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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EOn November 7, 2011, the American College of Cardiology Foundation, the American Heart Association, and the Society for Cardiovascular Angiography and Interventions published updated guidelines for the management of percutaneous coronary intervention and coronary artery bypass grafting [Levine G et al. \u003Cem\u003EJACC\u003C\/em\u003E 2001; Hillis D et al. \u003Cem\u003EJACC\u003C\/em\u003E 2011].\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EInterventional Techniques \u0026amp; Devices Guidelines\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EOn 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. \u003Cem\u003EJACC\u003C\/em\u003E 2001; Hillis D et al. \u003Cem\u003EJACC\u003C\/em\u003E 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: \u003Ca href=\u0022http:\/\/circ.ahajournals.org\/content\/early\/2011\/11\/07\/CIR.0b013e31823ba622.citation\u0022\u003Ehttp:\/\/circ.ahajournals.org\/content\/early\/2011\/11\/07\/CIR.0b013e31823ba622.citation\u003C\/a\u003E.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EThe 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\u0027s 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.\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EThe new revascularization guidelines also recommend using the Synergy between PCI with TAXUS and Cardiac Surgery (SYNTAX) score [\u003Ca href=\u0022http:\/\/www.syntaxscore.com\u0022\u003Ewww.syntaxscore.com\u003C\/a\u003E] in conjunction with the Society of Thoracic Surgeons (STS) surgical risk score [\u003Ca href=\u0022http:\/\/209.220.160.181\/STSWebRiskCalc261\/de.aspx\u0022\u003Ehttp:\/\/209.220.160.181\/STSWebRiskCalc261\/de.aspx\u003C\/a\u003E] 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 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.\u003C\/p\u003E\u003Cp id=\u0022p-5\u0022\u003EBased on recent clinical trial evidence, PCI to improve survival is reasonable as an alternative to CABG in selected stable patients with significant (\u226550% 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 [\u226422], 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 \u22655%) (Class IIa; LOE: B).\u003C\/p\u003E\u003Cp id=\u0022p-6\u0022\u003EPCI to improve survival may be a reasonable alternative to CABG in selected stable patients with significant (\u226550% 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\u2013intermediate SYNTAX score of \u0026lt;33, bifurcation left main CAD) [Genereux P et al. \u003Cem\u003ECirc Cardiovasc Interv\u003C\/em\u003E 2011]; and 2) clinical characteristics that predict an increased risk of adverse surgical outcomes (eg, moderate\u2013severe chronic obstructive pulmonary disease, disability from previous stroke, or previous cardiac surgery; STS [\u003Ca href=\u0022http:\/\/www.sts.org\u0022\u003Ewww.sts.org\u003C\/a\u003E]-predicted risk of operative mortality \u0026gt;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).\u003C\/p\u003E\u003Cp id=\u0022p-7\u0022\u003EThe updated PCI guideline includes new guidance on optimal antiplatelet therapy (APT). Ticagrelor treatment for at least 12 months following insertion of a drug-eluting 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).\u003C\/p\u003E\u003Cp id=\u0022p-8\u0022\u003ERecommendations 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 the first 6 hours, if it was not already initiated before the procedure. For those patients who are allergic to aspirin, clopidogrel is a reasonable alternative for postoperative APT. After CABG, patients should be restarted on aspirin therapy prior to discharge as well as prescribed other evidence-based cardioprotective therapies, such as statins, ACE inhibitors, and \u03b2-blockers 33, if they do not have contraindications.\u003C\/p\u003E\u003Cp id=\u0022p-9\u0022\u003EThe new 2011 guideline also expands on and adds to recommendations on numerous other topics including recommendations on statin therapy, the use of vascular closure devices, PCI in hospitals without on-site surgical backup, and coronary stenting.\u003C\/p\u003E\u003Cp id=\u0022p-10\u0022\u003EPCI might be considered in hospitals without onsite cardiac surgery facilities, provided that appropriate planning for program development has been accomplished and that rigorous clinical and angiographic criteria are used for proper patient selection (Class IIb; LOE: B).\u003C\/p\u003E\u003Cp id=\u0022p-11\u0022\u003EThe use of radial artery access can be useful in decreasing access site complications. Radial artery access is particularly appealing in patients with coagulopathy, elevated international normalized ratio due to warfarin, or morbid obesity (Class IIa: LOE: A).\u003C\/p\u003E\u003Cp id=\u0022p-12\u0022\u003EDrug-eluting stents are useful as an alternative to bare metal stents to reduce the risk of restenosis in cases in which the risk of restenosis is increased and the patient is likely to be able to tolerate and comply with prolonged dual APT (Class I; LOE: A for elective PCI; LOE: C for UA\/NSTEMI; LOE: A for STEMI).\u003C\/p\u003E\u003Cp id=\u0022p-13\u0022\u003EImplementing new guideline recommendations into daily practice is challenging for many clinicians, said David Faxon, MD, Brigham and Women\u0027s Hospital, Boston, Massachusetts, USA. The 2011 ACCF\/AHA\/SCAI guideline updates for PCI and CABG include 163 and 156 individual recommendations, respectively. Several tools are available to help health care professionals implement new standards of cardiac care, such as the AHA Get with the Guidelines initiative (\u003Ca href=\u0022http:\/\/www.heart.org\/HEARTORG\/HealthcareResearch\/GetWithTheGuidelines-Resuscitation\/Get-With-The-Guidelines-Resuscitation_UCM_314496_SubHomePage.jsp\u0022\u003Ehttp:\/\/www.heart.org\/HEARTORG\/HealthcareResearch\/GetWithTheGuidelines-Resuscitation\/Get-With-The-Guidelines-Resuscitation_UCM_314496_SubHomePage.jsp\u003C\/a\u003E), national registry programs that track patient outcomes and define new benchmarks, and electronic medical records that provide real-time feedback and documentation. Putting the 2011 ACCF\/AHA\/SCAI PCI and CABG guidelines into practice will require multidisciplinary approaches and collaboration among all members of the heart care team.\u003C\/p\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2011 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/11\/15\/32.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzmvy1\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}