第一章 TheTruthandConsequencesofObjectiveIschemiaThe.pptVIP

Objectives Identify pivotal observation(s) from the COURAGE trial nuclear substudy Is this observation(s) novel? Is the obsevation realistic and applicable to clinical practice? What are the limitations caveats regarding COURAGE observations? Summary and Conclusions Nuclear Substudy (n=314 / 2,287) MPS Ischemia Based on Total Perfusion Defect (TPD) TPD: Quantitative measure of defect extent and severity % Ischemic myocardium = (Stress TPD-Rest TPD) 5%: Minimal (“no ischemia”) 5.0%-9.9%: Mild ? 10%: Moderate to severe Significant reduction in ischemia ? 5% reduction in ischemic myocardium* Pre-Treatment Clinical Characteristics and MPS Results Conclusions PCI added to OMT was more effective in reducing ischemia and improving angina than OMT alone, particularly in patients with moderate to severe pre-RX ischemia Is this Observation Novel? Relationship Between Baseline Findings and Treatment Strategies with Adverse Outcomes* to 1 Year: ACIP Study** Ambulatory ECG and SPECT Perfusion Imaging: Lack of Concordance (ACIP Ancillary Study*) Cardiovascular Death or Myocardial Infarction Stratified by Self-Reported Angina and/or Inducible Ischemia*: The Heart and Soul Study Is the COURAGE Trial observation Realistic and Applicable to Practice? Clinical Events Following BMS or DES*+ Clinical Events Following BMS or DES* Mortality (DES vs. BMS) from 29 Trials / RegistriesPatient Year Weighted Regression* Multivariate Predictors of Crossover to PCI COURAGE Objective Ischemia : Conclusions Ischemia (SPECT,AECG,SECHO) is qualitatively and quantitatively correlated with adverse clinical outcomes (CVD,MI) Revascularization (PCI) is more effective in reducing ischemia than medical therapy (OMT) COURAGE PCI was inadequate (83-87% per-patient ; 89-91% per-lesion success rate) and incomplete (47% MVD) with suboptimal technology (14% POBA, 3% DES) COURAGE Objective Ischemia : Conclusions COURAGE OMT was unrealistic (90% compliance through 5 y