ACC Backs Off Stance Against Complete Revascularization

In response to 2 recent trials, the American College of Cardiology (ACC) has withdrawn a “Choosing Wisely” recommendation questioning revascularization of nonculprit arteries during primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI).

The recommendation was 1 of 5 issued in April 2012 as part of the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely campaign, which asks medical organizations to identify tests or procedures that are commonly used but whose utility should be questioned.

ACC President Patrick T. O’Gara, MD, of Brigham and Women’s Hospital (Boston, MA), said in a statement that the withdrawal of the recommendation is related to findings from 2 recent randomized trials, PRAMI and CvLPRIT, which suggest that revascularization of all coronary arteries with significant blockages instead of just the culprit vessel can reduce MACE over 1 to 2 years of follow-up.

“It’s a good move in that it recognizes that all these things we do in medicine have to constantly be reevaluated,” J.P. Reilly, MD, of Ochsner Medical Center (New Orleans, LA), told TCTMD in a telephone interview. “When new trials come out, we adjust our ideas about what we should do and what we can’t do. That signals that the system is working.”

Guidelines Also Likely to Change

Some questions remain following the release of the PRAMI and CvLPRIT results, including the timing of procedures, subgroups that might benefit the most from complete revascularization, the use of fractional flow reserve to guide treatment decisions, and the impact of patient complexity and hemodynamic stability.

Nevertheless, the combined data might be enough to lift the class III recommendation (indicating harm) against complete revascularization in primary PCI when the patient is hemodynamically stable, noted Sorin J. Brener, MD, of Weill Cornell Medical College (New York, NY), referring to the 2013 STEMI guidelines.

“I don’t think that we have a very good idea of what the right approach is, but it certainly is appropriate to eliminate some of this harsh language found in the guidelines,” he told TCTMD in a telephone interview, adding, “I didn’t think it deserved a class III recommendation to begin with.” 

Dr. Reilly, who is also the chair of the public relations committee for the Society for Cardiovascular Angiography and Interventions (SCAI), agreed that the combined trial results demonstrate that complete revascularization during primary PCI is safe and that they support lifting the class III prohibition on the practice.

Unlikely to Affect Daily Practice

But both Dr. Reilly and Dr. Brener said that the ACC’s withdrawal of the Choosing Wisely recommendation is not going to have an impact on day-to-day practice for interventional cardiologists.

“I don’t think the Choosing Wisely campaign particularly influences physician practices,” Dr. Reilly said, “but it is a very good tool for patients, for education, and raising [patient] awareness about treatments that they should ask questions about.”

Dr. Brener noted, however, that the ACC’s action might provide reassurance to some operators in that “it essentially removes the concern about the legal issue if you do more than 1 vessel at the time of the primary angioplasty.”

The ACC and Drs. Reilly and Brener all pointed to the ongoing COMPLETE trial as a possible source of answers to the questions that remain surrounding complete revascularization. The trial is aiming to enroll about 3,900 patients with STEMI.

 

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Source:
American College of Cardiology. American College of Cardiology Updates Heart Attack Recommendations [press release]. http://www.cardiosource.org/news-media/media-center/news-releases/2014/09/choosing-wisely-statement.aspx. Published September 22, 2014. Accessed September 26, 2014.

Related Stories:

• SCAI Contributes List of Top 5 Interventional Cardiology Procedures to Avoid
• PRAMI: Strong Showing for Complete Revascularization in Acute STEMI Patients
• CvLPRIT: Complete Revascularization Halves MACE Risk in STEMI Patients