Transatlantic editorial: A comparison between European and North American guidelines on myocardial revascularization
2016; Elsevier BV; Volume: 152; Issue: 2 Linguagem: Inglês
10.1016/j.jtcvs.2016.04.053
ISSN1097-685X
AutoresPhilippe Kolh, Paul Kurlansky, Jochen Cremer, Jennifer S. Lawton, Matthias Siepe, Stephen E. Fremes,
Tópico(s)Cardiac Imaging and Diagnostics
ResumoCentral MessageThis editorial compares myocardial revascularization guidelines between North America and Europe. Based on the differences, new recommendations are made to improve patient outcomes. This editorial compares myocardial revascularization guidelines between North America and Europe. Based on the differences, new recommendations are made to improve patient outcomes. The 2014 edition of the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society of Cardiology (ESC) joint Guidelines on Myocardial Revascularization (MR) marks the 50th anniversary of the first coronary artery bypass grafting (CABG) procedure.1Kolh P. Windecker S. Alfonso F. Collet J.P. Cremer J. Falk V. et al.2014 ESC/EACTS guidelines on myocardial revascularization: the task force on myocardial revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI).Eur J Cardiothorac Surg. 2014; 46: 517-592Crossref PubMed Scopus (647) Google Scholar The first percutaneous coronary intervention (PCI) procedure was performed 13 years later, in 1977. Since these early times, MR techniques have gained clinical importance worldwide and are now one of the most commonly performed interventions in modern medicine. On the other side of the Atlantic, the American societies have also published several guidelines on MR: In 2011, the ACCF/AHA Guidelines for CABG Surgery2Hillis L.D. Smith P.K. Anderson J.L. Bittl J.A. Bridges C.R. Byrne J.G. et al.2011 ACCF/AHA guideline for coronary artery bypass graft surgery. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons.J Am Coll Cardiol. 2011; 58: e123-e210Abstract Full Text Full Text PDF PubMed Scopus (601) Google Scholar; the 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease3Fihn S.D. Gardin J.M. Abrams J. Berra K. Blankenship J.C. Dallas A.P. et al.2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.J Am Coll Cardiol. 2012; 60: e44-e164Abstract Full Text Full Text PDF PubMed Scopus (1307) Google Scholar; the 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update4Fihn S.D. Blankenship J.C. Alexander K.P. Bittl J.A. Byrne J.G. Fletcher B.J. et al.2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.J Thorac Cardiovasc Surg. 2015; 149: e5-23Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar and in 2015, the Society of Thoracic Surgeons (STS) Clinical Practice Guidelines on Arterial Conduits.5Aldea G.S. Bakaeen F.G. Pal J. Fremes S. Head S.J. Sabik J. et al.The Society of Thoracic Surgeons Clinical Practice Guidelines on Arterial Conduits for coronary artery bypass grafting.Ann Thorac Surg. 2016; 101: 801-809Abstract Full Text Full Text PDF PubMed Scopus (251) Google Scholar In view of the rapidly evolving landscape of therapeutic options, this Transatlantic Editorial is intended to compare the European and American societies' guidelines on MR, covering important topics such as decision-making, patient information, timing of revascularization, risk scores, ischemia testing, revascularization with CABG versus PCI, use of arterial conduits in CABG, on-pump versus off-pump surgery, revascularization in diabetic patients and implementation of guidelines. The American as well as European guidelines strongly advocate the implementation of “Heart Team” decisions for complex and stable coronary artery disease (CAD) as a class of recommendation (COR) I, with level of evidence (LOE) C. Recommendations for Heart Team involvement in stable multivessel CAD are stronger in the European guidelines (“required”) compared with the American guidelines (“recommended”). Furthermore, the description of the Heart Team differs: According to the EACTS/ESC Guidelines, at least three specialists (clinical cardiologist, interventional cardiologist and surgeon) should meet on a regular basis and protocols be followed.1Kolh P. Windecker S. Alfonso F. Collet J.P. Cremer J. Falk V. et al.2014 ESC/EACTS guidelines on myocardial revascularization: the task force on myocardial revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI).Eur J Cardiothorac Surg. 2014; 46: 517-592Crossref PubMed Scopus (647) Google Scholar On the other side of the Atlantic, the American guidelines do not describe this multidisciplinary Heart Team in a conference style, but recommend that the interventional cardiologist and surgeon, together as a Heart Team, should discuss the treatment options.3Fihn S.D. Gardin J.M. Abrams J. Berra K. Blankenship J.C. Dallas A.P. et al.2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.J Am Coll Cardiol. 