New ESC guidelines on revascularisation PCI now an option for multivessel and left main stem disease29 September 2010
By: Paul Williams
The recently released ESC guidelines covering myocardial revascularisation procedures for both stable coronary artery disease (CAD) and following acute coronary syndromes will be of interest to all cardiologists managing patients with coronary artery disease. These guidelines supplant the ESC guidelines on PCI published in 2005 and offer a more comprehensive and, perhaps less biased, overview of the field as they were co-written by the European Association for Cardiothoracic Surgery as well as the European Association for Percutaneous Cardiovascular Interventions.
The guidelines take the format of a long and comprehensive document running to 55 pages. So what are the big take-home messages and how do these recommendations differ from mainstream UK practice?
The impact of SYNTAX and the Heart Team
The influence of the SYNTAX trial (which compared the first generation Taxus DES and CABG in multivessel disease) is felt throughout the guidelines. The SYNTAX score, an angiographic scale of severity of CAD, can be used to divide patients into three tertiles (low: <23; intermediate: 23-32; high: >32), and is used extensively to guide management decisions.
The importance of the Heart Team, consisting of an interventional cardiologist, general cardiologist and a cardiothoracic surgeon, to make management decisions has proved controversial but is strongly endorsed in this document.
Multivessel disease CABG best for complex disease
For complex disease (SYNTAX score >32) CABG is considered to be clearly better than PCI and should be the first choice option. For intermediate disease (SYNTAX score 23-32), CABG is also preferred: the 3 year SYNTAX data, which has just been presented at the European Association of Cardiothoracic Surgery 2010 Annual Meeting following the publication of these guidelines, supports this recommendation. However for less severe multivessel disease (SYNTAX score <23) for which full revascularisation with PCI can be achieved, PCI can now be considered (with a IIa recommendation).
Left main stem disease good news for PCI
Left main stem (LMS) disease has traditionally been thought of as a surgical condition and the last ESC guidelines in 2005 recommended LMS PCI only for non-surgical candidates and, even then, only gave a IIb recommendation. As discussed in my recent BCS editorial (http://www.bcs.com/pages/news_full.asp?NewsID=19791900), accumulating evidence suggests that LMS PCI may be a viable alternative, and possibly even superior, to CABG in certain patients. As a result of this data the ESC guidelines give ostial/body LMS disease a IIa recommendation and bifurcation LMS disease (with a SYNTAX score of <33) a IIb recommendation, even in surgical candidates.
The recommendations above for both multivessel and LMS disease mean that an increasing number of patients can be considered eligible for either PCI or CABG. These patients should therefore be discussed at a multidisciplinary Heart Team meeting to decide on their optimal revascularisation strategy.
Antiplatelet agents for acute coronary syndromes
This is an extremely rapidly developing field with a real risk that guidelines become obsolete prior to their widespread uptake. Perhaps with this in mind, the authors have given the new antiplatelet agents prasugrel and ticagrelor class IIa and class I recommendations respectively. This is despite the fact that prasugrel has only recently become available and ticagrelor has yet to receive FDA or EU approval! Nonetheless the trials on which these recommendations have been made are large and convincing (TRITON TIMI-38 and PLATO) and these agents appear to offer significant improvements over current antiplatelet regimes using aspirin and clopidogrel.
Technical aspects of PCI
As expected, the data from the FAME study has ensured that fractional flow reserve (FFR)-guided PCI by pressure wire assessment carries the highest level of recommendation (class 1, level A). Manual thrombectomy for primary PCI and drug-eluting balloons for instent restenosis are also newly endorsed (both class IIa).
PCI following successful thrombolysis
Primary PCI is unequivocally advocated as the optimal reperfusion strategy for STEMI. However, if thrombolysis is given, angiography with a view to intervention within 24hrs (drip and ship) has now been elevated to a top level recommnendation (class I, level A) primarily on the basis of the TRANSFER-AMI trial.
The new ESC guidelines represent an important collaboration between surgeons and interventionists, and thus the recommendations can be considered to be more balanced than previous guidelines generated by cardiologists alone. The fact that PCI is now considered a viable option for certain patients with multivessel and LMS disease is based directly on the current evidence base, and this is an important difference with the latest ACC/AHA guidelines which do not endorse PCI for these conditions in surgical candidates.
A brief overview such as this cannot cover all of the detail contained within the full document, which also cover the workup of patients, co-existing conditions such as renal failure, carotid disease and renal stenosis, and secondary prevention. For those interested in reading further, both the full text and the abridged pocket guidelines are available at: http://www.escardio.org/guidelines-surveys/esc-guidelines/Pages/percutaneous-coronary-interventions.aspx.
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