Percutaneous Coronary Intervention Guidelines Updated

Sue Hughes
December 20, 2007 — The American College of Cardiology (ACC), the American Heart Association (AHA) and the Society for Cardiovascular Angiography and Interventions (SCAI) have updated guideline recommendations for percutaneous coronary intervention (PCI) to take into account new clinical trial results [1].
The update, developed by a group led by Dr Spencer King (Emory University School of Medicine, Atlanta, GA) and Dr Sidney Smith (University of North Carolina, Chapel Hill), includes major changes from new clinical trials reported from 2004 until 2006. It is now available on the ACC, AHA, SCAI, and Circulation websites and will be published, along with the recent STEMI guideline update, in the January 15, 2008 issues of Circulation and the Journal of the American College of Cardiology.
King and Smith outlined to heartwire the most important changes from the 2005 guidelines, as follows:
A new recommendation that dual antiplatelet therapy (with aspirin plus clopidogrel) be continued for at least 12 months after the placement of a drug-eluting stent if patients are not at high risk of bleeding. This comes with the advice that before implanting a drug-eluting stent, the interventional cardiologist should discuss with the patient the need for and duration of such treatment and confirm the patient's ability to comply with this therapy for at least 12 months. Also, for patients who may undergo surgery of any kind, the recommendation is to consider use of a bare-metal stent, as dual antiplatelet therapy would likely have to be interrupted.
A new recommendation for a loading dose of 600 mg of clopidogrel before or when PCI is performed. For those treated within 12 to 24 hours of fibrinolytic therapy, a loading dose of 300 mg may be considered.
A new recommendation that a planned reperfusion strategy using full-dose fibrinolytic therapy followed by immediate PCI should be avoided (after the Assessment of the Safety and Efficacy of a New Treatment Strategy with Percutaneous Coronary Intervention [ASSENT-4] trial), but that other facilitated regimens might be considered in high-risk patients with a low risk of bleeding when PCI is not available within 90 minutes.
The update says that PCI is now not recommended in patients 24 hours to 28 days post-MI with one- or two-vessel disease and a totally occluded coronary artery if they are hemodynamically and electrically stable and have no ongoing or easily provoked chest pain (from the results of the Occluded Artery [OAT] trial). However, for these patients or a patient who responds favorably to initial fibrinolysis, some physicians might use PCI selectively for those who don't continue to do well on drug therapy alone.
While the update committee still agreed that the balance of evidence supports an early invasive strategy for patients with unstable angina or non-ST elevation myocardial infarction (NSTEMI), who are at moderate and higher risk, they noted one recent study (Invasive versus Conservative Treatment in Unstable Coronary Syndromes [ICTUS]) that suggested that in those patients who are initially stabilized on comprehensive medical therapy, PCI may be used selectively.
Two noteworthy changes regarding antithrombotic drugs have also been included in the update. These are the recommendation that fondaparinux should not be used on its own in STEMI patients who have undergone PCI, because of reports of catheter thrombosis associated with its use (in the Organization for Assessment of Strategies for Ischemic Syndromes [OASIS 6] study), and the recognition of the Acute Catheterization and Urgent Intervention Triage strategY (ACUITY) trial results showing that bivalirudin alone was associated with rates of ischemia similar to those with glycoprotein (GP) IIb/IIIa inhibitors plus heparin and significantly less bleeding.
King commented to heartwire that the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial, suggesting that PCI is no better at preventing future events than optimal medical therapy alone in patients with stable coronary disease, was not included in this update, as the results came out after the committee had met. But he added that the COURAGE results were being incorporated in the new guidelines for stable disease, which are currently being prepared.