New ESC/EACTS Guideline on Myocardial Revascularization

Liam Davenport

August 28, 2018

MUNICH — Patients should be involved in the decision about which myocardial revascularization procedure to perform, with a preference given to the procedure most likely to achieve "complete revascularization," new European revascularization guidelines conclude.

To help decision making, the guidelines recommend that patients be given unbiased, evidence-based information to understand the risks and benefits of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) and be given time and be encouraged to seek a second opinion in nonemergency situations.

The new guidelines were developed by the European Society of Cardiology (ESC) and European Association for Cardio-Thoracic Surgery (EACTS), in collaboration with the European Association for Percutaneous Cardiovascular Interventions.

The document is published in the European Heart Journal and on the ESC website and was presented here at the European Society of Cardiology Congress 2018.

The authors state that a multidisciplinary team be consulted for patients with chronic coronary artery disease who have complex anatomy, while taking into account the patients' preferences.

They also state that patients should have access to information on their clinician's level of experience and that of the hospital in performing the procedures.

Clinicians are urged in the guidelines to opt for the technique that is most likely to treat the whole lesion in one procedure and to score cases on whether PCI or CABG is most likely to be effective.

Franz-Josef Neumann, MD, ESC chairperson of the Guidelines Task Force, from University Heart Centre Freiburg–Bad Krozingen, Germany, told theheart.org | Medscape Cardiology that the guidelines aim to encourage treatment decisions to be based on "objective criteria."

"One important part is that we don't want to rely exclusively on angiographic images but to do functional testing, either invasively or noninvasively, and to have a sound basis for treatment decisions," Neumann said.

Changes to Recommendations

To develop the latest version of the guidelines, a Task Force consisting of members of the ESC and EACTS reviewed the available evidence for the diagnosis, management, and/or prevention of vascular disease.

Alongside a critical evaluation of current diagnostic and therapeutic procedures to determine their risk-benefit ratio, the committee also calculated estimates of expected health outcomes.

The Task Force made several changes to their recommendations from the previous version, published in 2014, with numerous additions and several cases in which the strength of recommendation was downgraded or upgraded.

New class I recommendations for the 2018 guidelines include calculation of the SYNTAX score, which predicts whether PCI can achieve benefits similar to those expected from CABG, if left main or multivessel revascularization is considered.

For more complex disease, long-term survival is better with surgery, but CABG and PCI have similar outcomes in less complex cases. Patients with diabetes have better outcomes with surgery, regardless of the complexity of the disease.

In addition, radial access is now recommended as the standard approach for coronary angiography and PCI, and drug-eluting stents are recommended for all PCI procedures.

For patients who have stabilized non-ST-segment elevation (NSTE) acute coronary syndrome (ACS), the guidelines say, revascularization strategy should be chosen in line with the principles used for stable coronary artery disease.

In patients with coronary artery disease, heart failure, and a left ventricular ejection fraction of 35% or less, CABG is recommended as the preferred method of achieving myocardial revascularization.

The guidelines also state that in patients with a high degree of stenosis, radial artery grafts should be used from the saphenous vein. If open vein harvesting is used for CABG, the guidelines add in a class IIa recommendation, that the no-touch vein technique should be used.

Finally, for class I recommendations, patients who have undergone myocardial revascularization should undergo systematic re-evaluation, the guidelines state.

Class IIa recommendations include considering PCI as an alternative to CABG, but that the completeness of revascularization be prioritized when choosing between the two procedures.

"The point is that it's the extent of the ischemia that is driving the benefit from revascularization, so if you have a larger area of ischemia, then you have a large benefit from revascularization, but if you don't revascularize completely this large area of ischemia, you lose some of the potential of revascularization," Neumann said.

"That is why you should always do complete revascularization," he added, "and if one procedure achieves complete revascularization but the other doesn't, this would be a strong argument in favor of the procedure that achieves complete revascularization."

The guidelines also recommend that the annual operator volume for left main PCI should be at least 25 cases per year.

