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10/18/2019 Interventional Cardiology for the Non-Cardiologist: New Innovations and New Guidelines Krishan Soni, MD, MBA, FACC Assistant Professor of Medicine Division of Cardiology Disclosures No Conflicts of Interest No Financial Disclosures Credit to Dr. Lucas Zier (UCSF) for several slides in this presentation Krishan.soni@ucsf.edu 1

10/18/2019 Objectives Prevention Understand the use of aspirin in the prevention of coronary 1. artery disease (CAD) Stable Ischemic Heart Disease Define the role of percutaneous coronary intervention (PCI) 1. in the management of stable ischemic heart disease Be familiar with contemporary data regarding surgery 2. versus stents for left main and triple vessel disease Updates in dual antiplatelet therapy (DAPT) after coronary 3. stenting procedures Approach to triple therapy in patients requiring antiplatelet 4. and anticoagulant agents Structural Heart Disease (if time allows) Define the expanding role of Transcatheter Aortic Valve 1. Replacement (TAVR) in the management of aortic stenosis Interventional Cardiology for the Non-Cardiologist Major Society Guideline Updates 2016-2019 Clinical Trials Published 2016-2019 Address common questions from Primary Care Community 2

10/18/2019 Acronyms ACS : Acute Coronary Syndrome BMS: Bare Metal Stent CAD : Coronary Artery Disease CABG: Coronary Artery Bypass Graft Surgery DAPT : Dual Antiplatelet Therapy DES: Drug Eluting Stent PCI : Percutaneous Coronary Intervention SIHD : Stable Ischemic Heart Disease VKA : Vitamin K Antagonist TAVR : Transcatheter Aortic Valve Replacement Strength of Guideline Recommendations 3

10/18/2019 Outline Prevention Aspirin and prevention of coronary artery disease (CAD) 1. Stable Ischemic Heart Disease Percutaneous coronary intervention (PCI) in the 1. management of stable ischemic heart disease Surgery versus stents for left main and triple vessel 2. disease Dual antiplatelet therapy (DAPT) after coronary stenting 3. Triple therapy in patients requiring antiplatelet and 4. anticoagulant agents Structural Heart Disease Expanding role of Transcatheter Aortic Valve Replacement 1. (TAVR) in the management of aortic stenosis A 55 yo male patient with mild hypertension on amlodipine sees you for routine exam. He has no cardiovascular disease or other risk factors. He asks “Should I start taking a baby aspirin?” A. Definitely! B. Maybe, w e don’t have enough data C. I’m not sure, we need further testing D. No, the risks outweigh the benefits 4

10/18/2019 “Should I start taking a baby aspirin?” A. Definitely! B. Maybe, we don’t have enough data C. I’m not sure, we need further testing D. No, the risks outweigh the benefits Primary Prevention: Aspirin 5

10/18/2019 Primary Prevention: Aspirin ARRIVE Trial Clinical Question: What is the clinical benefit of 100 mg per day of aspirin in reducing the risk of cardiovascular death, myocardial infarction, unstable angina, stroke, or transient ischemic attack in patients at moderate risk of cardiovascular events without diabetes ? Gaziano JM, Brotons C, Coppolecchia R, et al., on behalf of the ARRIVE Executive Committee. Use of aspirin to reduce risk of initial vascular events in patients at moderate risk of cardiovascular disease (ARRIVE): a randomised, double-blind, placebo-controlled trial. Lancet 2018;Aug 26: Primary Prevention: Aspirin ARRIVE Trial Aspirin Placebo p Value Composite Outcome of Cardiovascular Death, Myocardial 4.3% 4.5% p = 0.60 Infarction, Unstable Angina, Stroke, or TIA Gastrointestinal Bleeding 0.97% 0.43% p = 0.0007 6

10/18/2019 Primary Prevention: Aspirin ASCEND Trial Clinical Question: What is the clinical benefit of 100 mg per day of aspirin in reducing the risk of vascular death, myocardial infarction, or stroke/transient ischemic attack in patients with known diabetes but no history of cardiovascular disease ? The ASCEND Study Collaborative Group. Effects of Aspirin for Primary Prevention in Persons With Diabetes Mellitus. N Engl J Med 2018;379:1529-39. Primary Prevention: Aspirin ASCEND Trial Aspirin Placebo p Value Composite Outcome of Cardiovascular Death, Myocardial 8.5% 9.6% p = 0.01 Infarction, Stroke, or TIA Major Bleeding 4.1% 3.2% p = 0.003 Vascular Events Better Bleeding worse 7

