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ACC changes recommendations on complete revascularization
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In light of new data, the American College of Cardiology has withdrawn its recommendation in the Choosing Wisely campaign that patients and caregivers should examine whether complete coronary revascularization during an MI is truly necessary.
The change comes as a response to data from the CvLPRIT and PRAMI trials, presented at the European Society of Cardiology Congress in 2014 and 2013, respectively, which indicated that complete revascularization, including major stenoses in nonculprit arteries, improves outcomes.
In April 2012, as part of its American Board of Internal Medicine’s (ABIM) Choosing Wisely list of five things providers and patients should question, the ACC recommended questioning any coronary intervention beyond the culprit lesion in a hemodynamically stable patient, because data at that time from several nonrandomized trials suggested potential harm with the strategy.
Patrick T. O’Gara
“Science is not static, but rather constantly evolving,” ACC President Patrick T. O’Gara, MD, FACC, of Brigham and Women’s Hospital, Boston, said in a press release. “As such, one of the ACC’s primary roles is to stay abreast of this evolution and provide cardiovascular professionals and patients with the most up-to-date information on which to base decisions about the most appropriate and necessary treatment. The newest findings regarding coronary revascularization are great examples of science on the move, and we are responding accordingly.”
The release also stated that the ACC “is working with its partners to address current clinical guideline and appropriate use criteria recommendations in light of the new research. The College will also be working with the ABIM Foundation to update its current list of recommendations, as well as develop an additional list, in the future.”
The currently enrolling COMPLETE trial is anticipated to help answer some of the remaining questions with complete revascularization, including the exact timing of the procedures; whether certain patients benefit more than others; whether fractional flow reserve might guide decisions; and the role of patient complexity and hemodynamic stability, according to the release.
Perspective
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J.P. Reilly, MD, FSCAI
This change in the Choosing Wisely campaign is a very good step for the ACC. As Dr. O’Gara pointed out, this is a sign of how science and medicine continue to evolve over time as we collect new data and examine and reexamine issues. As a result, we become better informed and have to change our practice. The ACC changed its position based on the accumulation of data from the CvLPRIT trial that just came out and the PRAMI trial from 2013, so this change is not on the basis of one trial.
This change opens up some opportunities for certain patient populations. There had been a strong recommendation to avoid stenting more than one lesion at a time during an acute MI. This suggests that there may be a change or lifting of that prohibition in future guidelines. Neither of these two trials closely examined the exact timing of stenting the nonculprit vessel, but, nevertheless, I think there will be some patients with severe stenosis in addition to the heart attack vessel who may benefit from complete revascularization.
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