Physician's Weekly Article - Updating Guidelines for PCI

       A collaboration of medical associations has led to the release of updated recommendations on use of PCI. Long-term dual antiplatelet therapy after PCI with drug-eluting stents is critical to ensuring positive outcomes.

      In 2005, the American College of Cardiology (ACC), the American Heart Association (AHA), and the Society for Cardiac Angiography and Interventions (SCAI) collaborated to create guidelines for the use of PCI, an effective strategy for treating heart attacks and symptoms of angina. Since that time, several important late-breaking clinical trials were published. As a result, the ACC/AHA/SCAI guidelines for PCI were updated in 2007, incorporating new evidence into clinical practice recommendations for physicians.

      Provide Long-Term Dual Antiplatelet Therapy

      In the past several years, the use of drug-eluting stents (DES) has increased substantially. However, several investigations have reported that DES are associated with a slightly higher risk of clot formation. “One of the most important updates in the 2007 guidelines for PCI is that patients receiving DES must take dual antiplatelet therapy consisting of aspirin and clopidogrel for 1 year, or longer in some cases, after their procedure,” explains Spencer B. King, III, MD, MACC, FAHA, FSCAI, who co-chaired the writing group that updated the 2005 ACC/AHA/SCAI guidelines for PCI (Table 1). “It’s important that physicians understand that this requirement increases the patient’s responsibility in treatment to ensure successful stenting. Physicians should discuss with patients their need for dual antiplatelet therapy. Patients need to be informed about the required commitment to these medications and understand that they’ll need to adhere to them for a lengthy period of time. Efforts are needed to ensure that patients follow through with these required therapies when they are recommended.”

      According to the 2007 guideline update, continuing dual antiplatelet therapy is so important that physicians may need to consider the potential impact of undergoing future medical procedures. “Some procedures may require dual antiplatelet therapy to be interrupted,” says Dr. King. “If patients face additional surgery, the revised guideline recommendations call for implanting bare-metal stents or performing a PCI with provisional stent implantation instead of routinely using DES. In these situations, physicians must again reemphasize the importance of the patient’s role. They will need to be actively involved in the decision, and their participation is necessary for achieving success.”

      Recognize Timing Issues in PCI

      The 2007 ACC/AHA/SCAI update also addresses the timing of PCI in certain patient groups presenting at various clinical settings. For example, facilitated PCI refers to a strategy of planned immediate PCI after administering an initial pharmacological regimen intended to improve coronary patency before the procedure. “It was initially believed that facilitated PCI could improve times to reperfusion, improve patient stability, increase procedural success rates, and decrease mortality rates,” explains Dr. King. “However, there are risks associated with this approach, including increased bleeding complications, especially in older patients, and potentially higher costs. Despite the potential advantages, clinical trials of facilitated PCI have not demonstrated any benefit in reducing infarct size or improving outcomes. As such, the use of facilitated PCI is not recommended in the new guidelines.”

      The usefulness and efficacy of PCI for re-opening occluded arteries in patients with one- or two- vessel coronary artery disease was also addressed in the guidelines for asymptomatic patients without evidence of ongoing ischemia. “The guidelines indicate that PCI is not recommended as long as patients are hemodynamically and electrically stable, and have no ongoing or easily-provoked ischemia,” Dr. King says. “However, physicians could use PCI selectively for patients who do not continue to do well on drug therapy alone and in those who respond favorably to initial fibrinolysis.”

      Consider Initially Conservative & Invasive Strategies

      Most of the evidence addressed in the guidelines support using an early invasive strategy for PCI in patients with unstable angina or non-ST elevation myocardial infarction (UA/NSTEMI). “The key is that UA/NSTEMI patients being considered for early invasive strategies are at moderate and higher risk,” says Dr. King (Table 2). “However, one recent study suggests that PCI may be used selectively in patients who are initially stabilized on comprehensive medical therapy. The guidelines now recognize that a selective invasive strategy can be considered as an alternative treatment option in initially stabilized patients.”

      Dr. King notes that the writing group’s update is based on analysis of the data available at the time of preparing the update and that the document will continually be reviewed for relevancy. “As new data become available and validated, additional updates will be issued as appropriate.”

      Editor’s Note: The “2007 Focused Update of the ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention” are available in their entirety in online issues of the Journal of the American College of Cardiology, Circulation, and Catheterization and Cardiovascular Interventions.

      Spencer B. King, III, MD, MACC, FAHA, FSCAI has indicated to Physician’s Weekly that he has worked as a consultant and/or advisory member for Medtronic and Sanofi-Aventis.