2012; 60: e44-e164Abstract Full Text Full Text PDF PubMed Scopus (1307) Google Scholar For centres without infrastructure for on-site coronary surgery, the European guidelines recommend institutional protocols that need to be established with partner institutions providing surgery. The benefit of a Heart Team decision is convincingly presented throughout all available literature in line with the authors' attitudes. The superiority of a team decision-based treatment is derived from comparing randomized and registry cohorts with better results for the registry cohorts.6Feit F. Brooks M.M. Sopko G. Keller N.M. Rosen A. Krone R. et al.Long-term clinical outcome in the Bypass Angioplasty Revascularization Investigation Registry: comparison with the randomized trial. BARI Investigators.Circulation. 2000; 101: 2795-2802Crossref PubMed Scopus (176) Google Scholar, 7King III, S.B. Barnhart H.X. Kosinski A.S. Weintraub W.S. Lembo N.J. Petersen J.Y. et al.Angioplasty or surgery for multivessel coronary artery disease: comparison of eligible registry and randomized patients in the EAST trial and influence of treatment selection on outcomes. Emory Angioplasty versus Surgery Trial Investigators.Am J Cardiol. 1997; 79: 1453-1459Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar It has been shown that the initiation of the structured Heart Team approach could lead to beneficial clinical outcomes.8Bonzel T. Schachinger V. Dorge H. Description of a Heart Team approach to coronary revascularization and its beneficial long-term effect on clinical events after PCI.Clin Res Cardiol. 2015; ([Epub ahead of print])Google Scholar Other centres report that the decision and referral strategies did not change at all after initiation of the European guidelines, which is a clear example of how deep-set local habits and beliefs can be and how resistant some practitioners can be to change.9Yates M.T. Soppa G.K. Valencia O. Jones S. Firoozi S. Jahangiri M. Impact of European Society of Cardiology and European Association for Cardiothoracic Surgery Guidelines on myocardial revascularization on the activity of percutaneous coronary intervention and coronary artery bypass graft surgery for stable coronary artery disease.J Thorac Cardiovasc Surg. 2014; 147: 606-610Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar Interestingly, re-discussing the same patients after 1 year leads to different decisions in 24% of the cases. This fact underscores that, in some CAD patients, both treatment modalities might be appropriate.10Long J. Luckraz H. Thekkudan J. Maher A. Norell M. Heart team discussion in managing patients with coronary artery disease: outcome and reproducibility.Interact CardioVasc Thorac Surg. 2012; 14: 594-598Crossref PubMed Scopus (36) Google Scholar Also, the importance of including other clinical specialists as part of the Heart Team is reflected by the fact that taking the severe cases into this conference might lead to a significant proportion of treatment recommendations other than MR (eg, heart transplantation, ventricular assist device, valve surgery or medical therapy).8Bonzel T. Schachinger V. Dorge H. Description of a Heart Team approach to coronary revascularization and its beneficial long-term effect on clinical events after PCI.Clin Res Cardiol. 2015; ([Epub ahead of print])Google Scholar Patient consent discussion is handled differently in the existing guidelines. While the EACTS/ESC Guidelines expand on that topic including specific recommendation categorization, informed consent is only mentioned as a prerequisite of “any invasive or non-invasive procedure” in the American guidelines.3Fihn S.D. Gardin J.M. Abrams J. Berra K. Blankenship J.C. Dallas A.P. et al.2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.J Am Coll Cardiol. 2012; 60: e44-e164Abstract Full Text Full Text PDF PubMed Scopus (1307) Google Scholar Conversely, the American guidelines are much more precise on the topic of Patient Education. The EACTS/ESC Guidelines put forward the importance of patient information and need for an extensive informed consent process. They conclude that enough time should be allowed for informed decision-making. Specifically, in a high proportion of patients with stable CAD, a gap between diagnostic angiography and revascularization should exist to allow sufficient time to receive information about all therapeutic alternatives. Written informed consent is specifically needed for all procedures done with the exception of patients in shock or with ST-segment elevation myocardial infarction (STEMI). The treatment of STEMI patients with primary emergency PCI is unquestionable. The EACTS and ESC representatives have included this patient cohort in the joint guidelines, whereas the major American societies have formulated separate guidelines for the management of STEMI.11O'Gara P.T. Kushner F.G. Ascheim D.D. Casey Jr, D.E. Chung M.K. de Lemos J.A. et al.2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.Circulation. 