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Erschienen in:
25.06.2019 | commentary
The top 10 messages of the 2018 ESC guidelines on myocardial revascularization
Erschienen in: Wiener klinische Wochenschrift | Ausgabe 13-14/2019
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After 4 years the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) have released an updated version of the guidelines for myocardial revascularization from 2014 [1]. The present article summarizes the 10 key points of the new guidelines.
1.
The heart team approach has received a class 1C recommendation to identify the most optimal treatment strategy for patients with ischemic heart disease while taking the patients’ preferences into account. This multidisciplinary heart team decision-making process is critical as interventional cardiologists, clinical cardiologists and cardiac surgeons are increasingly targeting the same patient population for medical treatment, percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG).
2.
Prior to myocardial revascularization prognostic and symptomatic benefits should be estimated in patients with stable angina or silent ischemia. Left main or proximal left anterior descending coronary artery stenoses >50%, 2 or 3‑vessel disease with stenosis >50% with severely impaired left ventricular function, a large area of myocardial ischemia or a stenosis >50% of the last patent coronary artery are considered as prognostically relevant. Other hemodynamically significant coronary stenoses should be treated in the presence of limiting angina or angina equivalent, refractory to optimized medical treatment.
3.
The synergy between percutaneous coronary intervention with TAXUS and cardiac surgery (SYNTAX) score is appropriate for gauging the anatomical complexity of coronary disease and should be routinely calculated in patients with left main or multivessel disease for identifying the most appropriate revascularization strategy.
4.
The Society of Thoracic Surgery (STS) risk score should be calculated for prediction of the patient’s risk of mortality and morbidity after CABG. The EuroSCORE II for assessment of in-hospital mortality after CABG has been downgraded to a class IIbB recommendation.
5.
Clinical and anatomical aspects favoring PCI include severe comorbidities, advanced age, frailty, reduced life expectancy, restricted mobility, conditions that affect the rehabilitation process, multivessel disease with a SYNTAX score 0–22, porcelain aorta or a poor quality of potential conduits. Factors favoring the surgical approach are diabetes, reduced left ventricular function, contraindications to dual antiplatelet therapy (DAPT), multivessel disease with a SYNTAX score ≥23 and the need for concomitant cardiac or aortic surgery.
6.
Radial access is preferred over femoral access for any coronary angiography and PCI regardless of clinical presentation, unless there are overriding procedural considerations.
7.
The use of drug-eluting stents (DES) is recommended for any PCI regardless of clinical or anatomical aspects. Bioresorbable scaffolds should not be used outside clinical studies.
8.
Routine revascularization of noninfarct-related arterial lesions is not recommended during primary PCI in myocardial infarction complicated by cardiogenic shock. In PCI of bifurcation lesions, stent implantation should be in the main vessel followed by provisional balloon angioplasty with or without stenting of the side branch.
9.
In out-of-hospital cardiac arrest survivors presenting with an electrocardiogram consistent with ST-elevation myocardial infarction (STEMI), a primary PCI strategy is recommended.
10.
As individual operator experience strongly influences patient outcome, current guidelines recommend that the annual operator volume for PCI for acute coronary syndrome should be ≥75 cases per year and for left main PCI ≥25 cases per year.