2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention

79 Pages·2012·6 MB·English

JournaloftheAmericanCollegeofCardiology Vol.58,No.24,2011
©2011bytheAmericanCollegeofCardiologyFoundationandtheAmericanHeartAssociation,Inc. ISSN0735-1097/$36.00
PublishedbyElsevierInc. doi:10.1016/j.jacc.2011.08.007
PRACTICE GUIDELINE
2011 ACCF/AHA/SCAI Guideline for
Percutaneous Coronary Intervention
A Report of the American College of Cardiology Foundation/American Heart Association
Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions
Writing Glenn N. Levine, MD, FACC, FAHA, Chair† Richard A. Lange, MD, FACC, FAHA§
Committee
Eric R. Bates, MD, FACC, FAHA, Laura Mauri, MD, MSC, FACC, FSCAI*†
Members*
Vice Chair*† RoxanaMehran,MD,FACC,FAHA,FSCAI*‡
James C. Blankenship, MD, FACC, FSCAI, IssamD.Moussa,MD,FACC,FAHA,FSCAI‡
Vice Chair*‡ Debabrata Mukherjee, MD, FACC, FSCAI†
Brahmajee K. Nallamothu, MD, FACC¶
Steven R. Bailey, MD, FACC, FSCAI*‡ Henry H. Ting, MD, FACC, FAHA†
John A. Bittl, MD, FACC†§
Bojan Cercek, MD, FACC, FAHA† *Writingcommitteemembersarerequiredtorecusethemselvesfrom
Charles E. Chambers, MD, FACC, FSCAI‡ votingonsectionstowhichtheirspecificrelationshipswithindustryand
other entities may apply; see Appendix 1 for recusal information.
Stephen G. Ellis, MD, FACC*†
†ACCF/AHARepresentative.‡SCAIRepresentative.§JointRevascu-
Robert A. Guyton, MD, FACC*(cid:1) larization Section Author. (cid:1)ACCF/AHA Task Force on Practice
Steven M. Hollenberg, MD, FACC*† Guidelines Liaison. ¶ACCF/AHA Task Force on Performance
MeasuresLiaison.
Umesh N. Khot, MD, FACC*†
ACCF/AHA Alice K. Jacobs, MD, FACC, FAHA, Chair Robert A. Guyton, MD, FACC
TaskForce
Jeffrey L. Anderson, MD, FACC, FAHA, Jonathan L. Halperin, MD, FACC, FAHA
Members
Chair-Elect Judith S. Hochman, MD, FACC, FAHA
Frederick G. Kushner, MD, FACC, FAHA
Nancy Albert, PHD, CCNS, CCRN, FAHA E. Magnus Ohman, MD, FACC
Mark A. Creager, MD, FACC, FAHA William Stevenson, MD, FACC, FAHA
Steven M. Ettinger, MD, FACC Clyde W. Yancy, MD, FACC, FAHA
ThisdocumentwasapprovedbytheAmericanCollegeofCardiologyFoundation ThisarticleiscopublishedinCirculationandCatheterizationandCardiovascular
Board of Trustees and the American Heart Association Science Advisory and Interventions.
CoordinatingCommitteeinJuly2011,andtheSocietyforCardiovascularAngiog- Copies:ThisdocumentisavailableontheWorldWideWebsitesoftheAmerican
raphyandInterventionsinAugust2011. College of Cardiology (www.cardiosource.org), the American Heart Association
TheAmericanCollegeofCardiologyFoundationrequeststhatthisdocumentbecitedas (my.americanheart.org),andtheSocietyforCardiovascularAngiographyandInter-
follows: Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, ventions(www.scai.org).Forcopiesofthisdocument,pleasecontactElsevierInc.
ChambersCE,EllisSG,GuytonRA,HollenbergSM,KhotUN,LangeRA,MauriL,
ReprintDepartment,fax[phone],[email protected].
MehranR,MoussaID,MukherjeeD,NallamothuBK,TingHH.2011ACCF/AHA/
Permissions:Multiplecopies,modification,alteration,enhancement,and/ordis-
SCAIguidelineforpercutaneouscoronaryintervention:areportoftheAmericanCollege
tribution of thisdocumentarenotpermittedwithouttheexpresspermissionofthe
ofCardiologyFoundation/AmericanHeartAssociationTaskForceonPracticeGuide-
American College of Cardiology Foundation. Please contact healthpermissions@
lines and the Society for Cardiovascular Angiography and Interventions. J Am Coll
elsevier.com.
Cardiol2011;58:e44–122.
JACCVol.58,No.24,2011 Levineetal. e45
December6,2011:e44–122 2011ACCF/AHA/SCAIPCIGuideline
4.1.2. Staffing.........................................e61
TABLE OF CONTENTS
4.1.3. ‘Time-Out’Procedures.........................e62
4.2. EthicalAspects......................................e63
Preamble......................................................e46 4.2.1. InformedConsent..............................e63
4.2.2. PotentialConflictsofInterest..................e63
1. Introduction...............................................e48 4.3. RadiationSafety:Recommendation..............e63
4.4. Contrast-InducedAKI:Recommendations........e63
1.1. MethodologyandEvidenceReview...............e48 4.5. AnaphylactoidReactions:Recommendations....e64
1.2. OrganizationoftheWritingCommittee..........e49 4.6. StatinTreatment:Recommendation..............e65
1.3. DocumentReviewandApproval...................e49 4.7. BleedingRisk:Recommendation..................e65
1.4. PCIGuidelines:HistoryandEvolution............e49 4.8. PCIinHospitalsWithoutOn-SiteSurgical
2. CADRevascularization..................................e50 Backup:Recommendations........................e65
5. ProceduralConsiderations.............................e65
2.1. HeartTeamApproachtoRevascularization
Decisions:Recommendations.....................e50 5.1. VascularAccess:Recommendation...............e65
2.2. RevascularizationtoImproveSurvival: 5.2. PCIinSpecificClinicalSituations ................e66
Recommendations..................................e52 5.2.1. UA/NSTEMI:Recommendations..............e66
2.3. RevascularizationtoImproveSymptoms: 5.2.2. ST-ElevationMyocardialInfarction............e68
Recommendations..................................e53 5.2.2.1. CORONARYANGIOGRAPHYSTRATEGIESINSTEMI:
RECOMMENDATIONS.........................e68
2.4. CABGVersusContemporaneousMedicalTherapy...e53 5.2.2.2. PRIMARYPCIOFTHEINFARCTARTERY:
2.5. PCIVersusMedicalTherapy.......................e54 RECOMMENDATIONS.........................e69
2.6. CABGVersusPCI....................................e54 5.2.2.3. DELAYEDORELECTIVEPCIINPATIENTSWITHSTEMI:
2.6.1. CABGVersusBalloonAngioplastyorBMS...e54 RECOMMENDATIONS.........................e69
2.6.2. CABGVersusDES............................e55 5.2.3. CardiogenicShock:Recommendations.........e70
