Optimizing PCI Outcomes in Complex Coronary Disease

Podcast Transcript

Announcer:

Welcome to Cardiac Consult, brought to you by the Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute at Cleveland Clinic. This podcast will explore the latest innovations, medical and surgical treatments, diagnostic testing, research, technology and practice improvements.

Dr. Grant Reed, MD:

Thanks for joining us for Cardiac Consult. I'm Dr. Grant Reed, MD, an interventional cardiologist here at Cleveland Clinic.

Dr. Laura Young, MD:

I'm Dr. Laura Young, MD, another interventional cardiologist at Cleveland Clinic.

Dr. Grant Reed, MD:

Great. Well, what we'd like to do in the next few minutes is address some common questions that medical professionals will ask us, either when referring patients or when we're talking about some of the latest research that we're doing here at Cleveland Clinic.

So, just basic, from a 10,000-foot view, Dr. Young, when are you receiving patients for referrals for PCI (percutaneous coronary intervention) in the contemporary era, and when are stents used in patients these days?

Dr. Laura Young, MD:

When we're talking about outpatients and that stable angina elective setting, we're really looking at patients who have angina despite optimal medical therapy. For each patient, they might be able to tolerate a different amount of medication, right? That's one of the key points, too. I have some patients who are on all four antianginals, and they're still having symptoms, and some who can only tolerate one or two due to side effects.

Dr. Grant Reed, MD:

Yeah, and that's a great point is that the threshold to refer a patient for PCI is very different for different providers. Where some will say, "Okay, you have an abnormal stress test, you have moderate ischemia on a nuclear stress test." Is that an appropriate patient to have a stent done or not? I think the current evidence would support a medication-first approach, where we would optimize antianginals. But what we see, and in my practice, patients will often, they'll be able to tolerate it to some degree, but they don't want to wait too long, right? Patients will often still want their coronary anatomy defined.

So, how do you frame, especially in the context of the ISCHEMIA trial and some other data recently, how do you address the patient who has an abnormal stress test? Is it the amount of ischemia that matters to you, or is it just having abnormal stress? And when do you take a patient for a cath when they have an abnormal stress test?

Dr. Laura Young, MD:

Yeah, that's a really good question, because I think that gets down into a little bit more of the nuances of those trials and what we see on a day-to-day basis. Certainly, ischemic burden is important. Right? We know again, the more ischemia you have, the more myocardium that's at jeopardy for these patients. That does play a role, for sure. I think it's an individualized conversation with each patient, though, and understanding what their tolerance for that risk versus benefit is.

Coronary CT has come a long way. So, if there's a low clinical suspicion, despite an abnormal stress test, that might be a good way to start by defining their anatomy, and we do offer that here. But again, I think that conversation in those patients who have this moderate amount of ischemia and symptoms, it's not unreasonable to take them to the cath lab.

Dr. Grant Reed, MD:

Yeah, I agree with that, totally. I think the evidence and data would support, just as you said, that in patients who have a mild amount of ischemia, starting with coronary CT scan is not a bad idea, understanding that there are going to be limitations due to calcium burden in many patients. We have CT-FFR now, which is a good tool, albeit not perfect. It is a very useful tool because in patients that maybe have a mild ischemia that you think might be a diaphragmatic attenuation or otherwise, then having a normal coronary CT scan or with a minimal calcium burden and a negative CT-FFR (computed tomography–derived fractional flow reserve), you might say, "Okay, you don't need a catheterization." But in those patients who maybe have mild ischemia and have an abnormal CT, or then develop symptoms which are maybe refractory to antianginals, and that's a patient maybe to take a catheterization.

In those patients who have moderate to more ischemia, especially those who have large ischemia and have reduced ejection fraction, those are patients that may be less inclined to say a CTA will be the best next step, because if it's normal or if it's maybe an abnormal test, but the FFR is normal, the pretest probability of that patient having such significant disease is higher. So, doing catheterization is probably best, right?

Dr. Laura Young, MD:

Yeah, yeah.

Dr. Grant Reed, MD:

Yeah, and those are patients who may benefit from revascularization. But that's a very common referral that we get. Again, we encourage those listening to consider referral or consulting with a cardiologist for patients who do have an abnormal stress test.

In the contemporary era, with drug-eluting stents becoming so versatile, how do you approach patients with diabetes and multi-vessel disease? Are you referring them routinely to bypass surgery, or when do you really pull the trigger in that regard?

Dr. Laura Young, MD:

Yeah, I think that's, again, another very individualized approach, but those patients oftentimes, we know that the benefit in these patients is really that LIMA (left internal mammary artery) graft, going down to the LAD (left anterior descending). So, certainly if they have LAD involvement, it's a conversation to have with that patient. At Cleveland Clinic now, we offer minimally invasive bypass surgery as well. So, oftentimes we can do a hybrid approach where they have that LIMA graft sewn to the LAD, and we fix the remainder of the coronary disease with stents. But certainly with diabetics, we know that they have diffuse disease, they oftentimes will have multi-vessel involvement, and so it's very reasonable as a starting point for referral to surgery and having that heart team approach.

