Case and Plan:
76-year-old female presented with new onset CCS Class III angina with positive SPECT MPI for mild lateral ischemia. A Cardiac Cath on January 6, 2020 revealed 3 V + LM CAD: 70% distal LM, 80% proximal LAD/D1 bifurcation, 80% long calcified aneurysmal mid LAD, 80% LCx-OM1, SYNTAX Score of 35 and LVEF of 60%. In view of high SYNTAX Score, patient was referred for Heart Team discussion with recommendation for CABG, which was declined and patient opted for multi-vessel PCI. Patient underwent RCA PCI using Xience Sierra DES and discharged home. Now planned for OCT guided complex intervention of LM and long calcified aneurysmal proximal to mid LAD lesions.
Q So, what is the correct duration of DAPT?
A. The field of DAPT duration post DES is in flux at this time. Based on the recent RCTs, Aspirin should be given for 3 months along with Ticagrelor (or clopidogrel in elderly pts and in pts with high bleeding risk) for 1-3years and then switch to aspirin mono-therapy.
Q For ACS?
A. Above strategy (Prasugrel can replace Ticagrelor) for atleast 1year for ACS pts and can be reduced to 6M in stable or high bleeding risk pts.
Q And for stable lesion?
A. Above strategy for 6M in stable CAD pts.
Q When can one expect guideline changes for abbreviated duration of DAPT?
A. New DAPT guidelines are expected to be released in 3Q of 2020.
Q Is Aspirin completely on the way out?
A. Yes aspirin will be out after a short duration of 1-3 months.
Q Where will we have the application of QFR?
A. QFR is derived from a new software for coronary physiological assessment, which in my opinion will be useful in cases involving the diffuse disease where it will help to get the optimal PCI results.
Q What is your preference between Ticagrelor, Prasugrel and Clopidogrel?
A. Based on the ISAR React -5 trial results, we are now favoring Prasugrel over Ticagrelor in ACS pts less then 75yrs of age or Pt’s at low bleeding risk. In older pts and in pts with high bleeding risk, Clopidogrel remains the main agent. In stable complex CAD pts, Ticagrelor (based on TWILIGHT trial) is preferred over Prasugrel as we donot have data for Prasugrel in stable CAD pts.
Q I What has been the impact of ISCHEMIA in your institution?
A. Overall impact of ISCHEMIA trial is negligible at our institution as we have done a good job of educating our cardiology community appropriately.
Q Any impact from EXCEL?
A. So far EXCEL trial controversy also has not affected our referral patters for LMCA revascularization; high Syntax score cases getting CTS consultation before proceeding for PCI (which is being done in about half of the cases due to Pt’s and family preference).
Q Do you always perform co-registration during OCT?
A. Co-registration of angiographic view during OCT acquisition is recent tool being used routinely for last 2 years. It really helps us to localize the stent related issues, if any and then rectify them accordingly.
Can stent be placed in distal om if surgeon not willing to put graft there