2013; 127: e362-e425Crossref PubMed Scopus (778) Google Scholar For those patients with non-ST-segment elevation (NSTE)-acute coronary syndrome (ACS), the European guidelines recommend revascularization within 24 or 72 h, according to patient risk stratification. Primary criteria for urgency (invasive strategy within 24 h) are met with rising troponin levels, dynamic ST-segment or T-wave changes or a GRACE score of >140.1Kolh P. Windecker S. Alfonso F. Collet J.P. Cremer J. Falk V. et al.2014 ESC/EACTS guidelines on myocardial revascularization: the task force on myocardial revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI).Eur J Cardiothorac Surg. 2014; 46: 517-592Crossref PubMed Scopus (647) Google Scholar In the American guidelines,2Hillis L.D. Smith P.K. Anderson J.L. Bittl J.A. Bridges C.R. Byrne J.G. et al.2011 ACCF/AHA guideline for coronary artery bypass graft surgery. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons.J Am Coll Cardiol. 2011; 58: e123-e210Abstract Full Text Full Text PDF PubMed Scopus (601) Google Scholar, 3Fihn S.D. Gardin J.M. Abrams J. Berra K. Blankenship J.C. Dallas A.P. et al.2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.J Am Coll Cardiol. 2012; 60: e44-e164Abstract Full Text Full Text PDF PubMed Scopus (1307) Google Scholar, 4Fihn S.D. Blankenship J.C. Alexander K.P. Bittl J.A. Byrne J.G. Fletcher B.J. et al.2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.J Thorac Cardiovasc Surg. 2015; 149: e5-23Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar the recommendation for these urgent patients is based on a more general rule, indicating that the acuity of presentation and extent of ischemia dictate the timing of intervention. Interestingly, both guidelines see only the need for revascularization strengthened. However, the choice of revascularization method is mainly independent of the urgency and influenced by the same considerations for choosing PCI or CABG in the stable patient cohort. However, American guidelines state that PCI is reasonable in patients undergoing revascularization for NSTE-ACS. Both guidelines favor CABG over PCI for NSTE-ACS patients with diabetes mellitus with complex CAD. Comparisons between American and European Guidelines for patients with NSTE-ACS are outlined in Table 1.Table 1ACCF/AHA and EACTS/ESC Guidelines on NSTEMIACCF/AHA 2011 (Hillis2Hillis L.D. Smith P.K. Anderson J.L. Bittl J.A. Bridges C.R. Byrne J.G. et al.2011 ACCF/AHA guideline for coronary artery bypass graft surgery. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons.J Am Coll Cardiol. 2011; 58: e123-e210Abstract Full Text Full Text PDF PubMed Scopus (601) Google Scholar) and 2012 (Fihn3Fihn S.D. Gardin J.M. Abrams J. Berra K. Blankenship J.C. Dallas A.P. et al.2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.J Am Coll Cardiol. 2012; 60: e44-e164Abstract Full Text Full Text PDF PubMed Scopus (1307) Google Scholar)ACC/AHA 2014 Focused Update (Amsterdam12Amsterdam E.A. Wenger N.K. Brindis R.G. Casey Jr, D.E. Ganiats T.G. Holmes Jr., D.R. et al.2014 AHA/ACC guideline for the management of patients with non-st-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.J Am Coll Cardiol. 2014; 64: e139-e228Abstract Full Text Full Text PDF PubMed Scopus (2017) Google Scholar)ESC 2011 (Hamm13Hamm C.W. Bassand J.P. Agewall S. Bax J. Boersma E. Bueno H. et al.ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: the task force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC).Eur Heart J. 2011; 32: 2999-3054Crossref PubMed Scopus (3043) Google Scholar)EACTS/ESC 2014 (Kolh1Kolh P. Windecker S. Alfonso F. Collet J.P. Cremer J. Falk V. et al.2014 ESC/EACTS guidelines on myocardial revascularization: the task force on myocardial revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI).Eur J Cardiothorac Surg. 2014; 46: 517-592Crossref PubMed Scopus (647) Google Scholar)NSTEMIPCI vs CABG reference previous published guidelines for revascularization in stable CADClass I: PCI vs CABG with multivessel disease or complex lesions should be discussed with Heart TeamClass IIb (LOE B). A strategy of multivessel PCI, in contrast to culprit-only PCI, may be reasonable in patients undergoing coronary revascularization as part of treatment for NSTE-ACSClass I (LOE