00:01
Well, let’s look at controversies now. I've
given you six areas where pretty much
the cardiology community is in agreement.
00:09
There are four areas where there's some
debate. Number one, does revascularization -
either angioplasty, new vessels, opening vessels
again or having new vessels with coronary
bypass put into your heart, does it save lives?
Well, it turns out that there have been a
number of trials that have looked at this.
In fact, there's a decrease in mortality,
if you have severe three-vessel disease and
reduced heart function. But, in all other
settings, medical therapy has been shown to
be just as good as surgical or catheter intervention
therapy as long as the patients follow through
with their medical therapy.
00:53
There have been several trials
in the last 25 years that are important
to be aware of as well
as their implications
to be aware of as well
as their implications
for medical care
in daily clinical practice.
01:02
for medical care
in daily clinical practice.
01:04
The Barre Trial, Balloon Angioplasty,
Revascularization investigation
The Barre Trial, Balloon Angioplasty,
Revascularization investigation
compared angioplasty to coronary bypass
surgery and patients
with stable engine and coronary disease.
01:16
The results showed that
there was no significant
long term difference in death
or myocardial infarction
with either therapy
except in patients with diabetes.
01:23
with either therapy
except in patients with diabetes.
01:25
with either therapy
except in patients with diabetes.
01:25
Patients without diabetes had equivalent
survival with either intervention.
01:29
Those with diabetes did better
with the surgical intervention in 2007.
01:35
The Courage trial compared patients
with stable coronary artery disease,
undergoing an initial management
strategy of PCI or conservative management
including lifestyle interventions
and intensive drug therapy.
01:50
Patients who developed an acute
myocardial infarction or unstable
angina on the drug.
01:54
Therapy
were then switched to the invasive route.
01:57
And the courage trial
showed that using that strategy,
patients who adhered to optimal medical
therapy alone
and were shifted to interventional therapy
when they became unstable.
02:05
and were shifted to interventional therapy
when they became unstable.
02:08
Absolutely.
02:09
Were the same in terms of mortality
and non-fatal M.I.
02:10
Were the same in terms of mortality
and non-fatal M.I.
02:13
As those who underwent initial PCI.
02:16
The Arbiter
trial compared patients with stable
angina undergoing
PCI versus
those undergoing a sham procedure.
02:24
Instead of medical therapy, again,
there was no benefit with PCI, this time
with endpoints of an improvement
in exercise time or frequency of angina.
02:33
Recently, the ischemia trial compared
over 5000 patients
with stable coronary artery disease.
02:40
Keep in mind these are not patients
with acute coronary syndromes.
02:44
Is a patients with moderate
to severe, usually
exertional angina or ischemia
exertional angina or ischemia
on stress testing and also in the clinic
and the results
showed no evidence of a benefit
with the initial invasive strategy.
02:57
Overall conservative strategy
with regard to the endpoints
of cardiovascular death, M.I.
03:02
Or hospitalization for unstable angina.
03:04
So you now see we have a number of trials
that say it's a good idea
to start with conservative medical
and lifestyle therapy.
03:12
And when patients become more unstable
or it interferes with their lifestyle,
And when patients become more unstable
or it interferes with their lifestyle,
let's say this is someone who plays
tennis all the time and they have to stop
playing tennis
because they have angina during the game.
03:24
That might be an
indication after discussing with a patient
to shift them towards
or towards the invasive route
It's important to note, though,
that you're not going to prolong life.
03:34
You will reduce symptoms
with an invasive route.
03:37
And of course there are potential
complications with the invasive route.
03:41
A little diagram that you've
seen before demonstrating a coronary
bypass graft going into a blood vessel and
I already showed you earlier in this talk
an example of an angioplasty with the balloon
opening up an occluded artery. These days
we place a little metal stent in after the
balloon opens the artery in order to keep
it open and of course, that means you have
to take your Anti-platelet agents to prevent
blood clots from forming.
Just to reiterate on revascularization not
saving lives in the vast majority of patients
with chronic ischemic heart disease, then medical
therapy and lifestyle intervention works just
as well in terms of preventing another myocardial
infarction or dying from coronary heart disease
as does the intervention when chosen as the
initial strategy for taking care of these
patients. However, there are the settings -
acute ischemic heart disease or three vessel
disease with reduced left ventricular function,
those patients are pushed in the direction
of an intervention such as bypass or angioplasty
and the studies have shown that when those
settings are there, acute ischemic heart disease
or the three vessel disease with decreased
left ventricular function, those patients
will do better… a little bit better with the
intervention than with just medical therapy.
