Major advances in techniques, devices, medications spur update of PCI guidelines


Multidisciplinary document benefits from broad view of generalists, detailed focus of interventionalists

DALLAS-- For patients suffering the crushing pain of a heart attack, the trip of a lifetime may be to a hospital prepared to quickly open the blocked artery by inflating a small balloon and inserting a tiny metal structure called a stent to act as permanent scaffolding. The goal: to restore blood flow to the heart muscle within 90 minutes of the patient's arrival at the hospital. That is just one of many recommendations in updated guidelines on percutaneous coronary intervention (PCI), jointly released today by the American College of Cardiology, American Heart Association, and Society for Cardiovascular Angiography and Interventions. The guidelines will be the subject of a joint news conference held today , Nov. 13, at 3 p.m., CST, at the American Heart Association's Scientific Sessions 2005.

It is an aggressive goal, said Sidney C. Smith, Jr, M.D., FAHA, FACC, who headed the guideline writing committee and is a professor of medicine and director of the Center for Cardiovascular Science and Medicine at the University of North Carolina at Chapel Hill. "The science shows that patients truly benefit from a 'door-to-balloon time' of 90 minutes or less. We have consistently looked at where the science says we should be, and challenged ourselves."

Percutaneous coronary intervention (PCI) encompasses a variety of procedures used to treat patients with diseased arteries of the heart -- for example, chest pain caused by a build-up of fats, cholesterol, and other substances from the blood (referred to as plaque) that can reduce blood flow to a near-trickle, or a heart attack caused by a large blood clot that completely blocks the artery.

Typically, PCI is performed by threading a slender balloon-tipped tube--a catheter--from an artery in the groin to a trouble-spot in an artery of the heart. The interventional cardiologist then inflates the balloon to open the coronary artery, often also inserting an expandable metal stent.

The PCI Guidelines were last revised in 2001. In four short years, there have been dramatic advances in PCI techniques, devices, and medications. Drug-eluting stents are among the most notable. These stents not only prop open the artery, they also slowly release medication that prevents the overgrowth of scar tissue that can renarrow the artery and block blood flow to the heart, a complication known as restenosis.

Drug-eluting stents were not even commercially available in 2001. Today, they are widely used and are the focus of intense research. "The use of drug-eluting stents is rapidly changing the treatment of coronary artery disease," said Ted Feldman, M.D., FSCAI, FACC, professor of medicine at Northwestern University Medical School in Chicago and director of the cardiac catheterization laboratory at Evanston Hospital, Evanston, IL. "These guidelines address the real-world issues that are important to the use of drug-eluting stents."

Additional highlights of the guidelines include:

  • Updated recommendations on using anti-clotting medications, such as clopidogrel, low-molecular-weight heparin, and bivalirudin, before, during, and after PCI;
  • A recommendation that new protective devices be used to trap bits of plaque and blood clots that can break loose during PCI of aging veins from the legs transplanted to the heart during coronary artery bypass surgery;
  • A detailed analysis of the circumstances under which PCI is the best treatment for heart attack;
  • A recommendation for early follow-up of patients who have PCI of the left main coronary artery, which supplies blood to a large portion of the heart; and
  • Strategies for ensuring the best possible patient outcomes and for monitoring the quality of care.

Indeed, although guidelines are written as a reference for physicians to use in clinical decision-making, their use by hospitals, health insurers, and governmental regulators is becoming increasingly common. "These guidelines have applications--and implications--far beyond the practice of interventional cardiology," said William W. O'Neill, M.D., FACC, FSCAI, corporate chairman of cardiology for the William Beaumont Hospital System in Royal Oak, MI. "It's imperative that physicians and hospital administrators carefully review the guidelines, because they may be used to grade performance."

Source: Eurekalert & others

Last reviewed: By John M. Grohol, Psy.D. on 21 Feb 2009
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