revascularization arm. As it stands, their conclusions were not in favor of an aggressive strategy over a conservative one. Interestingly, these results didn’t differ very much from the COURAGE trial, where they found no significant difference between optimal medical therapy vs PCI for stable ischemic heart disease. Differences to note include the fact that COURAGE did NOT use FFR, and did not have routine use of DES.

Keep in mind, patients with left main stenosis > 50% were excluded from both of these trials, as were those who had recent revascularization within the past 6 to 12 months (PCI or CABG). The reason I mention this is because some people thought these results contradicted the findings of the COMPLETE trials – but no, these trials looked at different sets of patients altogether!

A few big wins for the ISCHEMIA trial:

  • CT-angiography was shown to be very reliable
  • FFR-guided PCI is becoming more routinely accepted as the preferred method of PCI
  • Optimal medical therapy really helps…even if there turns out to be a mortality benefit in favor of early-PCI, the fact that it takes several years to emerge is a statement about how helpful these medications truly are.

 

With regards to stable ischemic heart disease, clear indications for revascularization include left main stenosis > 50%, proximal LAD with >50% stenosis, or multi-vessel disease with signs of impaired ventricular function. Typically, cardiologists will employ the SYNTAX score, which is a validated system used to grade the severity and complexity of lesions. Typically, SYNTAX scores < 23 are amenable to PCI and non-inferior to CABG. The typical scenario for PCI is when you have isolated disease in only 1 or 2 vessels, and this is amenable to stenting.

Once you have significant left main disease, especially in conjunction with 2-3 vessel disease, the SYNTAX score is > 32, and CABG is superior.

Until very recently, it was generally accepted that isolated left main disease could be treated by PCI or CABG. However, some controversy has erupted recently after the results of the EXCEL trial were published. Specifically, the EXCEL trial had a composite endpoint of stroke, MI, or death, and there was no statistically significant differences between the two groups. Surgeons will tell you that the higher rates of the composite endpoint were driven by excess all-cause mortality in the PCI arm, as compared to peri-procedural MI in the CABG arm…in other words, while the composite endpoints were similar in both groups, the individual endpoint of mortality was higher with PCI, whereas peri-procedural MI was higher with CABG. This can certainly be a bit contentious, especially if you wonder what the clinical significance of a troponin elevation is after CABG. Nonetheless, the trial was powered to detect differences in the COMPOSITE endpoint, not in the individual endpoint of mortality.

The STICH trial demonstrated a significant benefit (albeit 10 years out) in favor of revascularization (this study only looked at CABG) for patients with ischemic heart failure. The FREEDOM trial took it one step further and tried to compare DES to CABG for mutli-vessel CAD in diabetics. The findings were strongly in favor of CABG over PCI, and this has become the accepted paradigm.

 

When you’re not sure, if they have funky looking anatomy AND they’re diabetic, you can make a safe gamble and ask your attending if they think this patient is a CABG candidate. 9 times out of 10, you’ll look like a genius.

In Conclusion:Stable ischemic heart disease has some controversy surrounding the role of revascularization, but ALL patients should be on optimal medical therapy

Patients with significantly reduced EF, Left main, proximal LAD disease, all should warrant a closer look at whether or not they would benefit from revascularization

Always try to involve a multi-disciplinary team when thinking about revascularization, at the end of the day, we are in the business of do no harm, so a second set of eyes can be beneficial.

 

The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.

 

References:

https://www.ischemiatrial.org/

Boden, W. E., O’rourke, R. A., Teo, K. K., Hartigan, P. M., Maron, D. J., Kostuk, W. J., … & Chaitman, B. R. (2007). Title LM, Gau G, Blaustein AS, Booth DC, Bates ER, Spertus JA, Berman DS, Mancini GB, Weintraub WS; COURAGE Trial Research Group. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med356(15), 1503-16.

Campos, C. M., van Klaveren, D., Farooq, V., Simonton, C. A., Kappetein, A. P., Sabik III, J. F., … & Serruys, P. W. (2015). Long-term forecasting and comparison of mortality in the Evaluation of the Xience Everolimus Eluting Stent vs. Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL) trial: prospective validation of the SYNTAX Score II. European heart journal36(20), 1231-1241.

Stone, G. W., Kappetein, A. P., Sabik, J. F., Pocock, S. J., Morice, M. C., Puskas, J., … & Banning, A. (2019). Five-year outcomes after PCI or CABG for left main coronary disease. New England Journal of Medicine381(19), 1820

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AHA19 Reflection

“Half of what we will teach you in medical school is right, and half of it is wrong – the problem is we don’t know which is which.” This quote, or some variation of it, is relayed by many educators at medical schools across the globe. At AHA19, these words rang in my ears as my head was spinning from attending lecture after lecture being given by experts in the field of cardiology. What I found to be most educational (and hilarious), were the debates on controversial topics.

