STEMI management including PART II for Sep 13 2011

STEMI management ACC/AHA 2009 focused Update: 

STEMI management ACC/AHA 2009 focused Update Sarayuth Eiamsa-ard July 19 th , 2011

Recommendation for the use of GP IIb/IIIa: 

Recommendation for the use of GP IIb / IIIa STEMI recommendation 2009 joint STEMI/PCI focused Update Recommendation Comment 2004/2005/2007 guideline Class IIa Start Tx with abciximab as early as possible before primary PCI (+/-stent) in pt with STEMI (B) Class IIb Tx with tirofiban or eptifibatide may be considered before primary PCI(+/- stent) in pt with STEMI © Start Tx with GPIIb / IIIa ( abiciximab (A), tirofiban (B), or eptifibatide (B) at the time of primary PCI(+/-stent) in selected pt with STEMI Usefulness of GPIIb / IIIa (as part of a preparatory pharmacological strategy before Cath lab arrival for CAG+/-PCI) is uncertain (B) Modified recommendation Chg class IIb IIa for tirofiban & eptifibatide Modifed recommendation Chg level of evidence C B AHA 2009

Slide 14: 

14 Ellis et al. N Eng J Med. 2008;358:2205-2217

Dosing table of GPIIb/IIIa: 

Dosing table of GPIIb / IIIa Appendix 4 AHA 2009 ( Aggrastat ) ( Integrilin ) ( Reopro )

Recommendation for the use of Thienopyridines (Class I): 

Recommendation for the use of Thienopyridines (Class I) STEMI recommendation PCI recommnedation 2009 joint STEMI/PCI focused Update Recommendation 2004 guideline 2007 PCI update -LD 600mg of CG before or when PCI is performed© -LD 300mg,CG, PCI in 12-24hr of receiving fibrinolytic RX © LD for whom PCI is planned LD 300-600mg CG as soon as possible or at time of PCI© LD 60mg Prasugrel (B) Non primary PCI 3.1) If has received FB, has been given CG, continue CG© 3.2) If has received FB without thienopyridine , LD 300-600mg CG© 3.3) No prior FB, LD 300-600mg CG or LD 60mg Prasugrel given promptly, < 1hr after PCI (B) AHA 2009

Loading dose of CG after Fibrinolysis: 

Loading dose of CG after Fibrinolysis Within 24 hr : non fibrin specific/fibrin specific LD : 300mg of Clopidogrel (CG) > 24 hr - Fibrin specific : LD 300-600mg CG 24-48 hr - Non fibrin specific :LD 300mg CG > 48 hr - Non fibrin specific :LD 300-600mg CG Foot note, Table 3 &Appendix 4, Dosing table, AHA 2009 CG : Clopidegrel , LD : Loading dose

Recommendation for the use of Thienopyridines (Class I): 

Recommendation for the use of Thienopyridines (Class I) STEMI recommendation PCI recommnedation 2009 joint STEMI/PCI focused Update Recommendation 2004 guideline 2007 PCI update For PCI is planned Rx : CG BMS : > 1 Mn DES : SES : 3 Mn PES: 6 Mn (B) All post PCI DES :MD 75mg CG > 12 Mn BMS : MD 75mg CG, min 1 Mn , idially up to 12 Mn , unless increase risk of bleeding(B) Stent (BMS or DES) > 12 Mn N.B. CG 75mg (B) PG 10mg(B) Earlier discontinuation if risk of bleeding >benefit AHA 2009

Recommendation for the use of Thienopyridines (Class IIa): 

Recommendation for the use of Thienopyridines (Class IIa ) STEMI recommendation PCI recommendation 2009 joint STEMI/PCI focused Update Recommendation 2004 STEMI 7.4.4 2007 PCI update table 14 “ Delete previous recommendation” CG at time of procedure, supplementation with GP IIb / IIIa can be beneficial(B) Absolute contraindication of ASA, Rx LD 300-600mg at least 6 hr before PCI +/- GP IIb / IIIa at time of PCI AHA 2009

Recommendation for the use of Thienopyridines (Class IIb): 

Recommendation for the use of Thienopyridines (Class IIb ) STEMI recommendation PCI recommendation 2009 joint STEMI/PCI focused Update Recommendation 2004 STEMI 7.4.4 2007 PCI update table 14 “ Delete previous recommendation” Cont CG > 1 yr in pt with DES © Cont CG or PG > 15 Mn in pt with DES © AHA 2009

Recommendation for the use of Thienopyridines (Class III): 

