A case of chest tightness

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• A case of chest tightness

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Case summary

• Profile An 80 y/o male
• Chief complaint exertional chest tightness for 1
  month
• Past medical and surgical history
• Patient denied of any significant past medical
  history, no HTN, DM, dyslipidemia.
• BPH s/p TURP for 7-8 years.

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• CAD risk factors
• HTN -
• DM -
• AGE
• FHx -
• SMOKING -
• MALE
• DYSLIPIDEMIA -

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HISTORY OF PRESENTING COMPLAINT

• Intermittent chest pain and chest tightness for 1
  month
• Chest pain was effort related, no radiation to
  lower jaw or neck or shoulder.
• Lasted for 10 minutes and relieved by rest, no
  associated symptoms.
• Visited CV OPD 1 week before admission, cardiac
  esho showed 1. adequate LV global
  performance(EF60) 2.No chamber dilatation. 3.No
  pericardial effusion
• Stress and rest Tl-201 myocardial perfusion SPECT
  scintiphotos showed a non-compromised myocardial
  perfusion.
• Chest CT showed RML nodule TB culture was
  collected.
• Antiplatelet with Bokey 100 mg 1qd was given for
  possible CAD.
• Admitted electively on 8/1 for further
  investigation cardiac catheterisation

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Physical examination

• Vital signs T36c, P64/min, R20/min,
  BP147/76 mmHg
• GCS 456
• JVP supple, estimated 7 cm H2O no goiter
• Chest BS clear
• Heart sounds dual no murmur, regular
• No pitting edema, good peripheral pulse

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Investigation

• WBC 6200, Hb 13.0, PLT 176000
• BUN 18, Cr 1.0, GOT/GPT 19/17
• GLU 92, Na 140.7, K 4.02
• T. cholesetrol 207, TG 117
• Uric acid 5.88
• EKG normal sinus rythm

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Cardiac angiography report

• Clinical diagnosis angina pectoris
• Indication for cath angina pectoris
• Post- cath diagnosis CAD/left main 3-V-D
• EF54,
• Left main 50-60 stenosis at distal left main
• LAD 95 stenosis at LAD-P
• LCX 95 stenosis at ostium and a 90 stenois at
  LCX-D
• RCA 50 stenosis at RCA-M
• Collateral none

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Cardiac angiography report

• Post- cath Diagnosis CAD left main 3VD s/p
  successful direct Taxus stenting for LAD-P and
  LCX-ostium and POBA and stenting for LCX-D/TIMI
  III
• CABG is recommended for left main and 3VD.
  However the family refused the OP due to old age
• PCI for LAD-P and LCX-ostium and LCX-D is
  recommended.

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Progress

• Patient recovered well the next day
• No active bleeding or hematoma over the puncture
  site, with good distal pulse and sensation.
• Discharged with OPD follow up.
• Medication
• Bokey 100 mg 1 qd po
• Gasgel 1 tid po
• Isosorbide 10 mg 1 tid po
• Acetylcystein 3 pk bid po
• Plavix 75 mg 1 qd po

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The question in mind..

• Did her familys decision to perform PTCA instead
  of CABG affect her outcome (morbidity and
  mortality) in the future?

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PTCA with stents VS coronary bypass

• PICOT ?? treatment
• P ACUTE CORONARY SYNDROME
• I PTCA
• C CORONARY BYPASS
• O morbidity and mortality
• T TREATMENT

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Keywords

• Acute coronary syndrome
• Angiography
• Coronary bypass

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Percutaneous transluminal coronary angioplasty
with stents versus coronary artery bypass
grafting for people with stable angina or acute
coronary syndromes

• Cochrane Database of Systemic Reviews 2005, 2007

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Background

• Coronary artery bypass graft (CABG) is the
  surgical technique used to treat critical
  obstructions in coronary arteries caused by
  atherosclerotic plaque disease
• saphenous veins OR internal mammary arteries OR
  radial artery
• risk of initial surgical mortality and morbidity
• need for a significant period of convalescence
• surgical centres require specialised staff and
  facilitates.

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• Percutaneous Coronary Interventions (PCI), which
  include Percutaneous Transluminal Coronary
  Angioplasty (PTCA), PTCA with stenting,
  brachytherapy and atherectomy technologies
• local anaesthetic , small vascular incisions in
  the groin or arm (percutaneously), as little as
  15 minutes
• rates of restenosis (re-narrowing of the treated
  vessel), 20 and 50
• debate on whether surgery or PCI is the most
  appropriate treatment

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Objectives

• To assess the clinical effects of the use of
  coronary artery stents (as part of Percutaneous
  Transluminal Coronary Angioplasty) compared to
  Coronary Artery Bypass Graft surgery for the
  treatment of people with coronary artery disease.

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Criteria for considering studies for this review

• Types of studies
• Randomised Controlled Trials (RCTs),
• published or unpublished
• use of coronary artery stents (in conjunction
  with Percutaneous Transluminal Coronary
  Angioplasty techniques
• compared with the application of Coronary Artery
  Bypass Graft (CABG) techniques.

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• Types of participants
• Adults
• Stable angina or Acute Coronary Syndrome
  (including AMI (ST segment elevation and
  depression, Q wave and non-Q wave) and unstable
  angina).
• Adults with single or multivessel coronary artery
  disease.
• Types of intervention
• Percutaneous transluminal coronary angioplasty
  with stents versus coronary artery bypass
  grafting surgery.

