Title: ACCAHA Guidelines for Percutaneous Coronary Intervention Revised 601, JACC
1ACC/AHA Guidelines for Percutaneous Coronary
Intervention Revised 6/01,
JACC
2Historical Timeline of Cardiac Catheterization
- 1844 Claude Bernard catheterizes both the right
and left ventricles of a horse via the jugular
vein and carotid artery. - 1929 Werner Forssmann credited with being the
first person to catheterize a living person,
himself. At age 25, while receiving clinical
instruction in surgery at Eberswalde, near
Berlin, he passed a catheter 65 cm through one of
his left antecubital veins, guiding it by
fluoroscopy until it entered his right atrium.
He then walked to the radiology department
(upstairs), where the catheter was documented
with a cxr.
3Historical Timeline of Cardiac Catheterization
- 1930 Klein reports 11 right-sided heart
catheterizations, and 2 measurements of CO using
the Fick equation. - 1932 Padillo et al also reports successful right
heart catheterization with CO measurement. - 1940-1950s Andre Cournand and Dickinson Richards
report a large series of investigations of right
heart physiology in humans. - 1947 Dexter reports his studies on congenital
heart disease. Reports the first catheterization
of the distal pulmonary artery. - 1953 Seldinger develops his percutaneous
technique of vascular access. - 1959 Sones selective coronary arteriography.
- 1977 Gruntzig introduces the technique of PTCA.
4ACC/AHA Style Classification
- Class I Conditions for which there is evidence
for - and/or general agreement that
the - procedure or treatment is useful
and effective. - Class II Conditions for which there is
conflicting evidence - and/or a divergence of opinion
about the - usefulness/efficacy of a
procedure or treatment. - Class IIa Weight of evidence/opinion
is - in favor of
usefulness/efficacy. - Class IIb Usefulness/efficacy is less
well - established by
evidence/opinion.
- Class III Conditions for which there is
evidence and/or - general agreement that the
- procedure/treatment is not
useful/effective, and - in some cases may be harmful.
5Level of Evidence
- A Data derived from multiple randomized
- clinical trials.
- B Data derived from a single randomized
- trial or nonrandomized studies.
- C Consensus opinion of experts.
6Recommendations for PCI Institutional and
Operator Volumes at Centers With Onsite Cardiac
Surgery
- Cited 11 studies which identified procedural
volumes as a determining factor for frequency of
complications with PCI. - Kimmel, et alJAMA 1995...Using data from the
Society of Cardiac Angiography and Interventions,
found that an inverse relationship existed
between the number of angioplasty procedures
performed at a hospital and the rate of major
complications. These results were risk
stratified and independent of patient risk
profile. Significantly fewer complications
occurred in labs performing gt400 angioplasty
procedures/year. Conversely, low volume
hospitals were associated with higher rates of
emergent CABG surgery and death. Improved
outcomes were identified with a threshold volume
of 75 Medicare angioplasties per physician and
200 Medicare angioplasties per hospital.
7Recommendations for PCI Institutional and
Operator Volumes at Centers With Onsite Cardiac
Surgery
- Class I
- PCI done by operators with acceptable volume
(gt75) at high volume centers (gt400).
(Level of evidence B) - Class IIa
- 1. PCI done by operators with acceptable
volume (gt75) at - low volume centers (200-400). (Level of
evidence C) - 2. PCI done by low volume operators (lt75) at
high-volume centers (gt400). Note Ideally,
operators with an annual procedure volume lt75
should only work at institutions with an activity
level of gt600 procedures/year. -
(Level of evidence C)
8Recommendations for PCI Institutional and
Operator Volumes at Centers With Onsite Cardiac
Surgery
- Class III
- PCI done by low-volume operators (lt75) at
low-volume centers (200-400). Note An
institution with a volume lt200 procedures/year,
unless in a region that is underserved because of
the geography, should carefully consider whether
it should continue to offer service. - (Level of
evidence C)
9Recommendations for PCI With and Without On-Site
Cardiac Surgery
- Primary PCI in the early phase of an acute MI can
be difficult, and requires even more skill and
experience than routine PCI. - The need for an experienced operator and
experienced lab technical support with
availability of a broad range of catheters,
guidewires, stents, IABPs, etc - Thrombolysis is still an acceptable form of
therapy and is preferable to acute PCI by an
inexperienced team.