Recommendation for the use of Thienopyridines (Class III) STEMI recommendation PCI recommendation 2009 joint STEMI/PCI focused Update Recommendation If primary PCI is planned in STEMI pt with prior Hx of stroke and TIA, PG is not recommended for dual antiplatelet © AHA 2009

PPI and Dual antiplatelet Rx for ACS: 

PPI and Dual antiplatelet Rx for ACS PPI medications interfere with metabolism of CG  less inhibitory effect to plt aggregation CYP450 2C19: Omeparazole,Lansoparazole , Rabeprazole , but not for Pantoprazole Retrospective report suggesting clinical harm or no clinical effect of CG in ACS pt PRINCIPLE, TIMI-44, TRITON-TIMI 38 ,COGENT PPI attenuated pharmacodynamic effect , CG>PG Not affect to clinical outcomes

The COGENT Trial: 

The COGENT Trial Deepak L. Bhatt MD, MPH, Byron Cryer MD, Charles F. Contant PhD, Marc Cohen MD, Angel Lanas MD, DSc , Thomas J. Schnitzer MD, PhD, Thomas L. Shook MD, Pablo Lapuerta MD, Mark A. Goldsmith, MD, PhD, Benjamin M. Scirica MD, Robert P. Giugliano MD, Christopher P. Cannon MD, on Behalf of the COGENT Investigators

COGENT: 

COGENT NEJM 2010 N = 3,602 F/U 1 yr

COGENT: 

COGENT NEJM 2010

COGENT: 

COGENT NEJM 2010

COGENT: 

COGENT NEJM 2010

Conclusions : 

Conclusions COGENT is the first, randomized assessment of clopidogrel and PPIs on clinical events The data provide strong reassurance that there is no clinically relevant adverse cardiovascular interaction between clopidogrel and PPIs The results call into question the exact relationship between ex vivo platelet assays and clinical outcomes, especially with respect to assessing drug interactions Platelet assays and observational data are not a substitute for RCT data Further research is needed to define the optimal strategy to reduce GI events in patients on antithrombotic therapy, though prophylactic PPIs seem very promising

PPI and Dual antiplatelet Rx for ACS: 

PPI and Dual antiplatelet Rx for ACS FDA : H2 blocker or antacid AHA 2009 : H2 blocker

Recommendation for the use of iv anticoagulant: 

Recommendation for the use of iv anticoagulant Modifies recommendation Bivalirudin was added as an acceptable anticoagulant for primary PCI UFH was modified to mention ACT level Information on enoxaparin & fondaparinux were unchanged

Recommendation for the use of parenteral anticoagulant (Class I): 

Recommendation for the use of parenteral anticoagulant (Class I) STEMI recommendation PCI recommendation 2009 joint STEMI/PCI focused Update Recommendation 2007 STEMI Update, section 8 2007 PCI guideline Update, Table 13 For pt undergoing PCI having receiving anticoagulant -Prior UFH, maintain ACT, +/- GP IIb / IIIa (C) or Bivalirudin ( C) -Prior Enoxa , last dose> 8-12 hr, iv enoxa 0.3mg/kg, last dose < 8 hr,no Rx Prior Fonda, additional Rx with an anticoagulant with anti IIa activity+/- GPIIb /IIIA For 1ry PCI, Tx ASA+Theinopyridine + anticoagulant Prior UFH, maintain ACT, +/- GP IIb / IIIa (C) Bivalirudin (B) with or without prior UFH AHA 2009

Recommendation for the use of parenteral anticoagulant (Class IIa): 

Recommendation for the use of parenteral anticoagulant (Class IIa ) STEMI recommendation PCI recommendation 2009 joint STEMI/PCI focused Update Recommendation 2007 STEMI Update, 2007 PCI guideline Update, STEMI pt undergoing PCI, at high risk of bleeding, Bivalirudin is resonable AHA 2009

Dosing of anticoagulant: 

Dosing of anticoagulant Appendix 4, AHA 2009

ACC/AHA 2009 focused update for STEMI: 

ACC/AHA 2009 focused update for STEMI PART II September 13, 2011

Recommendation for triage and transfer for PCI (Class I): 

Recommendation for triage and transfer for PCI (Class I) STEMI recommendation 2009 joint STEMI/PCI focused Update Recommendation Comment 2004/2005/2007 STEMI recommendation Each community should develop a STEMI system of care Ongoing multidisciplinary teams : EMS, non-PCI capable/PCI capable hosp Process of prehospital indentification and activation -Transfer protocol : 1ry PCI candidate, ineligible for FB and are in cardiogenic shock.(C) New recommendation AHA 2009