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• Types of outcome measures
• Clinical(1) Combined event rate or event free
  survival (e.g. Major Adverse Cardiac Events,
  Major Adverse Cardiac and Cerebrovascular Events,
  Target Vessel Failure or other composites of the
  events listed below)(2) Death (both cardiac and
  non-cardiac death)(3) Acute Myocardial
  Infarction (AMI)(4) Target Vessel
  Revascularisation (TVR)(5) Target Lesion
  Revascularisation (TLR)(6) Repeat treatment
  (PTCA, stent or CABG).RadiologicalBinary
  restenosis (greater than 50 luminal narrowing
  compared to diameter at completion of the
  procedure).Quality of lifeWhere quality of
  life (QoL) data were available the nature of the
  measures, timings of measurement and analytical
  tool used to assess QoL were recorded

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Search methods for identification of studies

• The search incorporated a number of methods to
  identity completed or ongoing RCTs
• (1) Searching of electronic databases
• (2) Handsearching of recent journals and
  conferences in relevant fields
• (3) Subscription to e-mail-based information
  newsletters and regular examination of webpages
  (including those supported by stent
  manufacturers) relevant to the review topic
• (4) Searching of bibliographies of identified
  sources
• (5) Use of submissions to National Institute for
  Clinical Excellence (NICE), London, UK.

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Description of studies

• Included studies
• Nine RCTs, involving a total of 3519
  participants, are included in this review..
• Three studies included patients with multivessel
  disease
• Five included only people with single vessel
  disease
• one included a mix of vessel involvement
• Reporting of outcomes extended beyond 1 year for
  ARTS Drenth ERACI II SIMA SOS, but were
  restricted to 6 months for Cisowski Diegeler
  Grip.

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Results

• 1. Death
• Although stents appeared to be favoured in terms
  of lower mortality, these differences were not
  statistically different
• SOS study reports eight cancer related deaths in
  the stent arm
• The uneven distribution of non-cardiac deaths in
  SOS would appear to contribute to it appearing to
  favour CABG
• AMI
• No significant difference observed, there was
  moderate to high degree of heterogeneity at 36
  days, 12 months and 2 years

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Results

• Revascularisation
• Repeat revascularisation procedures where less
  common in the CABG group
• Multiple vessel disease trials are included in
  the analysis at 12 months and 2 years, resulting
  in odds ratio 0.18 and odds ratio 0.21
• single vessel disease studies, producing an odds
  ratio 0.09
• Binary restenosis
• Binary restenosis rate was reduced with CABG,
  odds ratio 0.29 (95 confidence interval 0.17 to
  0.51) in the three single vessel trials at 6
  months random effects odds ratio 0.21

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Discussion

• The main findings of the meta-analysis
• over the duration of follow-up available from
  current RCTs, there is considerable benefit, in
  terms of reduction in repeat revascularisation
  rates, with CABG over stenting.
• These reductions were similar in single and
  multiple vessel disease studies

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• Multivessel disease
• The four studies (ARTS ERACI II OCTOSTENT
  SOS) included in this meta-analysis demonstrate
  some differences in mortality between CABG and
  stent groups, however these did not reach
  statistical significance .
• BUT considerable heterogeneity
• Similarly, the rates of AMI were also not
  significantly different.
• After 2 years the rates of AMI tend to favour
  surgery, but again this observation failed to
  reach statistical significance
• At 12 months the repeat revascularisation rates
  with CABG were approximately one fifth of the
  rates for stenting with an odds ratio 0.18 95

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• Single vessel disease
• In the four single vessel studies (Cisowski
  Diegeler Drenth Grip SIMA), given that
  mortality rates in the short term were generally
  low and the small number of total participants,
  the difference did not reach statistical
  significance
• but would appear to favour stenting in contrast
  to the multivessel disease studies
• The AMI and combined endpoint results closely
  mimic the respective results seen in the
  multivessel studies with CABG appearing to be
  better than stents in terms of composite event
  rate and repeat revascularisation at 6 months

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Clinical Interpretation

• The mortality rate trend seen in the single
  vessel studies favouring stenting was not
  surprising given that stenting is performed under
  local anaesthetic and does not entail the general
  anaesthesia required for surgery.
• While there would appear to be no significant
  difference in myocardial infarction rates at any
  time point, there is a trend in favour of CABG in
  those studies with longer follow up
• 1. different enzyme rise thresholds for the two
  techniques
• 2. grafts which are invariably placed distally on
  native vessels may occlude with less myocardial
  impact than vessels opened proximally by stent
  procedures
• 3. interventionists are more inclined to request
  cardiac enzymes on patients with post-PCI chest
  pains then surgeons who are inclined to accept a
  degree of chest pain from patients due to the
  nature of the operative procedure
• 4. modest follow-up duration is likely to capture
  stent failure more fully as opposed to graft
  failure

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Limitations

• 1. patients entered into such studies had to be
  suitable for either intervention and were not
  typical of all patients seen by cardiologists or
  cardiothoracic surgeons
• 2. practice changed over the periods of the
  trials e.g. Glycoprotein IIB/IIIA has in more
  recent practice reduced early stent thrombosis
  and the amount of Ischaemic enzyme release peri
  procedurally
• 3. we could not consider subgroups of patients in
  the current meta-analysis
• 4. analysis of 'other' adverse events (for
  example, neurological complications) were not
  completed as these were not commonly or
  consistently reported.

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Authors' conclusions

• Implications for practice
• Considerably more data is needed to make
  firm long term conclusions on the implications
  for practice, but in the short to medium term,
  CABG has far less repeat revascularisation
  procedures than PTCA with stents currently in
  common clinical use.
• Implications for research
• Re-evaluation of these technologies will be
  required as the development of new surgical
  techniques and stent designs is ongoing
• Future trials should recruit more realistic
  patient groupings, as the population selected for
  inclusion in the current review were prone to
  bias
• selection tended to focus on patients with
  generally less co-morbidities and with better
  left ventricular function than the overall
  population presenting for revascularisation in
  the real world setting