10Recommendations for PCI With and Without On-Site
Cardiac Surgery
- Class I
- 1. Patients undergoing elective PCI in
facilities with on-site cardiac surgery. - (Level of
evidence B) - 2. Patients undergoing primary PCI in
facilities with on-site cardiac surgery. - (Level of
evidence B)
11Recommendations for PCI With and Without On-Site
Cardiac Surgery
- Class IIb
- Patients undergoing primary PCI in facilities
without on-site cardiac surgery, but with a
proven plan for rapid access (within 1 h) to a
cardiac surgery operating room in a nearby
facility with appropriate hemodynamic support
capability for transfer. The procedure should be
limited to patients with ST-segment elevation MI
or new LBBB on ECG, and done in a timely fashion
(balloon inflation within 90 /- 30 min. of
admission) by persons skilled in the procedure
(gt75 PCIs/year) and only at facilities performing
a minimum of 36 primary PCI procedures per year. -
(Level of evidence B)
12Recommendations for PCI With and Without On-Site
Cardiac Surgery
Based on Class IIb recommendations, if patient
is not having active life-threatening
ischemia, better to arrange transfer of care,
rather than attempt PCI in a hospital without
on-site cardiac surgery.
13TIMI
- TIMI 0 Refers to the absence of any antegrade
flow beyond a coronary - occlusion.
- TIMI 1 Flow is faint antegrade coronary flow
beyond the occlusion, - although filling of the distal
coronary bed is incomplete. - TIMI 2 Flow is delayed or sluggish antegrade
flow with complete filling - of the distal territory.
- TIMI 3 Flow is normal flow which fills the
distal coronary bed - completely.
- The outcome after thrombolytic therapy in
patients with an STEMI is related to the degree - to which flow has been restored in the
infarct-related artery. The TIMI classification
is - commonly used. It characterizes coronary blood
flow in the infarct-related artery, which is - usually measured at 60 to 90 minutes after the
administration of thrombolytic therapy
14Recommendations for PCI With and Without On-Site
Cardiac Surgery
- Class III
- 1. Patients undergoing elective PCI in
facilities - without on-site cardiac surgery.
-
(Level of evidence C) - 2. Patients undergoing primary PCI in
facilities without on- - site cardiac surgery and without a proven
plan for rapid - access (within 1 h) to a cardiac surgery
operating room - in a nearby facility with appropriate
hemodynamic - support capability for transfer or when
performed by - lower skilled operators (lt75 PCIs/year)
in a facility - performing lt36 primary PCI
procedures/year. -
(Level of evidence C)
15Recommendations for PCI in Asymptomatic or Class
I Angina Patients
- In the previous (1993) guidelines, specific
recommendations were made separately for patients
with single vs. multi-vessel disease. - PCI techniques have improved such that, less
emphasis is given to the number of diseased
coronaries requiring PCI. More emphasis is given
to the patients clinical condition, specific
coronary lesion morphology and anatomy, LV
function, and associated medical co-morbidities. - The CCS Class of Angina (I to IV) is used to
define severity of symptoms.
16Canadian Cardiovascular Society
17Recommendations for PCI in Asymptomatic or Class
I Angina Patients
- Class I
- Patients who do not have treated diabetes with
asymptomatic ischemia or mild angina with 1 or
more significant lesions in 1 or 2 coronary
arteries suitable for PCI with a high likelihood
of success and a low risk of morbidity and
mortality. The vessels to be dilated must
subtend a large area of viable myocardium.
- (Level
of evidence B)
18Recommendations for PCI in Asymptomatic or Class
I Angina Patients
Davies RF, et alCirculation 1997Asymptomatic
Cardiac Ischemia Pilot (ACIP) study. Two year
outcomes of patients treated medically vs.
revascularization.
I
19Recommendations for PCI in Asymptomatic or Class
I Angina Patients
- Class IIa
- The same clinical and anatomic requirements
for Class I, except the myocardial area at risk
is of moderate size or the patient has treated
diabetes. - (Level of
evidence B)
20Recommendations for PCI in Asymptomatic or Class
I Angina Patients
- Class IIb
- Patients with asymptomatic ischemia or mild
angina with 3 coronary arteries suitable for PCI
with a high likelihood of success and a low risk
of morbidity and mortality. The vessels to be
dilated must subtend at least a moderate area of
viable myocardium. In the physicians judgment,
there should be evidence of myocardial ischemia
by ECG exercise testing, stress nuclear imaging,
stress echocardiography or ambulatory ECG
monitoring, or intra-coronary physiologic
measurements. - (Level
of evidence B)
21Recommendations for PCI in Asymptomatic or Class
I Angina Patients
I II
22Recommendations for PCI in Asymptomatic or Class
I Angina Patients
- Class III
- Patients with asymptomatic ischemia or mild
angina who do not meet the criteria as listed
under Class I or Class II and who have - a. Only a small area of viable myocardium
- at risk.
