New guidelines for coronary artery revascularisation recommend that treatment decisions should be based on clinical indications and involve a multidisciplinary heart team that includes the patient and patient preferences.
The new joint guideline from the American College of Cardiology (ACC) and the American Heart Association (AHA), in partnership with the Society for Cardiovascular Angiography and Interventions (SCAI), updates and consolidates the ACC/AHA 2011 coronary artery bypass graft (CABG) surgery guideline and ACC/AHA/SCAI 2011 and 2015 percutaneous coronary intervention (PCI) guidelines.
“Coronary artery disease remains a leading cause of morbidity and mortality globally, and coronary revascularisation is an important therapeutic option when managing patients with this disease,” said Jennifer S Lawton, guideline writing committee chair and professor of surgery (Johns Hopkins Medicine, Baltimore, USA). “Treatment recommendations in the guideline outline an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularisation, with the intent to improve quality of care and align with patients’ interests.”
Several factors are assessed to determine which procedure is best for a particular patient, including the location and severity of the blockage, the patient’s clinical status and symptoms, the patient’s age, having Type 2 diabetes or a weak heart, the number of vessels that are affected and the risk involved for each procedure.
Determining the revascularisation method and which treatment strategy is the best approach are not always clear for every patient, even when looking at the clinical indications, according to the guideline. In these cases, a multidisciplinary heart team approach is recommended, including a cardiologist, cardiac surgeon and other specialists. In addition to the heart team, the patient’s preferences, goals, support system and understanding of their condition and potential outcomes should be considered.
“The heart team has become an important paradigm in clinical practice, emphasising the importance of team consensus on the optimal approach to revascularization,” said Jacqueline E Tamis-Holland, guideline writing committee vice-chair and professor of medicine at the Icahn School of Medicine at Mount Sinai, New York, USA.
The guideline updates recommendations for intervention, surgery and/or medical therapy in certain populations, including appropriate use of surgical revascularisation or percutaneous revascularisation for different disease states.
Evidence has found that surgery is a reasonable recommendation to improve survival yet may not provide as strong a benefit over medication therapy as previously thought for patients with stable ischemic heart disease, normal left ventricular ejection fraction and triple-vessel coronary artery disease. Evidence also shows the ability of PCI to improve survival over medical therapy in this population is uncertain.
When PCI is the most appropriate treatment, recommendations are also made for radial access (through an arm artery) versus femoral (through a leg artery, which is the traditional access route) when a clinician experienced in radial access is available. Femoral access remains the default for people unable to receive radial artery catheterisation because of anatomic limitations or because available clinicians are not experienced to perform radial access PCI.
The guideline also recommends a shorter one-to-three-month duration of dual antiplatelet therapy (DAPT) after PCI as reasonable in select patients to reduce the risk of bleeding, based on the latest evidence. Previous recommendations were for six or 12 months of DAPT.