Download Recommendations - Canadian Cardiovascular Society

Surgical Coronary Revascularization
Who, What, When
Speaker - Jonathan G. Howlett, MD FRCPC
Chairperson – Gordon W. Moe, MD, MSc, FRCPC
WELCOME!
Accreditation
This event is an Accredited Group Learning Activity
(Section 1) as defined by the Maintenance of Certification
program of The Royal College of Physicians and
Surgeons of Canada, and approved by the Canadian
Cardiovascular Society for 1 Royal Credit MOC Section 1
Credit.
Heart Failure Guidelines
Learning Objectives
At the conclusion of this webinar, participants will be
able to:
•Review the potential role of surgical intervention as a heart failure
management and treatment option
•Discuss opportunities and challenges of surgery for heart failure
patients – where to begin, where to end
•Develop patient specific treatment plans that take into account the
benefits, risks and limitations of surgery as a treatment option
•Integrate CCS guidelines into best clinical practices
Heart Failure Guidelines
Disclosures- J. Howlett
• Speaker and/or Consultant Fees:
– AstraZeneca, Bayer, CVRx, Medtronic, Novartis,
Servier, Pfizer, Otsuka, Merck
• Research and/or Funding for Research:
– AstraZeneca, Bayer, CVRx, Medtronic, Novartis,
Servier
– NGOs: AIHS, NIH, Canada Health Infoway
Heart Failure Guidelines
Disclosures- Dr. Moe
• No disclosures
Heart Failure Guidelines
Case 1
• 75 year old female presenting with a diagnosis of HF
• Progressive SOBOE and orthopnea
– Atypical chest discomfort with variable exertion, emotional stress
• Past history
– HTN
– Former smoker
– Negative workup for atypical chest pain 10 years ago
• Initial assessment:
– BP 130/82, HR 84 bpm (regular), obvious volume overload
– NT-BNP 3800 pg/mL, troponin I negative
– ECG: sinus rhythm, Q waves leads II,III, AVF, QRS duration 110 msec
Heart Failure Guidelines
Case 1
• Echocardiogram performed:
–
–
–
–
LVEF ~25%, global hypokinesis
LVIDd 5.8cm; LVIDs 5.1cm, EF 29%
2+MR
RVSP ~ 45 mmHg
• Course in hospital over 7 days
– Diuresed 4 kg with IV furosemide, at “dry weight”
– Started on ramipril 5mg/d, and carvedilol 6.25 mg bid and MRA
Ambulatory, wondering what we are going to do??
Heart Failure Guidelines
…
prepare to provide your answers!
Heart Failure Guidelines
Case 1 - What would you like to
do next?
1. Coronary angiogram
2. Myocardial perfusion imaging (persantine sestamibi)
3. Cardiac MRI
4. Referral to EP for ICD and or CRT
Heart Failure Guidelines
Case 1 - What would you like to
do next?
1. Coronary angiogram
2. Myocardial perfusion imaging (persantine sestamibi)
3. Cardiac MRI
4. Referral to EP for ICD and or CRT
Heart Failure Guidelines
Back to Case 1
• Angiogram reveals multivessel coronary disease
–
–
–
–
Occluded RCA
80% mid LAD lesion
90% mid LAD lesion
70% OM1 and 90% OM2 lesions (medium size)
• Surgical colleague reviews the films:
– Technically graftable with good distal target vessels
– Serum creatinine stable at 120 mmol/L, GFR 51 ml/min
Heart Failure Guidelines
…
prepare to provide your answers!
Heart Failure Guidelines
Case 1- Your recommended
course of action ?
1. Discharge w/a plan for titrated medical tx until angina occurs
2. Present the patient to CV surgical colleagues to consider CABG
3. Refer to interventional colleague for multivessel PCI
4. Referral for ICD/CRT
Heart Failure Guidelines
Case 1 - Your recommended
course of action ?
1. Discharge w/ a plan for titrated medical tx until angina
occurs
2. Present the patient to CV surgical colleagues to
consider for CABG
3. Refer to interventional colleague for multivessel PCI
4. Referral for ICD/CRT
Heart Failure Guidelines
Prognostic significance of ischemic cardiomyopathy
>1200 patients with invasive evaluation for
cardiomyopathy over 15 years
Ischemic etiology is also an
independent predictor of
mortality in risk models:
Seattle Heart Failure
Model (SHFM)
Heart Failure Survival
Score (HFSS)
Levy et al, Circulation 2006
Aaronson et al, Circulation 1997
Felker et al, N Engl J Med 2000
Heart Failure Guidelines
Surgical Treatment for Ischemic Heart
Failure – where’s the evidence?