The debates I attended ranged from the age-old IABP vs impella in cardiogenic shock patients, to thought-provoking jabs at conventional practice, such as whether or not sodium restriction is necessary in acute decompensations of heart failure. However, I’m not here to convince you that one form of mechanical circulatory support is superior to another, or that perhaps some of the things we put a lot of stake in (hello salt restriction), might not be true in all cases.

With each debate, when a physician explained their reasoning for being Pro-X or Anti-Y, I couldn’t stop nodding in agreement. Gaining insight into their reasoning was thought provoking in and of itself! I found myself agreeing, disagreeing, and scratching my head at different concepts. It helped me discover gaps within my own knowledge, and pushed me to review the primary literature in a way that no amount of pimping on the wards ever could.

One of my favorite debates was watching Dr. Gregg Stone debate with Dr. Obadia on the merits of mitral valve clipping for secondary mitral regurgitation (the lead investigators of 2 separate trials that basically showed totally different results). Neither physician said the other was wrong! In fact, they both more or less agreed with one another, and helped highlight key differences that a discerning physician should look for when faced with such discrepancies.

And the lectures that weren’t meant to be debates ended up sparking hot debates anyways! I’m looking at you #ISCHEMIA trial. The #Cardiotwitter explosion that began that ensued has been so eye-opening to me as a trainee. Not only did it help highlight some details of landmark trials I might have missed, but it gave me a great window into the line of thought of many skilled clinicians.

Coming through college, medical school, and residency, I’ve been exposed to many different styles of teaching, and I’ve seen conventional medical education evolve from a bunch of disjointed sciences taught in school to a formal systems-based curriculum. Social media has changed the landscape of many fields, and medical education is not immune to its effects. FOAMed (Free open access medical education) and social media have become staples in how some trainees learn, and we must embrace that. The way that the AHA sought to integrate this into their programming was a great experience that truly helped to cement new knowledge for me, and ultimately improve my patients’ care. And as I’ve come to learn, when it comes to these debates, it’s not about who is right or wrong, it’s about how much you can learn form hearing both perspectives.

 

 

The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.

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A Few Things the Critical Care Cardiologist Might Have Missed While Talking About the #ISCHEMIA Trial

The ISCHEMIA trial definitely caused quite a chatter, and congratulations to the authors on a thought provoking and interesting study. I’m fascinated and can’t wait to do a deep dive on my own time. BUT, that’s for stable ischemic heart disease. There’s a time and a place for that, but that place is certainly not the ICU.

With that in mind, I’m going to briefly highlight a few presentations at this year’s AHA conference, and throw out a few breadcrumbs to pique your interest and hopefully encourage you to look into the primary literature.

 

Utilization and Outcomes of Impella vs IABP Among Patients with AMI Complicated by Cardiogenic Shock Undergoing PCI

In this talk, Dr. Sanket Dhruva and friends took data from the NCR CathPCI Registry, and created a linked cohort with the Chest Pain MI Registry. Out of 28,304 patients with AMI and CS, 8,471 received IABP only, 1,768 received Impella only. They were able to propensity match 1,680 (95%) of the Impella patients to IABP patients. The results were staggering: 45.0% mortality rate for Impella vs 34.1% with IABP. Major bleeds (as defined by the NCDR) occurred in 31.3% of Impella and 16.0% of IABP patients. They also stratified the patient event rates for pre and post-PCI initiation of mechanical circulatory support. Study perior was 10/2015 – 12/2017

Pre-PCI initiation of MCS:

  • Mortality 45.6% vs 36.8% Impella vs IABP
  • Major bleeding 27.4% vs 16.6% Impella vs IABP

Post-PCI initiation of MCS:

  • Mortality 44.0% vs 32.2% Impella vs IABP
  • Major bleeding 34.4% vs 15.7% Impella vs IABP

ischemia

Comments:

This was a historical cohort, this is observational data, and I think this highlights a need for a prospective RCT looking at the use of Impella vs IABP in patients with AMI and cardiogenic shock. Because of the nature of the dataset, the definitions of events were standardized across the board. I will also add that these patients were not stratified using the SCAI schema for cardiogenic shock (hard to use it when it wasn’t released during the study period!).  Is it possible that the sicker patients got Impella more frequently? Sure, but, Dr. Dhruva noted that most of the Impella devices used were the small 2.5, and not the 5.0. A study I was a part of looking at trends in utilization and mortality with MCS published earlier this year also found similarly increasing trends in utilization of MCS, but no difference overall with regards to mortality. That paper, too, performed retrospective data analysis, and carries many of the same limitations as this study.

 

1 year outcomes of the COACT: Coronary Angiography after Cardiac Arrest Trial

You are the physician on-call at your ICU. You hear of a patient who had an out-of hospital cardiac arrest, the rhythm was VT, ROSC was obtained in the field, and the post-ROSC ECG showed no STEMI. Do you take them to the cath lab, or do you just focus on targeted temperature management & stabilize the patient? What if it was an electrically silent MI!?

This study sought to provide some guidance for scenarios such as the one above. Followup was assessed at 90 and 365 days for the 538 patients enrolled in this study.

