Transcript No Slide Title - Dartmouth

Advances in the Treatment of Coronary
Artery Disease
Craig A. Thompson, M.D., MMSc.
Director, Cardiovascular Catheterization Laboratories
Dartmouth Hitchcock Medical Center
Dartmouth Medical School
How Your Heart Functions
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The heart pumps blood throughout the body.
Blood carries oxygen and nutrients.
Coronary arteries carry oxygenated blood
to the heart muscle, much like garden hoses might water the lawn to
maintain vitality
Coronary anatomy
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4 “Primary” Arteries run on
surface of the heart
These arteries have many
“branches” that can reach all
parts of the heart muscle
Left Main (LM)
• LAD
• LCx
Left anterior descending (LAD)
• Diagonals
• Septals
Left circumflex (LCx)
• Obtuse marginal (OM)
• Left PDA?
Right coronary artery (RCA)
• PDA
• PLV
TERMINOLOGY
Heart Attack
Cardiac Arrest
Heart Failure
Sudden blockage
of coronary artery
Caused by ventricular
arrhythmia
Weakness of heart muscle
or inability to pump blood
to organs
Atherosclerosis and the development of angina
Advances in the Treatment of Coronary Artery
Disease
improvements in medical therapy
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Aspirin
Beta Blockers
“Statins”
Plavix
ACE inhibitors
Others
New Medicines improve symptoms, prolong
life, reduce the likelihood of heart attack,
stroke, and death!!!
Different Presentations of Coronary Disease
one size does not fit all
No symptoms
Stable angina
Unstable Angina
•Symptoms and exam
NSTEMI
STEMI
Small “warning” heart Ongoing heart attack
attack
•EKG - electrocardiogram
•Bloodwork (“cardiac enzymes”)
How Does a Heart Attack Happen?
Courtesy Possis Medical
What People Expect a Heart Attack
to be Like
• Crushing chest pain
• Sudden, intense, falls to
the floor—like in
the movies
What Is a Heart Attack Really Like?
• Heart attacks often begin with vague
symptoms that slowly intensify.
• Pain or discomfort can be relatively
mild.
• Symptoms may come and go.
• Variety of symptoms may signal danger.
Heart Attack Warning Signs
• Chest discomfort—pressure, squeezing,
fullness, or pain in center of chest
• Discomfort in one or both arms, back, neck,
jaw, or stomach
• Shortness of breath, may come before or
with chest discomfort
• Breaking out in a cold sweat
• Nausea
• Light-headedness
I have symptoms of Heart Attack
what to do?
• Chew an aspirin
• Seek medical attention (911, emergency department, contact
physician)
• Medicines
• Oxygen
• Blood pressure
• Heart rate/rhythm
• Pain control
• Blood thinners (heparin, low molecular weight heparin,
glycoprotein 2b/3a blockers)
• Thrombolytics (“clot buster”)
• Cardiac catheterization and intervention
Why People Delay
• Think symptoms are due to something else
• Afraid or unwilling to admit symptoms
are serious
• Embarrassed about:
• “Causing a scene”
• Having a false alarm
• Do not understand need for getting
to hospital fast
Heart Attacks in Women
• Women are as vulnerable as men.
• Half of all heart attack deaths are in women.
• Tend to delay longer than men in
seeking help.
Heart Attacks in Women
• Like men, may feel pain or discomfort
• Somewhat more likely to experience:
• Shortness of breath
• Nausea/vomiting
• Back or jaw pain
• Tend to delay telling others about symptoms to
avoid causing bother or worry
Non-DHMC Emergency Dept
AMI diagnosed
>30 min of CP and/or
ECG with 1mmST elevation or LBBB
Oxygen, ASA, low dose heparin,
beta blocker, nitrates,
Morphine, 2 IV lines, treat pain,
CHF, shock, arrhythmias
December 2001
Facilitated PCI
Remote ER and
Age < 75
Administer
abciximab
and ½ Dose
Thrombolytic
Acute
Primary
PCI
ST elevationPrimary
MI is Thrombolytic Therapy
now on the DHMC “ALWAYS
Alice Peck Day or
TAKE” list
VA Hospital
Contraindication for
Thrombolytic therapy/
abciximab
Full Dose
Thrombolytic
Administer
abciximab
Transport to DHMC Cath Lab
ASAP
Transport to DHMC for
potential salvage PCI
ASAP
DHMC Cardiovascular Catheterization Laboratories
Interventional Gear
the standard issue
Guiding catheters
Guidewires
Deployed stent
Stent on balloon
Angioplasty balloon
Rotoblator
Removal of Blood Clot
Courtesy Possis Medical
Coronary Stents
BxVelocity™ Stent
Express2™ Stent
Liberté™ Stent
Express2™ Stent, Liberté™ Stent and BxVelocity™ Stent with equal amount of torque applied (0.576 N. mm). Stent size is 3.0 x 28 mm. Bench testing performed internally
by Boston Scientific. Data on file. N=3. Bench test results not necessarily indicative of clinical performance. All images taken by Boston Scientific. Actual values may vary.
