ESC/EACTS revascularization guidelines stress benefit of revascularization in stable CAD
The therapeutic benefit of revascularisation in coronary artery disease (CAD) is emphasised in the 2014 ESC/EACTS revascularisation guidelines presented at ESC Congress by joint Task Force Chairs Professor Stephan Windecker (Switzerland) of the European Society of Cardiology (ESC) and Professor Philippe Kolh (Belgium) of the European Association for Cardio-Thoracic Surgery (EACTS). The joint guidelines are published today on-line in European Heart Journal (1), on the ESC Website (2), in EuroIntervention and in the European Journal of Cardio-Thoracic Surgery.
Previous ESC/EACTS Guidelines on myocardial revascularisation were published in 2010 (3). As part of their update, the Task Force performed a systematic review of the evidence including 100 trials in 93 553 patients with 262 090 patient years in the field of coronary revascularisation. "The key finding was that among patients with stable CAD, coronary artery bypass grafting (CABG) reduces the risk of death, myocardial infarction and repeat revascularisation compared with medical treatment," Professors Kolh and Windecker said.
Professor Windecker said: "It was noteworthy that all stent based coronary revascularisation technologies were found to reduce the risk of repeat revascularisation, whereas new generation drug-eluting stents (DES) but no other percutaneous revascularisation technology improved survival compared with medical treatment"(4).
Following the results of the SYNTAX trial, the importance of this angiographic risk score is summarised and a useful algorithm to calculate the SYNTAX score is included in the document. Revascularisation is recommended based on symptomatic and prognostic indications. As compared with the previous 2010 edition, percutaneous coronary intervention (PCI) now assumes a similar Class and level of evidence as CABG in patients with proximal LAD disease (IA), simple left main disease (Syntax Score<22; IB) and simple three-vessel disease (Syntax Score<22, IB). Conversely, PCI was downgraded among patients with complex three-vessel disease (Syntax Score >22, IIIB) and left main disease (Syntax Score >32, IIIB). Based on the results of the FREEDOM trial, CABG is now the favoured revascularization therapy among diabetic patients with multivessel CAD and acceptable surgical risk (IA).
The new guidelines favour DES over bare metal stents in nearly all patients and lesion subsets. DES receive a Class I indication among patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary PCI. Professor Windecker said: "This upgrade is notable as there was concern about the use of first generation DES in the setting of STEMI but that has vanished with the advent of newer generation DES."
Antithrombotic therapy in revascularisation is the largest chapter and had numerous updates. In patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS), pretreatment with prasugrel before PCI is not recommended following the results of the ACCOAST trial. Recommendations on the duration of dual antiplatelet therapy (DAPT) after DES implantation in patients with stable CAD were changed to 6 months.
Professor Windecker said: "The new recommendation recognises that an extension beyond 6 months in patients with stable CAD is no longer necessary."
In patients with STEMI, the use of bivalirudin after PCI has been downgraded from a Class I to a Class IIa recommendation. The Task Force agreed that the lower risk of bleeding observed in HORIZON-AMI is offset at least in part by the higher risk of periprocedural stent thrombosis shown in HORIZON-AMI, EUROMAX, HEAT and BRAVE 4 although there appears to be no impact on mortality and myocardial infarction.
A new chapter on the volume-outcome relationship for revascularisation procedures has been added. It provides the first guidance on minimal numbers of PCI and CABG procedures for physicians and institutions, plus recommendations for training to ensure high quality of care.
Professor Kolh concluded: "Revascularisation requires input from cardiologists, surgeons and interventionalists and our Task Force brought together experts in these fields. We hope the guidelines help clinicians make the best use of the revascularisation techniques currently available and improve quality of care across Europe."
1) 2014 ESC/EACTS Guidelines on myocardial revascularisation. European Heart Journal. 2014 DOI: 10.1093/eurheartj/ehu278
2) Guidelines for Myocardial Revascularisation – ESC webpages
3) Guidelines on myocardial revascularization. European Heart Journal. 2010;31:2501. DOI: 10.1093/eurheartj/ehq277
4) Revascularisation versus medical treatment in patients with stable coronary artery disease: network meta-analysis. BMJ. 2014;348:g3859 DOI: 10.1136/bmj.g3859 (Published 23 June 2014)