5.2.3.1. PROCEDURALCONSIDERATIONSFORCARDIOGENIC
2.7. LeftMainCAD.......................................e55 SHOCK....................................e70
2.7.1. CABGorPCIVersusMedicalTherapyfor 5.2.4. RevascularizationBeforeNoncardiacSurgery:
LeftMainCAD................................e55 Recommendations..............................e71
2.7.2. StudiesComparingPCIVersusCABGfor
5.3. CoronaryStents:Recommendations..............e71
LeftMainCAD................................e56
2.7.3. RevascularizationConsiderationsfor 5.4. AdjunctiveDiagnosticDevices....................e73
LeftMainCAD................................e56 5.4.1. FFR:Recommendation.........................e73
2.8. ProximalLADArteryDisease......................e57 55..44..23.. IOVpUtiSca:lRCecoohmermenecnedTatoiomnos.g.r.a.p.h.y.................................ee7733
2.9. ClinicalFactorsThatMayInfluencethe
ChoiceofRevascularization.......................e57 5.5. 5A.d5j.u1.ncCtiovreonTahryerAatpheeuretcitcomDey:vRiceecsom..m..e.n..d.a.t.i.o.n.s...........ee7744
2.9.1. DiabetesMellitus...............................e57 5.5.2. Thrombectomy:Recommendation..............e74
2.9.2. ChronicKidneyDisease........................e57 5.5.3. LaserAngioplasty:Recommendations..........e74
2.9.3. CompletenessofRevascularization .............e58 5.5.4. CuttingBalloonAngioplasty:
2.9.4. LVSystolicDysfunction........................e58 Recommendations..............................e74
2.9.5. PreviousCABG................................e58 5.5.5. EmbolicProtectionDevices:Recommendation...e74
2.9.6. UnstableAngina/Non–ST-Elevation
5.6. PercutaneousHemodynamicSupportDevices:
MyocardialInfarction ..........................e58
2.9.7. DAPTComplianceandStentThrombosis: Recommendation....................................e74
Recommendation...............................e58 5.7. InterventionalPharmacotherapy..................e75
2.10. TMRasanAdjuncttoCABG........................e59 5.7.1. ProceduralSedation............................e75
2.11. HybridCoronaryRevascularization: 5.7.2. OralAntiplateletTherapy:Recommendations....e75
Recommendations..................................e59 55..77..34.. IAVntAicnotaigpulalatenltetTThherearpapyy.:..R.e.c.o..m..m..e.n.d.a.t.i.o.n.s.........ee7778
3. PCIOutcomes............................................e59 5.7.4.1. USEOFPARENTERALANTICOAGULANTSDURINGPCI:
RECOMMENDATION..........................e78
5.7.4.2. UFH:RECOMMENDATION......................e78
3.1. DefinitionsofPCISuccess.........................e59 5.7.4.3. ENOXAPARIN:RECOMMENDATIONS..............e79
3.1.1. AngiographicSuccess...........................e60 5.7.4.4. BIVALIRUDINANDARGATROBAN:
3.1.2. ProceduralSuccess..............................e60 RECOMMENDATIONS.........................e80
3.1.3. ClinicalSuccess ................................e60 5.7.4.5. FONDAPARINUX:RECOMMENDATION.............e80
3.2. PredictorsofClinicalOutcomeAfterPCI........e60 5.7.5. No-ReflowPharmacologicalTherapies:
3.3. PCIComplications ..................................e60 Recommendation...............................e80
5.8. PCIinSpecificAnatomicSituations..............e81
4. PreproceduralConsiderations.........................e61 5.8.1. CTOs:Recommendation.......................e81
5.8.2. SVGs:Recommendations ......................e81
4.1. CardiacCatheterizationLaboratory 5.8.3. BifurcationLesions:Recommendations.........e81
Requirements........................................e61 5.8.4. Aorto-OstialStenoses:Recommendations......e82
4.1.1. Equipment.....................................e61 5.8.5. CalcifiedLesions:Recommendation............e82
e46 Levineetal. JACCVol.58,No.24,2011
2011ACCF/AHA/SCAIPCIGuideline December6,2011:e44–122
5.9. PCIinSpecificPatientPopulations...............e82 detection, management, and prevention of disease. When
5.9.1. Elderly .........................................e83 properly applied, expert analysis of available data on the
5.9.2. Diabetes........................................e83 benefits and risks of these therapies and procedures can
5.9.3. Women ........................................e83
improve the quality of care, optimize patient outcomes, and
5.9.4. CKD:Recommendation........................e83
5.9.5. CardiacAllografts..............................e83 favorablyaffectcostsbyfocusingresourcesonthemosteffective
5.10. PeriproceduralMIAssessment: strategies.Anorganizedanddirectedapproachtoathorough
Recommendations..................................e83 review of evidence has resulted in the production of clinical
5.11. VascularClosureDevices:Recommendations...e84 practice guidelines that assist physicians in selecting the best
managementstrategyforanindividualpatient.Moreover,clinical
6. PostproceduralConsiderations.......................e84
practiceguidelinescanprovideafoundationforotherapplications,
6.1. PostproceduralAntiplateletTherapy: suchasperformancemeasures,appropriateusecriteria,andboth
Recommendations..................................e84 qualityimprovementandclinicaldecisionsupporttools.
6.1.1. PPIsandAntiplateletTherapy: The American College of Cardiology Foundation
Recommendations..............................e86 (ACCF)andtheAmericanHeartAssociation(AHA)have
6.1.2. ClopidogrelGeneticTesting:
jointly produced guidelines in the area of cardiovascular
Recommendations..............................e86
disease since 1980. The ACCF/AHA Task Force on
6.1.3. PlateletFunctionTesting:Recommendations.....e86
PracticeGuidelines(TaskForce),chargedwithdeveloping,
6.2. StentThrombosis...................................e87
updating,andrevisingpracticeguidelinesforcardiovascular
6.3. Restenosis:Recommendations....................e87
diseases and procedures, directs and oversees this effort.
