November 7th, 2011
ACC and AHA Release New PCI and CABG Guidelines
The new guidelines include for the first time a strong recommendation that hospitals adopt a “heart team” approach in choosing a treatment strategy for patients with coronary artery disease. For patients with unprotected left main or complex CAD, the team approach is a Class I recommendation.
“The 2011 guideline includes an unprecedented degree of collaboration in generating revascularization recommendations for patients with CAD,” said Glenn Levine, chair of the PCI guideline writing committee, in a press release from the ACC and AHA. The PCI and CABG committees coordinated their efforts and joined forces to write the section comparing the two revascularization procedures.
The PCI guidelines recommend using the SYNTAX score in patients with multivessel disease, and include specific recommendations for every anatomic subgroup of patients with stable CAD.
Drug-eluting stents (DES) gain a Class 1 recommendation to decrease the incidence of restenosis. However, this recommendation is “counterbalanced,” according to Levine, by the recommendation that before DES implantation, patients should be evaluated to assess whether they are suitable for dual antiplatelet therapy.
Low-dose aspirin gains a Class IIA recommendation while clopidogrel, prasugrel, and ticagrelor all receive Class I recommendations following PCI.
L. David Hillis, chair of the CABG guideline writing committee, said that physicians will pay close attention to the section on “whom to revascularize and how to do it,” in particular “because the debate over PCI versus CABG has seen the most action since the 2004 guideline was written.”
Because PCI has improved so much since the previous guidelines were issued in 2004, the new guidelines support the use of PCI as “a reasonable alternative to CABG in stable patients with left main CAD who have a low risk of PCI complications and an increased risk of adverse surgical outcomes.” CABG, however, still retains the advantage over PCI for most patients with three-vessel disease.