Coronary Interventions: Optimizing Outcomes
Nearly 1.5 million people in the U.S. undergo PCI each year (N Engl J Med 2011;364:453-464). Bare-metal stents became quickly accepted, but then the problem with restenosis surfaced. DES were shown to help reduce the rate of restenosis, with stent thrombosis emerging as the problem. Newer, smaller stent platform designs, as well as better antiplatelet and antithrombotic drug regimens, have helped reduce the rate of stent thrombosis to a reasonable level. Still, researchers are investigating bioresorbable stents to reduce stent thrombosis even further.
Attendees of ACC.11 should plan to listen in on the late-breaking clinical trials, where several studies highlight the latest research with next-generation DES. Much of the research in coronary interventions involves finding ways to better treat particular patient populations: left main disease, total chronic occlusions, poor clopidogrel responders and urgent STEMI cases. Is one stent better than another? Is one dose better than another? Is one approach better than another? Some of these answers will surface at ACC.11.
The GRAVITAS trial recently found that a higher dose of clopidogrel was not efficacious in poor responders. The data on platelet testing is only now emerging, but this approach will no doubt be widely used in the future. Nearly 30 percent of patients will not respond normally to clopidogrel. Clearly, it is in the best interest of interventional cardiologists to find ways to better treat these patients so that their outcomes are optimized. We have highlighted an interesting session focused on the genotypic and phenotypic aspect of treating PCI patients.
In urgent STEMI cases, the key is to coordinate a network of care within the hospital and also with the surrounding community. Many facilities have reduced their door-to-balloon times in an effort to better treat STEMI patients. There are challenges to both getting the STEMI patients to the cath lab in a timely fashion, as well as treating them optimally once they are under the fluoroscopy beam. This topic will be widely discussed in educational sessions at ACC.11.
Recent research has suggested that stenting patients with stable disease is a waste of healthcare dollars. While not everyone agrees with this assessment, the topic has received the attention of payors, including Medicare. That is why it is especially important to understand the variances of treatment associated with optimizing outcomes in patients with stable coronary disease. Several late-breaking clinical trials look at this patient population, as do several educational sessions.
PCI has been found to provide relief to some sufferers of angina with stable disease. But there are many questions that need to be answered including those surrounding long-term outcomes, differences between stents and differences between ethnic groups and men and women.
Attendees of ACC.11 need to remember one thing: What will help me optimally treat my patients? This mantra can help you take in all the exciting research and put it into context.
And be sure to follow our live coverage of ACC.11 from New Orleans starting Sunday, April 3rd.