6.3.1. BackgroundandIncidence .....................e87
6.3.2. RestenosisAfterBalloonAngioplasty ..........e88 Writing committees are charged with regularly reviewing
6.3.3. RestenosisAfterBMS..........................e88 and evaluating all available evidence to develop balanced,
6.3.4. RestenosisAfterDES..........................e88 patient-centric recommendations for clinical practice.
6.4. ClinicalFollow-Up...................................e88 Expertsinthesubjectunderconsiderationareselectedby
6.4.1. ExerciseTesting:Recommendations............e88 the ACCF and AHA to examine subject-specific data and
6.4.2. ActivityandReturntoWork...................e89
write guidelines in partnership with representatives from
6.4.3. CardiacRehabilitation:Recommendation......e89
other medical organizations and specialty groups. Writing
6.5. SecondaryPrevention..............................e89
committeesareaskedtoperformaformalliteraturereview;
7. QualityandPerformanceConsiderations...........e90 weighthestrengthofevidencefororagainstparticulartests,
treatments,orprocedures;andincludeestimatesofexpected
7.1. QualityandPerformance:Recommendations....e90 outcomes where such data exist. Patient-specific modifiers,
7.2. Training...............................................e90 comorbidities, and issues of patient preference that may
7.3. CertificationandMaintenanceofCertification:
influence the choice of tests or therapies are considered.
Recommendation....................................e90 When available, information from studies on cost is con-
7.4. OperatorandInstitutionalCompetencyand
sidered, but data on efficacy and outcomes constitute the
Volume:Recommendations........................e90
primary basis for the recommendations contained herein.
7.5. ParticipationinACCNCDRor
In analyzing the data and developing recommendations
NationalQualityDatabase.........................e91
and supporting text, the writing committee uses evidence-
8. FutureChallenges.......................................e91 basedmethodologiesdevelopedbytheTaskForce(1).The
ClassofRecommendation(COR)isanestimateofthesize
References...................................................e91 of the treatment effect considering risks versus benefits in
addition to evidence and/or agreement that a given treat-
Appendix1.AuthorRelationshipsWithIndustryand ment or procedure is or is not useful/effective or in some
OtherEntities(Relevant).................................e115 situationsmaycauseharm.TheLevelofEvidence(LOE)is
an estimate of the certainty or precision of the treatment
Appendix2.ReviewerRelationshipsWithIndustry effect. The writing committee reviews and ranks evidence
andOtherEntities(Relevant)............................e117 supporting each recommendation with the weight of evi-
dence ranked as LOE A, B, or C according to specific
Appendix3.AbbreviationList............................e119 definitions that are included in Table 1. Studies are identi-
fiedasobservational,retrospective,prospective,orrandom-
Appendix4.AdditionalTables/Figures.................e120 ized where appropriate. For certain conditions for which
inadequate data are available, recommendations are based
on expert consensus and clinical experience and are ranked
Preamble
as LOE C. When recommendations at LOE C are sup-
ported by historical clinical data, appropriate references
Themedicalprofessionshouldplayacentralroleinevaluating (including clinical reviews) are cited if available. For issues
the evidence related to drugs, devices, and procedures for the for which sparse data are available, a survey of current
JACCVol.58,No.24,2011 Levineetal. e47
December6,2011:e44–122 2011ACCF/AHA/SCAIPCIGuideline
Table1. ApplyingClassificationofRecommendationsandLevelofEvidence
ArecommendationwithLevelofEvidenceBorCdoesnotimplythattherecommendationisweak.Manyimportantclinicalquestionsaddressedintheguidelinesdonotlendthemselvestoclinicaltrials.
Althoughrandomizedtrialsareunavailable,theremaybeaveryclearclinicalconsensusthataparticulartestortherapyisusefuloreffective.
*Dataavailablefromclinicaltrialsorregistriesabouttheusefulness/efficacyindifferentsubpopulations,suchassex,age,historyofdiabetes,historyofpriormyocardialinfarction,historyofheart
failure,andprioraspirinuse.†Forcomparativeeffectivenessrecommendations(ClassIandIIa;LevelofEvidenceAandBonly),studiesthatsupporttheuseofcomparatorverbsshouldinvolvedirect
comparisonsofthetreatmentsorstrategiesbeingevaluated.
practiceamongthecliniciansonthewritingcommitteeis In view of the advances in medical therapy across the
thebasisforLOECrecommendationsandnoreferences spectrum of cardiovascular diseases, the Task Force has
are cited. The schema for COR and LOE is summarized designated the term guideline-directed medical therapy
in Table 1, which also provides suggested phrases for (GDMT)torepresentoptimalmedicaltherapyasdefinedby
writing recommendations within each COR. A new ACCF/AHA guideline recommended therapies (primarily
addition to this methodology is separation of the Class Class I). This new term, GDMT, will be used herein and
III recommendations to delineate if the recommendation throughout all future guidelines.
is determined to be of “no benefit” or is associated with Because the ACCF/AHA practice guidelines address
“harm” to the patient. In addition, in view of the patient populations (and healthcare providers) residing in
increasing number of comparative effectiveness studies, North America, drugs that are not currently available in
comparator verbs and suggested phrases for writing North America are discussed in the text without a specific
recommendations for the comparative effectiveness of COR. For studies performed in large numbers of subjects
onetreatmentorstrategyversusanotherhavebeenadded outsideNorthAmerica,eachwritingcommitteereviewsthe
for COR I and IIa, LOE A or B only. potentialinfluenceofdifferentpracticepatternsandpatient
e48 Levineetal. JACCVol.58,No.24,2011
2011ACCF/AHA/SCAIPCIGuideline December6,2011:e44–122
populations on the treatment effect and relevance to the aredisclosedinAppendixes1and2,respectively.Additionally,
ACCF/AHA target population to determine whether the toensurecompletetransparency,writingcommitteemembers’
findings should inform a specific recommendation. comprehensive disclosure information—including RWI not
The ACCF/AHA practice guidelines are intended to pertinent to this document—is available as an online supple-
assist healthcare providers in clinical decision making by ment. Comprehensive disclosure information for the Task
describingarangeofgenerallyacceptableapproachestothe Force is also available online at www.cardiosource.org/ACC/
diagnosis, management, and prevention of specific diseases About-ACC/Leadership/Guidelines-and-Documents-Task-
or conditions. The guidelines attempt to define practices Forces.aspx.Theworkofthewritingcommitteewassupported
thatmeettheneedsofmostpatientsinmostcircumstances. exclusivelybytheACCF,AHA,andtheSocietyforCardio-
Theultimatejudgmentregardingcareofaparticularpatient vascularAngiographyandInterventions(SCAI)withoutcom-
mustbemadebythehealthcareproviderandpatientinlight mercial support. Writing committee members volunteered
of all the circumstances presented by that patient. As a theirtimeforthisactivity.
