A New Intervention for
Coronary Artery Disease
Columbus D Batiste, MD, FACC, FSCAI
In just one year Heart Disease claims more lives in the United States than all Americans lost in
the wars of the past century
Permanent Disability
European Heart Journal – Quality of Care and Clinical Outcomes
(2017) 3, 101–106
(S)
Endothelial cells serve multiple functions.
The vascular endothelium serves multiple functions:1) Itregulates fluid and molecule traffic between blood and tissues
2) It is an anti-coagulantsurface
3) It contributes to vascular homeostasis andrepair
4) It plays a vital role in vascular tone and blood flow regulation ***
Assessing this function is the most practical way of measuring
endothelial function.
BASELINE POST OCCLUSION
Brachial Artery Ultrasound with FMD
Prediction of Future CV Events by
Measurement of Endothelial Function
Endothelial Function and Risk of Developing
Hypertension
Endothelial Function and Risk of Developing
Diabetes
Fatal thrombus
Plaque rupture site
Collagenous fibrous cap
Thrombogeniclipid core
Ischemic Heart Disease
Acute Coronary Syndrome
Stable Coronary Syndrome
Goals of Therapy
Decrease
SymptomsProlong Life
Decrease Heart Attacks
Medical Therapy
William Murrell
Nitroglycerin
Sir John Black
Beta Blockers
Akira Endo
Statins
Pioneers in Pharmaceuticals
Revascularization
Pioneers in Revascularization
PCI
Gruentzig
CABG
Favoloro
Treatment for Acute Myocardial Infarction
Doesn’t Equal Treatment for Stable Ischemic Heart
Disease
MEDICATIONS
Aspirin in SIHD
• ARRIVE trial revealed no benefit in patients with moderate risk
• ASCEND revealed bot a benefit and heightened risk balance in Diabetics
Beta Blockers in SIHD
• Do NOT decrease
incidence of Myocardial
Infarction
• Do NOT prolong survival
Statin Therapy in SIHD• 75 percent of heart attack
patients fell within targets for
LDL cholesterol
• Risk of Diabetes
• Risk of hepatotoxicity
• Risk of Muscle Symptoms
STENTS & SURGERY
BARI 2D TRIAL
Among patients with diabetes and stable coronary
artery disease, a strategy of revascularization by PCI or CABG failed to demonstrate superiority to medical therapy over a mean of 5.3 years
BARI 2D Study Group NEJM 2009; 360:2503
COURAGE TRIAL
“As an initial management strategy in patients with
stable coronary artery disease, PCI did not reduce the risk of death, myocardial infarction, or other major cardiovascular events when added to
optimal medical therapy…..”
N Engl J Med 2007; 356; 1503-1516
Initial Coronary Stent Implantation with
Medical Therapy vs Medical Therapy Alone for
SIHDMetanalysis of 8 trials and over 7000 patients initial
stent implantation for stable CAD showed no evidence of benefit compared with initial medical
therapy for prevention of death, nonfatal MI,
unplanned revascularization, or angina.
Arch Intern Med. 2012;172(4):312-319
ORBITA
First randomized SHAM procedure trial
🚫 No improvement in symptoms
🚫 Improvement in quality of life
🚫 No improvement in exercise time
Honorable Mention
FAME 1 showed stenting blockages with decreased
flow was better than treating all blockages
FAME 2 showed improved outcomes with
stenting blockages with decreased flow was better
than medical therapy
PCI in SIHD
💔PCI reduces the incidence of angina.
💔PCI has not been demonstrated to improve
survival in SIHDpatients.
💔PCI may increase the short-term risk ofMI.
💔PCI does not lower the long-term risk ofMI.
Revascularization in SIHDSYNTAX 5 YrFollow-Up
💔CABG: 49.4% of follow-up deaths were cardiovascular
(CHF, Arrhythmia, and Other).
💔PCI: 68% of the deaths after PCI were also cardiovascular
in origin, but these deaths were driven by fatalMI.
💔The rates of MI-related deaths were striking; there was a
10-fold higher rate in PCI-treated patients(4.1%) compared
with CABG-treated patients (0.4%).
