ACC/AHA/SCAI Updated PCI Guidelines

ACC/AHA/SCAI Updated PCI Guidelines

In November 2005, the ACC/AHA/SCAI jointly presented a major update of the Guidelines on Percutaneous Coronary Interventions (PCI). This document is a comprehensive analysis of the techniques, medications, and devices that have advanced the delivery of PCI since 2001, when the ACC/AHA last released guidelines on the topic. In my view, the updated guidelines are greatly strengthened by the equal participation of SCAI in their development. Four SCAI leaders - Drs. Ted Feldman, John Hirshfeld, Jr., Morton Kern, and Douglass Morrison - participated on the writing committee, ensuring that the document benefits from the detailed focus of cardiovascular interventionalists as well as the broad view of generalists. The result sets forth goals for optimal treatment of the many patients who are eligible for, and undergo, PCI procedures. Key new recommendations include the following:

* Door-to-balloon time for primary PCI of 90 minutes or less

* Annual operative volumes for PCI (> 75 elective PCI procedure with at least 11 on acute myocardial infarction patients annually) and high-volume facilities (more than 400 procedures annually)

* Broadened anatomic indicators for patients eligible for PCI - most notably, PCI for patients with left main coronary artery disease who are ineligible for coronary artery bypass graft surgery

* Monitoring and managing patients who have undergone PCI, including risk-factor modification for all patients; a regimen of aspirin and clopidogrel for most patients; ACE inhibitors for patients with coronary artery disease, left ventricular dysfunction, or hypertension; at least 6 months on beta-blockers for AMI or other acute conditions; aggressive lipid lowering for high-risk patients; and, for diabetic patients, glucose-lowering therapies aimed at bring HbA1c levels to less than seven percent

The updated guidelines examine closely the latest data on two of the most exciting advances in PCI: drug-eluting stents (DES) and distal embolic protection devices. While stressing the need for long-term study of both, the guidelines recommend DES in many settings, including diabetic patients, patients with longer lesions and smaller diameter vessels. Distal-protection devices have been recommended in this update specifically for patients who are undergoing PCI to saphenous vein grafts; to date their efficacy in AMI patients undergoing primary PCI has not been shown.

Perhaps the most controversial recommendation in the 2005 guidelines is that elective PCI should not be performed at facilities that do not have onsite cardiac surgery facilities. While SCAI supports this 2005 Guideline Update in general, the Society recognizes the reality that such an approach has developed in multiple locations both in the United States and other regions of the world. The Society feels that discussion of this important subject should ultimately revolve around what is in the best interest of the patient. Currently SCAI is assembling information on this important subject so that discussion can be focused on the true risks and benefits of this approach within the realities of each health care system.


Source:
http://www.medscape.com/viewarticle/524270

Note: This is a review article. For detailed version, click on following link:

http://www.chestjournal.org/cgi/reprint/126/3_suppl/172S