result, situations may arise for which deviations from these Inanefforttomaintainrelevanceatthepointofcarefor
guidelines may be appropriate. Clinical decision making practicing physicians, the Task Force continues to oversee
should involve consideration of the quality and availability an ongoing process improvement initiative. As a result, in
ofexpertiseintheareawherecareisprovided.Whenthese response to pilot projects, several changes to these guide-
guidelines are used as the basis for regulatory or payer lines will be apparent, including limited narrative text, a
decisions,thegoalshouldbeimprovementinqualityofcare. focus on summary and evidence tables (with references
The Task Force recognizes that situations arise in which linked to abstracts in PubMed) and more liberal use of
additional data are needed to inform patient care more summaryrecommendationtables(withreferencesthatsup-
effectively;theseareaswillbeidentifiedwithineachrespec- port LOE) to serve as a quick reference.
tive guideline when appropriate. In April 2011, the Institute of Medicine released 2
Prescribed courses of treatment in accordance with these reports: Finding What Works in Health Care: Standards for
recommendationsareeffectiveonlyiffollowed.Becauselack Systematic Reviews and Clinical Practice Guidelines We Can
ofpatientunderstandingandadherencemayadverselyaffect Trust (2,3). It is noteworthy that the ACCF/AHA guide-
outcomes,physiciansandotherhealthcareprovidersshould lines were cited as being compliant with many of the
makeeveryefforttoengagethepatient’sactiveparticipation standards that were proposed. A thorough review of these
in prescribed medical regimens and lifestyles. In addition, reports and of our current methodology is under way, with
patients should be informed of the risks, benefits, and further enhancements anticipated.
alternatives to a particular treatment and be involved in The recommendations in this guideline are considered
shared decision making whenever feasible, particularly for currentuntiltheyaresupersededbyafocusedupdateorthe
COR IIa and IIb, where the benefit-to-risk ratio may be full-textguidelineisrevised.Guidelinesareofficialpolicyof
lower. both the ACCF and AHA.
The Task Force makes every effort to avoid actual,
Alice K. Jacobs, MD, FACC, FAHA, Chair
potential,orperceivedconflictsofinterestthatmayariseas
ACCF/AHA Task Force on Practice Guidelines
aresultofindustryrelationshipsorpersonalinterestsamong
the members of the writing committee. All writing com-
1. Introduction
mittee members and peer reviewers of the guideline are
asked to disclose all such current relationships, as well as
1.1. Methodology and Evidence Review
thoseexisting12monthspreviously.InDecember2009,the
ACCF and AHA implemented a new policy for relation- The recommendations listed in this document are, when-
ships with industry and other entities (RWI) that requires everpossible,evidencebased.Anextensiveevidencereview
thewritingcommitteechairplusaminimumof50%ofthe wasconductedthroughNovember2010,aswellasselected
writingcommitteetohavenorelevantRWI(Appendix1for other references through August 2011. Searches were lim-
theACCF/AHAdefinitionofrelevance).Thesestatements ited to studies, reviews, and other evidence conducted in
arereviewedbytheTaskForceandallmembersduringeach human subjects and that were published in English. Key
conference call and/or meeting of the writing committee searchwordsincludedbutwerenotlimitedtothefollowing:
andareupdatedaschangesoccur.Allguidelinerecommen- ad hoc angioplasty, angioplasty, balloon angioplasty, clinical
dationsrequireaconfidentialvotebythewritingcommittee trial, coronary stenting, delayed angioplasty, meta-analysis,
and must be approved by a consensus of the voting mem- percutaneous transluminal coronary angioplasty, randomized
bers. Members are not permitted to write, and must recuse controlled trial (RCT), percutaneous coronary intervention
themselvesfromvotingon,anyrecommendationorsectionto (PCI) and angina, angina reduction, antiplatelet therapy,
which their RWI apply. Members who recused themselves bare-metal stents (BMS), cardiac rehabilitation, chronic stable
from voting are indicated in the list of writing committee angina, complication, coronary bifurcation lesion, coronary
members, and section recusals are noted in Appendix 1. calcifiedlesion,coronarychronictotalocclusion(CTO),coronary
Authors’ and peer reviewers’ RWI pertinent to this guideline ostial lesions, coronary stent (BMS and drug-eluting stents
JACCVol.58,No.24,2011 Levineetal. e49
December6,2011:e44–122 2011ACCF/AHA/SCAIPCIGuideline
[DES]; and BMS versus DES), diabetes, distal embolization, port, was written by an ad hoc group whose members
distal protection, elderly, ethics, late stent thrombosis, medical included Andreas Grüntzig. In 1980, the ACC and the
therapy, microembolization, mortality, multiple lesions, multi- AHA established the Task Force on Assessment of Diag-
vessel, myocardial infarction (MI), non–ST-elevation myocar- nostic and Therapeutic Cardiovascular Procedures, which
dialinfarction(NSTEMI),no-reflow,opticalcoherencetomog- was charged with the development of guidelines related to
raphy,protonpumpinhibitor(PPI),returntowork,same-day the role of new therapeutic approaches and of specific
angioplasty and/or stenting, slow flow, stable ischemic heart noninvasive and invasive procedures in the diagnosis and
disease (SIHD), staged angioplasty, STEMI, survival, and
management of cardiovascular disease. The first ACC/
unstable angina (UA). Additional searches cross-referenced
AHATaskForcereportonguidelinesforcoronaryballoon
these topics with the following subtopics: anticoagulant
angioplasty was published in 1988 (5). The 18-page docu-
therapy, contrast nephropathy, PCI-related vascular complica-
ment discussed and made recommendations about lesion
tions, unprotected left main PCI, multivessel coronary artery
classification and success rates, indications for and contra-
disease(CAD),adjunctivepercutaneousinterventionaldevices,
indications to balloon angioplasty, institutional review of
percutaneous hemodynamic support devices, and secondary pre-
angioplasty procedures, ad hoc angioplasty after angiogra-
vention. Additionally, the committee reviewed documents
phy, and on-site surgical backup. Further iterations of the
related to the subject matter previously published by the
guidelines were published in 1993 (6), 2001 (7), and 2005
ACCFandAHA.Referencesselectedandpublishedinthis
(8). In 2007 and 2009, focused updates to the guideline
document are representative and not all-inclusive.
were published to expeditiously address new study results
To provide clinicians with a comprehensive set of data,
and recent changes in the field of interventional cardiology
whenever deemed appropriate or when published, the ab-
(9,10). The 2009 focused update is notable in that there
solute risk difference and number needed to treat or harm
will be provided in the guideline, along with confidence was direct collaboration between the writing committees
intervals (CIs) and data related to the relative treatment for the STEMI guidelines and the PCI guidelines,
effects such as odds ratio (OR), relative risk, hazard ratio resulting in a single publication of focused updates on
(HR), or incidence rate ratio. STEMI and PCI (10).