Individual patient level meta-analysis of 7 trials
•2600 patients enrolled 1972-84
•CABG associated with mortality reduction
•39% at 5 years, 17% at 10 years
•No interaction with LV dysfunction and mortality
reduction but higher absolute benefits seen in
high risk subgroups
Yusuf et al, Lancet 2004
Heart Failure Guidelines
Surgical Treatment for Ischemic Heart
Failure – where’s the evidence?
• In these early studies:
–
–
–
–
90% had angina
80% had normal LVEF
10% had arterial conduits
Medical therapy = digoxin and
diuretics
Need to assess the benefits of revascularization in
contemporary patients with ischemic cardiomypathy
Yusuf et al, Lancet 2004
Heart Failure Guidelines
Current Era: Surgical Treatment for
Ischemic Heart failure (STICH)
Randomized non-blinded study of surgical
revascularization:
Included patients with LVEF <35% and
CAD suitable for revascularization
Hypothesis 1:
CABG + medical rx superior to medical rx
alone
Hypothesis 2:
CABG + SVR superior to CABG alone in
patients undergoing revascularization with
anterior wall akinesis/dyskinesis
Velazquez et al, J Thorac and Cardiovasc Surg
Heart Failure Guidelines
STICH Hypothesis 1: Primary outcome
1212 patients randomized to
CABG vs medical therapy
Patients with recent MI, major illness,
significant L Main disease and
severe angina excluded
No difference in all cause mortality
seen at median 56 months follow-up
17% of patients in medical therapy
arm crossed over to surgical arm
Heart Failure Guidelines
STICH Hypothesis 1: secondary outcomes
CABG associated with reduction in cardiovascular death and combined outcome of
death or cardiovascular hospitalization
CABG also associated with 30% relative reduction in mortality in “on-treatment”
analysis (accounting for patients crossing over within 1st year of study)
Heart Failure Guidelines
Recommendations - Revascularization
Procedures
Assessment for Coronary Disease
We recommend that coronary angiography be:
a)Performed in patients with heart failure with
ischemic symptoms, who are likely to be good
candidates for revascularization.
Strong Recommendation
Moderate Quality
Evidence
b)Considered in patients with systolic heart
failure (LVEF < 35%) at risk of coronary artery
disease, irrespective of angina, who may be
good candidates for revascularization.
Strong Recommendation
Low Quality Evidence
Heart Failure Guidelines
Recommendations - Revascularization
Procedures
Assessment for Coronary Disease
We recommend that coronary angiography be:
c) Considered in patients with systolic heart
Strong Recommendation
failure and in whom non-invasive coronary
Moderate Quality
perfusion testing yields features consistent with Evidence
high risk.
Values and Preferences:
These recommendations place value on the need of coronary angiography to identify coronary
artery disease amenable to revascularization. Patients with systolic heart failure due to ischemic
heart disease may derive clinical benefit from coronary revascularization even in the absence of
angina or reversible ischemia.
Heart Failure Guidelines
Recommendations - Revascularization
Procedures
Surgical Revascularization for Patients with IHD and HF
We recommend consideration of coronary
artery bypass surgery for patients with chronic
ischemic cardiomyopathy, LVEF < 35%,
graftable coronary arteries and who are
otherwise suitable candidates for surgery,
irrespective of the presence of angina in order
to improve quality of life, cardiovascular death
and hospitalization.
Strong Recommendation
Moderate Quality
Evidence
Heart Failure Guidelines
Recommendations - Revascularization
Procedures
Disease Management, Referral and Peri-operative Care
We recommend that performance of coronary
revascularization procedures in patients with
chronic heart failure and reduced LV ejection
fraction should be undertaken with a medicalsurgical team approach with experience and
expertise in high risk interventions.
Strong Recommendation
Low Quality Evidence
Values and Preferences:
This recommendation reflects the panel preferences that high risk revascularization is likely to
best occur in higher volume centres with significant experience, known outcomes, and
similar to participating in clinical trials involving high-risk coronary revascularization.
Practical Tip:
Assessment for advanced heart failure therapies by an appropriate team should be performed
prior to revascularization in any patient with advanced heart failure
Heart Failure Guidelines
Time-varying hazard ratios for all-cause
mortality in patients randomized to
CABG or MED.
Heart Failure Guidelines
However, there is interaction
with risk factors:
• LVEF < median value (28%)
• LV end systolic index > 60 ml/M2
• 3 vessel disease
Heart Failure Guidelines
Kaplan-Meier rate estimates of all-cause mortality among
patients with 2-3 (top panel) and 0-1 (bottom panel) prognostic
factors.