Dr. Grant Reed, MD:

The data really has been pretty stable over the last decade. In patients with diabetes and those patients who have multi-vessel coronary disease, and some data would even suggest patients who have reduced ejection fraction, that there may be a survival benefit with bypass surgery in comparison to PCI. I think it is important to frame that in the context of the patient's overall risk. As we've said, we get a large number of patients who are maybe turned down for surgery because of how complex their medical comorbidities are. In that case, stenting is very reasonable for those patients, but having a heart team approach is so important. I know you and I are both intimately involved in that aspect of things with our surgeons, and it's very rewarding to work with our surgeons because we develop really close friendships. I think it makes you better as an interventionalist to have a close relationship with the surgeon.

But then, when we think about optimizing results from PCI, what techniques have evolved recently that we can offer at the clinic that have changed the game? We think about IVL (intravascular lithotripsy), we think about DCB (drug-coated balloon) and otherwise, maybe you can touch on some of the most recent advances that we have here that we can offer patients.

Dr. Laura Young, MD:

First and foremost, it starts with intravascular imaging for us, and that really helps us define what we need to do to optimize that vessel, starting with even the preparation, right? From a preparation standpoint, intravascular lithotripsy is an amazing tool that can be a safe alternative to atherectomy for these calcific lesions. It doesn't take atherectomy off the table, certainly there are some patients where we need that as well. Oftentimes, it's a combination of both atherectomy and lithotripsy to really break up that calcium.

Dr. Grant Reed, MD:

Yeah. I think that's a great point. Imaging for guidance of PCI is underutilized nationally, and we're very keen on that here. I think the vast majority of our patients and PCI cases that we do, whether that be for an acute MI or stable coronary disease, we do use either IVUS (intravascular ultrasound) or OCT (optical coherence tomography) guidance. The data would suggest that that does improve outcomes, based on many numerous observational studies, but now also prospective and even some randomized data in this space. It starts with good imaging guidance and then starts with plaque modification and calcium modification, as you mentioned with IVL and atherectomy as well.

Then it's about contemporary treatment strategies for stenting. We have the ultra-low profile stenting with the latest polymer designs, which have really improved target lesion failure and ISR rates. I do think that it does make a difference where patients are treated. PCI and the standard and basic cases are well done throughout the country, no doubt, but it's those complex cases that I think we really excel at, and obviously, all the more straightforward ones as well.

So in the last few minutes, when you think about the role of PCI versus medical therapies, and that's another big topic with ORBITA and prior to that COURAGE, how do you counsel patients and even your fellow providers? We're talking about when to refer a patient for PCI, but what do you see as the role of medical therapy? And how hard do you really push now that we see these data like ORBITA, and how has that really changed your practice?

Dr. Laura Young, MD:

Yeah. I mean, I think certainly medications, to be frank, are a pillar no matter what we do, and that's what has to be counseled to the patient as well. It's not that we do these stents and they're magically off of all medications and feel better and they're back to normal life. But in discussing the antianginals, again, I think it's understanding for these patients that oftentimes that can be enough to help their symptoms and their quality of life. When we're dealing with stable angina and stable plaque burden, this is really a quality-of-life procedure. So, if they respond to the medications, that's great.

Dr. Grant Reed, MD:

I think that's still where the data is. I mean, there's some observational data that would say that having a large ischemia burden on a stress test, that maybe there's a signal for survival benefit with PCI, which maybe that then is the corollary to doing a LIMA to a large LAD, and that's why you've seen this in the CABG (coronary artery bypass grafting) trials or studies.

So yes, that's feasible, but I think that based on the randomized clinical trial data, just as you said, PCI is really for symptom benefit. Where it, I think, does extend survival is in patients with STEMI or high risk NSTEMI, and then we can postulate if patients that also have a large ischemia burden and maybe have a reduced ejection fraction at baseline. We've all appreciated and been a part of cases where we've done PCI to someone that has a low EF and has ischemia on a stress test and then their EF improves, but unfortunately, that's not consistent. We still don't have a great way of predicting which patients are going to have an EF improvement. We do know that there are some negative predictors, but we don't yet know, and we can't say for certain to patients that's going to be the case, either with bypass surgery or stenting.

So, this is where I think the field needs to evolve. We need to understand that better and try to really get to the point where we can more realistically predict which patients will have a survival benefit from PCI, which patients will have an EF improvement. Short of that, we can say that PCI is an excellent treatment for symptom reduction when medicines aren't enough. Right?

Dr. Laura Young, MD:

Yeah.

Dr. Grant Reed, MD:

Yeah. Well, with that said, I think we'll wrap up in the interest of time. I want to thank everyone for joining us today. We can talk all day about this. I know this is our excitement, both clinically as well as academically. If there's ever anything we can do to help you all, please do not hesitate to reach out to us individually or collectively at Cleveland Clinic. We would be happy to take care of your patients and help in any way. Thanks very much.

Dr. Laura Young, MD:

Thank you.

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