Revised PCI guidelines emphasize team approach to determining treatment

Guidelines on percutaneous coronary intervention (PCI) have been expanded to offer comprehensive and specific recommendations for every anatomic subgroup of patients with stable coronary artery disease.

The revised guidelines were released by the American College of Cardiology Foundation, American Heart Association, and Society for Cardiovascular Angiography and Interventions on Nov. 7. The recommendations on revascularizing patients are based on improving both survival and symptoms. For example:

• Use of drug-eluting stents to decrease the incidence of blood vessel renarrowing was given a Class I recommendation. This was balanced by a recommendation that before performing PCI, physicians must first evaluate patients to determine if they can tolerate and comply with dual antiplatelet therapy.
• Aspirin recommendations are simplified by including a Class IIA recommendation (“it is reasonable”) for using 81 mg of aspirin per day after PCI instead of higher maintenance doses.
• Ticagrelor, a new P2Y₁₂ inhibitor that was approved by the FDA after the release of the previous guidelines, received a Class I recommendation for a 180-mg loading dose and 90 mg twice daily for at least 12 months following PCI with a drug-eluting or bare-metal stent.

The 2011 guidelines expand and add recommendations on numerous other topics, including:

• ethical aspects of PCI, including informed consent, self-referral, and potential conflicts of interest;
• recommendations on statin therapy;
• the use of vascular closure devices;
• PCI in hospitals without on-site surgical backup; and
• a Class I recommendation for monitoring and recording procedural radiation data.

The guidelines resulted from collaborations between committees specific to coronary artery bypass grafting, ST-elevated myocardial infarction (STEMI), stable ischemic heart disease, and unstable angina/non-STEMI guidelines. In addition to undergoing a more collaborative writing process, the committee members also added new concepts to the guidelines. A “heart team” approach was included as a Class I recommendation for patients with unprotected left main or complex CAD. Interventional cardiologists and cardiothoracic surgeons are encouraged to jointly review the patient, evaluate the pros and cons of each treatment option, and then present this information to the patient, along with their recommendation.

The guidelines also advocate using a SYNTAX score in decisions regarding treatment of patients with multivessel disease. This scoring system estimates the extent and complexity of CAD when the patient's angiography results are entered into a computer-based score calculator. While this calculation is complex, using the score to classify extent of disease more objectively may help guide decisions regarding whether to perform CABG or PCI.

The guidelines were published by the participating societies' respective journals: Journal of the American College of Cardiology, Circulation: Journal of the American Heart Association and Catheterization and Cardiovascular Interventions.