The focus of this guideline is the safe, appropriate, and TheevolutionofthePCIguidelinereflectsthegrowthof
efficacious performance of PCI. The risks of PCI must be knowledgeinthefieldandparallelsthemanyadvancesand
balancedagainstthelikelihoodofimprovedsurvival,symp- innovationsinthefieldofinterventionalcardiology,includ-
toms, or functional status. This is especially important in ing primary PCI, BMS and DES, intravascular ultrasound
patients with SIHD. (IVUS) and physiologic assessments of stenosis, and newer
antiplateletandanticoagulanttherapies.The2011iteration
1.2. Organization of the Writing Committee
of the guideline continues this process, addressing ethical
The committee was composed of physicians with expertise aspects of PCI, vascular access considerations, CAD
ininterventionalcardiology,generalcardiology,criticalcare revascularization including hybrid revascularization, re-
cardiology,cardiothoracicsurgery,clinicaltrials,andhealth vascularization before noncardiac surgery, optical coher-
services research. The committee included representatives
ence tomography, advanced hemodynamic support de-
from the ACCF, AHA, and SCAI.
vices, no-reflow therapies, and vascular closure devices.
1.3. Document Review and Approval Mostofthisdocumentisorganizedaccordingto“patient
flow,” consisting of preprocedural considerations, proce-
This document was reviewed by 2 official reviewers nomi-
dural considerations, and postprocedural considerations.
nated by the ACCF, AHA, and SCAI, as well as 21
In a major undertaking, the STEMI, PCI, and coronary
individual content reviewers (including members of the
artery bypass graft (CABG) surgery guidelines were
ACCF Interventional Scientific Council and ACCF Sur-
written concurrently, with additional collaboration with
geons’ Scientific Council). All information on reviewers’
the SIHD guideline writing committee, allowing greater
RWI was distributed to the writing committee and is
collaboration between the different writing committees
published in this document (Appendix 2). This document
on topics such as PCI in STEMI and revascularization
wasapprovedforpublicationbythegoverningbodiesofthe
strategies in patients with CAD (including unprotected
ACCF, AHA, and SCAI.
left main PCI, multivessel disease revascularization, and
1.4. PCI Guidelines: History and Evolution hybrid procedures).
In 1982, a 2-page manuscript titled “Guidelines for the In accordance with direction from the Task Force and
Performance of Percutaneous Transluminal Coronary An- feedback from readers, in this iteration of the guideline,
gioplasty” was published in Circulation (4). The document, the text has been shortened, with an emphasis on
which addressed the specific expertise and experience phy- summary statements rather than detailed discussion of
sicians should have to perform balloon angioplasty, as well numerousindividualtrials.Onlinesupplementalevidence
as laboratory requirements and the need for surgical sup- and summary tables have been created to document the
e50 Levineetal. JACCVol.58,No.24,2011
2011ACCF/AHA/SCAIPCIGuideline December6,2011:e44–122
studiesanddataconsideredforneworchangedguideline theSYNTAXscore isa reasonable surrogatefortheextent
recommendations. of CAD and its complexity and serves as important infor-
mation that should be considered when making revascular-
izationdecisions.RecommendationsthatrefertoSYNTAX
2. CAD Revascularization
scoresusethemassurrogatesfortheextentandcomplexity
of CAD.
Recommendations and text in this section are the result of
Revascularizationrecommendationstoimprovesurvivaland
extensive collaborative discussions between the PCI and
symptomsareprovidedinthefollowingtextandaresumma-
CABG writing committees, as well as key members of the
rized in Tables 2 and 3. References to studies comparing
SIHD and UA/NSTEMI writing committees. Certain
revascularization with medical therapy are presented when
issues, such as older versus more contemporary studies,
availableforeachanatomicsubgroup.
primary analyses versus subgroup analyses, and prospective
versus post hoc analyses, have been carefully weighed in See Online Data Supplements 1 and 2 for additional data
designating COR and LOE; they are addressed in the regarding the survival and symptomatic benefits with CABG or
appropriate corresponding text. The goals of revasculariza- PCIfordifferentanatomicsubsets.
tion for patients with CAD are to 1) improve survival
and/or 2) relieve symptoms. 2.1. Heart Team Approach to
Revascularization recommendations in this section are Revascularization Decisions: Recommendations
predominantly based on studies of patients with symptom-
atic SIHD and should be interpreted in this context. As CLASSI
1. A Heart Team approach to revascularization is recommended in
discussedlaterinthissection,recommendationsonthetype
patientswithunprotectedleftmainorcomplexCAD(14–16).(Level
of revascularization are, in general, applicable to patients
ofEvidence:C)
with UA/NSTEMI. In some cases (e.g., unprotected left
main CAD), specific recommendations are made for pa- CLASSIIa
tients with UA/NSTEMI or STEMI. 1. CalculationoftheSocietyofThoracicSurgeons(STS)andSYNTAX
Historically, most studies of revascularization have been scores is reasonable in patients with unprotected left main and
based on and reported according to angiographic criteria. complexCAD(13,14,17–22).(LevelofEvidence:B)
Most studies have defined a “significant” stenosis as (cid:1)70% One protocol used in RCTs (14–16,23) often involves a
diameter narrowing; therefore, for revascularization deci- multidisciplinary approach referred to as the Heart Team.
sions and recommendations in this section, a “significant”
Composed of an interventional cardiologist and a cardiac
stenosis has been defined as (cid:1)70% diameter narrowing
surgeon, the Heart Team 1) reviews the patient’s medical
((cid:1)50% for left main CAD). Physiological criteria, such as
condition and coronary anatomy, 2) determines that PCI
an assessment of fractional flow reserve (FFR), has been
and/or CABG are technically feasible and reasonable, and
used in deciding when revascularization is indicated. Thus,
3)discussesrevascularizationoptionswiththepatientbefore
forrecommendationsaboutrevascularizationinthissection,
a treatment strategy is selected. Support for using a Heart
coronarystenoseswithFFR(cid:2)0.80canalsobeconsideredto
Team approach comes from reports that patients with
be “significant” (11,12).
complex CAD referred specifically for PCI or CABG in
As noted, the revascularization recommendations have
concurrent trial registries have lower mortality rates than
been formulated to address issues related to 1) improved
those randomly assigned to PCI or CABG in controlled
survival and/or 2) improved symptoms. When one method
trials (15,16).
