PCI Gains Ground for Left Main and Multivessel Disease in New ESC Revascularization Guidelines

Shelley Wood

August 29, 2010

August 29, 2010 (Stockholm, Sweden) — In a first for the European Society of Cardiology (ESC), a new task force report on myocardial revascularization released on the first day of the society's annual meeting was jointly written with the European Association for Cardiothoracic Surgery (EACTS), and, among other things, concludes that in certain settings PCI can reasonably be considered as a treatment for both left main and three-vessel disease.

At the core of the new report is the role of the "heart team," in which an interventionalist, a surgeon, and a general cardiologist are all involved in the decision-making for patients seeking treatment for coronary disease.

The guidelines "represent a new collaborative effort between clinical cardiologists, interventional cardiologists, and cardiac surgeons to manage the whole spectrum of CAD from optimal medical therapy, to PCI with stents, to CABG," Dr William Wijns (Cardiovascular Center Aalst, Belgium) said during a presentation with surgeon Dr Philippe Kolh (University of Liège, Belgium). "Our task force is convinced that the heart-team approach represents an advance for patients and doctors."

Touchstones for Controversy

Published August 29, 2010 on the ESC website, the document tackles a number of issues that have been touchstones for controversy in recent years, including the role of optimal medical therapy vs PCI in patients with stable coronary artery disease and scenarios in which "ad hoc" PCI is acceptable--that is, situations when it is appropriate to proceed with percutaneous revascularization following a diagnostic catheterization, while the patient is still on the table.

A separate section of the report discusses antiplatelet and anticoagulant therapies: of note, the new antiplatelet prasugrel is given a class IIa B recommendation for use in non-STE-ACS and a I B for use in STEMI. More strikingly, ticagrelor, which is not yet approved in Europe, is given a class I B recommendation for use in both non-STE-ACS, and STEMI.

But the recommendations that may prove to be the talking point in the guidelines are the shades of class II recommendations given to different forms of three-vessel and left main disease. In the report, single-vessel disease or two-vessel disease in a nonproximal left anterior descending (LAD) coronary artery is the only scenario for which PCI is the "favored" intervention (class I, level of evidence C) in patients with lesions suitable for either surgery or PCI. For all other disease subsets, surgery is favored (class I, level of evidence A), but according to Wijns, PCI either "can" or "should" be considered as an option, with the exception of patients with three-vessel disease and a SYNTAX score >22 or with left main plus two- or three-vessel disease and a SYNTAX score >33.

Indications for CABG vs PCI in Patients Suitable for Both Procedures

CAD subset CABG favored PCI favored
1- or 2-vessel disease, nonproximal LAD IIb C I C
1- or 2-vessel disease, proximal LAD IA IIa B
3-vessel disease, simple lesions, full revascularization achievable with PCI, SYNTAX score <22 IA IIa B
3-vessel disease, complex lesions, incomplete revascularization achievable with PCI, SYNTAX score >22 IA III A
Left main (isolated or 1-vessel disease ostium/shaft) IA IIa B
Left main (isolated or 1-vessel disease distal bifurcation) IA IIb B
Left main plus 2- or 3-vessel disease, SYNTAX score <32 IA IIb B
Left main plus 2- or 3-vessel disease, SYNTAX score >33 IA III B

LAD=left anterior descending coronary artery

By way of comparison, a 2009 "focused update" to the American Heart Association (AHA)/American College of Cardiology (ACC) guidelines for the management of patients with STEMI and guidelines on PCI give unprotected left main coronary artery disease a class IIb, level of evidence B, without breaking out isolated/single-vessel disease of the left main, which, in the new ESC guidance, is given a IIa B recommendation. Triple-vessel disease is not addressed at all in the AHA/ACC document.

Speaking with heartwire , Dr David Holmes (Mayo Clinic, Rochester, MN) pointed out that European practitioners have had more experience with stenting lesions that were once considered untouchable by interventionalists.

"Europeans have more data and more experience, and their practice is further along in terms of some of these things. For the SYNTAX trial, when we first began to look at three-vessel disease and left main, the penetration of left main and three-vessel-disease therapy in Europe at that time was much more broadly based than in the US. So these [recommendations] are a little further ahead, or, not necessarily further ahead, but broader in scope, and the US will be moving in that direction."

Guidelines Will Differ Where Practices Differ

But Dr Magnus Ohman (Duke Clinical Research Institute, Durham, NC), who serves on the ACC/AHA guidelines oversight committee as well as participating in the European guidelines for non-STE-ACS, said he sees key differences in the way guideline documents are compiled in the US. European operators are quicker to explore the bounds of new therapies, then base guidelines on established practices, whereas American guideline-writing committees, he says, hold out longer for randomized clinical-trial results.

While there is a move toward greater "harmonization" of different regional practice guidelines, this might not always be feasible, he adds.

"European practices--for example, with percutaneous valves or left main stenting--are going to be different from what they are in the US, where we don't have percutaneous aortic valves available to us yet, and while left-main stenting is done in many centers in the US, it's not done to the level that it is done here, because their practices have evolved differently. Harmonization of guidelines is terrific, but we have to recognize because of different practice patterns in different parts of the world, guidelines by definition will have to be slightly different. That's not the end of the world--I actually think it's healthy for us."

Dr Alec Vahanian (Bichat Hospital, Paris, France), also commenting on the new ESC guidelines, stopped short of characterizing the European recommendations as ahead of the American ones, focusing instead on the fact that it's become a "global view" that decisions for any given patient will be made by an interventional cardiologist in conjunction with a general cardiologist and a cardiac surgeon.

The SYNTAX trial paved the way, he added. "If it's a complex [case], surgery is the winner and is highly recommended. But if it's not complex, if the left main disease is in isolation, or if it's not a complex multivessel with a low SYNTAX score, surgery is still the winner, but revascularization now has a IIa or IIb recommendation. That means the team should discuss it. You cannot summarize a patient based on the anatomy alone, you have to take into account the comorbidities and also the skill of the team."

Team Players

The concept of a "heart team" has been a recurring theme at European cardiology meetings more so than in the US, ever since the release of the SYNTAX results in 2008 and reinforced through the burgeoning growth of transcatheter-valve procedures. Holmes agrees with Vahanian, however, that, like it or not, cardiac physicians of different stripes in the US and elsewhere will increasingly be working together.

"What all the guidelines should move toward is what is best for the patient. And what is best is decided by having the surgeon, the interventional cardiologist, and the 'quarterback cardiologist' involved."

Will turf wars persist? Yes, says Holmes. "There will always be that; they won't completely go away. But I don't think physicians will pretend to get along; I think the systems are going to evolve so that indeed, they won't be pretending anymore."

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