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Trial Update 2. Other Trials Alun Harcombe. from 1 April: Nottingham University Hospitals NHS Trust. NO CONFLICT OF INTEREST TO DECLARE. Other Trials. LE MANS SENIOR PAMI PROXIMAL. Early Conclusion. - PowerPoint PPT Presentation
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Advanced Angioplasty 2006
Trial Update 2Other Trials
Alun Harcombe
from 1 April: Nottingham University Hospitals NHS Trust
NO CONFLICT OF INTEREST TO DECLARE
Advanced Angioplasty 2006
Other Trials
• LE MANS
• SENIOR PAMI
• PROXIMAL
Advanced Angioplasty 2006
Early Conclusion
• Left Main Stenting Safe and Feasible, might avoid some morbidity and improve ejection fraction
• Elderly patients do quite badly with heart attacks – however managed, unless they’re not that elderly
• Proximal protection for vein grafts is quite good when it is possible and it works
Advanced Angioplasty 2006
LE MANS
• Dr Pawel Buszman
Silesian Medical School, Katowice, Poland
• First Randomised Trial in Modern Era:
Unprotected LMS Stenting vs CABG
Advanced Angioplasty 2006
Advanced Angioplasty 2006
Advanced Angioplasty 2006
Advanced Angioplasty 2006
LE MANS Endpoints
• Primary:– LVEF– functional capacity– angina status (12 months)
• Secondary – major adverse cardiac events (MACE)– hospital length of stay– survival– any major adverse events (MAEs)
• any MACE, procedure-related infection, bleeding, or renal or respiratory insufficiency.
Advanced Angioplasty 2006
LE MANS
PCI CABGRegistry 163 184Randomised 52 53Age 60 61Distal LM 58 62DES (<3.8) 35% 62% LIMAVessels 2.3±0.8 2.9 ±0.8 Grafts
Advanced Angioplasty 2006
Events by 30 days
PCI CABG
Death 0 2 ns
AMI 1 2 ns
CVA 0 2 ns
HF 1 4 ns
Repeat revasc. 0 1 ns
Any MACE 2 90.028
Advanced Angioplasty 2006
Results
Outcomes CABG, n (%) PCI, n (%) p
Any MACE (<30 days)
9 (20.7) 2 (3.8) 0.028
Any MAE (<30 days)
19 (35.8) 3 (5.8) 0.0001
Any MACE(30 d-12 mo)
11 (20) 11 (21) NS
Advanced Angioplasty 2006
Ejection Fraction
Advanced Angioplasty 2006
Comments
• LV function estimates – not blinded– applies if LV impaired to begin with?
• Low rate of DES usage
• Small single centre study
• LMS stenting a reasonable option?– The era of data has begun
Advanced Angioplasty 2006
Senior PAMI
• Senior Primary Angioplasty in Myocardial Infarction: International multi-centre randomised
• Dr Cindy Grines
William Beaumont Hospital
Royal Oak
Michigan
USA
Advanced Angioplasty 2006
Advanced Angioplasty 2006
Senior PAMI• Aged ≥70years
– Acute MI symptoms 30 minutes to 12 hours 1mm ST elevation, or LBBB– Eligible for lytic therapy
• Excluded: – SBP >180 mm Hg or DBP>100 mm Hg – Warfarin, INR>1.4– Cardiogenic shock
• Randomised to Thrombolysis or Transfer to Cardiac Catheter Laboratory for PCI
• International, multi-centre• Stopped early (slow recruitment, 47 short of 530)
Advanced Angioplasty 2006
Senior PAMI Demographics
PCI Lytic p valueAge 78 ±6 77 ±6 0.47
range 70-99 70-101
Female 42% 40% 0.54
Hypertension 65% 67% 0.65
Diabetes (all T2DM)
25% 20% 0.22
Impaired mobility
