NEW YORK (Reuters Health) – For stable patients with left main coronary artery disease, percutaneous coronary intervention (PCI) is a “reasonable” alternative to coronary artery bypass grafting (CABG) if patients are at low risk for PCI complications but at increased risk of surgical complications.
That’s one recommendation included in revised guidelines for PCI and for CABG. The two separate guidelines are being released jointly by the American College of Cardiology Foundation (ACCF), American Heart Association (AHA) and, in the case of the PCI guideline, by the Society for Cardiovascular Angiography and Interventions (SCAI). They will be published in the December 6 issue the Journal of the American College of Cardiology and have been issued online November 7.
The 88-page CABG document covers topics such as off-pump versus on-pump surgery, choice of graft conduits, approaches to different clinical subsets of patients, and perioperative monitoring.
Topics covered in the PCI guideline, which runs to 79 pages, include the involvement of a “heart team” in making revascularization decisions, cardiac catheterization lab requirements, statin treatment recommendations, and the latest advice on anticoagulant therapy.
Both guidelines include an extensive section on CABG versus PCI, co-written by the two guideline panels, which discusses both who should be revascularized and whether it should be performed using CABG or PCI.
“I think physicians will hone in on this section, because it addresses an everyday question, and because the debate over PCI versus CABG has seen the most action since the 2004 guideline was written,” said Dr. L. David Hillis, with the University of Texas Health Science Center at San Antonio and chair of the CABG guideline writing committee, in a journal statement.
The authors note that nine randomized clinical trials have compared CABG with balloon angioplasty, 14 have compared CABG with bare metal stent (BMS) implantation and three have compared CABG with drug-eluting stents (DES).
Based on this evidence, the guidelines note, for example, that for left main CAD revascularization the “gold standard” has been CABG but “more recently PCI has emerged as a possible alternative mode of revascularization in carefully selected patients.” Selection considerations include lesion location, the SYNTAX score and operative risk factors, and these have been factored into the recommendations.
Clinical factors that generally influence the choice of revascularization mode include diabetes, chronic kidney disease, and LV systolic dysfunction. Also, the guideline advises, “PCI with coronary stenting (BMS or DES) should not be performed if the patient is not likely to be able to tolerate and comply with DAPT (dual antiplatelet therapy) for the appropriate duration of treatment based on the type of stent implanted.
The authors discuss the use of hybrid coronary revascularization, defined as the combination of grafting the left internal mammary artery to the left anterior descending (LAD) artery plus PCI of one or more non-LAD coronary arteries. This approach is recommended as “ideal in patients in whom technical or anatomic limitations to CABG or PCI alone may be present and for whom minimizing the invasiveness (and therefore the risk of morbidity and mortality) of surgical intervention is preferred.”
However, the authors note that while preliminary data support this strategy in some patients with multivessel CAD, “its real effect will not be known until results of RCTs are available.”
The journal statement notes that the guidelines were developed under a new policy that requires more than 50% of the writing committee members — and the committee chair — to be free of relevant industry relationships.
Reference:
2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery
J Am Coll Cardiol 2011.