Recommendation for triage and transfer for PCI (Class IIa): 

Recommendation for triage and transfer for PCI (Class IIa ) STEMI recommendation 2009 joint STEMI/PCI focused Update Recommendation Comment 2004/2005/2007 STEMI recommendation High risk according to CARESS-in-AMI, Rx FB from non-PCI capable hosp.  transfer to PCI as soon as possible Initiating a preparatory antithrombic ( anticoagulant+antiplatlet ) before or during transfer to Cath Lab(B) New recommendation High risk (≥ 1) Ext ST elevation New LBBB Prev MI Killip > 2 LVEF <35% for Inf MI Ant MI alone+ST > 2mm+>2 leads) AHA 2009

CARESS-in-AMI: 

CARESS-in-AMI France, Italy and Poland N=600 STEMI, onset <12 hr, age < 75yr, High risk*, Rx Heparin, ASA, Clopidogrel Half dose reteplase / abciximab , randomized to immediate PCI or rescue PCI ? (if persistent ST elevation or clinical deterioration) Di Mario C et al. Lancet 2008; 371: 559–568.

CARESS-in-AMI: 

CARESS-in-AMI 86% of the immediate PCI group underwent PCI vs. 30% of the standard care group Death, MI, or refractory ischemia at 30 days (4.4% vs. 10.7%, p = 0.005) Refractory ischemia (0.3% vs. 4.0%, p = 0.003) Trial design: STEMI patients admitted to non-PCI hospitals and initially treated with heparin, half-dose reteplase, and abciximab were randomized to immediate transfer for urgent PCI (n = 299) or standard therapy with rescue PCI if needed (n = 301) . Results Conclusions STEMI patients treated with half-dose lytics and abciximab did better with immediate transfer for PCI This approach reduced death, MI, or refractory ischemia at 30 days Benefit driven by reduction in refractory ischemia Di Mario C, et al. Lancet 2008;371:559-68 (p = 0.005) (p = 0.47) % 4.4 10.7 3.4 2.3 Transfer for PCI (n = 299) Standard therapy (n = 301) MACE Major bleeding

Slide 46: 

Definition of high risk patient in TRANSFER-AMI study ST elevation ≥ 2 mm in 2 anterior leads or ≥ 1 mm in inferior leads…+ ≥ 1 following SBP < 100 mmHg HR > 100 bpm Killip class II to IV ST depression ≥ 2 mm in anterior lead leads, or ≥ 1 mm ST elevation in V4R (=RV involvement)

Recommendation for triage and transfer for PCI (Class IIb): 

Recommendation for triage and transfer for PCI (Class IIb ) STEMI recommendation 2009 joint STEMI/PCI focused Update Recommendation Comment 2007 STEMI Update Section 5 Facilitated PCI + regimens other than full-dose FB, might be considered if … High risk PCI not available in 90 min Low bleeding risk (young age, no poor controlled HT, Normal BW) (C) Not high risk according to CARESS-in-AMI, but Rx FB from non-PCI capable hosp.  transfer to PCI as soon as possible Initiating a preparatory antithrombic ( anticoagulant+antiplatlet ) before or during transfer to Cath Lab(C) Modified recommendation High risk (≥ 1) Ext ST elevation New LBBB Prev MI Killip > 2 LVEF <35% for Inf MI Ant MI alone+ST > 2mm+>2 leads) AHA 2009

Recommendation for triage and transfer for PCI (Class IIb): 

Recommendation for triage and transfer for PCI (Class IIb ) STEMI recommendation 2009 joint STEMI/PCI focused Update Recommendation Comment 2007 STEMI Update Section 6 CAG with intent to perform PCI without high risk (CARESS-AMI), without Class I or IIa indication might be resonable in moderate to high risk pt, but its benefit & risk are not well established. © Deleted recommendation AHA 2009

Triage and Transfer for PCI: 

Triage and Transfer for PCI Appendix 5 AHA 2009

Recommendation for intensive glucose control in STEMI: 

Recommendation for intensive glucose control in STEMI STEMI recommendation 2009 joint STEMI/PCI focused Update Recommendation Comment 2004 STEMI guideline Class I An insulin infusion to normalizied BS (B) Class IIa Insulin infusion to normalized BS during acute phase (first 24-48hr) (B) Insulin based regimen to achieve and maintain glucose < 180mg/dl while avoiding hypoglycemia(B) Not current use, see Class IIa New recommendation Not current use, see Class IIa AHA 2009