C). The revascularization strategy (ad hoc culprit lesion PCI/multivessel PCI/CABG) should be based on the clinical status as well as the disease severity (SYNTAX score), according to the Heart Team protocolClass I (LOE C). It is recommended to base revascularization strategy (ad hoc culprit lesion PCI multivessel PCI/CABG) on clinical status and comorbidities as well as disease severity (SYNTAX) according to the Heart Team protocolDiabetic patientsClass IIa (LOE B). Reasonable to choose CABG over PCI in older (≥75 years) patients with NSTE-ACS who are appropriate candidates, DM, three-vessel CAD (SYNTAX >22) with or without involvement of proximal LAD to decrease events and readmission, and improve survivalClass I (LOE B). CABG should be favored over PCI in diabetic patients with main stem lesions and/or advanced multivessel diseaseUnprotected LMClass IIa (LOE B) PCI for unstable angina/NSTEMI if not a CABG candidateClass I (LOE C). Recommend to base revascularization strategy on clinical status and comorbidities as well as the disease severity (SYNTAX) according to the local Heart Team protocolACCF, American College of Cardiology Foundation; ACS, acute coronary syndrome; AHA, American Heart Association; CABG, coronary artery bypass grafting; CAD, coronary artery disease; DM, diabetes mellitus; EACTS, European Association for Cardio-Thoracic Surgery; ESC, European Society of Cardiology; LAD, left anterior descending; LM, left main; LOE, level of evidence; NSTEMI, non-ST-segment elevation myocardial infarction; PCI, percutaneous coronary intervention. Open table in a new tab ACCF, American College of Cardiology Foundation; ACS, acute coronary syndrome; AHA, American Heart Association; CABG, coronary artery bypass grafting; CAD, coronary artery disease; DM, diabetes mellitus; EACTS, European Association for Cardio-Thoracic Surgery; ESC, European Society of Cardiology; LAD, left anterior descending; LM, left main; LOE, level of evidence; NSTEMI, non-ST-segment elevation myocardial infarction; PCI, percutaneous coronary intervention. For stable patients without severe symptoms, the EACTS/ESC Guidelines consider a maximum waiting time of 6 weeks to revascularization appropriate. Whenever symptoms are severe, anatomy high-risk or left ventricular function depressed, the European guidelines recommend revascularization within 2 weeks.1Kolh P. Windecker S. Alfonso F. Collet J.P. Cremer J. Falk V. et al.2014 ESC/EACTS guidelines on myocardial revascularization: the task force on myocardial revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI).Eur J Cardiothorac Surg. 2014; 46: 517-592Crossref PubMed Scopus (647) Google Scholar Interestingly, the American guidelines do not cover this problem. The waiting times in American centres appear to have been reduced and this topic might not be of the same significance as in previous years.14Southern D.A. Izadnegahdar M. Humphries K.H. Gao M. Wang F. Knudtson M.L. et al.Trends in wait times for cardiac revascularization.Can J Cardiol. 2011; 27: 262-267Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar Also, differences in payer systems in Europe and America contribute to timing considerations. In addition, cultural and social expectations are likely to be different among patients and cardiologists across the Atlantic. Various risk scores validated for the short-term mortality after CABG are available (STS score, EuroSCORE and EuroSCORE II, ACEF), but these scores do not predict medium- or long-term outcome. The SYNTAX score was developed to summarize the complexity of coronary lesions.15Sianos G. Morel M.A. Kappetein A.P. Morice M.C. Colombo A. Dawkins K. et al.The SYNTAX score: an angiographic tool grading the complexity of coronary artery disease.EuroIntervention. 2005; 1: 219-227PubMed Google Scholar It was found that medium- and long-term outcomes correlated with the SYNTAX score. Both guidelines see an important role of using risk scores—especially the SYNTAX score. The American guidelines provide a COR IIa (LOE B) for the use of STS and SYNTAX scores in patients with complex CAD and unprotected left main (LM) disease, whereas the EACTS/ESC Guidelines recommend the use of the SYNTAX score to assess medium- to long-term outcome before CABG or PCI (COR I, LOE B). The STS score (COR I, LOE B) or the EuroSCORE II (COR IIa, LOE B) should be used to assess short-term outcome after CABG. Also, some recommendations in the choice of treatment modality are based on the SYNTAX score in the guidelines (see specific paragraph). Of note, limitations exist in all risk models and the performance in the specific centre's patient cohort should be taken into consideration. The risk scores should only