1. Management Strategies for Post-Intervention in Patients with CAD VBWG

2. Target lesion Nontarget lesion 1.7 6.7 1 3 5 7 Target lesion Nontarget lesion Cutlip DE et al. Circulation. 2004;110:1226-30. *Non-drug eluting stents Average event rate, years 2–5 1.5 1.3 2.3 1.6 18.3 6.7 5.7 7.0 5.6 12.4 0 5 10 15 20 25 12345 % Year CV event rate 0 Disease progression in nonstented lesions causes most CV events N = 1228 in 2nd-generation coronary stent trials* VBWG

3. Glaser R et al. Circulation. 2005;111;143-9. NHLBI Dynamic Registry: N = 3747 for PCI Adjusted odds ratio 15243 P 0 Female gender0.05 Three-vessel disease (vs 1)<0.001 Two-vessel disease (vs 1)0.005 Prior coronary intervention<0.001 Age <65 years0.003 Diabetes 1.0 Hypertension 0.84 Predictors of nontarget lesion PCI for progression of disease VBWG

4. Improving long-term outcomes after PCI Restenosis is less of a problem in drug-eluting stent era A significant number of patients return to cath lab with new lesions Patients with more extensive CAD have increased risk Glaser R et al. Circulation. 2005;111:143-9. Vetrovec GW. Circulation. 2005;111:125-6. Aggressive post-PCI risk factor management offers the greatest opportunity to improve long-term outcomes VBWG

5. CRUSADE: Discharge care for CABG vs PCI Dyke CK et al. Circulation. 2004;110 (suppl):III-420. 95% 88% 65% 87% 73% 72% 79% 51% 86% 68% 72% 44% 83% 92% 0 20 40 60 80 100 AspirinBeta- blockers ACE inhibitors StatinsSmoking- cessation counseling Cardiac rehab Diet- modification counseling PCI (n = 25,653) CABG (n = 7663) Discharge therapy (%) VBWG

6. CRUSADE: Hospital variations in quality of care vs outcome Peterson ED et al. J Am Coll Cardiol. 2004;43(suppl):406A. http://www.crusadeqi.com/;July 2005. ACC/AHA class I indications Lagging hospitals (bottom 25%) Leading hospitals (top 25%) *Relative to total care opportunities 0 20 40 60 80 100 BB ASAHeparin GP llb/IIIa ACEI Statin BB Treat- ment* (%) <24 hours Discharge ASA Clopidogrel 5.95 4.16 0 2 4 6 In- hospital mortality (%) VBWG

7. Mukherjee D et al. Circulation. 2004;109:745-9. N = 1358 *Number of evidence-based medications used (aspirin, ACE inhibitor,  -blocker, statin) vs number indicated 0.51.01.53.0 Lower mortalityHigher mortality 2.00.0 IV III II I 0.10 (0.03–0.42) 0.17 (0.04–0.75) 0.18 (0.04–0.77) 0.36 (0.08–1.75) Appropriateness level* Odds ratio (95% CI) 630 314 302 91 Greater use of evidence-based medications lowers 6-month mortality in ACS patients n VBWG

8. Medication class RRR (%) 5-Year CV-event risk (%) None020.0 Aspirin2515.0  -Blocker 2511.3 ACE inhibitor25 8.4 Lipid lowering30 5.9 Cumulative risk reduction if all 4 medication classes are used: ~70% NNT to prevent 1 major CV event in 5 years: 7 Fonarow GC. Rev Cardiovasc Med. 2003;4(suppl 3):S37-46. Potential long-term risk reduction with cardioprotective medications in post-MI patients VBWG