Milojevic et al. J Am Coll Cardiol2016;67:42–55)
“Here’s to the crazy ones. The misfits. The rebels. The
troublemakers. The round pegs in square holes. The ones who see
things differently. ”
“... They are not found of rules. And they have no respect for the status quo. You can quote them,
glorify or vilify them. ”
“…. About the only thing you can’t do is ignore them. Because they push the human race forward and while some see them as crazy We see them as genius”
Nathan Pritikin Dean Ornish Caldwell Esselstyn
T. Colin Campbell John McDougall Neil Barnard
Heart DiseaseCancer Diabetes Mellitus
Obesity Hypertension
Hyperlipidemia Autoimmune
Stroke Allergies
Standard American Diet
Poor Sleep Dehydration
Endothelial Damage
StressPoor Relationships
Endothelial Damage
Inflammation
Artery Response
Symptoms
Effect of Intensive Lifestyle
Changes on Endothelial Function
and Inflammatory Markers of
Atherosclerosis
EVADE CAD
1
1.05
1.1
1.15
1.2
1.25
BASELINE 8 WEEKS
WFPB AHA
Endothelial Damage
Inflammation
Artery Response
Symptoms
Effect of Intensive Lifestyle Changes on
Endothelial Function and Inflammatory
Markers of Atherosclerosis
0.02
0.07
0.04
0.03
0
0.01
0.02
0.03
0.04
0.05
0.06
0.07
0.08
Baseline 3 months
Experimental Control
Comparative Effects of 3 Popular Diets on
Lipids, Endothelial Function and C-Reactive
Protein during Weight Maintenance
• Ornish Diet associated with higher FMD compared to Atkins
• Inverse correlation between FMD
and saturated fat
Saturated Fat
FM
D
J Am Diet Assoc 2009 Apr 109 (4); 713-717
Omnivore
Vegetarian
4.42
4.21
3.13
13.78
13.78
21.99
VASODILATORY FUNCTIONS OF VEGETARIANS COMPARED WITH
OMNIVORES
NTG induced dilataton Flow-mediated dilatation Baseline size
DECREASE ISCHEMIA
Endothelial Damage
Inflammation
Artery Response
Symptoms
Weight Reduction
• reduces ROS, Lipid
profiles, and BP
• Improves exercise
capacity
Reduce BP
-improve vascular function
-reduced inflammation
-reduced ROS
-Enhanced NO utilizationImprove Vascular Function
-reduce inflammation
-improve platelet function
-enhance NO ablation
Reduce Oxidative Stress
- Reduce LDL oxidation
- Improve anti oxidant
- Reduce ROS
Improve Lipid Profile
- Reduced LDLc, TG &
TC
- Increase HDL
- Reduce LDL oxidation
Decrease Events
Decrease Ischemia
Improve Dilation
Repair Endothelium
Class I
Benefit >>> Risk
Procedure/ TreatmentSHOULD be
performed/ administered
Benefit >> Risk Additional studies with focused objectives needed
IT IS REASONABLE to
perform procedure/administer treatment
Benefit ≥ Risk Additional studies withbroad objectives needed;
Additional registry data would be helpful
Procedure/TreatmentMAY BE CONSIDERED
Class IIa Class IIb Class III
Risk ≥ BenefitNo additional studies needed
Procedure/Treatment should NOT be performed/administered SINCE IT IS NOT HELPFUL AND MAY BE HARMFUL
should
is recommended is indicatedis useful/effective/
beneficial
is reasonable
can be useful/effective/ beneficial
is probably recommended orindicated
may/might be considered may/might be reasonable usefulness/effectiveness is
unknown /unclear/uncertain or not well established
is not recommended is not indicated should notis not
useful/effective/beneficial may be harmful
Classification and Level of Evidence
Level of Evidence
Level of Evidence A: Data derived from
multiple randomized clinical trials or meta-analyses.
Level of Evidence B: Data derived
from a single randomized trial, or
nonrandomized studies.
Level of Evidence C:
Only
consensus opinion
of experts, case
studies, or
standard
of
care.
Clinical Practice Guidelines💔“Should do, should not do”
💔Class I is do and Class III is don’t do
💔In the 16 guidelines
💔19% of class I guidelines are LOE A
💔48% of recommendations are LOE C
Cardiologist
Lifestyle Specialist
Interventional Cardiologist
Initial Treatment Strategy
for Patients
Transition to a Whole Food Plant Based Diet
I IIa IIb III
B
Patients identified as having stable ischemic
heart disease should be referred to cardiac
rehab
Patients should have medications adjusted as lifestyle is increased
Initial Treatment Strategy for
Patients
I IIa IIb III
I IIa IIb III
B
B
QUESTIONS