AHA: New 'fast-tracked' guidelines update STEMI management, PCI treatments

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Two sets of fast-tracked clinical guidelines, issued today at the AHA conference in Orlando, Fla., focus on a community-wide collaboration of emergency services for the management of STEMI patients, and present new treatment options for PCI.

The guidelines update is a joint effort of the American College of Cardiology (ACC), the American Heart Association (AHA) and the Society for Cardiovascular Angiography and Interventions (SCAI).

One of the new recommendations is for each community to develop an organized system of emergency care for MI patients, modeled after the AHA’s Mission: Lifeline initiative and the ACC’s Door-to-Balloon (D2B) campaign.

This plan would include protocols for identifying heart attack patients before they reached the hospital and directing ambulances to medical centers capable of rapidly performing PCI.

The guidelines include protocols for managing MI patients, who arrive at hospitals ill-equipped to perform PCI, including “arrangements for rapid transfer to a PCI center whenever possible.”

For MI patients who initially go to a non-PCI hospital and cannot be transferred quickly, the guidelines recommend they be treated with lytics. If the patients are later judged to be high risk, they should be transfered to a PCI center “without delay,” rather than waiting to observe whether the lytics were successful—as is common practice today.

“Patients should become advocates and urge their local hospital to become part of a community network that follows the recommendations of the Mission: Lifeline program,” said co-chair of the writing committee Frederick G. Kushner, MD, medical director of the Heart Clinic of Louisiana in New Orleans.

Another major change in the guidelines is greater acceptance of stenting for treatment of unprotected left main coronary artery disease. Traditionally, bypass surgery has been the recommended treatment for these patients; however, recent studies have shown that stenting of the left main is safe and effective.The new guidelines allow for left main stenting as an option when procedural complications are likely to be low and the patient faces an increased risk if treated surgically.

The guidelines recommend stenting left main disease only with no other vessel or one-vessel disease.

“There is mounting evidence that left main coronary stenting, under certain circumstances, does carry a reasonably good outcome,” said co-chair of the writing committee Spencer B. King, III, MD, president of St. Joseph’s Heart and Vascular Institute in Atlanta.

The guidelines update incorporates several additional changes, including the:

  • Use of fractional flow reserve;
  • Use of aspiration thrombectomy;
  • Use of prasugrel (Effient), which received a Class 1 recommendation;
  • Recommendations for use of a variety of blood thinners and anti-clotting medications before, during or after PCI; and
  • Broader recommendations on the types of x-ray contrast media that may be safely used to view the coronary arteries during PCI in patients with chronic kidney disease.

“The new process of rapidly updating guidelines will allow practitioners the opportunity to utilize contemporary evidence-based medicine to make critical decisions. Our patients will have more treatment options because the new guidelines include provisions for stenting left main and complex three-vessel coronary artery disease and stress the use of physiologic lesion assessment to optimize clinical outcomes,” said Steven R. Bailey, MD, SCAI president and cardiology division chief at the University of Texas Health Sciences Center at San Antonio.

The new guidelines update will be published in the Dec. 1 issues of the Journal of the American College of Cardiology and Circulation, and published online Nov. 18 in Catheterization and Cardiovascular Interventions.