Recommendation for intensive glucose control in STEMI: 

Recommendation for intensive glucose control in STEMI Base on NICE-SUGAR study Enrolled critically ill med and surg. pt ?extrapolated to Mx of STEMI is unclear N= 6000 Population : intensive sugar control vs conventional glucose control (81-108 vs < 180mg%) Risk of death ↑ and Hypoglycemia ↑↑ in intensive sugar control (NNH =38)

Recommendation for thrombus aspiration during PCI for STEMI: 

Recommendation for thrombus aspiration during PCI for STEMI 2009 joint STEMI/PCI focused Update Recommendation Comment Class IIa Aspiration thrombectomy is reasonable for pt undergoing primary PCI (B) New recommendation AHA 2009

Meta-analysis for thrombus aspiration during PCI for STEMI: 

Meta-analysis for thrombus aspiration during PCI for STEMI A.A. Bavry , European Heart Journal 2008;29 , 2989–3001

Recommendation for use of stents in STEMI: 

Recommendation for use of stents in STEMI STEMI recommendation 2009 joint STEMI/PCI focused Update Recommendation Comment 2004/2005/2007 STEMI guideline Class IIa - Class IIb 2007 PCI guideline Update, Table 16 DES may be considered for clinical & anatomical ………….., but has not been fully confirmed by clinical trials © Reasonable to use DES as alternative to BMS for primary PCI in STEMI (B) DES may be considered for clinical & anatomical setting in which the efficacy/safety appears favorable (B) New recommendation Modified recommendation (C B) AHA 2009

HORIZONS AMI: 

Emergent angiography, followed by triage to primary PCI, CABG or medical therapy HORIZONS AMI Aspirin, thienopyridine R 1:1 R 1:3 Paclitaxel-eluting TAXUS stent Bare metal EXPRESS stent Clinical FU at 30 days, 6 months, 1 year, and then yearly through 5 years UFH + GP IIb/IIIa inhibitor (abciximab or eptifibatide) Bivalirudin monotherapy (± provisional GP IIb/IIIa) 3,602 pts with STEMI with symptom onset ≤12 hours 3006 pts eligible for stent randomization Stone GW. NEJM 2008;358:2218-30.

1-Year Net Adverse Clinical Events*: 

*MACE or major bleeding (non CABG) Number at risk Bivalirudin alone Heparin+GPIIb / IIIa 1800 1559 1514 1483 1343 1802 1499 1459 1427 1281 Time in Months 18.3% 15.7% Diff [95%CI] = -2.6% [-5.1, -0.1] HR [95%CI] = 0.84 [0.71, 0.98] P =0.03 1-Year Net Adverse Clinical Events* NACE (%) Bivalirudin alone (n=1800) Heparin + GPIIb / IIIa (n=1802 ) Mehran R, TCT 2008

1-Year Major Bleeding : 

Number at risk Bivalirudin alone Heparin+GPIIb / IIIa 1800 1621 1601 1586 1448 1802 1544 1532 1515 1368 Major Bleeding (%) Time in Months 9.2% 5.8% Diff [95%CI] = -3.4% [-5.2, -1.7] 2 HR [95%CI] = 0.61 [0.48, 0.78] P<0.0001 1-Year Major Bleeding Bivalirudin alone (n=1800 ) Heparin + GPIIb / IIIa (n=1802) Mehran R, TCT 2008

1-Year Mortality (All-Cause): 

4.0% 3.0% P int =0.75 4.6% 2.6% Mortality (%) Time in Months 1-Year Mortality (All-Cause ) Heparin + GPI / TAXUS (n=1111) Heparin + GPI / EXPRESS (n=368) Bivalirudin / TAXUS (n=1146) Bivalirudin / EXPRESS (n=381) Mehran R, TCT 2008

HORIZONS-AMI: 

HORIZONS-AMI DES vs BMS (3:1) -No difference in the 12 Mn composite safety end point of death, reinfarction , stroke, stent thrombosis. -↓rate of ischemia driven TVR & TLR in DES (NNT=33 at 1 yr) ↓binary stenosis rate (13 Mn )

Recommendation for angiography in patient with CKD: 

