Feature: New ACC/AHA guidelines on PCI emphasize collaboration
The revised guidelines reflect a strategy implemented by the American Heart Association (AHA), the American College of Cardiology Foundation (ACCF) and the Society for Cardiovascular Angiography and Interventions (SCAI) to streamline the text, present more information in tables, reduce ambiguity and make the guideline writing more collaborative and nimble, said Blankenship, who is also director of cardiology for Geisinger Medical Center in Danville, Pa.
Features include a “heart team” approach when treating patients with unprotected left main or complex coronary artery disease (CAD), a section that compares CABG and PCI, subgroup recommendations and other updates.
“One of the common threads is collaboration, with other writing groups and among specialties,” Blankenship explained. “The guidelines themselves call for collaboration between cardiologists and surgeons with the heart team recommendations.”
For instance, the CAD revascularization section was co-written by the PCI committee and the CABG committee to make recommendations about patient selection for revascularization and for determining which procedure to use. The PCI committee engaged in similar collaborations with guideline committees developing documents on STEMI, stable ischemic heart disease and unstable angina/non-STEMI, according to a statement.
By collaborating, the committees were able to harmonize recommendations and minimize confusion, Blankenship said. “We came up with one master set of guidelines that could be dropped into PCI guidelines or CABG guidelines to make sure we didn’t have conflicting recommendations,” he said. “The same is true for PCI and STEMI guidelines, where overlapping recommendations were written by both groups.”
The guidelines offer specific recommendations for every anatomic subgroup of patient, include recommendations for newer antiplatelet drugs such as ticagrelor (Brilinta, AstraZeneca) and support use of the SYNTAX scoring system when considering treatment for patients with multivessel disease.
Blankenship said a flexible writing process allowed them to include trials that came out as they were writing the guidelines. For instance, recommendations for drugs such as ticagrelor were flagged while FDA approval was pending and included if approved or deleted if not approved. “There was an effort to keep it up-to-date and current,” he said.
Of all the recommendations, Blankenship sees the heart team concept as the most game-changing as it makes a Class 1 recommendation that cardiothoracic surgeons and interventional cardiologists review cases together and jointly provide treatment options. “We are finally codifying the importance of collaborating between specialties,” he said.
Some areas such as platelet function testing and clopidogrel (Plavix, Bristol-Myers Squibb/Sanofi Aventis) genetic testing remain “murky,” Blankenship said. Future research is likely to bring clarity, making them candidates for the next revision of the guidelines.
“There are many unresolved issues in interventional cardiology that we wrestle with on a daily basis,” Blankenship said. “These guidelines do not resolve, or even offer guidance, in all of the difficult situations we face every day. What they do is clearly delineate areas where there is sufficient evidence to make a recommendation, or where there is expert consensus clear enough to make a type C recommendation.”