After developing chest pains, a patient with a complex medical history was referred to UCSF Medical Center. Cardiac catheterization revealed multivessel coronary artery disease (CAD), with high-grade blockages in every major artery. After prescribing aggressive risk factor modifications, blood pressure and cholesterol therapies, and smoking cessation, physicians faced a final treatment choice: open heart coronary artery bypass graft (CABG) surgery or multivessel percutaneous coronary intervention (PCI) with balloon angioplasty and stent placement.
The case above illustrates that despite decades of clinical research, physicians still debate the best revascularization approach to take for treatment of multivessel CAD. Recent technology improvements help patients, but can further complicate the debate. Therefore, say experts at UCSF Medical Center, the best approach must emerge from a discussion among interventional cardiologists and cardiothoracic surgeons that carefully considers the needs and anatomy of the individual patient.
Some of the more recent studies, like SYNTAX, seem to swing the pendulum back toward surgical revascularization because it's safer for some patients and it lasts longer," says Scot Merrick, M.D., chief of cardiothoracic surgery at UCSF Medical Center. "But nothing's been fully resolved because, of course, PCI is less invasive and safer for other patients."
"The key in complex cases is to look carefully at coronary anatomy and the patient's comorbidities, and then decide on the right procedure through an interdisciplinary consultation," says cardiologist Yerem Yeghiazarians, M.D., co-director of the Adult Cardiac Catheterization Laboratory at UCSF Medical Center. "And with technology improvements, the choice is no longer simply PCI vs. CABG. One should also consider hybrid procedures — some blockages treated with stents and others with bypass."
UCSF has already approved and begun plans for a dedicated, hybrid operating room where doctors can optimize these procedures through ready access to a full range of mechanical support devices. Everything from Impella pumps and TandemHeart percutaneous ventricular assist devices (pVADs) to extracorporeal membrane oxygenation (ECMO) machines will be on hand.
For high-risk patients, access to this advanced equipment is one important component of treatment at an academic medical center. Another is the availability of experienced, patient-centered, interdisciplinary teams intimately familiar with the latest evidence-based protocols. Such teams are well equipped to discuss with patients the three potential options for revascularization.
According to both Merrick and Yeghiazarians, patients should be referred who have one or more of the following:
Follow-up care involves arming patients with a comprehensive secondary prevention plan, and then working with community cardiologists to help patients follow that plan.
To contact Scot Merrick, M.D., call (415) 353–1606.
To contact Yerem Yeghiazarians, M.D., call (415) 353–3817.
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