- b. No objective evidence of ischemia.
- c. Lesions that have a low likelihood of
- successful dilation.
- d. Mild symptoms that are unlikely to be
due to - myocardial ischemia.
- e. Factors associated with increased risk
of morbidity and - mortality.
- f. Left main disease.
- g. Insignificant disease lt 50
-
(Level of evidence C)
-
23Recommendations for Patients with Moderate or
Severe Symptoms (Angina Class II to IV, Unstable
Angina or Non ST Elevation MI) With Single or
Multi-vessel Coronary Disease on Medical Therapy.
24The Treat Angina with Aggrastat and Determine the
Cost of Therapy with an Invasive or Conservative
Strategy (TACTICS) Trial
- Randomized 2220 patients to an early invasive
strategy (cath and pci 4-48 h after
randomization) or to a conservative strategy
(revascularization reserved for patients who
develop recurrent ischemia after medical
stabilization). - All patients treated with aspirin, heparin,
b-blockers, lipid therapy, and tirofiban. - Composite primary end point (death, MI,
re-hospitalization for worsening chest pain) at 6
months, was significantly lower in patients
assigned to the invasive strategy (15.9 vs 19.4
in patients assigned to conservative therapy
p0.0025) - Rate of death or MI was also significantly
reduced at 6 months in the invasive strategy arm
(7.3 vs 9.5 in patients assigned to
conservative therapy plt0.05).
25Recommendations for Patients with Moderate or
Severe Symptoms (Angina Class II to IV, Unstable
Angina or Non ST Elevation MI) With Single or
Multi-vessel Coronary Disease on Medical Therapy.
- Class I
- Patients with 1 or more significant lesions in
1 or more coronary arteries suitable for PCI with
a high likelihood of success and low risk of
morbidity or mortality. The vessel(s) to be
dilated must subtend a moderate or large area of
viable myocardium and have high risk. - (Level of evidence
B)
26Recommendations for Patients with Moderate or
Severe Symptoms (Angina Class II to IV, Unstable
Angina or Non ST Elevation MI) With Single or
Multi-vessel Coronary Disease on Medical Therapy.
- Class IIa
- Patients with focal saphenous vein graft
lesions or multiple stenoses who are poor
candidates for re-operative surgery.
-
(Level of evidence C) - Class IIb
- Patient has 1 or more lesions to be dilated
with reduced likelihood of success or the
vessel(s) subtend a less than moderate area of
viable myocardium. Patients with 2 or 3 vessel
disease, with significant proximal LAD CAD and
treated diabetes or abnormal LV function. -
(Level of evidence C)
27Recommendations for Patients with Moderate or
Severe Symptoms (Angina Class II to IV, Unstable
Angina or Non ST Elevation MI) With Single or
Multi-vessel Coronary Disease on Medical Therapy.
- Class III
- 1. Patient has no evidence of myocardial
injury or ischemia on objective testing and has
not had a trial of medical therapy, or has - a. Only a small area of myocardium at
- risk
- b. All lesions or the culprit lesion to
be dilated - with morphology with a low
likelihood of success. - c. A high risk of procedure-related
morbidity or mortality. -
(Level of evidence C) - 2. Patients with insignificant coronary
stenoses (e.g., lt 50). -
(Level of evidence C) - 3. Patients with significant left main CAD
who are candidates for CABG. -
(Level of evidence B)
28Recommendations for Primary PCI for Acute
Transmural MI Patients as an Alternative to
Thrombolysis
- Class I
- 1. As an alternative to thrombolytic therapy
in patients with AMI and ST segment elevation or
new or presumed new left bundle branch block who
can undergo angioplasty of the infarct artery lt
12 hrs. from the onset of ischemic symptoms or gt
12 hrs. if symptoms persist, if performed in a
timely fashion by individuals skilled in the
procedure and supported by experienced personnel
in an appropriate laboratory environment.
