Four Areas of Controversy – Coronary Artery Disease

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.