ofrevascularizationispreferredovertheotherforimproved
TheSIHD,PCI,andCABGguidelinewritingcommit-
survival, this consideration, in general, takes precedence
tees endorse a Heart Team approach in patients with
over improved symptoms. When discussing options for
unprotectedleftmainCADand/orcomplexCADinwhom
revascularization with the patient, he or she should under-
theoptimalrevascularizationstrategyisnotstraightforward.
standwhentheprocedureisbeingperformedinanattempt
A collaborative assessment of revascularization options, or
to improve symptoms, survival, or both.
thedecisiontotreatwithGDMTwithoutrevascularization,
Although some results from the SYNTAX (Synergy
betweenPercutaneousCoronaryInterventionwithTAXUS involving an interventional cardiologist, a cardiac surgeon,
and Cardiac Surgery) study are best characterized as sub- and (often) the patient’s general cardiologist, followed by
group analyses and “hypothesis generating,” SYNTAX discussion with the patient about treatment options, is
nonetheless represents the latest and most comprehensive optimal. Particularly in patients with SIHD and unpro-
comparison of PCI and CABG (13,14). Therefore, the tected left main and/or complex CAD for whom a revas-
results of SYNTAX have been considered appropriately cularizationstrategyisnotstraightforward,anapproachhas
when formulating our revascularization recommendations. beenendorsedthatinvolvesterminatingtheprocedureafter
Although the limitations of using the SYNTAX score for diagnosticcoronaryangiographyiscompleted:thisallowsa
certain revascularization recommendations are recognized, thorough discussion and affords both the interventional
JACCVol.58,No.24,2011 Levineetal. e51
December6,2011:e44–122 2011ACCF/AHA/SCAIPCIGuideline
Table2. RevascularizationtoImproveSurvivalComparedWithMedicalTherapy
Anatomic
Setting COR LOE References
UPLMorcomplexCAD
CABGandPCI I—HeartTeamapproachrecommended C (14–16)
CABGandPCI IIa—CalculationofSTSandSYNTAXscores B (13,14,17–22)
UPLM*
CABG I B (24–30)
PCI IIa—ForSIHDwhenbothofthefollowingarepresent: B (13,17,19,23,31–48)
●AnatomicconditionsassociatedwithalowriskofPCIproceduralcomplicationsandahighlikelihood
ofgoodlong-termoutcome(e.g.,alowSYNTAXscoreof(cid:2)22,ostialortrunkleftmainCAD)
●Clinicalcharacteristicsthatpredictasignificantlyincreasedriskofadversesurgicaloutcomes(e.g.,
STS-predictedriskofoperativemortality(cid:1)5%)
IIa—ForUA/NSTEMIifnotaCABGcandidate B (13,36–39,44,45,47–49)
IIa—ForSTEMIwhendistalcoronaryflowisTIMIflowgrade(cid:1)3andPCIcanbeperformedmorerapidly C (33,50,51)
andsafelythanCABG
IIb—ForSIHDwhenbothofthefollowingarepresent: B (13,17,19,23,31–48,52)
●AnatomicconditionsassociatedwithalowtointermediateriskofPCIproceduralcomplicationsand
anintermediatetohighlikelihoodofgoodlong-termoutcome(e.g.,low-intermediateSYNTAXscore
of(cid:1)33,bifurcationleftmainCAD)
●Clinicalcharacteristicsthatpredictanincreasedriskofadversesurgicaloutcomes(e.g.,moderate-
severeCOPD,disabilityfrompriorstroke,orpriorcardiacsurgery;STS-predictedriskofoperative
mortality(cid:2)2%)
III:Harm—ForSIHDinpatients(versusperformingCABG)withunfavorableanatomyforPCIandwhoare B (13,17,19,24–32)
goodcandidatesforCABG
3-vesseldiseasewithorwithoutproximalLADarterydisease*
CABG I B (26,3053–56)
IIa—ItisreasonabletochooseCABGoverPCIinpatientswithcomplex3-vesselCAD(e.g.,SYNTAXscore B (32,46,56,71,72)
(cid:2)22)whoaregoodcandidatesforCABG.
PCI IIb—Ofuncertainbenefit B (26,46,53,56,82)
2-vesseldiseasewithproximalLADarterydisease*
CABG I B (26,30,53–56)
PCI IIb—Ofuncertainbenefit B (26,53,56,82)
2-vesseldiseasewithoutproximalLADarterydisease*
CABG IIa—Withextensiveischemia B (60–63)
IIb—Ofuncertainbenefitwithoutextensiveischemia C (56)
PCI IIb—Ofuncertainbenefit B (26,53,56,82)
1-vesselproximalLADarterydisease
CABG IIa—WithLIMAforlong-termbenefit B (30,56,69,70)
PCI IIb—Ofuncertainbenefit B (26,53,56,82)
1-vesseldiseasewithoutproximalLADarteryinvolvement
CABG III:Harm B (30,53,60,61,94–98)
PCI III:Harm B (30,53,60,61,94–98)
LVdysfunction
CABG IIa—EF35%to50% B (30,64–68)
CABG IIb—EF(cid:1)35%withoutsignificantleftmainCAD B (30,64–68,83,84)
PCI Insufficientdata N/A
Survivorsofsuddencardiacdeathwithpresumedischemia-mediatedVT
CABG I B (57–59)
PCI I C (57)
Noanatomicorphysiologiccriteriaforrevascularization
CABG III:Harm B (30,53,60,61,94–98)
PCI III:Harm B (30,53,60,61,94–98)
*Inpatientswithmultivesseldiseasewhoalsohavediabetes,itisreasonabletochooseCABG(withLIMA)overPCI(62,74–81)(ClassIIa;LOE:B).