Recommendation for angiography in patient with CKD STEMI recommendation 2009 joint STEMI/PCI focused Update Recommendation Comment 2004/2005/2007 STEMI Guideline Update, Table 9 Class I Isoosmolar contrast agent are indicated & prefered in CKD pt undergoing angiography (A) LMW CM other than ioxaglate or iohexol (B) or Isosmolar CM (A) were indicated in pt with CKD undergoing CAG who are not undergoing chronic dialysis Modified recommendation AHA 2009 LMW = low molecular weight, CM=contrast media

Contrast media: 

Contrast media 1 . First generation : High Osm (1400-1800mOsm/kg), ionic monomer 2. Second generation : - Iohexal : Interm Osm (500-850),non-ionic monomer - Ioxaglate : Low Osm , non-ionic dimer - Iodixanol : Iso Osm (290), non-ionic dimer Michael R. Rudnick, Cleve Clin J Med 2006; 73(1); 75-87

Contrast media: 

Contrast media Michael R. Rudnick, Cleve Clin J Med 2006; 73(1); 75-87

CIN: 

CIN Incidence : 0-50% vary among CIN definition Mostly ↑Cr 0.2mg% from baseline 14.4% ↑Cr start D1-2, peak D3-5, recover D7-10 0.8% require H/D( esp baseline Cr >4) Estimated risk of CIN = Cr x 10 Risk factor : Pre-existing kidney disease, DM, CHF, CM( vol,Osm,ionic ), MM Ionic CM / non-ionic CM = 3.3 times CIN Risk Low volume CM(<300ml or 5 ml/kg) 2% vs High volume CM 20% Michael R. Rudnick, Cleve Clin J Med 2006; 73(1); 75-87

Pathophysiology of CIN: 

Pathophysiology of CIN 1. Renal vasoconstriction/blood flow 2. Direct renal toxicity including O2 free radical and reduced antioxidative enzyme-> toxic ATN

Slide 68: 

+ Statin

Slide 69: 

Visipaque Hexabrix = isosmolar

Recommendation for use of fractional flow reserve(FFR): 

Recommendation for use of fractional flow reserve(FFR) STEMI recommendation 2009 joint STEMI/PCI focused Update Recommendation Comment 2005 STEMI Guideline PCI Update, Section 5.6.2 Class IIa 1. –blank-- 2......... 3………. FFR or Doppler velocity can be useful to determine …. 1.whether PCI of a specific coronary lesion is warranted 2.Alternative for to performing noninvasive functional testing to determine whether as intervention is warranted 3.Assessment of intermediate coronary stenosis (30-70%) vs angina symptoms by FFR (A), or Doppler velocity © Modified recommendation (B A) AHA 2009

Recommendation for use of fractional flow reserve(FFR): 

Recommendation for use of fractional flow reserve(FFR) STEMI recommendation 2009 joint STEMI/PCI focused Update Recommendation Comment 2005 STEMI Guideline PCI Update, Section 5.6.2 Class III Routine assessment with intracoronary physiologic measurement e.g. FFR or Doppler velocity to assess the severity angiographic disease in + ve , unequivocal noninvasive functional study is not recommended © Routine assessment with intracoronary physiologic measurement e.g. FFR or Doppler velocity to assess the severity angiographic disease in concordant vascular distrubution in pt with angina and + ve , unequivocal noninvasive functional study is not recommended © Modified recommendation AHA 2009

FFR: 

FFR FFR =distal coronary pressure/aortic pressure during maximal hyperemia Pressure-derived estimate of the percent of normal coronary blood flow that would be available to the myocardium A normal value is 1, while values <0.75 are associated with provocable ischemia

Slide 74: 

CVR=Coronary Vasodilatory Reserve

FFR: 

FFR Superior to CVR and IVUS for lesion assessment in the appropriate decision for stent placement. Patients having normal or nonischemic FFR in intermediate stenoses have very low event rate over five years (DEFER Study). Superior to radionuclide imaging in patients with multivessel disease to identify regions of ischemia needing revascularization. FFR guided PCI is superior to traditional angiographically guided PCI with outcomes of fewer MIs, death, CABG and MACE over the first year (FAME study).

