62-year-old male presented with new onset Class III angina, NIDDM and positive MPI for multivessel ischemia in inferior, lateral and anterior walls. A Cardiac Cath on September 6, 2019 revealed 3V CAD: 100% proximal RCA, 80% calcified proximal LAD/D1 bifurcation Medina (1,1,1), calcified 80% mid LAD, calcified diffuse subtotal LCx-OM2 with SYNTAX Score of 39 and LVEF of 40%. After Heart Team discussion, CABG was recommended, but declined by the patient. Patient is now planned for Impella assisted protected PCI of calcific LAD and LCx using rotational atherectomy.
Q&A
Q
So what is the relevance of Themis in our interventional practice?
A.
Themis trial results as such will not change our current practice of using aspirin alone in all diabetic pts without prior MI, stroke or PCI.
Q
And of Themis PCI?
A.
Themis PCI suggested that in diabetic pts with prior PCIs, adding Ticagrelor on top of aspirin, for 2 years will be beneficial without an increase in major bleeding. These data may change our interventional practice somewhat.
Q
Do you think the recommendations of either will reach the guidelines?
A.
I do not think Themis or Themis PCI will change our guidelines recommendations as overall trial conclusions are weak.
Q
How will these two important trials affect your practice at Mt. Sinai?
A.
As mentioned above, my final conclusion of these two trials is either neutral or even negative. Our current practice in diabetic pts who had prior PCI is just to continue DAPT for 1 year and unlikely will be changed.
Q
What is your present preference for oral P2Y12 inhibitor agents?
A.
For PCI, now we will be using more Prasugrel then Ticagrelor in ACS and high risk Angio features.
Distribution will be as follows; Clopidogrel in 40-50%, Prasugrel in 30% and Ticagrelor in 30%. Shift from Ticagrelor to Prasugrel has started happening already. It is because many insurances still give trouble in approving Ticagrelor and pt has to pay a high copay premium (upto $300 per month). Prasugrel is now generic and has no insurance issues now.
Q
For ACS and for stable CAD?
A.
We have analyzed our data and use of Ticagrelor and Prasugrel remains around 50% in both ACS and Stable CAD. All STEMI cases gets Ticagrelor (60-70%) or Prasugrel (20-30%) with clopidogrel use in only 10-20% cases (very old pts and pts with high bleeding risk).
Q
Regarding COMPLETE trial, what guidance does it provide regarding staging of the procedure?
A.
COMPLETE trial showed that after STEMI, staged PCI can either be done during same hospital admission (1-3 days later) or within 3-4 weeks of discharge. Outcomes after both strategies were similar. I personally will advocate staged PCI to be done after 4 weeks of index culprit vessel PCI. This app strategy will allow safe early discharge of STEMI pts. Cases with 90% + lesion, should get non culprit vessel PCI before discharge to avoid any events in the 4 weeks waiting interval period.
Q
What does it tell us about doing a non-culprit at the time of the index procedure?
A.
COMPLETE trial strategy was to do non-culprit vessel PCI 1-3 days later or 3 weeks later and not doing it at the time of index procedure. Hence staging non-culprit vessel PCI 3-4 weeks later will be the best approach.
Q
There has been a total reversal in STEMI care in the last 3 years - culprit only for cardiogenic shock and multi-vessel for STEMI without shock?
A.
Yes that is the irony of data and really underscores the importance of the RCT rather then going by the expert opinion and consensus.
Q
Would you use FFR for staged, STEMI lesion?
A.
After the COMPLETE trial, where FFR was used only in 1-2% of cases, my recommendation will be as follows;
-If non-culprit lesion is >80% angiographically, then do the PCI without FFR
-If non-culprit lesion is 50-80% angiographically, then PCI should be guided by FFR/iFR; lesions with <0.80/0.89 should get the PCI.
a more of surgical question, would it be possible for such a patient to have jump graft LAD/D1 ? obviously if not diffusely diseased/calcified ?