Friday, December 14, 2007

Guideline Update for Percutaneous Coronary Intervention - 2007

2007 Focused Update of the ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines

Date Posted: 12/13/2007

Author(s): King S, Smith S, Hirschfeld JW, et al.

J Am Coll Cardiol. 2008;51:[Epub ahead of print].

Perspective: The following are 10 points to remember about this guideline update for percutaneous coronary intervention (PCI):

1. In patients with unstable angina (UA)/non–ST-elevation myocardial infarction (NSTEMI), an early invasive strategy is favored in the presence of recurrent angina or ischemia at rest or with low-level activities despite intensive medical therapy, elevated cardiac biomarkers (troponin T or troponin I), new or presumably new ST-segment depression, signs or symptoms of heart failure or new or worsening mitral regurgitation, high-risk findings from noninvasive testing, hemodynamic instability, sustained ventricular tachycardia, PCI within the prior 6 months, prior coronary artery bypass graft surgery or a high-risk score (e.g., TIMI, GRACE), or reduced left ventricular function (left ventricular ejection fraction <40%).

2. PCI is not indicated for a persistently occluded infarct-related artery after NSTEMI or STEMI older than 24 hours in a stable patient.

3. Creatinine clearance should be estimated in UA/NSTEMI patients, and medication dosage should be adjusted appropriately in patients with altered renal function.

4. In patients with chronic kidney disease undergoing coronary angiography or intervention, isosmolar contrast agents should be preferentially used (Level of Evidence: A).

5. In patients with STEMI, a planned reperfusion strategy using full-dose fibrinolytic therapy followed by immediate PCI may be harmful, and is not advocated.

6. A strategy of coronary angiography with intent to perform revascularization is recommended for patients who have received fibrinolytic therapy and are in cardiogenic shock and candidates for revascularization, and have severe heart failure or pulmonary edema or hemodynamically significant ventricular arrhythmias.

7. Rescue PCI should be considered in patients with STEMI who have received a fibrinolytic agent, have evidence of failed reperfusion (ST-segment resolution <50%) 90 minutes after initiation of fibrinolytic therapy, and have a moderate or large area of myocardium at risk.

8. Given the risk of catheter thrombosis, fondaparinux should not be used as the sole anticoagulant to support PCI. For patients who undergo PCI with prior treatment with fondaparinux, additional intravenous treatment with an anticoagulant possessing anti-IIa activity (such as unfractionated heparin) should be used.

9. Before implanting a drug-eluting stent (DES), the physician should discuss with the patient the need for and duration of dual antiplatelet therapy, and confirm the patient’s ability to comply with the recommended therapy. In patients who are likely to require invasive or surgical procedures for which antiplatelet must be interrupted during the next 12 months after PCI, consideration should be given to implantation of a bare-metal stent or performance of balloon angioplasty with a provisional stent implantation.

10. Continuation of clopidogrel therapy beyond 1 year may be considered in patients treated with DES.

Hitinder S. Gurm, M.B.B.S., F.A.C.C.

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