#JustReleased 2018 ESC/EACTS Guidelines on Myocardial Revasc

2018 ESC/EACTS Guidelines on Myocardial Revascularization

The Task Force on myocardial revascularization of the European Society of Cardiology (ESC) and European Association for Cardio-Thoracic Surgery (EACTS) have jointly issued patient-centred practice guidelines on myocardial revascularization. The guidance document has been published recently in the European Heart Journal.

What is new in the 2018 Guidelines?

A. New recommendations

B. Changes in class of recommendation

Some of the key points in the guidleine are:-
• Myocardial revascularization is performed for the relief of symptoms of myocardial ischaemia and the improvement of prognosis. In SCAD (stable coronary artery disease), the prognostic benefit is dependent on the extent of myocardium subject to ischaemia
• The prognostic and symptomatic benefits of myocardial revascularization critically depend on the completeness of revascularization. Therefore, the ability to achieve complete revascularization is a key issue when choosing the appropriate treatment strategy
• Non-invasive stress imaging (CMR, stress echocardiography, SPECT, or PET) may be considered for the assessment of myocardial ischaemia and viability in patients with HF and CAD (considered suitable for coronary revascularization) before the decision on revascularization
• When evidence of ischaemia is not available, FFR (fractional flow reserve) or iwFR (instantaneous wave-free ratio) are recommended to assess the haemodynamic relevance of intermediate-grade stenosis
• Urgent coronary angiography (<2h) is recommended in patients at very high ischaemic risk
• An early invasive strategy (<24 h) is recommended in patients with at least one high-risk criterion
• An invasive strategy (<72 h after first presentation) is indicated in patients with at least one intermediate-risk criterion

• Reperfusion therapy is indicated in all patients with time from symptom onset <12 h duration and persistent ST-segment elevation
• In patients with time from symptom onset >12 h, a primary PCI strategy is indicated in the presence of ongoing symptoms or signs suggestive of ischaemia, haemodynamic instability, or life-threatening arrhythmias
• Emergency coronary angiography is indicated in patients with acute heart failure or cardiogenic shock complicating ACS
• Emergency PCI of the culprit lesion is indicated for patients with cardiogenic shock due to STEMI or NSTE-ACS, independent of time delay of symptom onset, if coronary anatomy is amenable to PC

• All patients should be assessed for the risk of contrast-induced nephropathy, use of low-osmolar or iso-osmolar contrast media is recommended
• CABG is recommended in patients with a primary indication for aortic/mitral valve surgery and coronary artery diameter stenosis >70%

• In some instances, both PCI and CABG are equally reasonable, or sometimes even equally problematic, options. This calls for the Heart Team to be consulted to develop individualized treatment concepts, with respect for the preferences of the patient who has been informed about early and late outcomes
• SAVR (surgical aortic valve replacement) is indicated in patients with severe AS undergoing CABG, or surgery of the ascending aorta or another valve
• Mitral valve surgery is indicated in patients with severe secondary MR undergoing CABG and LVEF >30%
• DES (drug-eluting stents) are recommended over BMS (bare-metal stents) for any PCI irrespective of:

1. Clinical presentation
2. Lesion type
3. Planned non-cardiac surgery
4. Anticipated duration of DAPT
5. Concomitant anticoagulant therapy

• Even though 6 months of DAPT is generally recommended after PCI in SCAD and 12 months of DAPT after ACS, the type and duration of DAPT should be individualized according to the ischaemic and bleeding risks, and appropriately adapted during followup. Based on this judgement, treatment durations for DAPT after DES that are as short as 1 month or even as long as lifelong may be reasonable
• Multiple arterial grafting should be considered using the radial artery for high-grade stenosis and/or BIMA grafting for patients who do not have an increased risk of sternal wound infection

About ESC
The European Society of Cardiology (ESC) is a non-profit knowledge-based professional association that facilitates the improvement and harmonization of standards of diagnosis and treatment of cardiovascular diseases. The ESC produces, organizes and supports many scientific and educational activities and products aimed at cardiology professionals wishing to increase their knowledge and update their skills. The ESC was founded in 1950 and its headquarters are located in Sophia Antipolis in the South of France.

Note: This list is a brief compilation of some of the key recommendations included in the guidelines and is not exhaustive and does not constitute medical advice. Kindly refer to the original publication here: https://pxmd.co/zC1vm

About Author
Dr. Prachi Chhimwal
Dr. Prachi Chhimwal is an Editor at PlexusMD and is a part of the Engagment Team. She curates the Technical Content posted daily on the news feed. She graduated from Army College of Dental Sciences (B.D.S) and went on to pursue her post-graduation (M.D.S) in Oral & Maxillofacial Pathology. After a decade in the field of dentistry she took a leap of faith and joined PlexusMD. A badminton enthusiast, when not working you can find her reading, Netflixing or enjoying stand-up comedy shows.
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