Collaboration of the two guideline writing teams reflects a push for closer interdisciplinary cooperation in decision making about coronary revascularization.
Sponsoring Organizations: American College of Cardiology (ACC), American Heart Association (AHA), American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons
Background and Purpose: These new coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) guidelines update versions from 2004 and 2007, respectively. Unique to the revisions is a joint set of recommendations produced collaboratively to address the question of which patients should undergo which procedure. Additional input was also provided by the authors of the ACC/AHA guidelines on management of stable ischemic heart disease; revision expected in 2012) and unstable angina/non-ST-segment-elevation myocardial infarction.
1. Because data from trial registries show lower mortality rates in patients referred for a specific procedure compared with patients in concurrent randomized cohorts, these guidelines contain a new Class I recommendation for a multidisciplinary heart team (MHT) to coordinate care of patients with left main or complex coronary artery disease (CAD). The MHT includes an interventional cardiologist and a cardiac surgeon who jointly develop a revascularization plan to present to the patient for a final decision. A new recommendation for the use of transesophageal echocardiography during CABG (Class IIa) supports the inclusion of a cardiac anesthesiologist on the MHT.
2. The authors encourage the use of the SYNTAX and STS scoring systems in formulating revascularization decisions (Class IIa). This recommendation reflects a trend away from simple angiographic criteria toward a more integrated approach that incorporates functional assessment of lesion severity with measures such as fractional flow reserve.
3. PCI is now recognized as a reasonable alternative to CABG for unprotected left main lesions (Class designation raised to IIa from IIb) when anatomy is favorable for PCI and surgical risk is high. CABG retains a Class I indication for unprotected left main lesions and is also preferred (Class IIa) for most patients with three-vessel disease.
4. In separating survival indications from symptom relief, the authors now recommend PCI for angina that persists despite “guideline-determined medical therapy” (Class I), on the basis of findings from the COURAGE trial (in which the term “optimal medical therapy” was used.
5. Many recommendations pertain to appropriate medical therapy before and after PCI and CABG:
- High-dose statin therapy is recommended before PCI (Class IIa).
- The recommended aspirin dose after PCI has been reduced to 81 mg per day (Class IIa).
- Ticagrelor now carries a Class I recommendation as an alternative to clopidogrel or prasugrel for 12 months after stenting.
- Aspirin and beta-blockers are recommended before CABG (Class I).
- Clopidogrel and ticagrelor should be discontinued 5 days before elective CABG and 24 hours before emergency CABG (Class I).
- After CABG, patients should receive beta-blockers, statins, and intravenous insulin to maintain a blood glucose of <180 mg/dL (Class I).
6. N-acetylcysteine is no longer recommended for PCI in patients at risk for acute kidney injury (Class III).
7. Hybrid revascularization, off-pump CABG, and use of robotic techniques are discussed. Hybrid revascularization is deemed reasonable in patients with aortic, target-vessel, or conduit constraints to traditional CABG (Class IIa).
Comment: These updated guidelines provide a wealth of new information and recommendations. Most interesting, and perhaps most controversial, is the formal endorsement of a multidisciplinary heart team approach to revascularization decisions for complex coronary artery disease. This model is similar to one recently recommended for consideration of transcatheter aortic valve replacement in patients with extremely high-risk aortic stenosis, but it will be new to many involved in the treatment of CAD. I hope that the MHT approach will begin to build a new relationship between interventional cardiologists and cardiac surgeons, discouraging competition and promoting collaboration to improve patient outcomes.
Source: Journal Watch Cardiology.