1. Home>
2. Specialties>
3. Cardiology>
4. Clinical Practice Guideline Watch

Guidelines: Percutaneous Coronary Intervention

Revised recommendations from the American College of Cardiology and American Heart Association

Sponsoring Organizations: American College of Cardiology, American Heart Association, Society for Cardiovascular Angiography and Interventions

Purpose: Since PCI guidelines were last published (2001), drug-eluting stents have become available and PCI has become the most widely used form of coronary revascularization. Grounded in evidence published through 2005, the new guidelines should help to guide decision making about PCI. The class I recommendations mentioned below reflect consistent evidence and/or consensus opinion; class IIa recommendations reflect some conflict among evidence or opinion, with the weight in favor of usefulness or efficacy.

Key Points:

1. Troponin now joins creatine kinase-MB as a class I–recommended measurement in patients with signs or symptoms of MI during or after PCI, and in those with complicated procedures. Measuring these biomarkers routinely 8 to 12 hours after PCI is now also considered reasonable in all patients (class IIa).

2. New class I recommendations call for institutions to conduct continuing quality-assessment reviews of outcomes and to participate in a recognized national data registry.

3. Recommended annual procedure volumes are:

• for elective PCI, >75 for operators and >400 for institutions. New language calls for the availability of on-site cardiac surgery.
  
• for primary PCI in ST-segment-elevation MI (STEMI), >11 for operators and >36 for institutions. Specific programmatic qualifications for performance of primary PCI without on-site surgery are suggested.
  

4. There are class IIa recommendations for PCI in asymptomatic patients with moderate to severe ischemia on noninvasive testing and, now, in patients with >50% left-main stenosis who are not candidates for bypass surgery. For this new anatomic indication (left-main disease), a class IIa recommendation calls for follow-up angiography 2 to 6 months after PCI.

5. Randomized trial data now support a class I–recommended early invasive PCI strategy for patients with unstable angina/non–ST-segment-elevation MI and high-risk features.

6. PCI is recommended in fibrinolytic-ineligible patients who present with STEMI within 12 hours of symptom onset (class I). There is also a new class IIb recommendation (with some evidence still forthcoming) for facilitated PCI as a possible reperfusion strategy in higher-risk patients when PCI is not immediately available and bleeding risk is low.

7. There is a new class I recommendation for distal embolic protection (when technically feasible) in patients undergoing PCI to saphenous-vein grafts.

8. The guidelines include class I recommendations for loading with clopidogrel before PCI and for continuation for up to 12 months after stenting in patients without high risk for bleeding.

9. Class IIa recommendations now identify bivalirudin and low-molecular-weight heparin as reasonable alternatives to unfractionated heparin, with bivalirudin also an alternative to glycoprotein IIb/IIIa inhibition in low-risk patients.

Comment: These updated guidelines emphasize quality assurance and operator and institutional competence. They also embrace the expanding use of and indications for drug-eluting stents. The recommendations for left-main PCI in nonsurgical patients and against elective PCI without onsite cardiac surgery are viewed as controversial by some interventionalists.

— Howard C. Herrmann, MD

Published in Journal Watch Cardiology January 12, 2006

Citation(s):

Smith SC Jr et al. ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention — Summary article: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention). Circulation 2006 Jan 3; 113:156-75.

• Original article (Subscription may be required)
• Medline abstract (Free)