CABGindicatescoronaryarterybypassgraft;CAD,coronaryarterydisease;COPD,chronicobstructivepulmonarydisease;COR,classofrecommendation;EF,ejectionfraction;LAD,leftanterior
descending;LIMA,leftinternalmammaryartery;LOE,levelofevidence;LV,leftventricular;N/A,notapplicable;PCI,percutaneouscoronaryintervention;SIHD,stableischemicheartdisease;STEMI,
ST-elevationmyocardialinfarction;STS,SocietyofThoracicSurgeons;SYNTAX,SynergybetweenPercutaneousCoronaryInterventionwithTAXUSandCardiacSurgery;TIMI,ThrombolysisInMyocardial
Infarction;UA/NSTEMI,unstableangina/non–ST-elevationmyocardialinfarction;UPLM,unprotectedleftmaindisease;andVT,ventriculartachycardia.
e52 Levineetal. JACCVol.58,No.24,2011
2011ACCF/AHA/SCAIPCIGuideline December6,2011:e44–122
Table3. RevascularizationtoImproveSymptomsWithSignificantAnatomic(>50%LeftMainor>70%Non–LeftMainCAD)
orPhysiological(FFR<0.80)CoronaryArteryStenoses
ClinicalSetting COR LOE References
(cid:1)1significantstenosesamenabletorevascularizationandunacceptable I(cid:3)CABG A (82,99–108)
anginadespiteGDMT I(cid:3)PCI
(cid:1)1significantstenosesandunacceptableanginainwhomGDMTcannotbe IIa(cid:3)CABG C N/A
implementedbecauseofmedicationcontraindications,adverseeffects,or IIa(cid:3)PCI
patientpreferences
PreviousCABGwith(cid:1)1significantstenosesassociatedwithischemiaand IIa(cid:3)PCI C (86,89,92)
unacceptableanginadespiteGDMT IIb(cid:3)CABG C (93)
Complex3-vesselCAD(e.g.,SYNTAXscore(cid:2)22)withorwithoutinvolvementof IIa(cid:3)CABGpreferred B (32,46,56,71,72)
theproximalLADarteryandagoodcandidateforCABG overPCI
Viableischemicmyocardiumthatisperfusedbycoronaryarteriesthatarenot IIb(cid:3)TMRasan B (109–113)
amenabletografting adjuncttoCABG
Noanatomicorphysiologiccriteriaforrevascularization III:Harm(cid:3)CABG C N/A
III:Harm(cid:3)PCI
CABGindicatescoronaryarterybypassgraft;CAD,coronaryarterydisease;COR,classofrecommendation;FFR,fractionalflowreserve;GDMT,guideline-directedmedicaltherapy;LOE,levelofevidence;
N/A,notapplicable;PCI,percutaneouscoronaryintervention;SYNTAX,SynergybetweenPercutaneousCoronaryInterventionwithTAXUSandCardiacSurgery;andTMR,transmyocardiallaser
revascularization.
cardiologist and cardiac surgeon the opportunity to discuss plicationsandanintermediatetohighlikelihoodofgoodlong-term
revascularizationoptionswiththepatient.BecausetheSTS outcome(e.g.,low-intermediateSYNTAXscoreof(cid:1)33,bifurcation
score and the SYNTAX score have been shown to predict left main CAD); and 2) clinical characteristics that predict an
increasedriskofadversesurgicaloutcomes(e.g.,moderate-severe
adverse outcomes in patients undergoing CABG and PCI,
chronic obstructive pulmonary disease, disability from previous
respectively, calculation of these scores is often useful in
stroke,orpreviouscardiacsurgery;STS-predictedriskofoperative
making revascularization decisions (13,14,17–22).
mortality(cid:2)2%)(13,17,19,23,31–48,52).(LevelofEvidence:B)
2.2. Revascularization to Improve
CLASSIII:HARM
Survival: Recommendations
1. PCItoimprovesurvivalshouldnotbeperformedinstablepatients
Left Main CAD Revascularization with significant ((cid:1)50% diameter stenosis) unprotected left main
CAD who have unfavorable anatomy for PCI and who are good
CLASSI candidatesforCABG(13,17,19,24–32).(LevelofEvidence:B)
1. CABGtoimprovesurvivalisrecommendedforpatientswithsignif-
icant((cid:1)50%diameterstenosis)leftmaincoronaryarterystenosis Non–Left Main CAD Revascularization
(24–30).(LevelofEvidence:B)
CLASSI
CLASSIIa 1. CABGtoimprovesurvivalisbeneficialinpatientswithsignificant
1. PCItoimprovesurvivalisreasonableasanalternativetoCABGin ((cid:1)70% diameter) stenoses in 3 major coronary arteries (with or
selectedstablepatientswithsignificant((cid:1)50%diameterstenosis) withoutinvolvementoftheproximalleftanteriordescending[LAD]
unprotectedleftmainCADwith:1)anatomicconditionsassociated artery)orintheproximalLADplus1othermajorcoronaryartery
withalowriskofPCIproceduralcomplicationsandahighlikelihood (26,30,53–56).(LevelofEvidence:B)
ofgoodlong-termoutcome(e.g.,alowSYNTAXscore[(cid:2)22],ostial 2. CABGorPCItoimprovesurvivalisbeneficialinsurvivorsofsudden
ortrunkleftmainCAD);and2)clinicalcharacteristicsthatpredicta cardiacdeathwithpresumedischemia-mediatedventriculartachy-
significantly increased risk of adverse surgical outcomes (e.g., cardiacausedbysignificant((cid:1)70%diameter)stenosisinamajor
STS-predictedriskofoperativemortality(cid:1)5%)(13,17,19,23,31–48). coronaryartery.(CABGLevelofEvidence:B[57–59];PCILevelof
(LevelofEvidence:B) Evidence:C[57])
2. PCItoimprovesurvivalisreasonableinpatientswithUA/NSTEMI
CLASSIIa
whenanunprotectedleftmaincoronaryarteryistheculpritlesion
1. CABGtoimprovesurvivalisreasonableinpatientswithsignificant
andthepatientisnotacandidateforCABG(13,36–39,44,45,47–
((cid:1)70%diameter)stenosesin2majorcoronaryarterieswithsevere
49).(LevelofEvidence:B)
orextensivemyocardialischemia(e.g.,high-riskcriteriaonstress
3. PCItoimprovesurvivalisreasonableinpatientswithacuteSTEMI
testing,abnormalintracoronaryhemodynamicevaluation,or(cid:2)20%
whenanunprotectedleftmaincoronaryarteryistheculpritlesion,
perfusiondefectbymyocardialperfusionstressimaging)ortarget
distalcoronaryflowislessthanTIMI(ThrombolysisInMyocardial
vesselssupplyingalargeareaofviablemyocardium(60–63).(Level
Infarction) grade 3, and PCI can be performed more rapidly and
ofEvidence:B)
safelythanCABG(33,50,51).(LevelofEvidence:C)
2. CABG to improve survival is reasonable in patients with mild-
CLASSIIb moderateleftventricular(LV)systolicdysfunction(ejectionfraction
1. PCI to improve survival may be reasonable as an alternative to [EF]35%to50%)andsignificant((cid:1)70%diameterstenosis)multi-
CABGinselectedstablepatientswithsignificant((cid:1)50%diameter vesselCADorproximalLADcoronaryarterystenosis,whenviable
stenosis)unprotectedleftmainCADwith:1)anatomicconditions myocardiumispresentintheregionofintendedrevascularization