10/18/2019 Primary Prevention: Aspirin ASCEND Trial Primary Prevention: Aspirin ASCEND Trial NNH: 111 NNT: 91 Aspirin resulted in a Aspirin resulted in a 1.1% absolute risk 0.9% absolute reduction in major increase in major adverse bleeding cardiovascular events 8

10/18/2019 Primary Prevention: Aspirin ASCEND Trial What about cancer?... Aspirin Placebo p Value Gastrointestinal Cancer 2.0% 2.0% p = 1 All Cancer 11.6% 11.5% p = 0.98 No Benefit in Reducing Fatal or Non-Fatal Cancer Primary Prevention: Aspirin 9

10/18/2019 Primary Prevention: Aspirin Aspirin and All Cause Mortality in 14 Primary Preventions Trials Primary Prevention: Aspirin An aspirin a day… Should not routinely be prescribed to patients without prior cardiovascular events due to a lack of clinical benefit and/or increased risk of bleeding that offsets the reduction in cardiovascular events 10

10/18/2019 Primary Prevention: Aspirin 2019 AHA/ACC Guidelines Stable Ischemic Heart Disease 11

10/18/2019 Outline Prevention Aspirin and prevention of coronary artery disease (CAD) 1. Stable Ischemic Heart Disease Percutaneous coronary intervention (PCI) in the 1. management of stable ischemic heart disease Surgery versus stents for left main and triple vessel 2. disease Dual antiplatelet therapy (DAPT) after coronary stenting 3. Triple therapy in patients requiring antiplatelet and 4. anticoagulant agents Structural Heart Disease Expanding role of Transcatheter Aortic Valve Replacement 1. (TAVR) in the management of aortic stenosis Stable Ischemic Heart Disease: Prognosis 12

10/18/2019 Stable Ischemic Heart Disease The problem with coronary revascularization… Stable Ischemic Heart Disease Fractional Flow Reserve (FFR) and Physiologic Guided PCI FFR tests for: 1.Objective ischemia 2.Viability 13

10/18/2019 Stable Ischemic Heart Disease FAME 2 Clinical Question: What is the clinical benefit of percutaneous coronary intervention in reducing the risk of death, myocardial infarction, or urgent revascularization in patients with stable ischemic heart disease and at least one hemodynamically significant coronary stenosis? Xaplanteris P, Fournier S, Pijls NH, et al., on behalf of the FAME 2 Investigators. Five-Year Outcomes With PCI Guided by Fractional Flow Reserve. N Engl J Med 2018;379:250-9. Stable Ischemic Heart Disease FAME 2 FFR Guided PCI plus Medical Medical p Value Therapy Therapy Composite Outcome of Death, Myocardial Infarction, or Urgent 13.9% 27% p < 0.001 Revascularization Components of Primary End Point 5.1% 5.2% Not Significant Death • 8.1% 12.0% Borderline Myocardial Infarction • 6.3% 21.1% Significant Urgent Revascularization • 14

10/18/2019 Stable Ischemic Heart Disease FAME 2 What about angina?… Results: Quality of Life % of Patients with Class II-IV Angina at each Time Point % with CCS II-IV Angina Stable Ischemic Heart Disease FAME 2 Physiologic (i.e. FFR) guided PCI… Reduces the composite risk of death/myocardial infarction/urgent revascularization and the severity of angina compared to medical therapy alone in patients with stable ischemic heart disease In 2019, coronary physiology (demonstrating objective ischemia) should be used to guide the decision for PCI in stable coronary artery disease 15

10/18/2019 Objectives Prevention Understand the use of aspirin in the prevention of coronary 1. artery disease (CAD) Stable Ischemic Heart Disease Define the role of percutaneous coronary intervention (PCI) 1. in the management of stable ischemic heart disease Be familiar with contemporary data regarding surgery 2. versus stents for left main and triple vessel disease Updates in dual antiplatelet therapy (DAPT) after coronary 3. stenting procedures Approach to triple therapy in patients requiring antiplatelet 4. and anticoagulant agents Structural Heart Disease Define the expanding role of Transcatheter Aortic Valve 1. Replacement (TAVR) in the management of aortic stenosis Stable Ischemic Heart Disease Syntaxes Trial Clinical Question: What is the long term (10 year) mortality benefit of bypass surgery (CABG) vs coronary stenting (PCI) in patients with severe three vessel or left main disease ? Thuijs DJFM, Kappetein AP, Serruys PW, et al. SYNTAX Extended Survival Investigators. Percutaneous coronary intervention versus coronary artery bypass grafting in patients with three- vessel or left main coronary artery disease: 10-year follow-up of the multicentre randomised controlled SYNTAX trial. Lancet 2019;Sep 2 16