ACCF/AHA Pocket Guideline Management of Patients Undergoing Coronary Artery Revascularization November 2011 Adapted from the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention and the 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery (Developed in Collaboration With the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons) © 2011 by the American College of Cardiology Foundation and the American Heart Association, Inc. The following material was adapted from the 2011 ACCF/AHA/ SCAI guideline for percutaneous coronary intervention. J Am Coll Cardiol 2011; doi: 10.1016/j.jacc.2011.08.007; and the 2011 ACCF/ AHA guideline for coronary artery bypass graft surgery. J Am Coll Cardiol 2011; doi: 10.1016/j.jacc.2011.08.009. This pocket guideline is available on the World Wide Web sites of the American College of Cardiology (www.cardiosource.org) and the American Heart Association (my.americanheart.org). For copies of this document, please contact Elsevier Inc. Reprint Department, e-mail: [email protected]; phone: 212-633-3813; fax: 212-633-3820. Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American College of Cardiology Foundation. Please contact Elsevier’s permission department at [email protected]. Contents 1. Introduction .............................................................................................. 4 2. The Heart Team Approach ....................................................................... 6 3. Guidelines for Revascularization to Improve Survival .......................... A. Left Main CAD ..................................................................................... 7 B. Single and Multivessel CAD .............................................................. 10 4. Guidelines for Revascularization to Improve Symptoms ................... 14 5. Clinical Factors That May Influence the Choice of Revascularization ... 15 A. Diabetes Mellitus ................................................................................ 15 B. Chronic Kidney Disease ..................................................................... 15 C. Completeness of Revascularization ................................................. 15 D. LV Systolic Dysfunction ................................................................... 16 E. Previous CABG ..................................................................................... 16 F. UA/NSTEMI ........................................................................................... 16 G. DAPT Compliance ................................................................................ 17 6. Post-PCI Management.............................................................................. 17 7. Post-CABG Management ......................................................................... 19 8. Secondary Prevention.............................................................................. 20 1. Introduction The goals of revascularization for patients with coronary artery disease (CAD) are 1) to improve survival and/or 2) to relieve symptoms, so the recommendations have been formulated to address these specific issues. When one method of revascularization is preferred over the other for improved survival, this consideration, in general, takes precedence over improved symptoms. When discussing options for revascularization with the patient, he or she should understand when the procedure is being performed in an attempt to improve symptoms and/or to improve survival. Revascularization recommendations are predominantly based on studies of patients with symptomatic stable ischemic heart disease (SIHD), and they should be interpreted in this context. When appropriate, specific recommendations are given for patients with unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI) or ST-elevation myocardial infarction (STEMI). 2 Historically, most studies regarding revascularization have been based on and reported according to angiographic criteria. Most studies have defined a “significant” stenosis as >70% diameter narrowing; therefore, for revascularization decisions and recommendations in this section, a “significant” stenosis has been defined as >70% diameter narrowing (>50% for left main CAD). More recently, physiologic criteria, such as an assessment of fractional flow reserve (FFR), has been used in deciding when revascularization is indicated. Thus, for recommendations in this section regarding revascularization, coronary stenoses with FFR <0.80 can also be considered to be “significant.” The ACCF/AHA classifications of recommendations and levels of evidence are utilized, and described in more detail in Table 1. 