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)

Perspective:

The following are 10 points to remember about these guidelines on myocardial revascularization:

1. It is recommended that patients are adequately informed about short- and long-term benefits and risks of the revascularization procedure as well as treatment options. Enough time should be allowed for informed decision making.

2. Coronary artery bypass grafting (CABG) is recommended for patients with significant left main (LM) stenosis and LM equivalent with proximal stenosis of both left anterior descending (LAD) and left circumflex arteries.

3. CABG is recommended for patients with significant LAD artery stenosis and multivessel disease to reduce death and hospitalization for cardiovascular causes.

4. Taking currently available evidence into consideration, CABG is the revascularization modality of choice among diabetic patients with multivessel CAD; however, percutaneous coronary intervention (PCI) can be considered as a treatment alternative among diabetic patients with multivessel disease and low SYNTAX score (≤22).

5. For patients with moderate or severe chronic kidney disease, CABG should be considered over PCI in patients with multivessel coronary artery disease (CAD) and symptoms/ischemia whose surgical risk profile is acceptable and life expectancy is beyond 1 year.

6. Coronary angiography is recommended before valve surgery in patients with severe valvular heart disease and any of the following:

  1. History of CAD
  2. Suspected myocardial ischemia
  3. Left ventricular systolic dysfunction
  4. In men aged over 40 years and in postmenopausal women
  5. One cardiovascular risk factor for CAD.

7. It is recommended to make the decision on redo CABG or PCI by ad hoc consultation in the Heart Team and based on feasibility of revascularization, area at risk, comorbidities, and clinical status.

8. Fractional flow reserve is indicated to identify hemodynamically relevant coronary lesion(s) in stable patients when evidence of ischemia is not available.

9. A P2Y12 inhibitor is recommended in addition to aspirin in patients undergoing PCI for non–ST-segment elevation-acute coronary syndrome or ST-segment elevation myocardial infarction, and maintained over 12 months unless there are contraindications such as excessive risk of bleeding. Options are:
  1. Prasugrel (60 mg loading dose, 10 mg daily dose) in patients in whom coronary anatomy is known and who are proceeding to PCI if no contraindication.
  2. Ticagrelor (180 mg loading dose, 90 mg twice daily) for patients at moderate-to-high risk of ischemic events, regardless of initial treatment strategy including those pre-treated with clopidogrel if no contraindication.
  3. Clopidogrel (600 mg loading dose, 75 mg daily dose), only when prasugrel or ticagrelor are not available or are contraindicated.

10. All patients after myocardial revascularization should be advised on lifestyle changes (including smoking cessation, regular physical activity, and a healthy diet).

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Valvular Heart Disease, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and VHD, Interventions and Coronary Artery Disease, Interventions and Imaging, Interventions and Structural Heart Disease, Angiography, Nuclear Imaging, Diet

Keywords: Coronary Artery Disease, Myocardial Infarction, Life Style, Life Expectancy, Risk Factors, Thoracic Surgery, Constriction, Pathologic, Angioplasty, Balloon, Coronary, Purinergic P2Y Receptor Antagonists, Coronary Angiography, Heart Valve Diseases, Motor Activity, Diet, Coronary Artery Bypass, Hospitalization, Diabetes Mellitus, Renal Insufficiency, Chronic, Smoking Cessation


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