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Updated PCI Guidelines: ‘Most Evidence-Based to Date’
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The American College of Cardiology Foundation, American Heart Association and Society for Cardiovascular Angiography and Interventions have released revised guidelines for the treatment of patients undergoing PCI.
Among the changes in the 2011 guidelines include an emphasis on careful consideration before determination to treat CAD, such as use of a “heart team” approach, and an extensive section comparing PCI with CABG and a recommendation for use of ticagrelor (Brilinta, AstraZeneca).
A Heart Team Approach
In the updated guidelines, the heart team approach is a Class I recommendation for patients with unprotected left main or complex CAD.
Using this approach, interventional cardiologists and cardiothoracic surgeons are encouraged to jointly review a patient’s condition/coronary anatomy, evaluate the pros and cons of each treatment option and then present this information to the patient, along with their recommendation.
“The addition of this recommendation reflects the fact that all of cardiology is trending toward a more collaborative approach to some of these most difficult problems,” James C. Blankenship, MD, vice chair of the PCI guideline writing committee, told Cardiology Today Intervention. “That naturally leads to involve not only cardiologists, but also cardiac surgeons.”
SYNTAX, Antiplatelet Therapy Modifications
The 2011 revision also advocates using a SYNTAX score to determine treatment of patients with multivessel disease. Using a SYNTAX score to classify extent of disease more objectively may help guide decisions regarding CABG or PCI, Blankenship said in a press release.
The antiplatelet section of the guidelines now contains simplified recommendations for aspirin use, including a Class IIa recommendation for using 81 mg of aspirin per day after PCI, rather than higher maintenance doses. In addition, the committee provided a Class I recommendation for giving 180 mg of ticagrelor as a loading dose and 90 mg twice daily for at least 12 months after PCI with either a drug-eluting stent or bare-metal stent.
Other Notable Updates
The guidelines were also revised to include recommendations on a number of other topics, including ethical aspects of PCI, statin therapy, use of vascular closure devices and PCI in hospitals without onsite surgical backup, as well as updated to include a Class I recommendation for monitoring and recording procedural radiation data.
Another change involves the separation of guidelines for survival and those for symptom relief, as well as recommendations for each subset of anatomy. Blankenship said it has been historically difficult to obtain data for each subgroup; therefore, they conducted an extensive effort to find information so that each group could be included.
“In the past, there were recommendations for some subsets of anatomy, but not all,” Blankenship said. “So for cardiologists who wanted to see what the recommendation was for their particular patient, they might be disappointed and find that, in fact, there was nothing there to describe their patient.
“The task force has made a concerted effort to make the guidelines leaner and meaner so there is less text,” Blankenship said. “If you add up the number of A, B and C recommendations, you’ll find there are more B recommendations, which are evidence-based, and fewer C recommendations, which are expert consensus, compared with the 2005 guidelines. These are the most evidence-based PCI guidelines that have been produced yet.” – by Casey Murphy
Disclosure:Dr. Blankenship reports no relevant financial disclosures.