Heart Failure Guidelines
Case 2
• 65 year old male patient assessed in your office
• Multiple admissions for heart failure, difficulty with
self management
• Past history
–
–
–
–
–
–
Prior lateral wall MI, 2001 (not revascularized)
Hypertension
Significant COPD with FEV1 < 750 ml
Type 2 DM. Right AKA due to severe PVD and ABI 0.22
CKD Atrial fibrillation, previous right sided CVA
Poor mobility, refuses walking aids, but able to perform
basic ADLs slowly
Heart Failure Guidelines
Case 2
• Currently NYHA class III, no angina
• Medications
– Carvedilol 25 mg bid, amlodipine 10mg/d, furosemide 120mg
bid, Nitro patch 1.2 mg/h, hydralazine 50mg tid, insulin,
warfarin 4 mg OD, rosuvastatin 40mg/d, Slow K 2400
mg/day, several alternative agents and periodic metolazone
• Examination: BP 90/70, HR 80 bpm, AF, enlarged
heart with normal JVP, 3+ edema and clear chest
with poor pulses.
• ECG: Atrial fibrillation, Heart rate 76, Q waves lateral
and QRS Duration 130 msec.
• Hemoglobin 95, Creat 250, GFR 19, K 5.0 and INR 2.8
Heart Failure Guidelines
Case 2
• Patient wishes to live as long as possible but most
fearful becoming dialysis dependent
http://riskcalc.sts.org
www.euroscore.org
Heart Failure Guidelines
…
prepare to provide your answers!
Heart Failure Guidelines
Case 2 - Your recommended course of
action ?
1. Angiogram and possible CABG
2. Angiogram and possible ad hoc PCI of flow-limiting lesions
3. Non-invasive perfusion/viability test
4. Referral for ICD/CRT
5. Ongoing medical optimization only
Heart Failure Guidelines
Case 2 - Your recommended course of
action ?
1. Angiogram and possible CABG
2. Angiogram and possible ad hoc PCI of flow-limiting
lesions
3. Non-invasive perfusion/viability test
4. Referral for ICD/CRT
5. Ongoing medical optimization only
Heart Failure Guidelines
The average heart failure patient
Age
75 years
Hypertension
72%
Diabetes
44%
Atrial fibrillation
31%
COPD
31%
Chronic kidney
disease
30%
Gheorghiade, Eur Heart J, 2005
Heart Failure Guidelines
Frailty and cardiac surgery
• Prospective cohort, 4 sites, ≥ 70 yrs, for CABG ± valve
– Non-emergent / urgent; no major psychiatric Dx
• 5 meter walk: if ≥6 seconds, classified as frail
• 131 pts, 75.8±4.4 yrs old
– 46% frail (usually diabetic, IADL problems)
– No correlation with STS risk score (i.e. different domains)
• Outcome: mortality, renal failure, stroke, reoperation,
prolonged ventilation, deep sternal infection
Afilalo et al J Am Coll Cardiol 2010
Heart Failure Guidelines
Frailty and cardiac surgery
Gait speed predicts mortality/major morbidity (OR 3.05, 95%CI 1.23–7.54)
Afilalo et al J Am Coll Cardiol 2010
Heart Failure Guidelines
Viability and LV functional recovery
after revascularization
Systematic review of non-invasive
Imaging techniques in predicting
Regional myocardial recovery
37 observational studies
Thallium, FDG PET and DSE show
high degree of sensitivity
DSE and FDG PET show greatest
specificity
Bax et al J Am Coll Cardiol 1997
Heart Failure Guidelines
Viability and survival after
revascularization
Systematic review of 24 observational studies
Evaluating relationship between death,
viability and revascularization
Allman et al, J Am Coll Cardiol 2002
Heart Failure Guidelines
STICH Analysis
Improved prognosis with viability
Analysis of 601 patients with
viability testing data available
Viability defined as ≥ 11
segments on SPECT or ≥ 5
segments on DSE imaging
Bonow et al, N Engl J Med 2011
Heart Failure Guidelines
STICH Analysis
Viability doesn’t necessarily predict improved outcomes
with surgery vs medical therapy
Bonow et al, N Engl J Med 2011
Heart Failure Guidelines
Recommendations - Revascularization
Procedures
Disease Management, Referral and Peri-operative Care
We recommend that the decision to refer
patients with heart failure and ischemic heart
disease for coronary revascularization should
be made on a individual basis and in
consideration of all cardiac and non- cardiac
factors which affect procedural candidacy.
