AHA: Guidelines Favor High-Volume Cardiologists for Stent Placements

DALLAS, Nov. 13 - The latest guidelines for percutaneous coronary interventions have come down heavily on the side of new technology -- drug eluting stents over bare metal stents and distal protection devices to catch errant emboli.
Action Points
Explain to patients that the new guidelines for percutaneous coronary interventions recommend that elective procedures be performed by cardiologists who do 75 or more PCI procedures annually.
Explain that the new guidelines recommend that stents procedures be done at centers with onsite cardiac surgery availability.
But experience counts in the fast evolving world of stents, said William W. O'Neill, M.D., of the William Beaumont Hospital in Royal Oak, Mich., who was an American College of Cardiology representative on the task force that hammered out the new guidelines.
Dr. O'Neill said the new guidelines recommend that elective PCI procedures should only be done by cardiologists who are heavy-volume operators. They should do: more than 75 elective procedures a year and at least 11 emergent procedures a year.
The guidelines, which were unveiled here today at the American Heart Association meeting, also reaffirm the recommendation from the 2001 guidelines that elective PCI only be performed at sites that have onsite cardiac surgery facilities.
Sidney C. Smith Jr. M.D., of the University of North Carolina at Chapel Hill and chairman of the guideline writing committee, acknowledged that some centers-notably a few Mayo Clinic-affiliated sites-have had good outcomes with elective PCI performed without on-site heart surgery facilities. But he noted that overall data indicate a higher mortality for elective procedures performed at centers without heart surgeons on site.
Dr. O'Neill added that there is really no reason to perform PCI at those limited sites. "It's not a matter of access, because we have plenty of access to PCI in the U.S.," he said. He suggested that he suspected hospital administrators eying potential profit centers are the driving force behind centers that perform PCI without on-site surgery.
The guidelines, which are a joint effort of the American College of Cardiology, the American Heart Association, and the Society for Cardiovascular Angiography and Interventions, cram 109 recommendations into a 122-page document.
In addition to recommendations about volume and on-site surgery the guidelines recommend:
That cardiologists give preference to drug-eluting stents over bare metal stents in diabetic patients, patients with long lesions, and patients with small-diameter vessels.
Using Plavix (clopidogrel) for at least three months after placement of the Cypher (sirolimus-eluting) stent and for at least 6 months after placement of the Taxus (paclitaxel-eluting) stent.
Using distal-embolic protection devices whenever technically feasible in patients who are undergoing PCI to saphenous vein grafts.
Initiation of a regimen of aspirin and Plavix for all post-PCI patients unless otherwise indicated.
Consideration of ACE inhibitors for all patients with coronary artery disease, left ventricular dysfunction, or who have hypertension.
Initiation of beta-blocker therapy for six months post-MI for all patients unless contraindicated.
Initiation of glucose-lowering therapies in diabetic patients to bring hemoglobin A1C to levels to less than 7%.
Initiation of aggressive lipid-lowering therapy with the LDL cholesterol goal of less than 70 mg/dL.