Recomendações: evidências e lacunas- Revascularização do Miocárdio. Lacunas

Transcrição

1 Recomendações: evidências e lacunas- Revascularização do Miocárdio Lacunas

2 CTO PCI in secondary revascularisation after CABG failure Revascularização do Miocárdio The Guidelines are appropriately conservative, don t tell us all truth

3 -Why do we need a conse? CTO PCI in secondary revascularisation after CABG failure What is the best treatment for my patient?

4 Randomised Clincal Trials: 3 main issues Gap between RCTs - daily practice Analyse - interpretation of RCTs Clinical practice and socioeconomic constrains 4

5 Randomised Clincal Trials: 3 main issues Gap between RCTs - daily practice Explore an hypotesis Address averaged selected patients inclusion/exclusion criteria Primary clinical endpoints combined clinical endpoints Collective ethics what is the best for the future group of patients or society 5

6 Randomised Clincal Trials

7 Randomised Clincal Trials

8 Randomised Clincal Trials

9 Why? to improve the symptoms to improve survival When? How Failure of OMT Amount of ischemia PCI vs CABG Complete vs incomplete 9

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11 Unresolved Issues/Outlook How to integrate: comorbidity factors local experience patient preference into the decision making process 11

12 Definition of the CHIP population 12

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16 Myocardial revascularisation 16

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18 Patients with increased complexity: Older Co-morbidity Post CABG/graft failure Renal failure Gender (female)?

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20 Gender Female gender is a risk factor in cardiac surgery females present at older age with several comorbidities females tend to have smaller body size acquired risk factors have higher impact on women..referral bias??? 20

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29 Myocardial revascularisation 29

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31 Incomplete revascularization after PCI is associated with increased rates of death, MI and recurrent ischemia requiring rehospitalization and revascularization Non-revascularized plaques which are ischemia producing and/or vulnerable (TCFAs with large plaque burden) are most likely to cause future events 31

32 Why do we need a consensus?

33 Myocardial revascularisation 33

34 yocardial revascularization - consensus What is the best treatment for each individual patient? is the revascularisation need for this particular patient? if so, which revascularisation technique seems to be the most appropriate for this particular patient? 34

35 Myocardial revascularisation - consensus A decision making process based on A step-by-step analysis and global appraisal of the patient s presentation A critical reflexion of the available knowledge: are the available scientific data applicable to this particular patient? The experience and consensus of the local team 35

36 CTO PCI in secondary revascularisation after CABG failure Why do we need a consensus? Guidelines must be used as guide not as a rule in clinical practice

37 THANK YOU