05:09
By the way, after intervention, the patients
have to stick with medical therapy as well.
So, it’s really intervention plus medical
therapy versus medical therapy alone. But,
the vast majority of stable patients with
ischemic heart disease that represents the
overwhelming majority of patients do just
as well with medical therapy from the start
as they would with an intervention like bypass
or angioplasty from the start.
05:34
Second area of controversy is that all patients
with coronary disease should have a cardiac
catheterization with an angiogram, which you
see a little diagram of on the right hand
side. If you believe that an intervention
makes a difference in terms of preventing
death, why then all patients should have an
angiogram. But, as I've just demonstrated, really
for the vast majority of patients with coronary
disease, intervention should only be done
when the patients develop acute symptoms or
very severe symptoms with minimal exertion.
06:07
So, really cardiac catheterization is not
necessary and usually, we can do a non-invasive
stress test which will give us a sense of
how much ischemia - how much lack of blood
flow there is in the heart and the patients,
again, can be followed on medical therapy.
06:22
Again, the importance of the doctor and the
cardiac rehab program, lifestyle changes and
taking your medication. These things are very
important as we've talked about in the areas
of consensus, not everybody needs an urgent
coronary angiogram.
06:39
Now, let’s talk about another controversy
and that is that older patients with coronary
disease should never undergo revascularization.
In fact, its been shown, yes, the older
you are, there is higher risk as you can see
from the diagram here when they do angioplasty
or bypass, there is a higher risk of death.
But, in fact, the overwhelming majority of
very elderly patients and I've seen individuals
who are vigorous and active in their 90s,
who developed a non-ST elevation or even an
ST-elevation myocardial infarct have angioplasty
and do extremely well. Now, I live in an area
in Arizona where there's a lot of very vigorous
retired people. They move to Arizona because
they want to be playing tennis, they want
to be hiking, they want to maintain a very
active lifestyle and the weather allows them
to do that in Arizona. We have done a number
of these older patients who are vigorous and
active. We don’t hesitate to do an intervention
in them when the indications are there, that
is they have an acute ischemic event or their
symptom of angina becomes so severe that they're
having a hard time doing their normal
activity. Intervention does reduce the anginal
episodes and therefore, in an active person,
the intervention such as bypass or angioplasty
does help to reduce angina and at least make
people’s quality of life a little better.
08:07
Although, medicines are not far behind when
the patient is not interested in having an
angioplasty or bypass. In patients who are
very symptomatic, as you can see from these
two diagrams, there is an improvement when
intervention is used, but you can see that
long term, the difference is really not very
much. So, again, emphasizing that good medical
therapy really works and that in patients
who are very symptomatic, there is a little
bit of an improvement with intervention, but
long-term, the difference is, on the right
hand side, not very much.
Another area of debate, of controversy is whether
patients with coronary artery disease should
be seen as occurring only in the elderly population
and never occurring in the younger population.
Where you can see from the diagram here on
the right hand side that yes, coronary disease,
the manifestations of it, angina, myocardial
infarction are more common in individuals
who are elderly. But, look at the left hand
side of the diagram, there are still a substantial
number of younger people who developed this
and it is not uncommon for us to see in a
week in our hospital, individuals in their
40s and early 50s with clinical manifestations
of coronary disease, for example, myocardial
infarction. So, although this disease is much
more common in the elderly and of course,
the mortality is higher in the elderly, just
as with all diseases the mortality is higher
in the elderly, there is less vigor of resistance.
On the other hand, this is not just a disease
of old folks, it is definitely something that
is seen in younger individuals as well.
09:53
Well, so, in summary, coronary artery disease
is extremely common, but in fact, it appears
that at least in the US and in Western Europe
and Canada, there is a decrease in mortality
and even a decrease in atherosclerosis as
reflected by autopsy studies and a declining
average serum cholesterol in the country.
There is excellent evidence based therapy
for acute ischemic heart disease that is myocardial
infarction, unstable angina as well as chronic
ischemic heart disease that is exertional
angina and that patients usually will do just
as well with medicines as they will with intervention
as long as they're not acutely ischemic or
as long as they don’t have three vessel
disease and reduced left ventricular function.
10:45
Effective medicine, as delivered by good doctors,
and good cardiac rehab programs make a huge
difference. Lifestyle changes are just as
important as the medicines that one takes
in reducing the risk for recurrent events
and death.