Exclusion criteria was STEMI, obvious non-coronary cause of arrest, delivery of electric shock

Inclusion criteria: Initial shockable rhythm, comatose after ROSC (GCS < 8) , and no ST elevation on post-ROSC ECG.

End-result, 61.4% of patients in the immediate angiography and 64.0% in the delayed angiography group were alive 1 year post-arrest. No significant difference in rates of revascularization, MI, or hospitalization for heart failure or ICD shocks between either group.

Comments:

Looking at the details, I saw roughly similar rates of PCI in both groups, I am curious if PCI utilizing FFR would have had different results in the delayed angiography group. Overall, I think this provides solid evidence to support the importance of focusing on stabilizing the post-cardiac arrest patient, and looking for other, non-cardiac causes of the arrest (assuming no obvious signs of MI).

 

Session on Hemodynamics in Cardiogenic Shock

This has a lot of buzz words that I like, and I’m a huge geek for physiology, so I basically camped outside the room in anticipation of this session.

The speakers were an all-star lineup, including Dr. Hall from Baylor University, Dr. van Diepen from University of Alberta, Dr. Wong of the University of British Columbia, Dr. Kapur from Tufts, and Dr. Thiele from the University of Leipzig.

 

My breadcrumb summary:

  1. The old definition of cardiogenic shock is not very helpful (sustained SBP < 90 mm Hg for at least 30 minutes and CI < 1.8 L/min/m2 along with elevated fillings pressures of LV, RV, or both).
  2. The newly released scheme from the SCAI is more useful, and helps to better standardize and stratify patients across the spectrum of CS (and this was already validated in a huge cohort).
    scai
  3. The duration and type of CS matters! Cardiogenic shock in a patient with ADHF is different than the patient with acute myocardial infarction!
  4. When considering what device to use for MCS, it is important to consider a few things, namely, what is your center most familiar (and therefore best) at doing? How much volume/flow do you anticipate needing?
    acuity
  5. The existing literature regarding MCS and CS associated with AMI is lacking in sample size, and we need more data.

 

Neurologic Function and Outcome After Cardiac Arrest

I’m not an expert, so I’m going to shamelessly regurgitate what the experts said. Namely, multi-modal imaging approaches can, with good specificity (but poor sensitivity), prognosticate poor chances of neurologic recovery 0 a very meaningful endpoint for these patients.

Similarly, there are a few biomarkers that may serve as standard serum measurements in the future, as we study them more.

Lastly, intranasal evaporative cooling (sounds super cool doesn’t it?) is a method of targeted temperature management that can improve neurologic outcomes after cardiac arrest.

summary

Check my references below for more reading, I highly recommend doing a deep dive, as I could not possibly do these excellent physicians justice on their expert summaries.

 

References:

  1. Dhruva SS. Utilization and outcomes of Impella vs IABP among patients with AMI complicated by cardiogenic shock undergoing PCI. Presented at: AHA 2019. November 17, 2019. Philadelphia, PA.
  2. Panhwar, Muhammad Siyab, et al. “Trends in the Use of Short-Term Mechanical Circulatory Support in the United States–An Analysis of the 2012–2015 National Inpatient Sample.” Structural Heart (2019): 1-8.
  3. Lemkes J.One Year Outcomes of Coronary Angiography After Cardiac Arrest. Presented at: AHA 2019. November 17, 2019. Philadelphia, PA.
  4. Lemkes JS, Janssens GN, van der Hoeven NW, et al. Coronary Angiography After Cardiac Arrest Without ST-Segment Elevation. N Engl J Med 2019;380:1397-407.
  5. Schrage, Benedikt, et al. “Impella Support for Acute Myocardial Infarction Complicated by Cardiogenic Shock: Matched-Pair IABP-SHOCK II Trial 30-Day Mortality Analysis.” Circulation10 (2019): 1249-1258.
  6. Thiele, Holger, et al. “Intraaortic balloon support for myocardial infarction with cardiogenic shock.” New England Journal of Medicine14 (2012): 1287-1296.
  7. Van Diepen, Sean, et al. “Contemporary management of cardiogenic shock: a scientific statement from the American Heart Association.” Circulation16 (2017): e232-e268.
  8. Baran, David A., et al. “SCAI clinical expert consensus statement on the classification of cardiogenic shock: This document was endorsed by the American College of Cardiology (ACC), the American Heart Association (AHA), the Society of Critical Care Medicine (SCCM), and the Society of Thoracic Surgeons (STS) in April 2019.” Catheterization and Cardiovascular Interventions(2019).
  9. Jentzer, Jacob C., et al. “Cardiogenic shock classification to predict mortality in the cardiac intensive care unit.” Journal of the American College of Cardiology17 (2019): 2117-2128.
  10. Nordberg P, Taccone FS, Truhlar A, et al. Effect of Trans-Nasal Evaporative Intra-arrest Cooling on Functional Neurologic Outcome in Out-of-Hospital Cardiac Arrest: The PRINCESS Randomized Clinical Trial. 2019;321(17):1677–1685. doi:https://doi.org/10.1001/jama.2019.4149

 

 

The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.