The most recent edition of the ESC and EACTS joint guidelines on myocardial revascularization celebrates the 50th anniversary of the first coronary artery bypass graft procedure. The first percutaneous coronary revascularization procedure was performed only 13 years thereafter. Since their introduction, revascularization techniques have gained expertise and clinical relevance worldwide, becoming one of the most commonly performed interventions in modern medicine. The 2014 edition of the ESC/EACTS revascularization guidelines provides a concise and updated summary of the evidence surrounding the value of revascularization in various clinical scenarios, including elective, urgent, and emergency settings.
The 2010 edition of the ESC guidelines introduced and strongly empowered the concept of the Heart Team. This has been a great achievement whereby all relevant cardiac specialties and heart care providers are brought together to choose the best revascularization modality for each single patient. Current guidelines further extend the importance of the Heart Team discussion, by inciting the development of shared institutional protocols, in order to better select the patients who deserve a multidisciplinary evaluation, saving time and resources, and avoiding delays for urgent procedures especially in centers without on-site surgery. Although nobody disagrees on the value of a Heart Team approach, its implementation in everyday clinical practice is not as widespread as it should be.
The use of risk scores is highly recommended. STS score, EuroSCORE II, and Syntax II factor should be considered when assessing patients undergoing revascularization. The EuroSCORE II, which is a derivative of more current datasets and may have a better ability to predict early mortality after CABG, has replaced the EuroSCORE in the 2014 guidelines as the latter was shown to overestimate the risk of mortality. Additionally, use of models like the logistic clinical SYNTAX score and the SYNTAX score II, which have been developed by amalgamating the anatomical SYNTAX score with clinical variables, has been recommended by the new guidelines to assess medium- to long-term outcomes after PCI and to provide a personalized approach to decision-making between CABG and PCI, respectively.Clinical judgment and heart team decision should always be incorporated in the final decision of complex cases.
A new feature, in the current guidelines, is the recommendation of a time-line of 2 weeks for revascularization of highly symptomatic patients (CCS class 3) with stable, but anatomically high-risk multivessel CAD [MVCAD: left main (LMD) or equivalent, three-vessel (3VD) or proximal LAD disease] and 6 weeks for all other patients once the decision of revascularization has been made. This could potentially avoid the occurrence of untoward events in patients awaiting revascularization.
In patients with involvement of the proximal LAD, PCI indication was upgraded and is now equally recommended as CABG for the treatment of proximal LAD alone as well as in the context of a two-vessel disease. Regarding revascularization of lesions of the left main coronary artery, various randomized studies, predefined subanalyses, and meta-analyses suggest that the 2 revascularization types exhibit similar rates of total mortality, cardiovascular mortality, and myocardial infarction. Moreover, although CABG increased stroke risk, PCI was associated with a greater need for revascularization during follow-up. Longer-term results indicate that the evidence in favor of surgery is more robust.At variance with the previous guidelines, PCI is now equally recommended as CABG for the treatment of three-vessel disease with a low anatomical complexity (SYNTAX score≤22), whereas in more complex anatomies (SYNTAX score >22), PCI is still contraindicated .These recommendations are largely based on the results of the 5-year follow-up of the SYNTAX trial. CABG showed better outcomes in the overall three-vessel disease population, whereas PCI demonstrated to be a reasonable alternative in those with a low SYNTAX score ≤22, although at the price of an increased risk of repeat revascularization. The risk of stroke in this population has been shown to be lower after PCI as compared to CABG.
Regarding the preoperative management of CABG, no withdrawal of previous medication is recommended, except for ACE inhibitors 1-2 days before the procedure. Blood transfusions and preoperative anemia have been associated with greater perioperative morbidity and mortality.Also recommended is endoscopic vein harvesting (IIa), as well as the use of the bilateral internal mammary artery, ideally obtained via skeletonized dissection. Bilateral internal mammary artery grafting should be used in all patients < 70 years or whose life expectancy exceeds 5 years. The benefit-risk ratio should be evaluated in obese and diabetic patients due to the higher risk of sternal infection entailed by bilateral internal mammary artery grafts. The radial artery remains as an intermediate graft between the mammary artery and venous grafts. Off-pump surgery does not seem to improve short- or long term outcomes for most patients and is associated with inferior early and late graft patency rates.
The guidelines indicate that there is no clinical or anatomical context supporting the use of BMSs over DESs. Drug-eluting balloons have shown their usefulness in patients with in-stent restenosis within BMSs or DESs. Both the use of a DES and that of a drug-eluting balloon receive a I-A recommendation in these guidelines for patients with in-stent restenosis within BMSs or DESs. The guidelines indicate that intravascular ultrasound is the best technique for assessing the progression/regression of coronary atherosclerosis and for stent optimization during its implantation (IIa-B). Fractional flow reserve during diagnostic angiography often changes management decisions; nearly 50% of coronary artery stenosis in the intermediate range is functionally misclassified.
Optimal medical treatment should accompany revascularization with focus on risk factor reduction. In some cases, medical treatment can have the same prognosis as PCI and therefore should be the first line of treatment in all non high risk CAD cases.
New guidelines no longer indicate to pretreat with clopidogrel all patients scheduled for a diagnostic coronary angiogram. Differently, it remains reasonable to pretreat patients with known coronary anatomy scheduled for PCI. Pretreatment may still be considered in cases where the probability of CAD is high and the anticipated need for urgent CABG unlikely.
The novel P2Y12 inhibitors, prasugrel or ticagrelor, are recommended as first-line treatment during acute coronary syndrome (ACS), whereas clopidogrel should be used only when prasugrel and ticagrelor are not available.
In patients with non–ST-segment elevation acute coronary syndrome revascularized by PCI, the level of recommendation is similar for prasugrel and ticagrelor (I-B), although prasugrel is recommended in patients with known coronary anatomy and established PCI indication. Prasugrel use is discouraged (III-A) before coronary angiography in patients admitted with non–ST-segment elevation acute coronary syndrome.
In patients with ST-segment elevation acute myocardial infarction treated with PPCI, the guidelines clearly recommend prasugrel or ticagrelor administration in the first physician contact (I-B).A novel aspect is the reduction of dual antiplatelet therapy to 6 months after DES implantation (I-B). In addition, the guidelines reiterate the need to instruct patients on the importance of adhering to dual antiplatelet therapy after the PCI. In relation to anticoagulation, there has been a notable downgrading in the recommendation level for bivalirudin in PPCI, dropping from I-A to IIa-A, due to the results of the EUROMAX23 and HEAT-PPCI24 studies, which confirm a significant increase in the rates of early stent thrombosis compared with heparin. A new development is the incorporation of bolus intravenous enoxaparin as an anticoagulant for PPCI.
The anticoagulation section has also been revised with some novelties regarding the use of novel oral anticoagulants (NOAC). With respect to NOACS, these guidelines also mention the possibility of adding a third agent, namely, rivaroxaban, on top of the standard DAPT with aspirin and clopidogrel for ACS patients treated with PCI in patients at low bleeding risk.
In patients with SCAD with absolute indication to anticoagulation and low bleeding risk (HAS BLED ≤2), the duration of the triple therapy—consisting of aspirin, clopidogrel, and a (N)OAC—should be of at least 1 month and ideally continued up to 12 months, whereas in patients presenting ACS, triple therapy should be considered for 6 to 12 months, irrespective of the stent used. Importantly, for patients at high bleeding risk (HAS BLED>2), the duration of triple therapy should be of 1 month irrespective the presentation (i.e., SCAD or ACS) and the type of stent used.
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