New ESC guideline recommends radial approach for PCI in patients with ACS

LONDON — A new European Society of Cardiology guideline on management of ACS without persistent ST-segment elevation recommends that PCI performed on patients with ACS be done via a transradial approach.

In addition, the guideline proffers a general recommendation of 1 year of dual antiplatelet therapy (DAPT) after PCI, but states that DAPT for 3 to 6 months is appropriate for patients at high bleeding risk and DAPT for up to 30 months is appropriate for patients at high ischemic risk.

The guideline was published in the European Heart Journal and presented at the ESC Congress here.

Radial PCI

The guideline gives a class I, level of evidence A recommendation for the transradial approach over the transfemoral approach when coronary angiography or PCI is performed in patients with ACS.

Marco Roffi

“New data show that the radial approach is superior to the femoral [approach] not only in terms of vascular complications and major bleeding events but also in reducing all-cause mortality,” Marco Roffi, MD, FACC, FESC, chairperson of the guideline task force and from the University of Switzerland in Geneva, said in a press release. “It is recommended that centers treating ACS patients implement a transition from transfemoral to transradial access. However, proficiency in the femoral approach should be maintained, as this access is indispensable in a variety of procedures, including intra-aortic balloon counterpulsation implantation, structural heart disease interventions and peripheral revascularization procedures.”

According to the task force, this recommendation was influenced by results of the RIVAL and MATRIX studies, in which transradial access was associated with favorable outcomes. In particular, “An updated meta-analysis including MATRIX found a significant reduction in major bleeds, death, MI or stroke and in all-cause mortality associated with radial as compared with femoral access,” the task force wrote.

DAPT duration

In the document, the task force cites results of the CURE and CREDO studies as evidence for 1 year of DAPT as opposed to aspirin alone following PCI, and results of the TRITON-TIMI 38 and PLATO studies as evidence for a prasugrel-based (Effient, Daiichi Sankyo/Eli Lilly) DAPT regimen (in TRITON-TIMI 38) or a ticagrelor-based (Brilinta, AstraZeneca) regimen (in PLATO) over a clopidogrel-based strategy. The task force recommends clopidogrel for patients who cannot tolerate prasugrel and ticagrelor or who are on anticoagulation therapy.

DAPT with P2Y12 inhibition for 3 to 6 months after drug-eluting stent implantation may be considered for those determined to be at high bleeding risk, and DAPT with P2Y12 inhibition may be considered for longer than 1 year “after careful assessment of the ischemic and bleeding risks of the patient,” according to the guideline. Both recommendations received a designation of class IIb, level of evidence A.

“The duration of DAPT is a hot topic,” Roffi said in the release. “With improved drug-eluting stent technology, stent thrombosis rates have dropped dramatically and recent data suggest that shorter duration of DAPT in patients at high bleeding risk is safe and effective. In addition, new data [show] that DAPT beyond 1 year is effective in reducing ischemic events in selected patients at high ischemic and low bleeding risk.”

Other recommendations

Based on the results of the ACCOAST study, the new guidelines recommend against pretreatment with prasugrel in patients with non-STEMI. ACCOAST found no benefit but increased bleeding risk for patients were pretreated compared with those who did not receive pretreatment. According to the task force, there is not enough evidence to recommend for or against pretreatment with clopidogrel or ticagrelor.

The guideline also features a new algorithm for patients suspected of having non-STEMI. If high-sensitivity troponin assays are available, blood tests can be performed at presentation and at 1 hour. If assays are not available, blood tests can be performed at presentation and at 3 hours in accordance with previous guidelines, the task force wrote.

The guidelines are accompanied by companion manuscripts on diagnosis and risk assessment, antithrombotic therapy and coronary revascularization in patients with NSTEACS. – by Erik Swain

References:

Roffi M, et al. ESC Guidelines – Acute Coronary Syndromes Non-ST-Elevation. Presented at: ESC 2015; Aug. 29-Sept. 2, 2015; London.

Roffi M, et al. Eur Heart J. 2015;doi:10.1093/eurheartj/ehv320.

Disclosures: Roffi reports no relevant financial disclosures. See the full guideline for a list of the relevant financial disclosures of the other writers and reviewers.