Strong Recommendation
Low Quality Evidence
Heart Failure Guidelines
Practical Tips
Revascularization Procedures
Imaging
1.Several non-invasive methods for detection of coronary artery disease are in
widespread use
• Dobutamine stress echocardiography (DSE)
• perfusion cardiac magnetic resonance (CMR)
• cardiac positron emission testing (PET)
• nuclear stress imaging
Local factors (availability, price, expertise, practice patterns) will determine the
optimal strategy for imaging.
2.Non- invasive imaging modalities may provide critical information such as the
degree of ischemic or hibernating myocardium, and may be used to determine the
likelihood of regional and global improvement in left ventricular systolic function.
Heart Failure Guidelines
Practical Tips (cont’d)
Revascularization Procedures
Imaging
3. Patients with heart failure, and reduced LV ejection fraction are likely to
experience significant improvement in LVEF following successful coronary
revascularization if they demonstrate:
a) Reversible ischemia or a large segment of viable myocardium (> 30% of
LV) by nuclear stress testing/ viability study;
b) Reversible ischemia or >7% hibernating myocardium on PET scanning;
c) Reversible ischemia or > 20% of LV shown as viable by DSE;
d) Less than 50% wall thickness scarring as shown by late gadolinium
enhancement by cardiac CMR.
Heart Failure Guidelines
PCI or CABG for ischemic symptoms
and heart failure? (Angina included!!)
Revasc.
HR 0.50
Med Rx
4200 patients with HF
referred for angiography in Alberta 1995-2001
Adjusted for baseline risk and propensity for
revascularization
2538 underwent revascularization; 1690
managed medically
CABG
PCI
Med Rx
Majority of patients had ischemic syndromes
Medical management was suboptimal
Revascularization with CABG or PCI associated
with improved survival
Signal for differential outcome, favoring CABG
Tsuyuki et al, CMAJ 2006
Heart Failure Guidelines
Recommendations - Revascularization
Procedures
Surgical Revascularization for Patients with IHD and HF
We suggest consideration of percutaneous
coronary angioplasty for patients with heart
failure and limiting symptoms of cardiac
ischemia, and for whom CABG is not
considered appropriate.
Weak Recommendation
Low Quality Evidence
Heart Failure Guidelines
Practical Tips
Revascularization Procedures
Surgical Revascularization for Patients with IHD and HF
1.In the setting of heart failure, angina and single territory coronary artery disease,
PCI may be the treatment of first choice. However, PCI has not been shown to
improve outcomes for patients with chronic stable heart failure, irrespective of
underlying anatomy.
2.Urgent directed culprit vessel angioplasty continues to be the revascularization
modality of choice for patients with heart failure and acute coronary syndrome.
Heart Failure Guidelines
Figure 1. Approach to Assessment for
Coronary Artery Disease in Patients with
Heart Failure
Heart Failure Guidelines
Figure 2. Decision Regarding Coronary
Revascularization in Heart Failure
Heart Failure Guidelines
Case 3
• 77 year old female, recent admission for worsening HF, now
stable NYHA II symptoms- quite happy with current state
– Occasional exertional chest discomfort with more than usual activity
• Past history:
–
–
–
–
–
Anterior wall MI, late PCI (2005)- no angina since then
Family history of premature CAD
Mild CRF and COPD with FEV1 of 1.9 L (no admissions)
Dyslipidemia- longstanding
IGT but not DM
• Medications:
– Lisinopril 20mg/d, bisoprolol 10mg/d, eplerenone 25mg/d,
ASA 81mg/d, atorvastatin 80mg/d, furosemide 20mg/d, metformin,
gliclazide, nitroglycerin patch 0.8
• ECG:
– Sinus rhythm, LBBB (QRS 144msec), multifocal PVCs
Heart Failure Guidelines
Case 3
• Cardiac SestaMibi with Exercise- 7 METS on treadmill,
limited by SOB but not angina, normal recovery
– Large area of moderate ischemia in infero-lateral territory on
persantine MIBI imaging. Large apical scar without viability and
mild cardiac dilation during exercise.
• Cardiac MRI demonstrates subendocardial scar in
inferior and lateral walls, transmural scar at apex with
large region of anterior wall akinesis, LVEF 35%
Heart Failure Guidelines
Case 3
• Coronary angiogram during hospitalization shows
progressive disease:
–
–
–
–
–
–
–
–
Left main disease
Moderate in stent restenosis with focal 80% lesion (mid LAD)
70% ostial circumflex lesion
Diffuse flow limiting disease in dominant RCA
All vessels graftable
Large akinetic, apical segment of LV Angiogram- no thrombus.