Stent Placement
Courtesy Possis Medical
Drug eluting stents
Courtesy Possis Medical
Evolution of Angioplasty
The Dominant Coronary Revascularization Therapy
Over the last 30 years, percutaneous coronary intervention (PCI) has undergone progressive improvements in
success, safety, and durability, as serial new technologies have been launched.
While each innovation solved a serious prior problem, it has sometimes introduced rare new adverse events (e.g.,
40 restenosis, stent thrombosis).
in-stent
Event Rate %
30
20
10
0
Failure
Em CABG
Restenosis
Stent thrombosis
VLST
POBA early
1977
Dr. Don Baim, FDA Panel Meeting December 2006
Current results of
DES-PCI are the
BEST they have
ever been.
POBA late
1985
Stent early
1994
Innovations over time
Stent late
1997
DES
2003-present
Doctors Rethink Widespread Use Of Heart Stents
By BARNABY J. FEDER
Published: October 21, 2006
Doctors study risk of clots in new stents
Incidence in drug-eluting models is extremely low but usually very serious
By Stephen Heuser, Globe Staff | October 21, 2005
Benefit
Risk
Number of Revascularizations
TAXUS® Stent
BMS
TAXUS® Stent
BMS
Identical long term risk for
TAXUS® Stent and BMS
= Large MI
= Death
Boston Scientific, Data on File.
TAXUS Stent 4-year meta-analysis includes TAXUS II (4 yr), IV (4 yr), V (2 yr), VI (3 yr).
With a >50% improved benefit
through sustained reduction in
need for revascularizations
What Should Patients Really Be Concerned About?
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If I have a TAXUS® Stent vs. a BMS…
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What are my chances of death or having a large MI at the end of 4 years?
• The chance of death are the same or lower with the TAXUS Stent vs. BMS
• This annual death rate of 1.5% per year represents roughly the background rate seen in the “natural
history” of patients with stable CAD
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Should I be concerned about stent thrombosis?
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Given the identical or lower death and MI rate, why should I have a TAXUS Stent?
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Late stent thrombosis is a low frequency event (0.5% over 4 years)
It is just one small contributor to the risk of death or MI
Looking at all causes, the chances of dying or having a large MI at the end of 4 years are still
equivalent or less with the Taxus Stent versus a BMS
Restenosis and repeat procedures can also cause major complications
The TAXUS Stent prevents restenosis and reduces the need for a repeat procedure by half (from
~20%, to 10% percent or less)
Is there anything else different if I get a TAXUS Stent?
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With a TAXUS Stent, you need to take Plavix® Medication for at least 6 months (or longer if
recommended by your doctor)
Prematurely stopping your Plavix Medication can increase your risk of stent thrombosis
The safety and effectiveness of the TAXUS Express Stent have not been established in patients for longer than 12 months.
Core
Topics
DHMC…the present and future
Integrated imaging and telemedicine
Conclusions
• Heart attack is a major cause of death and disability in
the US each year
• Early recognition of symptoms and evaluation by
medical personnel improves outcomes
• Best therapy in 2005 includes medicines for heart
rate/rhythm control, blood pressure management, and to
thin blood to stabilize or dissolve clots
• Best therapy in 2005 includes cardiac catheterization
with coronary angiography, and if appropriate,
intervention (angioplasty) or surgery
• Risk factor modification is important both to prevent
initial and recurrent coronary events