New PCI, CABG Guidelines Embrace the Heart Team



The Heart Team is now officially the home team for selecting the best revascularization approach for patients with challenging coronary artery disease.

Two expert panels organized by the American College of Cardiology and American Heart Association each simultaneously released on Nov. 7 a revised set of guidelines – for Percutaneous Coronary Intervention (PCI) and for Coronary Artery Bypass Grafting (CABG). Both documents firmly recommended that physicians rely on Heart Teams to determine the best way to revascularize each patient who presents with either unprotected left main or "complex" coronary artery disease. The new revisions were also notable for the congruence of their recommendations, down to identical tables in both documents, and the collaboration between the two guideline-writing committees in coming up with their core revascularization sections (J. Am. Coll. Cardiol. 2011;58:doi:10.1016/j.jacc.2011.08.007; J. Am. Coll. Cardiol. 2011;58:doi:10.1016/j.jacc.2011.08.009).

"The 2011 guideline includes an unprecedented degree of collaboration [among cardiologists and cardiothoracic surgeons] in generating revascularization recommendations for patients with CAD [coronary artery disease]," said Dr. Glenn N. Levine, professor of medicine and director of the cardiac care unit at Baylor College of Medicine in Houston, and chairman of the PCI guidelines panel, in a written statement.

[Read more: Highlights of Revised PCI Guidelines.]

"It’s a breakthrough, the complete concordance of the revascularization sections" of the PCI and CABG guidelines, said Dr. Peter K. Smith, professor of surgery and chief of cardiovascular and thoracic surgery at Duke University in Durham, N.C., and vice-chairman of the CABG panel. The revascularization recommendations contained in both documents "were made with complete unanimity between the two groups," he said in an interview.

The new PCI guidelines also received endorsement from the Society for Cardiovascular Angiography and Interventions, while the new CABG recommendations carried imprimaturs from the Society of Thoracic Surgeons (STS), the American Association for Thoracic Surgery, and the Society of Cardiovascular Anesthesiologists.

The concept of relying on a Heart Team, a collaboration between at least one cardiologist and cardiac surgeon, to determine the best management strategy for a patient with coronary disease who could be managed by either an endovascular or surgical approach, first came to prominence in the mid-2000s during the SYNTAX (Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery) trial, the most recent large study to compare the safety and efficacy of PCI and CABG (N. Engl. J. Med. 2009;360:961-72). More recently, the PARTNER (Placement of Aortic Transcatheter Valves) trial for assessing the safety and efficacy of transcatheter aortic valve replacement, served as another high-profile setting for Heart Teams (N. Engl. J. Med. 2011;364:2187-98). The new guidelines for both PCI and CABG, which each gave the Heart Team approach a class 1 recommendation for managing patients with unprotected left main or complex CAD, represent the first time the Heart Team strategy received official endorsement from a health-policy setting group.

"The Heart Team concept evolved from these randomized trials, where patients could get either treatment. If that was how the trials led to their results, they are best replicated by using the same design," said Dr. Smith. When the guidelines refer to "complex" CAD, they mean triple vessel disease, as well as patients with two-vessel CAD that involves the proximal left anterior descending coronary artery, he noted. In such patients, as well as those with unprotected left main disease, the goal of revascularization is reduced mortality. Both sets of guidelines suggest assessing CAD complexity by calculating each patient’s SYNTAX score, a formula for quantifying CAD complexity originally developed for the SYNTAX trial. A score of 23 or higher defines more complex CAD, according to the new guidelines.

Results from "SYNTAX and other trials showed that [patients can] do as well with PCI or CABG for their longevity benefit," As a consequence, it is important for a cardiologist and surgeon to determine the suitability of each of these patients for the two options, Dr. Smith said.

The guidelines suggest physicians assess patients’ risk for surgery by quantifying their cardiac health and comorbidity severity by calculation of a STS score, as well as taking into account any other comorbidities not included in the STS score. "When the surgical risk is low, CABG is preferred even when PCI is possible, but if the surgery risk is high then patients should undergo PCI," he said. "Cardiac surgeons need to refer some patients with left main disease to PCI" because their clinical status makes them poor surgical candidates. "This is a big change [for cardiac surgeons], compared with 5 years ago," Dr. Smith said. "But only about 25% of left main patients fall into this category," where PCI is the better option.


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