New PCI, CABG Guidelines Emphasize Team Approach

Reed Miller

November 08, 2011

November 7, 2011 (Washington, DC) — The American College of Cardiology Foundation and American Heart Association have released new guidelines for bypass surgery and PCI featuring a common section on coronary artery disease revascularization [1,2].

The new guidelines were partly a collaboration between surgeons and interventionalists, mirroring the "heart-team" approach to coronary revascularization decisions recommended in the guidelines.

Both guidelines are published online November 7, 2011 in the Journal of the American College of Cardiology.

Both include the same section, entitled "CAD revascularization," the result of extensive collaborative discussions between the PCI and CABG writing committees, with input from members of the Stable Ischemic Heart Disease (SIHD) and UA/NSTEMI guidelines writing committees.

"The most important thing about these new guidelines is the consensus that was established between cardiologists and surgeons over patient selection for those two main procedures," CABG guidelines writing committee vice chair Dr Peter K Smith (Duke University, Durham, NC) told heartwire . "Most of the recommendations are related to randomized clinical-trial data, and most of those data were achieved from patients where there was consensus between a cardiac surgeon and a cardiologist that the patient could be . . . equally well-treated by PCI or surgery," Smith said.

"Mutual evaluation and mutual decision making will result in these guidelines being more often followed and lead to the best results for the patients." The guidelines strongly recommend (class I) that decisions about revascularization of an unprotected left main or complex coronary artery disease be made by a heart team, including a surgeon and an interventionalist.

Chair of the CABG guidelines writing committee, Dr L David Hillis (University of Texas Health Science Center, San Antonio), agreed that the emphasis on the team approach is the most important new feature of these guidelines and told heartwire that this team approach "will require a fundamentally different approach to the way patients are managed, particularly here in the United States. It's not uncommon for patients to agree to have a coronary angiogram, and with the patient lying on the table, the cardiologist doing the procedure looks at the films and then on the spot recommends percutaneous therapy to the patient, and then it's done in the same sitting." By contrast, the heart-team approach would require that the procedure be terminated after the angiography so that the surgeon and interventionalists can discuss how to proceed with that patient, Hillis explained.

The guidelines advise using the Society of Thoracic Surgeons (STS) and SYNTAX scores to guide these decisions. Commenting on the new guidelines, president-elect of the Society for Cardiovascular Angiography and Interventions, Dr Jeffery Marshall (Northeast Georgia Medical Center, Gainesville) told heartwire , "SYNTAX was revolutionary and disruptive in that, instead of just a gestalt or art of medicine, we now have a score that helps us decide which is the best therapy for a patient needing triple-vessel revascularization."

New and Improved!

The new guidelines' recommendations on antiplatelet therapy were written with the team approach in mind, Smith said. "There's been a lot of consternation [among] the surgeons and cardiologists on when to use these agents and how to use these agents," especially in patients who may need to soon undergo surgery, he said.

Hillis added that antiplatelet therapy with bypass surgery is an area where more research is urgently needed, especially with the recent influx of new antiplatelet drugs. "We're just beginning to understand how long one has to be off those medicines before one can safely perform surgery. . . . We have some suggestion about how long that wait needs to be, but it's still a little bit of a guessing game."

The surgery guidelines also include, for the first time, information on the anesthesia used during bypass surgery, which "has become specialized over time and has a lot more to offer to support coronary bypass surgery," Smith said. "It was time to recognize that and start making recommendations related to the specialty qualifications of the anesthesiologist member of the surgical team."

Dr James C Blankenship (Geisinger Medical Center, Danville, PA), the vice chair of the committee that wrote the PCI guidelines, told heartwire that these are the first revascularization guidelines that provide separate recommendations for improving survival vs mitigating symptoms, depending on which is the patient's higher priority. Blankenship also pointed out that these are the first guidelines for revascularization that make separate recommendations for each anatomic subgroup. "That will make it easier for clinicians who are trying to determine optimal therapy for their individual patient," he said.

Blankenship also said, "We're trying to streamline the process to make [the guidelines] more user-friendly, with less text, and make them more concise, in contrast to previous guidelines." He said the new guidelines documents are about 30% shorter than previous versions.

What's Next?

Blankenship said that "in the discussions that led to particular recommendations, time and time again we came up against situations where we thought it would be nice to make recommendations, but we just didn't have the data for it. That was a very common thing."

Smith added that "we still don't have enough evidence for decision making on PCI vs CABG. In a large number of patient subsets, the current evidence base is too small to be further 'subsetted' and create clearer recommendations for certain kinds of information." The SYNTAX score identifies patients who will likely have good outcomes with PCI and those who certainly won't, but it does not provide much guidance with patients who might be considered for PCI or surgery, Smith said. The SYNTAX score is "a unilateral view of these patients; it doesn't really talk about their comorbidities or potential risks," he said. "It's really the combination of the patients' clinical characteristics and their risk of having an adverse outcome with surgery that has a real role to play here."

Blankenship has received research funding from Abiomed, AstraZeneca, Boston Scientific, Conor Medsystems, Kai Pharmaceutical, and Schering-Plough. Smith has consulted for Eli Lilly, Baxter, and BioSurgery.

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