New PCI, CABG Guidelines Support 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 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.

"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.

While a Heart Team is important for deciding the best treatment for patients with life-threatening CAD, this subgroup probably represents about a quarter of all patients who need revascularization treatment, Dr. Smith said. The remaining three-quarters need revascularization for symptom relief, and while CABG also works well for this purpose, most patients in this category would also benefit from PCI, which may be the preferred choice, he added.

This new approach will probably not have a big impact on the volume of U.S. PCIs performed, predicted Dr. James C. Blankenship, vice-chairman of the PCI guidelines committee and an interventional cardiologist practicing in Danville, Pa. "On the complex end, I doubt that many PCIs today are done in super complex patients. On the low end, there has been a big shift in recognizing coronary lesions that need PCI," using tools that identify ischemia-causing lesions such as intravascular ultrasound and measuring fractional flow reserve. "Most interventionalists have shifted to this paradigm. For any who haven’t, the guidelines emphasize the importance of this approach," Dr. Blankenship said in an interview.

The call for Heart Teams by the new guidelines raises the issue whether enough U.S. teams exist to handle the volume of appropriate patients. Dr. Smith said there are, although they may not have a formal Heart Team designation.

"I think surgeons and cardiologists collaborate on this more than people think. They may not even realize they are doing it. To a large extent today it is not a formal process, but cardiologists and surgeons have multiple encounters with each other over their patients and they develop a sense of where to go, and when it is a close call [on how to manage a patient] they get together," Dr. Smith said

"It may not be a Heart Team as defined in the SYNTAX study. It can be any cardiac surgeon, and any interventional cardiologist," said Dr. Blankenship.

But, Dr. Smith noted, "the average cardiologist doesn’t calculate a SYNTAX score. We hope [the new guidelines] will lead to a resetting of the thought process."

And there are undoubtedly cardiologists today who do not consult with surgeons as often as they should, said Dr. Blankenship. "For many cardiologists it’s routine, but some cardiologists may be more aggressive about using PCI and less aggressive about getting surgical input." The new guidelines "set it forth as standard, and codify it by making the SYNTAX score a surrogate for disease complexity."

Dr. Levine said that he had no disclosures. Dr. Smith said that he has been a consultant to Eli Lilly and Baxter BioSurgery. Dr. Blankenship said that he has received research support from Abiomed, AstraZeneca, Boston Scientific, Conor Medsystems, Kai Pharmaceuticals, and Schering-Plough.☐

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 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.

"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.

While a Heart Team is important for deciding the best treatment for patients with life-threatening CAD, this subgroup probably represents about a quarter of all patients who need revascularization treatment, Dr. Smith said. The remaining three-quarters need revascularization for symptom relief, and while CABG also works well for this purpose, most patients in this category would also benefit from PCI, which may be the preferred choice, he added.

This new approach will probably not have a big impact on the volume of U.S. PCIs performed, predicted Dr. James C. Blankenship, vice-chairman of the PCI guidelines committee and an interventional cardiologist practicing in Danville, Pa. "On the complex end, I doubt that many PCIs today are done in super complex patients. On the low end, there has been a big shift in recognizing coronary lesions that need PCI," using tools that identify ischemia-causing lesions such as intravascular ultrasound and measuring fractional flow reserve. "Most interventionalists have shifted to this paradigm. For any who haven’t, the guidelines emphasize the importance of this approach," Dr. Blankenship said in an interview.

The call for Heart Teams by the new guidelines raises the issue whether enough U.S. teams exist to handle the volume of appropriate patients. Dr. Smith said there are, although they may not have a formal Heart Team designation.

"I think surgeons and cardiologists collaborate on this more than people think. They may not even realize they are doing it. To a large extent today it is not a formal process, but cardiologists and surgeons have multiple encounters with each other over their patients and they develop a sense of where to go, and when it is a close call [on how to manage a patient] they get together," Dr. Smith said

"It may not be a Heart Team as defined in the SYNTAX study. It can be any cardiac surgeon, and any interventional cardiologist," said Dr. Blankenship.

But, Dr. Smith noted, "the average cardiologist doesn’t calculate a SYNTAX score. We hope [the new guidelines] will lead to a resetting of the thought process."

And there are undoubtedly cardiologists today who do not consult with surgeons as often as they should, said Dr. Blankenship. "For many cardiologists it’s routine, but some cardiologists may be more aggressive about using PCI and less aggressive about getting surgical input." The new guidelines "set it forth as standard, and codify it by making the SYNTAX score a surrogate for disease complexity."

Dr. Levine said that he had no disclosures. Dr. Smith said that he has been a consultant to Eli Lilly and Baxter BioSurgery. Dr. Blankenship said that he has received research support from Abiomed, AstraZeneca, Boston Scientific, Conor Medsystems, Kai Pharmaceuticals, and Schering-Plough.☐

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 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.

"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.

While a Heart Team is important for deciding the best treatment for patients with life-threatening CAD, this subgroup probably represents about a quarter of all patients who need revascularization treatment, Dr. Smith said. The remaining three-quarters need revascularization for symptom relief, and while CABG also works well for this purpose, most patients in this category would also benefit from PCI, which may be the preferred choice, he added.

This new approach will probably not have a big impact on the volume of U.S. PCIs performed, predicted Dr. James C. Blankenship, vice-chairman of the PCI guidelines committee and an interventional cardiologist practicing in Danville, Pa. "On the complex end, I doubt that many PCIs today are done in super complex patients. On the low end, there has been a big shift in recognizing coronary lesions that need PCI," using tools that identify ischemia-causing lesions such as intravascular ultrasound and measuring fractional flow reserve. "Most interventionalists have shifted to this paradigm. For any who haven’t, the guidelines emphasize the importance of this approach," Dr. Blankenship said in an interview.

The call for Heart Teams by the new guidelines raises the issue whether enough U.S. teams exist to handle the volume of appropriate patients. Dr. Smith said there are, although they may not have a formal Heart Team designation.

"I think surgeons and cardiologists collaborate on this more than people think. They may not even realize they are doing it. To a large extent today it is not a formal process, but cardiologists and surgeons have multiple encounters with each other over their patients and they develop a sense of where to go, and when it is a close call [on how to manage a patient] they get together," Dr. Smith said

"It may not be a Heart Team as defined in the SYNTAX study. It can be any cardiac surgeon, and any interventional cardiologist," said Dr. Blankenship.

But, Dr. Smith noted, "the average cardiologist doesn’t calculate a SYNTAX score. We hope [the new guidelines] will lead to a resetting of the thought process."

And there are undoubtedly cardiologists today who do not consult with surgeons as often as they should, said Dr. Blankenship. "For many cardiologists it’s routine, but some cardiologists may be more aggressive about using PCI and less aggressive about getting surgical input." The new guidelines "set it forth as standard, and codify it by making the SYNTAX score a surrogate for disease complexity."

Dr. Levine said that he had no disclosures. Dr. Smith said that he has been a consultant to Eli Lilly and Baxter BioSurgery. Dr. Blankenship said that he has received research support from Abiomed, AstraZeneca, Boston Scientific, Conor Medsystems, Kai Pharmaceuticals, and Schering-Plough.☐