Revised guidelines for both percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgery, produced by an expert joint task force from several prominent medical societies, feature a consensus approach to revascularization choices for situations where the interventional and surgical fields overlap.

The task force comprised representatives of the American College of Cardiology Foundation (ACCF), the American Heart Association (AHA), and the Society for Cardiovascular Angiography and Interventions (SCAI). The guidelines were released online November 7, 2011, ahead of print, in the Journal of the American College of Cardiology and are simultaneously co-published online in Circulation and Catheterization and Cardiovascular Interventions. 

The new guidelines were produced in an accelerated fashion to keep the information as timely as possible, said PCI writing committee vice chair James C. Blankenship, MD, of the Geisinger Medical Center (Danville, PA). In addition, to make the recommendations more accessible for busy practitioners, the text has been pared down from previous versions, with much supporting data relegated to appendices and recommendations organized into convenient charts color-coded by class, he told TCTMD in a telephone interview. 

Interventionalists, Surgeons on the Same Page

For the extensive section on CAD revascularization, a common goal of ACCF and AHA was to be sure that the PCI and CABG guidelines were in sync. To that end, subgroups from both committees worked with “an unprecedented degree of collaboration” to hammer out harmonious guidelines, outlining who should be revascularized and whether such procedures should be performed via PCI or CABG, said PCI writing committee chair Glenn N. Levine, MD, of Baylor College of Medicine (Houston, TX), in a press release.

“I think physicians will hone in on this section, because it addresses an everyday question, and because the debate over PCI vs. CABG has seen the most action since the 2004 guideline was written,” said CABG writing committee chair L. David Hillis, MD, of the University of Texas Health Science Center at San Antonio (San Antonio, TX), in the press statement. As PCI technology has matured and operators have gained experience, PCI has been used for more cases than in the past, he added. 

That includes patients with left main or multivessel disease, for whom the guidelines endorse the new ‘heart team’ approach, giving it a class I recommendation. Interventional cardiologists and cardiothoracic surgeons are encouraged to jointly review these patients’ conditions and coronary anatomies, evaluate the pros and cons of each treatment option, and then present that information to patients along with their recommendations.

For these patients, the guidelines also recommend use of the Syntax score. While its calculation of angiographic metrics can be complex, the Syntax score provides more objective guidance for decisions regarding choice of treatment when it is used to classify the extent of disease, said Dr. Blankenship in a press statement.

Also important is that for the first time the guidelines provide specific revascularization recommendations for every anatomic subgroup of patients with stable CAD, Dr. Blankenship observed. In the past, there have been gaps in this area, he noted, but now clinicians “can go down the list and see which subgroup their patient falls into” along with the recommended treatment.

Antiplatelet Therapy Brought Up to Date

In the evolving field of antiplatelet therapy, the new PCI guidelines address use of the recently approved P2Y12 inhibitor ticagrelor, giving it a Class I recommendation for a 180-mg loading dose and 90 mg twice daily for at least 12 months following PCI with either DES or BMS. Another useful revision involves simplification of recommendations for post-PCI aspirin. Replacing what Dr. Blankenship called a “hodgepodge” of dose recommendations depending on the type of stent and time period after PCI, now an across-the-board 81-mg daily dose carries a Class IIA recommendation.

Also for the first time, the guidelines address functional platelet and genetic testing for clopidogrel response. Both are accorded limited roles in high-risk patients, receiving Class IIb recommendations with level C evidence.

The PCI guidelines address a miscellany of other topics, including statin therapy, use of vascular closure devices, PCI in hospitals without on-site surgical backup, and recommendations for monitoring and recording procedural radiation exposure. Ethical issues such as appropriate informed consent, self-referral, and potential conflicts of interest are also discussed.

CABG Issues Addressed

The updated CABG guidelines, meanwhile, take up issues such as the appropriate choice of bypass graft conduit, off- vs. on-pump CABG, use of CABG in certain patient subsets such as diabetics, and preoperative and postoperative antiplatelet regimens.

With regard to antiplatelet therapy, Peter K. Smith, MD, of Duke University Medical Center (Durham, NC), noted in the press release that since the last guidelines, several new, more potent drugs have become available, complicating therapeutic choices. The current guidelines specify that aspirin should be given to CABG patients preoperatively, and that in those undergoing elective CABG, clopidogrel and ticagrelor should be discontinued for at least 5 days before elective surgery, or at least 24 hours, if possible, for patients needing urgent surgery. Postoperatively, aspirin should be given within 6 hours of surgery if it was not initiated preoperatively, and then continued indefinitely.

Dr. Blankenship noted that both updated guidelines were written under a new strict ACCF and AHA policy that requires more than half of the writing committee members and the committee chair to be free of relevant industry relationships. 

 

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Sources:
1. Levine GN, Bates ER, Blankenship JC, et al. 2011 ACCF/AHA/SCAI guidelines for percutaneous coronary intervention: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol. 2011;Epub ahead of print.

2. Hillis LD, Smith PK, Anderson JL, et al. 2011 ACCF/AHA guidelines for coronary artery bypass graft surgery: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2011;Epub ahead of print.

 

 

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