ESC/EACTS Guidelines on Myocardial Revascularisation

Preamble

Introduction

Scores and risk stratification

Process for decision-making and patient information

• Patient information and informed consent
• Multidisciplinary decision-making (heart team)
• Timing of revascularization and ad hoc percutaneous coronary intervention

Strategies for diagnosis: functional testing and imaging

• Non-invasive tests
• Invasive tests
• Detection of myocardial viability

Revascularization for stable coronary artery disease

• Rationale for revascularization
• Evidence basis for revascularization
  • Revascularization with the use of PCI
  • PCI with drug-eluting stents vs. bare-metal stents
  • Revascularization with the use of coronary artery bypass grafting

• Percutaneous coronary intervention vs. coronary artery bypass grafting
  • Proximal left anterior descending coronary artery disease
  • Left main coronary artery disease
  • Three-vessel coronary artery disease

Revascularization in non-ST-segment elevation acute coronary syndromes

• Early invasive vs. conservative strategy
• Timing of angiography and intervention
• Type of revascularization
  • Coronary artery bypass surgery
  • Percutaneous coronary intervention

Revascularization in ST-segment elevation myocardial Infarction

• Time delays
• Selection of reperfusion strategy
• Primary percutaneous coronary intervention
• Fibrinolysis
• Secondary percutaneous coronary intervention
• Coronary artery bypass surgery

Revascularization in patients with heart failure and cardiogenic shock

• Chronic heart failure
  • Revascularization
  • Myocardial viability and revascularization
  • Ventricular reconstruction

• Cardiogenic shock
  • Revascularization
  • Mechanical circulatory support
  • Right ventricular failure
  • Mechanical complications

Revascularization in patients with diabetes

• Evidence for myocardial revascularization
  • Stable coronary artery disease
  • Acute coronary syndromes

• Type of myocardial revascularization
  • Randomized clinical trials
  • Meta-analyses

• Revascularization with the use of percutaneous coronary intervention
• Revascularization with the use of coronary artery bypass grafting
• Antithrombotic pharmacotherapy
• Anti-diabetic medications

Revascularization in patients with chronic kidney disease

• Evidence-base for revascularization
  • Patients with moderate chronic kidney disease
  • Patients with severe chronic kidney disease and end-stage renal disease or in haemodialysis

• Prevention of contrast-induced nephropathy

Revascularization in patients requiring valve interventions

• Primary indication for valve interventions
• Primary indication for coronary revascularization

Associated carotid/peripheral artery disease

• Associated coronary and carotid artery disease
  • Risk factors for stroke associated with myocardial revascularization
  • Preventive measures to reduce the risk of stroke after CABG
  • Carotid revascularization in patients scheduled for myocardial revascularization
  • Type of revascularization in patients with associated carotid and coronary artery disease

• Associated coronary and peripheral arterial disease

Repeat revascularization and hybrid procedures

• Early graft failure
• Disease progression and late graft failure
• Repeat percutaneous coronary intervention
• Hybrid procedures

Arrhythmias

• Ventricular arrhythmias
  • Revascularization for prevention of sudden cardiac death in patients with stable coronary artery disease and reduced left ventricular function
  • Revascularization for treatment of electrical storm
  • Revascularization after out-of-hospital cardiac arrest

• Atrial arrhythmias
  • Atrial fibrillation complicating percutaneous coronary intervention
  • Atrial fibrillation complicating coronary artery bypass grafting
  • Post-operative atrial fibrillation and stroke risk

• Concomitant surgical procedures for atrial fibrillation or stroke treatment

Procedural aspects of coronary artery bypass grafting

• Pre-operative management
• Blood management
  • Blood salvage interventions
  • Pharmacological strategies
  • Blood transfusion

• Surgical procedures
  • Conduit harvest
  • Coronary vessel
  • Completeness of revascularization
  • Construction of central anastomosis
  • Bypass grafts
  • On-pump and off-pump procedures
  • Minimally invasive procedures

• Reporting perioperative outcome

Procedural aspects of percutaneous coronary intervention

• Percutaneous coronary intervention devices
  • Balloon angioplasty
  • Coronary stents
  • Bioresorbable scaffoldsstents
  • Drug-coated balloons
  • Other devices

• Adjunctive invasive diagnostic tools
  • Intravascular ultrasound
  • Optical coherence tomography
  • Pressure-derived fractional flow reserve

• Specific lesion subsets
  • Bifurcation stenosis
  • Chronic total coronary occlusion
  • Ostial lesions

Antithrombotic treatments

•  Percutaneous coronary intervention in stable coronary artery disease
  • Oral antiplatelet therapy
  • Intravenous antiplatelet therapy
  • Anticoagulation       

• Non-ST-segment elevation acute coronary syndrome
  • Oral antiplatelet therapy      
  • Intravenous antiplatelet therapy
  • Anticoagulation      

• ST-segment elevation myocardial infarction
  • Oral antiplatelet therapy        
  • Intravenous antiplatelet therapy
  • Anticoagulation

• Points of interest and special conditions
  • Pre-treatment with P2Y12 inhibitors
  • Intravenous P2Y12 inhibitors
  • Anticoagulation after PCI in acute coronary syndrome patients
  • Anticoagulation during PCI in patients on oral anticoagulation
  • Antithrombotic therapy after PCI in patients requiring oral anticoagulation
  • Duration of dual antiplatelet therapy after percutaneous coronary intervention
  • Drug interactions: a clopidogrel-related topic
  • Renal dysfunction
  • Surgery in patients on dual antiplatelet therapy
  • Antiplatelet therapy monitoring and genetic testing
  • Patients with hypersensitivity to acetylsalicylic acid
  • Heparin-induced thrombocytopaenia

Volume–outcome relationship for revascularization procedures

• Coronary artery bypass grafting
• Percutaneous coronary intervention

Medical therapy, secondary prevention, and strategies for follow-up

Appendix

References