LVEDP 22 mmHG
No valvular heart disease.
Heart Failure Guidelines
…
prepare to provide your answers!
Heart Failure Guidelines
Case 3 - You recommend surgical
revascularization with concomitant:
1. Medical therapy
2. Medical therapy + CABG
3. Medical therapy + CABG + SVR
4. Medical therapy + SVR + CRT/ICD
Heart Failure Guidelines
Case 3 - You recommend surgical
revascularization with concomitant:
1. Medical therapy
2. Medical therapy + CABG
3. Medical therapy + CABG + SVR
4. Medical therapy + SVR + CRT/ICD
Heart Failure Guidelines
STICH Hypothesis 2:
CABG and CABG +SVR improved HF symptoms
1000 patients undergoing
CABG in STICH trial further
randomized to CABG alone vs
CABG + SVR
Dominant anterior wall
motion abnormality required
for inclusion
Median f/u 48 months
CABG + SVR achieved a
reduction in LV end-systolic
index by 19% vs 6% for CABG
alone
Jones et al, N Engl J Med 2009
Heart Failure Guidelines
STICH Hypothesis 2:
No difference in primary or secondary outcomes
between CABG vs CABG + SVR
All cause death or cardiovascular hospitalization
Jones et al, N Engl J Med 2009
Heart Failure Guidelines
All cause death
Recommendations - Revascularization
Procedures
Surgical Revascularization for Patients with IHD and HF
We recommend against routine performance of
the SVR or surgical ventricular restoration for
patients with heart failure undergoing CABG
who have akinetic or dyskinetic LV segments.
Strong Recommendation
Moderate Quality
Evidence
Heart Failure Guidelines
Practical Tips
Revascularization Procedures
Surgical Revascularization for Patients with IHD and HF
1.In highly selected cases, patients with advanced HF symptoms in association
with large areas of dyskinetic and non-viable myocardium may experience
significant clinical improvement with SVR or similar type procedures, when
performed by experienced surgeons.
2.Mitral valve repair may, when used concomitantly during CABG, may, in selected
cases, lead to clinical improvement in symptoms of heart failure.
Heart Failure Guidelines
…
prepare to provide your answers!
Heart Failure Guidelines
Case 3: When should you insert
the ICD/CRT?
1. At the time of surgery
2. Before Surgery (CRT may obviate need of CABG)
3. After surgery, before discharge
4. After 3-6 months stable following surgery
Heart Failure Guidelines
Case 3: When should you insert
the ICD/CRT?
1. At the time of surgery
2. Before Surgery (CRT may obviate need of
CABG)
3. After surgery, before discharge
4. After 3-6 months stable following surgery
Heart Failure Guidelines
Timing of implantable device therapy in ischemic
cardiomyopathy
Study
Comparison
Included
Survival
benefit with
device
CABG patch (1997)
ICD vs no ICD
Implanted at the
time of CABG
-
MADIT II (2002)
ICD vs no ICD
MI > 1month;
Revasc > 3months
+
DINAMITE (2004)
ICD vs no ICD
MI < 40 days
-
COMPANION (2004)
ICD vs CRT-ICD vs
medical rx
MI > 2months;
Revasc >2 months
+
+
SCD HeFT (2005)
ICD vs amio vs
placebo
MI > 1month;
Revasc >1 month
+
CARE (2005)
CRT vs medical rx
MI > 6 weeks
+
IRIS (2009)
ICD vs no ICD
MI < 1 month
-
RAFT (2010)
CRT-ICD vs ICD
Revasc >1 month
+
Heart Failure Guidelines
Recommendations - Revascularization
Procedures
Device Considerations in HF Patients Following Cardiac Surgery
We recommend that following successful
cardiac surgery, patients with HF undergo
assessment for implantable cardiac devices
within 3-6 months of optimal treatment.
Strong Recommendation
High Quality Evidence
We recommend that patients with implantable
cardiac devices in situ should be evaluated for
programming changes prior to surgery and
again following surgery, in accordance with
existing CCS recommendations.
Strong Recommendation
Low Quality Evidence
Heart Failure Guidelines
Practical Tip
Revascularization Procedures
Device Considerations in HF Patients Following Cardiac Surgery
1.During surgical revascularization, consideration should be given to implantation
of epicardial LV leads to facilitate biventricular pacing in eligible patients who may
be candidates for cardiac resynchronization therapy, especially if the coronary
sinus anatomy is known to be unfavourable for lead placement.
Heart Failure Guidelines
Heart Failure Guidelines
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Heart Failure Guidelines
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Heart Failure Guidelines