Slide 80: 

The DEFER Study: Design prospective randomized multicentric trial (14 centers) in 325 patients with stable chest pain and an intermediate stenosis without objective evidence of ischemia Aalst Amsterdam Eindhoven Essen Gothenborg Hamburg Liège Maastricht Madrid Osaka Rotterdam Seoul Utrecht Zwolle data collection & analysis: Jan Willem Bech, MD, PhD Pepijn van Schaardenburgh, MD

Slide 81: 

The DEFER Study: Objectives to test safety of deferring PCI of stenoses not responsible for inducible ischemia as indicated by FFR > 0.75 ( “ outcome ” ) Secondary objective to compare quality of life in such patients, whether or not treated by PCI (CCS-class, need for anti-anginal drugs) (“symptoms”) Primary objective

Slide 82: 

DEFER Group REFERENCE Group PERFORM Group The DEFER Study: Flow Chart Patients scheduled for PCI without Proof of Ischemia (n=325) performance of PTCA (158) deferral of PTCA (167) FFR  0.75 (91) No PTCA FFR  0.75 (90) PTCA FFR < 0.75 (76) PTCA FFR < 0.75 (68 ) PTCA Randomization

Slide 83: 

THE DEFER STUDY: RANDOMIZATION 1 : 1 randomization deferral of PCI performance of PCI If FFR < 0.75 performance anyway reference group If FFR > 0.75 randomization followed defer PCI perform PCI

Slide 84: 

The DEFER Study: Diameter Stenosis versus FFR

Slide 85: 

No. at risk Defer group 90 85 82 74 73 72 Perform group 88 78 73 70 67 65 Reference gr 135 105 103 96 90 88 78.8 72.7 64.4 0 1 2 3 4 5 0 25 50 75 100 Defer Perform Reference (FFR < 0.75) p=0.52 p=0.17 p=0.03 Years of Follow-up event – free survival (%)

Slide 86: 

72 % 58 % 68 % Pts free of angina(%) 52 (39 %) 24 (27 %) 19 (21 %) Patients ≥1 event (%) 70 29 21 Total events 2 (1.5) 1 (1.1) 0 Other (%) 11 (8.2) 6 (6.8) 6 (6.7) Non-TLR(%) 14 (10.4) 4 (4.5) 1 (1.1) CABG(%) 7 (5.2) 1 (1.1) 0 Non-Q wave MI(%) 6 (4.5) 4 (4.5) 0 Q wave MI (%) 4 (3.0) 3 (3.4) 3 (3.3) Non Cardiac Death(%) 8 (6.0) 2 (2.3) 3 (3.3) Cardiac Death(%) 144 90 91 Number of patients Reference Perform Defer FFR<0.75 FFR ≥0.75 18 (13.4) 8 (9.1) 8 (8.9) TLR(%) DEFER: Clinical Outcome at 5 Years Lost to follow-up 1 2 10

Cardiac Death And Acute MI After 5 Years: 

Cardiac Death And Acute MI After 5 Years 3.3 7.9 15.7 0 5 10 15 20 % P=0.20 P< 0.03 P< 0.005 DEFER PERFORM REFERENCE FFR > 0.75 FFR < 0.75

Slide 88: 

0% 20% 40% 60% 80% 100% baseline 1month 1 year 2 year 5 year Defer group Perform group Reference group freedom from chest pain FFR > 0.75 FFR > 0.75 FFR < 0.75 * * * * * * * *

Slide 89: 

No. at risk FFR ≥ 0.75 178 162 154 143 138 136 FFR < 0.75 135 105 103 96 90 88 75.8 64.4 0 1 2 3 4 5 0 25 50 75 100 FFR ³ 0.75 FFR < 0.75 p=0.03 Years of Follow-up event – free survival (%)

Slide 90: 

DEFER: Summary and Conclusions (2) Conclusion Stenting a “non-ischemic” stenosis does not benefit patients with stable chest pain, neither in prognostic nor symptomatic respect.

Recommendation for PCI for Unprotected LM CAD: 

Recommendation for PCI for Unprotected LM CAD STEMI recommendation 2009 joint STEMI/PCI focused Update Recommendation Comment 2004/2005/2007 Recommendation Class IIa 2005 PCI guideline, Section 6.3.4 Pt undergoing PCI to unprotected LM obstruction, F/U CAG between 2-6 Mn after PCI © Class IIb - PCI of LM with stent as alternative to CABG may be considered in pt anatomic conditions that are asso with a low risk of PCI complication & clinical condiation that predict an ↑risk of surgical outcome (B) Deleted recommendation New recommendation AHA 2009

Unprotected Left main CAD: 

Unprotected Left main CAD Favor PCI Favor CABG Isolated LM CAD LM CAD with multiple VV disease LM CAD with single vv disease Distal /bifurcation LM CAD Ostial or mid LM CAD Low surgical risk with good chance of technical success Patient factors e.g. severe lung disease, prior thoracic surgery, or poor bypass graft targets Low syntax score High syntax score (> 33)

Thank you : 

Thank you