be used as an adjunct, whereas the Heart Team's decision based on the clinical profile remains essential. The EACTS/ESC Guidelines recommend diagnostic testing in stable CAD only in symptomatic patients and based on the probability of significant disease. In patients with intermediate probability (15%–85%) of significant disease, functional testing using stress echocardiography, nuclear imaging, stress MRI or PET perfusion scan is recommended (COR I, LOE A for all four modalities), while CT angiography should be considered (COR IIa, LOE A). In case of higher probability, coronary angiography is recommended (COR I, LOE A). Exercise electrocardiogram (ECG) is not mentioned. The American guidelines delve into the recommendation of diagnostic tests in greater detail, which are presented in an algorithm.3Fihn S.D. Gardin J.M. Abrams J. Berra K. Blankenship J.C. Dallas A.P. et al.2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.J Am Coll Cardiol. 2012; 60: e44-e164Abstract Full Text Full Text PDF PubMed Scopus (1307) Google Scholar Taking together the COR I from the algorithm, they recommend the use of exercise ECG in those patients with interpretable ECG (COR I, LOE A). In patients with non-interpretable ECG, exercise test with nuclear imaging or echocardiography is advocated (COR I, LOE B). In patients unable to exercise, pharmacological stress nuclear imaging or echocardiography should be performed (COR I, LOE B). CT angiography should be considered (COR IIa, LOE C) in several circumstances with inconclusive results or inability to perform class I recommended tests. With the 5-year results of the SYNTAX trial showing a clear survival benefit for several surgical subgroups,16Mohr F.W. Morice M.C. Kappetein A.P. Feldman T.E. Stahle E. Colombo A. et al.Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial.Lancet. 2013; 381: 629-638Abstract Full Text Full Text PDF PubMed Scopus (1249) Google Scholar the European guidelines focus very precisely on the grading of the complexity of the coronary disease according to the original SYNTAX score. Thus, these guidelines give a clear COR I (LOE A or B) for surgery of any coronary disease exhibiting proximal left anterior descending (LAD) coronary artery stenosis, any three-vessel disease and any LM stenosis. However, PCI is recommended as an alternative for patients with one- and two-vessel disease with proximal LAD involvement, LM disease with a low SYNTAX score and three-vessel disease also with a low SYNTAX score. Conversely, PCI should not be used (COR III) in patients with LM disease and high SYNTAX score or with three-vessel disease and intermediate or high SYNTAX score. The American guidelines, in general, appear more liberal with the use of PCI in patients with three-vessel disease when low or intermediate complexity is present and more restrictive when LM disease is involved. They are not so closely structured according to the SYNTAX score or other means representing the complexity of the coronary anatomy. Rather, a subset of clinical scenarios is taken into consideration. Comparisons between American and European guidelines for patients with stable CAD are detailed in Table 2.Table 2ACCF/AHA and EACTS/ESC Guidelines on Myocardial RevascularizationGuidelines for myocardial revascularization to improve survival in stable ischemic diseaseACCF/AHA 2011 (Hillis2Hillis L.D. Smith P.K. Anderson J.L. Bittl J.A. Bridges C.R. Byrne J.G. et al.2011 ACCF/AHA guideline for coronary artery bypass graft surgery. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons.J Am Coll Cardiol. 2011; 58: e123-e210Abstract Full Text Full Text PDF PubMed Scopus (601) Google Scholar) and 2012 (Fihn3Fihn S.D. Gardin J.M. Abrams J. Berra K. Blankenship J.C. Dallas A.P. et al.2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.J Am Coll Cardiol. 2012; 60: e44-e164Abstract Full Text Full Text PDF PubMed Scopus (1307) Google Scholar)ACC/AHA 2014 Focused Update (Fihn4Fihn S.D. Blankenship J.C. Alexander K.P. Bittl J.A. Byrne J.G. Fletcher B.J. et al.2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.J Thorac Cardiovasc Surg. 2015; 149: e5-23Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar)EACTS/ESC 2014 (Kolh1Kolh P. Windecker S. Alfonso F. Collet J.P. Cremer J. Falk V. et al.2014 ESC/EACTS guidelines on myocardial revascularization: the task force on myocardial revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI).Eur J Cardiothorac Surg. 2014; 46: 517-592Crossref PubMed Scopus (647) Google Scholar)Unprotected LM or complex CADClass 1 (LOE C): Heart Team approach recommendedMultidisciplinary decision-making required for multivessel stable
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