3 Table 1. Applying ClassificationTableTable 1. of Applying1. Recommendations Applying Classification Classification and Level of ofRecommendations of Evidence and Level of Evidence Recommendation and Level of Evidence SIZE OF TREAT MENSIZET E FFECOF TREAT T MENT E FFECT CLASS I CLASSCLASS IIa I CLASSCLASS IIb IIa CLASSCLASS III IIb No Benefit CLASS III No Benefit Benefit >>> Risk BenefitBenefit >> >>> Risk Risk BenefitBenefit > >> Risk Risk orBenefit CLASS > III Risk Harm or CLASS III Harm Additional studies with AdditionalAdditional studies studies with with broad AdditionalProcedure/ studies with broad Procedure/ Procedure/Treatment Procedure/Treatment Test Treatment Test Treatment focused objectives needed objectivesfocused objectivesneeded; additional needed objectives needed; additional SHOULD be performed/ SHOULD be performed/ COR III: Not No Proven COR III: Not No Proven administered IT administeredIS REASONABLE to per- registryIT IS REASONABLE data would be to helpful per- Noregistry benefit dataHelpful would Benefitbe helpful No benefit Helpful Benefit form procedure/administer Procedure/Treatmentform procedure/administer CORProcedure/Treatment III: Excess Cost Harmful COR III: Excess Cost Harmful treatment MAYtreatment BE CONSIDERED HarmMAY BE w/oCONS BenefitIDERED to Patients Harm w/o Benefit to Patients or Harmful or Harmful T T LEVEL A n RecommendationLEVEL A that n Recommendationn Recommendation in thatfavor n nRecommendation’s Recommendation in favor n nRecommendation Recommendation’s that n Recommendation that FFEC FFEC procedure or treatment of proceduretreatment or proceduretreatment usefulness/efficacyof treatment or procedure less procedureusefulness/efficacy or treatment less is procedure or treatment is E Multiple populations E Multiple populations is useful/effective beingis useful/effective useful/effective wellbeing established useful/effective notwell useful/effective established and may T not useful/effective and may evaluated* T evaluated* n Sufficient evidence from n Somen Sufficient conflicting evidence evidence from n nGreater Some conflicting evidence ben harmful Greater conflicting be harmful MEN Data derived from multiple MEN Data derived from multiple multiple randomized trials frommultiple multiple randomized randomized trials n n T evidencefrom multiple from multiple randomized T evidenceSufficient from evidence multiple from Sufficient evidence from randomized clinical trials or meta-analysesrandomized clinical trials trialsor meta-analyses or meta-analyses randomizedtrials or meta-analyses trials or multiplerandomized randomized trials or trials or multiple randomized trials or or meta-analyses or meta-analyses meta-analyses meta-analysesmeta-analyses meta-analyses LEVEL B n RecommendationLEVEL B that n Recommendationn Recommendation in thatfavor n nRecommendation’s Recommendation in favor n nRecommendation Recommendation’s that n Recommendation that procedure or treatment of proceduretreatment or proceduretreatment usefulness/efficacyof treatment or procedure less procedureusefulness/efficacy or treatment less is procedure or treatment is ION) OF TREA Limited populations ION) OF TREA Limited populations S S is useful/effective beingis useful/effective useful/effective wellbeing established useful/effective notwell useful/effective established and may not useful/effective and may evaluated* evaluated* n Evidence from single n Somen Evidence conflicting from single n nGreater Some conflicting ben harmful Greater conflicting be harmful Data derived from a Data derived from a randomized trial or evidencerandomized from trialsingle or evidenceevidence from from single single n evidenceEvidence fromfrom singlesingle n Evidence from single single randomized trial single randomized trial Y (PRECI randomized trial or Y (PRECI nonrandomized studies nonrandomized studies randomizedrandomized trial trial or or randomizedrandomized trial trial or or randomized trial or T or nonrandomized studies T or nonrandomized studies nonrandomized studies nonrandomizednonrandomized studies studies nonrandomizednonrandomized studies studies nonrandomized studies AIN AIN T T LEVEL C n RecommendationLEVEL C that n Recommendationn Recommendation in thatfavor n nRecommendation’s Recommendation in favor n Recommendation’s ER ER n Recommendation that n Recommendation that C C procedure or treatment is of proceduretreatment or proceduretreatment is usefulness/efficacyof treatment or procedure less usefulness/efficacy less Very limited populations Very limited populations procedure or treatment is procedure or treatment is useful/effective beinguseful/effective useful/effective wellbeing established useful/effective