6.1% 1.8% 0.16
Dementia 5.7% 0.0% 0.0003
Advanced Angioplasty 2006
Senior PAMI PresentationPCI
(n=252)Lytic
(n=229)p value
CP to ED
(median mins)
155 148 0.38
CP to Rx
(median mins)
237 210(+ reperf. time)
0.014
Infarct: Inferior
Anterior/LBBB
49
48
60
41
0.22
0.12
Diuretic in ED 8.8 3.5 0.018
Advanced Angioplasty 2006
PCI ArmMultivessel Disease
2 vessel
3 vessel
LM/4 vessel
77%31.2%
40%
5.6%
Initial TIMI: 0
1-2
3
80%
12.1%
8.2%
No PCI (1 patient died, 13 risky anatomy/LMS, 4 <70%stenosis)
8%
Post PCI: TIMI 0
1-2
3
CABG
4.3%
9.6%
86.1%
3.6%
Advanced Angioplasty 2006
Thrombolytic Arm
Lytic given (99.6%) Streptokinase
TNK, tPA, rPA
37.6%
62%
Clinical Reperfusion 65%
Non-protocol Cath: <12hrs
In-hospital
21%
51%
Non-protocol PCI In-hospital 37%
CABG 4.4%
Advanced Angioplasty 2006
Senior PAMI 30 Day Events
10
13
0.82.2 1.6
5.4
11.313
11.6
18
0
2
4
6
8
10
12
14
16
18
Death ReMI D/CVA/ReMI
PCI (n=252)
Lytic (n=229)
DisablingCVA
Death/dCVA
0.48 0.26
0.039
0.57 0.05
%
Advanced Angioplasty 2006
Senior PAMI 30 Day Events by Age
7.1
11.3
7.7
12
7.7
17
0
5
10
15
20
25
%
Death Death/CVA D/CVA/reMI
PCI Lytic
19
16
20
16
22 22
0
5
10
15
20
25
%
Death D/CVA D/CVA/reMI
PCI Lytic
0.0093
70-80yrs (n=381) >80yrs (n=130)
Advanced Angioplasty 2006
Conclusions
• Primary PCI effective at reducing combined endpoint, but not primary endpoint of death or disabling stroke
• In sub-group of very elderly PCI may have no advantage at all– Lysis followed by rescue where needed?
• Main PCI advantages:– Avoid intracranial bleeding– Reduce re-infarction & recurrent ischaemia
Advanced Angioplasty 2006
Points
• Selected population, slow recruitment– No prior CVAs– Warfarin and hypertension exclusions
• Event rates low in lytic arm– Lower dose heparin regimes (60u/kg, max
4000u)
• High rates of invasive investigation, rescue and later PCI (&CABG) in lytic arm
• Lytic ineligible patients?
Advanced Angioplasty 2006
Proximal Trial
Proximal Protection during Saphenous Vein Graft Intervention using the Proxis Embolic Protection System: A Randomised Prospective Multicenter Trial
Campbell RogersBrigham and Womens Hospital, Boston
Advanced Angioplasty 2006
Advanced Angioplasty 2006
Advanced Angioplasty 2006
Advanced Angioplasty 2006
Advanced Angioplasty 2006
Advanced Angioplasty 2006
Advanced Angioplasty 2006
Advanced Angioplasty 2006
Advanced Angioplasty 2006
Advanced Angioplasty 2006
Advanced Angioplasty 2006
Advanced Angioplasty 2006
Advanced Angioplasty 2006
Conclusions
• Left main stenting – here to stay
• Primary PCI – up to 80yrs age
• Proxis – good for embolic protection in
distal lesions
Advanced Angioplasty 2006
Advanced Angioplasty 2006
30 Day Outcomes: Research/T-Search
Pre-DES Group DES Group P* (n=86) (n=95)
Death 6 (7) 10 (11) 0.60Nonfatal MI 8 (9) 4 (4) 0.24Death/non- fatal MI 14 (16) 14 (15) 0.84TVR 2 (2) 0 (0) 0.22Repeated PCI 1 (1) 0 (0)CABG 1 (1) 0 (0)Any event 16 (19) 14 (15) 0.56Stent thrombosis 0 (0) 0 (0)1
*By Fisher exact test. Angiographically documented.
Circulation. 2005 Nov 1;112(18) Valgimigli M et al