Chronic stable angina revascularization guidelines for percutaneous coronary intervention
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S.; Aysha Anwar, M.B.B.S[2]
Overview
2014 Focused update of 2012 ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina (DO NOT EDIT)[1]
Revascularization With PTCA in Patients With Stable Angina (DO NOT EDIT)[2]
Revascularization to Improve Survival
Left Main CAD Revascularization
| Class IIa |
| "1. PCI to improve survival is reasonable as an alternative to CABG in selected stable patients with significant (greater than or equal to 50% diameter stenosis) unprotected left main CAD with: 1) anatomic conditions associated with a low risk of PCI procedural complications and a high likelihood of good long-term outcome (e.g., a low SYNTAX score [less than or equal to 22], ostial or trunk left main CAD); and 2) clinical characteristics that predict a significantly increased risk of adverse surgical outcomes (e.g., STS-predicted risk of operative mortality greater than or equal to 5%) (Level of Evidence: B)" |
| "2. PCI to improve survival is reasonable in patients with unstable angina/non–ST-elevation MI when an unprotected left main coronary artery is the culprit lesion and the patient is not a candidate for CABG (Level of Evidence: B)" |
| "3. PCI to improve survival is reasonable in patients with acute ST elevation MI when an unprotected left main coronary artery is the culprit lesion, distal coronary flow is less than TIMI (Thrombolysis In Myocardial Infarction) grade 3, and PCI can be performed more rapidly and safely than CABG. (Level of Evidence: C)" |
| Class IIb |
| "1. PCI to improve survival may be reasonable as an alternative to CABG in selected stable patients with significant (greater than or equal to 50% diameter stenosis) unprotected left main CAD with: a) anatomic conditions associated with a low to intermediate risk of PCI procedural complications and an intermediate to high likelihood of good long-term outcome (e.g., low–intermediate SYNTAX score of less than 33, bifurcation left main CAD); and b) clinical characteristics that predict an increased risk of adverse surgical outcomes (e.g., moderate–severe chronic obstructive pulmonary disease, disability from previous stroke, or previous cardiac surgery; STS-predicted risk of operative mortality greater than or equal to 2%) (Level of Evidence: B)" |
| Class III |
| "1. PCI to improve survival should not be performed in stablepatients with significant (greater than or equal to 50% diameter stenosis) unprotected left main CAD who have unfavorable anatomy for PCI and who are good candidates for CABG(Level of Evidence: B)" |
Non–Left Main CAD Revascularization
| Class IIb |
| "1. The usefulness of PCI to improve survival is uncertain in patients with 2- or 3-vessel CAD (with or without involvement of the proximal LAD artery) or 1-vessel proximal LAD disease (Level of Evidence: B)" |
| "2. The usefulness of CABG or PCI to improve survival is uncertain in patients with previous CABG and extensive anterior wall ischemia on noninvasive testing (Level of Evidence: B)" |
| Class III |
| "1. CABG or PCI should not be performed with the primary or sole intent to improve survival in patients with SIHD with 1 or more coronary stenoses that are not anatomically or functionally significant (e.g., <70% diameter non–left main coronary artery stenosis, fractional flow reserve >0.80, no or only mild ischemia on noninvasive testing), involve only the left circumflex or right coronary artery, or subtend only a small area of viable myocardium(Level of Evidence: B)" |
Revascularization to Improve Symptoms
| Class I |
| "1. CABG or PCI to improve symptoms is beneficial in patients with 1 or more significant (greater than or equal to 70% diameter) coronary artery stenoses amenable to revascularization and unacceptable angina despite GDMT (Level of Evidence: A)" |
| "2. CABG is generally recommended in preference to PCI to improve survival in patients with diabetes mellitus and
multivessel CAD for which revascularization is likely to improve survival (3-vessel CAD or complex 2-vessel CAD involving the proximal LAD), particularly if a LIMA graft can be anastomosed to the LAD artery, provided the patient is a good candidate for surgery (Level of Evidence: B)" |
| Class I |
| "1. CABG or PCI to improve symptoms is reasonable in patients with 1 or more significant (greater than or equal to 70% diameter) coronary artery stenoses and unacceptable angina for whom GDMT cannot be implemented because of medication contraindications, adverse effects, or patient preferences. (Level of Evidence: C)" |
| "2. PCI to improve symptoms is reasonable in patients with previous CABG, 1 or more significant (greater than or equal to 70% diameter) coronary artery stenoses associated with ischemia, and unacceptable angina despite GDMT (Level of Evidence: C)" |
| Class III |
| "1. CABG or PCI to improve symptoms should not be performed in patients who do not meet anatomic (greater than or equal to 50% diameter left main or greater than or equal to 70% non–left main stenosis diameter) or physiological (e.g.,abnormal fractional flow reserve) criteria for revascularization.(Level of Evidence: C)" |
ESC Guidelines- Revascularization to Improve Prognosis (DO NOT EDIT)[3]
| Class IIa |
| "1. PCI or CABG for patients with reversible ischaemia on functional testing and evidence of frequent episodes of ischaemia during daily activities. (Level of Evidence: C)" |
ESC Guidelines- Revascularization to Improve Symptoms (DO NOT EDIT)[3]
| Class I |
| "1. PCI for one-vessel disease technically suitable for percutaneous revascularization in patients with moderate-to-severe symptoms not controlled by medical therapy, in whom procedural risks do not outweigh potential benefits. (Level of Evidence: A)" |
| "2. PCI for multi-vessel disease without high-risk coronary anatomy, technically suitable for percutaneous revascularization in patients with moderate-to-severe symptoms not controlled by medical therapy, in whom procedural risks do not outweigh potential benefits. (Level of Evidence: A)" |
| Class IIa |
| "1. PCI for one-vessel disease technically suitable for percutaneous revascularization in patients with mild-to-moderate symptoms which are nonetheless unacceptable to the patient, in whom procedural risks do not outweigh potential benefits. (Level of Evidence: A)" |
| "2. PCI for multi-vessel disease technically suitable for percutaneous revascularization in patients with mild-to-moderate symptoms which are nonetheless unacceptable to the patient, in whom procedural risks do not outweigh potential benefits. (Level of Evidence: A)" |
References
- ↑ Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM; et al. (1999). "ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina)". Circulation. 99 (21): 2829–48. PMID 10351980.
- ↑ Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP; et al. (2012). "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 126 (25): 3097–137. doi:10.1161/CIR.0b013e3182776f83. PMID 23166210.
- ↑ 3.0 3.1 Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F; et al. (2006). "Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology". Eur Heart J. 27 (11): 1341–81. doi:10.1093/eurheartj/ehl001. PMID 16735367.