ACC Revokes Choosing Wisely Advice for PCI in CVLPRIT's Wake

Shelley Wood

September 22, 2014

WASHINGTON, DC — In an unusual move, the American College of Cardiology has announced that it is "withdrawing" one of its Choosing Wisely recommendations, following the announcement of the CVLPRIT results last month at the European Society of Cardiology 2014 Scientific Sessions[1].

This is the first time since announcing its list of "do-not-do" procedures more than two years ago that the ACC has taken the step of revising its advice.

As reported by heartwire , CVLPRIT showed that patients undergoing primary PCI who had complete revascularization at the time of their index admission had lower rates of major adverse cardiac events at 12 months, as compared with patients who had only their "culprit" vessel treated. Deaths were doubled in the patients who had only their infarct-related artery treated, as were rates of recurrent MI and rates of heart failure, although none of these were statistically significant, given the low patient numbers. Importantly, no difference in procedure-related adverse events was seen between groups.

In April 2012, the ACC issued its list of cardiology "don'ts" as part of the broader Choosing Wisely campaign organized by the American Board of Internal Medicine, among them advice to leave untreated any stenosis unrelated to the occlusion causing the MI.

Now, says the ACC, results from the CVLPRIT trial, as well as from last year's Preventive Angioplasty in Myocardial Infarction (PRAMI) trial, warrant a rethink of this advice.

"Science is not static but rather constantly evolving," ACC president Dr Patrick T O'Gara said in a statement issued today. "As such, one of the ACC's primary roles is to stay abreast of this evolution and provide cardiovascular professionals and patients with the most up-to-date information on which to base decisions about the most appropriate and necessary treatment. The newest findings regarding coronary revascularization are great examples of science on the move, and we are responding accordingly."

"Keeping guidelines contemporary is always difficult, as I am well aware, having been a member of the European STEMI Guideline Committee," the lead investigator for CVLPRIT, Dr Anthony Gershlick (University Hospitals of Leicester, UK), commented to heartwire by email. "The ACC therefore should be congratulated for taking account of contemporary trials, but with the caveat that these were small, and larger trials confirming the hard-end-point benefit are needed and ongoing. Having said that, these were two randomized trials with similar outcomes of large differences in outcomes for complete revascularization."

Hopefully the ACC's revision will permit clinicians to make "reasonable decisions" on whether to intervene or not based on what they judge to be an individual patient's "best interest," Gershlick added.

Several questions still need to be addressed, the ACC statement notes. These include the exact timing of the procedures, which patients/lesions would benefit most, and whether fractional flow reserve (FFR) should be used to improve decision-making.

"The COMPLETE trial, which is currently in the enrollment phase, will hopefully answer some of these questions over the next several years," the statement reads.

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