(Level of
evidence A) - 2. In patients who are within 36 hrs. of an
acute ST elevation/Q-wave or new left bundle
branch block MI who develop cardiogenic shock,
are lt 75 years of age, and revascularization can
be performed within 18 h of the onset of shock by
individuals skilled in the procedure in an
appropriate laboratory environment.
(Level of evidence A) - Performance standard
balloon inflation within 90 /- 30 min. of
hospital - admission.
Individuals who perform gt75 PCI procedures/year.
Centers that - perform gt
200 PCI procedures/year and have cardiac surgical
capability. -
29Weaver, et alMeta-analysis of primary coronary
angioplasty and intravenous thrombolytic
therapy for acute MI. JAMA 1997.
30Recommendations for Primary PCI for Acute
Transmural MI Patients as an Alternative to
Thrombolysis
- Class IIa
- As a reperfusion strategy in candidates who
have a contraindication to thrombolytic therapy.
(Level of evidence C)
31Recommendations for Primary PCI for Acute
Transmural MI Patients as an Alternative to
Thrombolysis
32Recommendations for Primary PCI for Acute
Transmural MI Patients as an Alternative to
Thrombolysis
- Class III
- 1. Elective PCI of a non-infarct related
artery at the time of acute MI. -
(Level of evidence C) - 2. In patients with acute MI who
- a. have received fibrinolytic therapy
- within 12 h and have no symptoms of
- myocardial ischemia.
- b. are eligible for thrombolytic therapy
and are - undergoing primary angioplasty by an
- inexperienced operator (individual
who performs - lt 75 PCI procedures/year).
- c. are beyond 12 h after onset of
symptoms and have no evidence - of myocardial ischemia.
-
(Level of evidence C)
33Recommendations for PCI After Thrombolysis
- Class I
- Objective evidence for recurrent
- infarction or ischemia (rescue PCI).
- (Level of evidence B)
- RESCUE trial randomized 151 anterior wall MI
patients with 0/1 TIMI flow (mean 4.5 hrs.)
after initial thrombolysis to PCI vs.
conservative management. The PCI group
demonstrated a reduction in rates of combined
death and CHF maintained up to 1 year. (6 in
PCI group vs. 17 in conservative management
group)
34Recommendations for PCI After Thrombolysis
- Class IIa
- Cardiogenic Shock or hemodynamic instability.
- (Level of
evidence B) -
- SHOCKHochman et alNEJM 1999
- 302 patients with AMI and cardiogenic shock
randomly assigned to emergency revascularization
by coronary angioplasty (60) or bypass surgery
(40) within 6 hours or to initial medical
stabilization. The 30 day mortality was
significantly lower (p lt 0.01) for patients lt 75
years old treated with ERV (41.1 mortality)
compared to IMS (56.8 mortality). By contrast,
mortality among patients gt75 years was worse for
those treated with ERV. Overall 30 day mortality
was comparable in both groups (ERV 47 vs IMS
56, p0.11). Revascularization did reduce
mortality at 6 months (ERV 50 vs. IMS 63,
p0.027). -
35Recommendations for PCI After Thrombolysis
IIb-2
- SWIFT study (BMJ 1991)
- Examined 800 patients with AMI randomly
assigned to PCI within 2-7 days after
thrombolysis or to conservative management with
intervention for spontaneous or provocable
ischemia. There was no difference in the two
treatment strategies regarding LV function,
incidence of reinfarction, in-hospital survival,
or 1 year survival rate. - TIMI Phase II trial (NEJM 1989)
- 3262 patients randomized to angioplasty within
18-48 h vs. conservative management after acute
infarct and receiving t-pa. The two groups had
similar mortality at 6 weeks (5.2 vs. 4.7),
incidence of nonfatal reinfarction (6.4 vs.
5.8), and LV ejection fraction (0.5 vs 0.5).
The 1 and 3 year survival rates, anginal class,
and frequency of bypass surgery were also similar
between the two groups.
36Recommendations for PCI After Thrombolysis
- Class IIb
- 1. Recurrent angina without objective
evidence of - ischemia/infarction.
(Level of evidence C) - 2. Angioplasty of the infarct-related
artery stenoses - within hours to days (48 h) following
successful - thrombolytic therapy in asymptomatic
patients - without clinical and/or inducible
evidence of ischemia. -
(Level of evidence B)
37Recommendations for PCI After Thrombolysis
III
- TAMI-6 study (Topol, et alCirculation 1992)
- Angioplasty of a persistently occluded infarct
artery 7-48 hrs. after symptom onset demonstrated
that the infarct-related artery patency was
similar in aggressive vs. conservatively treated
groups at 6 month follow-up. There was a higher
incidence of infarct-related artery patency in
patients who did not receive angioplasty, as well
as a high incidence of re-occlusion in those who
did.