Another class IIa recommendations new for this version is that patients with nonvalvular atrial fibrillation who require anticoagulation and antiplatelet treatment should be given non–vitamin K oral anticoagulants over vitamin K antagonists.

Finally, the document recommends patients with moderate or severe chronic kidney disease should have pre- and postprocedural hydration with isotonic saline, if the expected contrast volume is over 100 mL.

Class IIb recommendations include preference of the double-kissing crush technique over provisional T-stenting for true left main bifurcations.

In terms of drugs, P2Y12-inhibitor–naive patients who are undergoing PCI should be given cangrelor, or glycoprotein IIb/IIIa inhibitors if the patients have ACS.

After PCI, the guidelines say that dabigatran at 150 mg is preferred to the 100-mg dose when combined with single antiplatelet therapy, while patients with ACS should have their P2Y12 inhibitor de-escalated via platelet function testing.

Finally, the guidelines state that high-risk patients should have routine noninvasive imaging surveillance 6 months after revascularization.

The last two new recommendations for the 2018 guidelines are class III. One is a recommendation against the use of bioresorbable vascular scaffolds outside of clinical studies.

Neumann explained that this is due to the "bad experience" they had with the everolimus-eluting bioresorbable vascular scaffold (Absorb BVS, Abbott Vascular).

As reported by theheart.org | Medscape Cardiology, this was associated with a significant increase in major adverse cardiac events in the ABSORB 3 trial compared with the standard everolimus-eluting metal stent.

"If you look at the initial studies, they looked brilliant, there were no problems," Neumann said, "but then the more studies we had, the more negative the data became.

"In the end, we have learned that it's really a bad thing for the patient to receive a BVS."

 "We don't know about the new technologies, like the magnesium stent," he added. "It may be the same, it may be different. We don't know, but this is a reason not to push ahead [with BVS]."

The other class III recommendation relates to routine revascularization of non–infarct-related artery lesions in patients with myocardial infarction in cardiogenic shock.

Recommendations that have been upgraded in the 2018 guidelines include that stent implantation should be in the main vessel when PCI of bifurcation lesions is performed, followed by provisional balloon angioplasty with or without stenting of the side branch. This recommendation increased from class IIa to class I.

The recommendation that survivors of out-of-hospital cardiac arrest who have an electrocardiogram consistent with ST-elevation myocardial infarction (STEMI) should have immediate coronary angiography and revascularization has also been increased to class I, as has the recommendation that all patients be assessed for their risk for  contrast-induced nephropathy.

The recommendation that optical coherence tomography be used for stent optimization has also been upgraded, from class IIb to class IIa.

Recommendations that have been downgraded include the use of distal protection devices for PCI of saphenous vein graft lesions and the use of bivalirudin for PCI in NSTE-ACS and STEMI.

The recommendation that PCI be used for multivessel coronary artery disease in patients with diabetes and a SYNTAX score of less than 23 has also been downgraded, as has the recommendation that patients undergoing cardiac surgery should undergo platelet function testing to guide platelet therapy interruption.

Last, the recommendation that European System for Cardiac Operative Risk Evaluation Score II be used to assess in-hospital mortality after CABG has also been downgraded.

No funding declared. Neumann declares speaker fees, honoraria, consultancy, advisory board fees, being an investigator or committee member, et cetera, with Boehringer-Ingelheim, Daichi Sankyo, Pfizer, Bayer Healthcare, Bristol-Myers Squibb, AstraZeneca, Boston Scientific, Edwards Lifesciences, and Medtronic. He also reports departmental or institutional research funding from Bayer Healthcare, Novartis, Pfizer, GlaxoSmithKline, Biotronik, Abbott Vascular, Edwards Lifesciences, Medtronic. Other authors reports numerous potential conflicts.

European Society of Cardiology (ESC) Congress 2018. Presented August 27, 2018.

Eur Heart J.  Published online August 25, 2018. Full text

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