associatedwithalowtointermediateriskofPCIproceduralcom- (30,64–68).(LevelofEvidence:B)
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3. CABGwithaleftinternalmammaryartery(LIMA)grafttoimprove or without involvement of the proximal LAD artery who are good
survivalisreasonableinpatientswithsignificant((cid:1)70%diameter) candidatesforCABG(32,46,56,72,73).(LevelofEvidence:B)
stenosis in the proximal LAD artery and evidence of extensive
ischemia(30,56,69,70).(LevelofEvidence:B) CLASSIIb
1. CABGtoimprovesymptomsmightbereasonableforpatientswith
4. It is reasonable to choose CABG over PCI to improve survival in
previous CABG, 1 or more significant ((cid:1)70% diameter) coronary
patientswithcomplex3-vesselCAD(e.g.,SYNTAXscore(cid:2)22),with
artery stenoses not amenable to PCI, and unacceptable angina
or without involvement of the proximal LAD artery who are good
despiteGDMT(93).(LevelofEvidence:C)
candidatesforCABG(32,46,56,71,72).(LevelofEvidence:B)
2. Transmyocardial laser revascularization (TMR) performed as an
5. CABG is probably recommended in preference to PCI to improve
adjunct to CABG to improve symptoms may be reasonable in
survival in patients with multivessel CAD and diabetes mellitus,
patients with viable ischemic myocardium that is perfused by
particularlyifaLIMAgraftcanbeanastomosedtotheLADartery
arteries that are not amenable to grafting (109–113). (Level of
(62,74–81).(LevelofEvidence:B)
Evidence:B)
CLASSIIb CLASSIII:HARM
1. TheusefulnessofCABGtoimprovesurvivalisuncertaininpatients 1. CABG or PCI to improve symptoms should not be performed in
with significant ((cid:1)70%) diameter stenoses in 2 major coronary patientswhodonotmeetanatomic((cid:1)50%diameterleftmainor
arteriesnotinvolvingtheproximalLADarteryandwithoutextensive (cid:1)70% non–left main stenosis diameter) or physiological (e.g.,
ischemia(56).(LevelofEvidence:C) abnormalFFR)criteriaforrevascularization.(LevelofEvidence:C)
2. TheusefulnessofPCItoimprovesurvivalisuncertaininpatients
with2-or3-vesselCAD(withorwithoutinvolvementoftheproximal 2.4. CABG Versus Contemporaneous
LADartery)or1-vesselproximalLADdisease(26,53,56,82).(Level Medical Therapy
ofEvidence:B)
In the 1970s and 1980s, 3 RCTs established the survival
3. CABG might be considered with the primary or sole intent of
benefit of CABG compared with contemporaneous (al-
improving survival in patients with SIHD with severe LV systolic
though minimal by current standards) medical therapy
dysfunction(EF(cid:1)35%)whetherornotviablemyocardiumispresent
without revascularization in certain subjects with stable
(30,64–68,83,84).(LevelofEvidence:B)
angina: the Veterans Affairs Cooperative Study (114), Eu-
4. TheusefulnessofCABGorPCItoimprovesurvivalisuncertainin
ropeanCoronarySurgeryStudy(55),andCASS(Coronary
patientswithpreviousCABGandextensiveanteriorwallischemia
Artery Surgery Study) (115). Subsequently, a 1994 meta-
onnoninvasivetesting(85–93).(LevelofEvidence:B)
analysis of 7 studies that randomized a total of 2,649
CLASSIII:HARM patients to medical therapy or CABG (30) showed that
1. CABGorPCIshouldnotbeperformedwiththeprimaryorsoleintent CABGofferedasurvivaladvantageovermedicaltherapyfor
toimprovesurvivalinpatientswithSIHDwith1ormorecoronary patientswithleftmainor3-vesselCAD.Thestudiesalso
stenosesthatarenotanatomicallyorfunctionallysignificant(e.g.,
established that CABG is more effective than medical
(cid:1)70%diameternon–leftmaincoronaryarterystenosis,FFR(cid:2)0.80,
therapy for relieving anginal symptoms. These studies
nooronlymildischemiaonnoninvasivetesting),involveonlythe
havebeenreplicatedonlyonceduringthepastdecade.In
leftcircumflexorrightcoronaryartery,orsubtendonlyasmallarea
MASS II (Medicine, Angioplasty, or Surgery Study II),
ofviablemyocardium(30,53,60,61,94–98).(LevelofEvidence:B)
patients with multivessel CAD who were treated with
CABG were less likely than those treated with medical
2.3. Revascularization to Improve Symptoms:
therapy to have a subsequent MI, need additional revas-
Recommendations
cularization, or experience cardiac death in the 10 years
after randomization (104).
CLASSI
1. CABGorPCItoimprovesymptomsisbeneficialinpatientswith1or Surgical techniques and medical therapy have improved
moresignificant((cid:1)70%diameter)coronaryarterystenosesame- substantially during the intervening years. As a result, if
nabletorevascularizationandunacceptableanginadespiteGDMT CABGweretobecomparedwithGDMTinRCTstoday,
(82,99–108).(LevelofEvidence:A) the relative benefits for survival and angina relief observed
several decades ago might no longer be observed. Con-
CLASSIIa
versely, the concurrent administration of GDMT may
1. CABGorPCItoimprovesymptomsisreasonableinpatientswith1
substantially improve long-term outcomes in patients
ormoresignificant((cid:1)70%diameter)coronaryarterystenosesand
treated with CABG in comparison with those receiving
unacceptable angina for whom GDMT cannot be implemented
medical therapy alone. In the BARI 2D (Bypass Angio-
becauseofmedicationcontraindications,adverseeffects,orpatient
preferences.(LevelofEvidence:C) plasty Revascularization Investigation 2 Diabetes) trial of
2. PCItoimprovesymptomsisreasonableinpatientswithprevious patients with diabetes mellitus, no significant difference in
CABG, 1 or more significant ((cid:1)70% diameter) coronary artery risk of mortality in the cohort of patients randomized to
stenoses associated with ischemia, and unacceptable angina de- GDMT plus CABG or GDMT alone was observed,
spiteGDMT(86,89,92).(LevelofEvidence:C) although the study was not powered for this endpoint,
3. ItisreasonabletochooseCABGoverPCItoimprovesymptomsin excluded patients with significant left main CAD, and
patientswithcomplex3-vesselCAD(e.g.,SYNTAXscore(cid:2)22),with included only a small percentage of patients with proximal