38Recommendations for PCI After Thrombolysis
- Class III
- 1. Routine PCI within 48 h following failed
- thrombolysis. (Level of evidence B)
- 2. Routine PCI of the infarct-artery
- stenoses immediately after thrombolytic
- therapy. (Level of evidence
A)
39Recommendations for PCI During Subsequent
Hospital Management After Acute Therapy for AMI
Including Primary PCI
- Class I
- 1. Spontaneous or provocable myocardial
- ischemia during recovery from
- infarction. (Level of evidence
C) - 2. Persistent hemodynamic instability.
- (Level of
evidence C)
40Recommendations for PCI During Subsequent
Hospital Management After Acute Therapy for AMI
Including Primary PCI
- Class IIa
- Patients with LV ejection fraction lt 40,
CHF, or serious ventricular - arrythmias.
(Level of evidence C) - Class IIb
- 1. Coronary angiography and angioplasty for
an occluded infarct- - related artery in an otherwise stable
patient to revascularize that artery - (open artery hypothesis).
(Level of evidence C) - 2. All patients after a non Q wave MI.
-
(Level of evidence
C) - 3. Clinical HF during the acute episode, but
subsequent - demonstration of preserved LV function
(LVEF gt 40). -
(Level of evidence
C) -
41Recommendations for PCI During Subsequent
Hospital Management After Acute Therapy for AMI
Including Primary PCI
- Class III
- PCI of the infarct-related artery within 48
- to 72 h after thrombolytic therapy without
- evidence of spontaneous or provocable
- ischemia. (Level of
evidence C)
42Recommendations for PCI With Prior CABG
- Ischemic symptoms recur in 4-8 of patients/year
following CABG. - Recurrence of symptoms can be attributed to
progression of native vessel coronary disease
(5/year) and bypass conduit occlusion,
particularly SVG failure (7 in week 1 15-20 in
first year 1-2/yr during the first 5-6 years,
and 3-5/yr in years 6-10 postop). - At 10 years postop, approximately half of all
SVG conduits are occluded and only half of the
remaining patent grafts are free of significant
disease.
43Recommendations for PCI With Prior CABG
- Class I
- Patients with early ischemia (usually within
30 days) after CABG. -
(Level of evidence B) - Class IIa
- 1. Patients with ischemia occurring 1 to 3
years post-operatively and - preserved LV function with discrete
lesions in graft conduits. -
(Level of evidence B) - 2. Disabling angina secondary to new
disease in a native coronary - circulation. (If angina is not
typical, the objective evidence of - ischemia should be obtained).
(Level of evidence B) - 3. Patients with diseased vein grafts gt 3
years following CABG. -
(Level of evidence B)
44Recommendations for PCI With Prior CABG
- Class III
- 1. PCI to chronic total vein graft
occlusions. - (Level of
evidence B) - 2. Patients with multivessel disease, failure
- or multiple SVGs, and impaired LV
- function. (Level of evidence
B)
45Recommendations for PCI With Prior CABG
- Patients with prior bypass surgery who undergo
successful PCI have a long-term outcome that is
dependent on patient age, the degree of LV
dysfunction, and the presence of multi-vessel
coronary atherosclerosis. - The best long-term results are observed after
re-canalization of distal anastomotic stenoses
(both svg and ima) occurring within 1 year of
operation. - Conversely, event-free survival is less
favorable following angioplasty of totally
occluded SVGs, ostial vein graft stenoses, or
grafts with diffuse or multicentric disease.
46Werner Forssmann, amidst criticisms over the
inherent recklessness of his experiments, turns
his attention to other endeavors. Eventually
pursued a career as a Urologist. Ultimately, he
did receive (shared with Cournand and Richards)
the Nobel Prize in Medicine in 1956.
47References
- ACC/AHA Guidelines for Percutaneous Coronary
Intervention. JACC, June 2001. (Revision of the
1993 PTCA Guidelines) - Baim, Grossman. Grossmans Cardiac
Catheterization, Angiography, and Intervention,
6th Edition. 2000. pp 1-5. - Up To Date