The new ESC guidelines incorporate data from a network
The new ESC guidelines incorporate data from a network meta-analysis of 100 studies confirming that new-generation drug-eluting stents (DES) improve survival compared with medical treatment, although this has not been demonstrated in any individual study.
REVASCULARIZATION IN NON–ST-ELEVATION ACUTE CORONARY SYNDROME The invasive strategy remains the standard treatment for most patients with non–ST-segment elevation acute coronary syndrome (NSTEACS). The early invasive strategy (intervention in the first 24hours) is recommended for most NSTEACS patients, including those with elevated troponins, repolarization changes, or a GRACE score> 140. The debate about the basis for intervention within 24hours is an old one, and this strategy has well-known logistic and procedural implications that may significantly contribute to its incomplete implementation in Spain. Therefore, in Spain, the decision on whether to use the early invasive strategy should be informed by consideration of regional health care organization and the type of hospital to which the patient is admitted.
REVASCULARIZATION IN ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION
MYOCARDIAL REVASCULARIZATION IN PATIENTS WITH HEART FAILURE
Revascularization in special patient groups
REPEAT REVASCULARIZATION Patients treated by PCI can develop novobiocin mass during follow-up due to restenosis, incomplete revascularization, or disease progression, with disease progression being the most frequent cause in the long-term. In patients with restenosis, repeat PCI remains the strategy of choice. Both DES and drug-coated balloon angioplasty are recommended for patients with restenosis of a bare-metal stent or a DES (class I A). Intracoronary imaging provides useful information about the mechanism of stent failure caused by restenosis or thrombosis and aids decision-making about optimal treatment (IIa C).
ARRHYTHMIAS Coronary revascularization should always be considered for CAD patients with LVEF <35% before they are fitted with an implantable cardioverter-defibrillator for primary prevention. CABG reduces 10-year mortality in patients with reduced LVEF. Irrespective of the ECG pattern, survivors of out-of-hospital cardiac arrest with no obvious noncardiac cause of the arrhythmia should undergo early coronary angiography (IIa C). Patients who develop atrial fibrillation (AF) as a complication of PCI or CABG should be assessed for anticoagulation. Beta-blocker therapy should be considered as a measure to prevent the appearance of AF after CABG (I B).
PROCEDURAL ASPECTS OF CORONARY ARTERY BYPASS GRAFTING The recommendations for fully arterial revascularization (with no saphenous vein grafts) are based exclusively on the 5-year results of the Arterial Revascularization Trial.
PROCEDURAL ASPECTS OF PERCUTANEOUS CORONARY INTERVENTION The maximum recommendation (class I A) is maintained for the use of DES in all clinical contexts and for all lesion types. However, implementation of this recommendation could be limited by spending restrictions in the health care sector. Despite this concern, DES are very widely used in Spain.3 The guidelines discuss the polymers used or their absence in the different types of DES available; studies published to date have shown no significant clinical differences between the new-generation DES devices. This applies even to the high bleeding risk and the subsequent reduction in dual antiplatelet therapy duration, although the evidence in this area is limited to specific types of DES. The use of bioresorbable scaffolds is not recommended (class III C) except in clinical trials. The use of IVUS and optical coherence tomography (OCT) is recommended to optimize stent implantation (class IIa B). The 2014 guidelines already included this recommendation for IVUS, and now OCT has been upgraded to the same recommendation class (from IIb C in the previous guidelines). Reclassification to a firmer recommendation (class I) is impeded by the predominance of observational studies.