Como tratar o paciente multiarterial

nos dias atuais: Medicamentos vs

Angioplastia vs Cirurgia
SAMUEL SILVA DA SILVA
PROF. ADJ. DE CARDIOLOGIA DA UEL - APOSENTADO
MEMBRO TITULAR DA SBHCI
CARDIOLOGISTA INTERVENCIONISTA DOS HOSPITAIS HEL E HRJF

DECLARO NÃO POSSUIR CONFLITOS DE INTERESSE NESTA

APRESENTAÇÃO.
Schömig A et al. J Amer Coll Cardiol 2008; 52: 894 – 904.
 2002 2004 2008 2008 2008 2006
sirolimus paclitaxel paclitaxel zotarolimus zotarolimus everolimus
 From: Predicting Outcome in the COURAGE Trial (Clinical Outcomes Utilizing Revascularization
and Aggressive Drug Evaluation): Coronary Anatomy Versus Ischemia

Proportion of Patients With Death, Myocardial Infarction or Non–ST-Segment Elevation Acute

Coronary Syndrome by Ischemic Myocardium and Atherosclerotic Burden of Disease
Mancini GB et al. J Am Coll Cardiol Intv. 2014;7(2):195-201. doi:10.1016/j.jcin.2013.10.017
N. Engl. J. Med. 2009; 360: 961–972.
FAME 2 TRIAL

N Engl J Med 2014;371:1208-17.

n = 1829 - 1988 a 1991 - 18 Centros USA
JACC 2007;49:1600-6.
 ACCF/SCAI/STS/AATS/AHA/ASNC 2009 Appropriateness Criteria for
Coronary Revascularization
by , Manesh R. Patel, Gregory J. Dehmer, John W. Hirshfeld, Peter K. Smith, and John
A. Spertus

Critérios para elaboração dos 180 cenários: Critérios de julgamento:

Sintomas apresentados. Notas individuais para cada cenário:
Estratificação de risco não invasiva. Utilização da média das notas.
Medicação em uso. Painelistas (59) não induzidos à consensos.
Extensão da doença coronária. Atribuição de notas em escala de 1 a 9.

A = appropriate 7 - 9.

U = uncertain 4 - 6.

I = inappropriate 1 - 3.

Circulation
Volume 119(9):1330-1352
March 10, 2009
Copyright © American Heart Association, Inc. All rights reserved.
 Figure 1. Acute coronary syndromes.

CORONARY REVASCULARIZATION WRITING GROUP et al. Circulation. 2009;119:1330-1352

Copyright © American Heart Association, Inc. All rights reserved.
Em 100 ICPs primária 2 óbitos e 3 reinfartos imediatos são evitados
 Em 100 ICPs primária 5 óbitos e 5 reinfartos tardios são evitados

Em 100 ICPs primária 1 acidente vascular cerebral desabilitante é evitado

Lemos P – SBHCI 2013

Lemos P – SBHCI 2012

Lemos P – SBHCI 2012
BIOABSORÇÃO E A RESTAURAÇÃO DA CAPACIDADE DE
REMODELAMENTO POSITIVO
Londrina - Foto Josoé de Carvalho - ACIL
Lago Igapó - Foto Josoé de Carvalho - ACIL
Gleba Palhano - vista geral - Foto Josoé de Carvalho - ACIL
Diretriz de Doença Coronária Estável Arq Bras Cardiol 2014; 103(2Supl.2): 1-59
 Figure 5. Method of revascularization of advanced coronary artery disease.

CORONARY REVASCULARIZATION WRITING GROUP et

al. Circulation. 2009;119:1330-1352

Copyright © American Heart Association, Inc. All rights reserved.

 Optimal medical therapy with or without percutaneous coronary intervention to reduce
ischemic burden: results from the Clinical Outcomes Utilizing Revascularization and Aggressive
Drug Evaluation (COURAGE) trial nuclear substudy.

Shaw L J et al. Circulation. 2008;117:1283-1291

Mangione SBHCI 2010
Figure. Approach to patients with type 2 diabetes mellitus with stable CAD. LDL indicates
low-density lipoprotein.

Valentin Fuster, and Michael E. Farkouh Circulation.

2010;121:2450-2452

Copyright © American Heart Association, Inc. All rights reserved.

Mangione SBHCI 2010
 Comparison of primary percutaneous coronary intervention and fibrinolytic therapy in ST-segment-
elevation myocardial infarction: bayesian hierarchical meta-analyses of randomized controlled trials and
observational studies.

Figure 2. Bayesian forest plot of all-cause short-term mortality rates in RCTs.

Thao Huynh et al. Circulation. 2009;119:3101-3109

Copyright © American Heart Association, Inc. All rights reserved.

 PCI vs. Conservative Therapy: Study Design
2950 patients from randomized trials comparing coronary revascularization by PCI versus
consevative medical therapy for treatment of patients with CAD documented by
angiographic evidence of stenosis of 1 or more coronary vessels

Mean age range 53-61 years, predominantly or exclusively male population, mean follow-up in 5 trials ( with 1790
patients) exceeded 2 years, more limited follow-up data available in other 6 trials (1160 patients). no trial used DES

PCI Conservative Therapy

n=1476 n=1474

Primary Endpoint: Death, Cardiac Death or non fatal MI, CABG, and PCI during
follow-up (in the target vessel or other vessel/segment).
- All data used pertained to the longest follow-up available per outcome from each study

Katritsis DG & Ioannidis J.P.A., Circulation 2005; 111:2906-2912

 PCI vs. Conservative Therapy: Primary
Endpoint
Number events per treatment group (# patients)
Katritsis DG & Ioannidis J.P.A., Circulation 2005; 111:2906-2912
• There were a total of 195
deaths, 235 patients had
cardiac death or MI, 153
patients had nonfatal
Mis, 215 patients underwent
CABG, and 462 had PCI
during follow-up.
•Despite some
differences, there was no
statistically significant
between-study
heterogeneity for death,
cardiac death or
MI, nonfatal MI, and need
for CABG; thus, random
and fixed effects estimates
were very similar for these
outcomes.
Figure 2. Kaplan–Meier survival for patients with ≥5% reduction in ischemic myocardium and
for those without significant reduction in ischemia after 6 to 18 months of PCI+OMT or OMT.
Overall event-free survival was 86.6% vs 75.3% for patients with vs without significant
ischemia reduction (P=0.037).

Leslee J. Shaw et al. Circulation. 2008;117:1283-1291 Copyright © American Heart Association, Inc. All rights reserved.
From: The Final 10-Year Follow-Up Results From the BARI Randomized Trial

J Am Coll Cardiol. 2007;49(15):1600-1606. doi:10.1016/j.jacc.2006.11.048

From: The Final 10-Year Follow-Up Results From the BARI Randomized Trial

J Am Coll Cardiol. 2007;49(15):1600-1606. doi:10.1016/j.jacc.2006.11.048

Mangione J A SBHCI - 2010
FAME 2 TRIAL N Engl J Med 2014;371:1208-17.
Alexandre B Cavalcanti SBHCI 2010
J Am Coll Cardiol. 2011;58(1):11-18. doi:10.1016/j.jacc.2011.02.023