By Lawrence M. Prescott, Ph.D.

Because of the numerous major advances in the techniques, devices, and medications used in percutaneous coronary intervention (PCI), a 2005 update of the 2001 Guidelines for Percutaneous Coronary Intervention was jointly released by the American College of Cardiology, the American Heart Association, and the Society for Cardiovascular Angiography and Interventions at a special briefing during the American Heart Association Scientific Sessions 2005 held in Dallas in mid-November.

"These guidelines have applications and implications far beyond the practice of interventional cardiology," said William W. O'Neill, M.D., Corporate Chairman of Cardiology for the William Beaumont Hospital System in Royal Oak, Michigan. "It's imperative that physicians and hospital administrators review the guidelines, because they may be used to grade performance."

Percutaneous coronary intervention encompasses a wide variety of procedures used to treat patients with blocked coronary arteries. Typically, PCI is performed by threading a balloon-tipped catheter from the femoral artery in the groin to the blockage in the coronary artery. The balloon is then inflated to open the artery and an expandable metal stent often placed to keep the artery open.

In the four years since the 2001 revision of the PCI Guidelines, there have been dramatic advances. Drug-eluting stents that not only keep the artery open but also release medication that prevents scar tissue overgrowth were not even commercially available in 2001.

"The use of drug-eluting stents is rapidly changing the treatment of coronary artery disease," stated Ted Feldman, M.D., Professor of Medicine, Northwestern Medical School, Chicago, Illinois, and Director of the Cardiac Catheterization Laboratory, Evanston Hospital, Evanston, Illinois. "These guidelines address the real-world issues that are important to the use of drug-eluting stents."

Additional highlights of the guidelines include:

Recommendations for Institutional and Annual Operator Volume: PCI procedures should be performed by experienced physicians who perform more than 75 elective PCI procedures per year and at least 11 PCI procedures on heart attack patients at high-volume centers.

Anatomic Indicators: It is reasonable to perform PCI on patients who have significant coronary artery disease of the left main coronary artery but who are not eligible for bypass surgery. Careful post-procedural surveillance should include a post PCI angiogram at two to six months post-procedure as part of the follow-up.

Onsite Surgical Facilities for Elective Angioplasty: Elective PCI should not be performed at institutions that do not have onsite cardiac surgery facilities.

Use of Distal-Protection Devices: While these devices require further study, it is recommended that distal embolic protection devices be used whenever it is technically feasible in patients who are undergoing PCI to saphenous vein grafts transplanted to the heart during coronary artery bypass surgery.

Antiplatelet and Antithrombolytic Adjunctive Therapies for Patients Undergoing PCI:

• All patients should be taking aspirin before PCI procedure, whether or not already taking daily chronic aspirin therapy.
• A loading dose of clopidogrel should be administered before PCI is performed.
• If clopidogrel is given at the time of the procedure, supplementation with GP IIb/IIIa receptor antagonists can be beneficial to facilitate earlier platelet inhibition than with clopidogrel alone.

Post-Procedural Pharmacotherapeutic Recommendations:

• In addition to risk-factor modification, all post-PCI patients should begin taking a regimen of aspirin and clopidogrel unless these medications are contraindicated.
• ACE inhibitors should be considered for all patients with coronary heart disease, left ventricular dysfunction, or high blood pressure.
• All patients who have suffered a heart attack or have another acute condition, such as left ventricular dysfunction, should be given ?-blockers for at least six months, unless there are contraindications.
• Diabetic patients need glucose-lowering therapies that will bring their HbA1c levels to less than 7%.
• Aggressive lipid lowering therapy, reducing low-density lipoprotein cholesterol (LDL-C) to less than 70 mg/dL is recommended as an optional target for very high risk patients.

Finally, one of the key recommendations in the updated guidelines concerns the goal of PCI: to restore blood flow to the heart muscle within 90 minutes of the patient's arrival at the hospital.

"It is an aggressive goal," said Sidney C. Smith, Jr., M.D., who headed the guideline writing committee and is Professor of Medicine and Director, Center for Cardiovascular Science and Medicine, University of North Carolina, Chapel Hill, North Carolina. "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." This update on the new percutaneous coronary intervention (PCI) guidelines released at the American Heart Association Scientific Sessions 2005 was written by Lawrence M. Prescott, Ph.D.

To make any comments on this article, or to ask a question of the author, please contact the publisher. If you would like to submit an article, please contact the editors.

The opinions expressed in the articles published in this section do not necessarily reflect those of Pharmalicensing or UTEK Corporation. No actions including proposals to or agreements with other companies should be taken by any reader without obtaining specific business or legal advice. Neither the publisher nor the authors accept any liability for any actions or activities undertaken by any reader or other third party as a consequence of these articles or for any errors or omissions therein.