MD Conference Express AHA 2011 - (Page 32)

n O T H E R N E W S is conflicting evidence whether aspirin can prevent ischemic stroke (Class IIb recommendation). Future trials of primary and secondary prevention strategies in CVD should enroll diverse populations of female patients. With additional evidence, guidelines can be refined further to meet the specific needs of women who are at risk for adverse cardiovascular outcomes. Further reading: Masca L et al. Circulation 2011. disease, the SYNTAX scoring system provides an objective approach to guide the selection of revascularization strategies. By also utilizing the STS risk score, the risk/ benefit comparison of the two procedures is placed in perspective for the heart team. Based on recent clinical trial evidence, PCI to improve survival is reasonable as an alternative to CABG in selected stable patients with significant (≥50% diameter stenosis) unprotected left main CAD with: 1) anatomical conditions that are associated with a low risk of PCI procedural complications and a high likelihood of good long-term outcome (eg, a low SYNTAX score [≤22], ostial or trunk left main CAD); and 2) clinical characteristics that predict a significantly increased risk of adverse surgical outcomes (eg, STS predicted risk of operative mortality ≥5%) (Class IIa; LOE: B). PCI to improve survival may be a reasonable alternative to CABG in selected stable patients with significant (≥50% diameter stenosis) unprotected left main CAD with: 1) anatomical conditions that are associated with a low to intermediate risk of PCI procedural complications and an intermediate to high likelihood of good longterm outcome (eg, low–intermediate SYNTAX score of <33, bifurcation left main CAD) [Genereux P et al. Circ Cardiovasc Interv 2011]; and 2) clinical characteristics that predict an increased risk of adverse surgical outcomes (eg, moderate–severe chronic obstructive pulmonary disease, disability from previous stroke, or previous cardiac surgery; STS [www.sts.org]predicted risk of operative mortality >2%) (Class IIb; LOE: B). However, for patients with three-vessel disease, the updated guidelines reaffirm the superiority of CABG compared with both PCI and medical therapy (Class IIa; LOE: B). The updated PCI guideline includes new guidance on optimal antiplatelet therapy (APT). Ticagrelor treatment for at least 12 months following insertion of a drugeluting or bare metal stent is now included as a Class I recommendation. The guideline also recommends a simplified aspirin regimen (81 mg daily for all patients) following PCI, rather than higher maintenance doses, based on type of stent that is used, that could be reduced in the long term (Class IIa; LOE: B). Recommendations for APT before and after CABG have also been updated. All patients who undergo CABG should be given aspirin preoperatively. For patients who are undergoing elective CABG, treatment with clopidogrel and ticagrelor should be discontinued 5 days prior to surgery. In cases of emergency CABG, these agents should be discontinued for at least 24 hours before surgery when possible. After surgery, aspirin should be restarted within www.mdconferencexpress.com New Revascularization Guidelines Focus on Collaborative Care Written by Anne Jacobson On November 7, 2011, the American College of Cardiology Foundation (ACCF), the American Heart Association (AHA), and the Society for Cardiovascular Angiography and Interventions (SCAI) published updated guidelines for the management of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) [Levine G et al. JACC 2001; Hillis D et al. JACC 2011]. Peter K. Smith, MD, Duke University Medical Center, Durham, North Carolina, USA, moderated a session that reviewed key updates. Selected recommendations from the guidelines are summarized in this article. The online version of the complete report, along with updated information and services, can be found at: http:// circ.ahajournals.org/content/early/2011/11/07/ CIR.0b013e31823ba622.citation. The updated ACCF/AHA/SCAI guidelines for PCI and CABG emphasize the role of multidisciplinary heart teams that work together to develop a cardiac care plan for patients with coronary artery disease (CAD). Within this multidisciplinary model, cardiac surgeons and interventional cardiologists collaborate to review the patient’s coronary anatomy and presenting symptoms to determine the appropriateness of PCI and/or CABG. The heart team concept is included as a Class I recommendation for patients with unprotected left main or complex CAD. The new revascularization guidelines also recommend using the Synergy between PCI with TAXUS and Cardiac Surgery (SYNTAX) score [www.syntaxscore.com] in conjunction with the Society of Thoracic Surgeons (STS) surgical risk score [http://209.220.160.181/ STSWebRiskCalc261/de.aspx] when planning treatment for patients with multivessel disease (Class IIa; Level of Evidence [LOE]: B). By incorporating angiography results to estimate the extent and complexity of arterial 32 January 2012  http://www.mdconferencexpress.com http://circ.ahajournals.org/content/early/2011/11/07/CIR.0b013e31823ba622.citation http://www.sts.org http://circ.ahajournals.org/content/early/2011/11/07/CIR.0b013e31823ba622.citation http://circ.ahajournals.org/content/early/2011/11/07/CIR.0b013e31823ba622.citation http://www.syntaxscore.com http://209.220.160.181/STSWebRiskCalc261/de.aspx http://209.220.160.181/STSWebRiskCalc261/de.aspx http://www.mdconferencexpress.com

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MD Conference Express AHA 2011

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