2011 ACCF/AHA/SCAI Guideline
for Percutaneous Coronary
Intervention
(and Coronary Revascularization)
•
•
•
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PCI Revascularization Recommendations
Pre-Procedural Considerations
Procedural Considerations
Post-Procedural Considerations
2011 ACCF/AHA/SCAI
Guideline for Percutaneous
Coronary Intervention
Revascularization
Recommendations
UPLM PCI to Improve Survival in SIHD
Recommendations
• 3 complementary recommendations based on the
risk of PCI complication, likelihood of long-term
durability, and surgical risk
• Includes a new PCI class IIa recommendation
• SYNERGY score and STS score can be used to help
guide UPLM revascularization decisions
UPLM PCI to Improve Survival (ACS)
COR
IIaFor UA/NSTEMI if not a CABG candidate
IIaFor STEMI when distal coronary flow is <TIMI
grade 3 and PCI can be performed more rapidly and
safely than CABG
Single and Multivessel CAD PCI To Improve Survival
(SIHD)
Anatomic Scenario
2-3 Vessel CAD or 1 VD With Proximal LAD CAD
1 VD Without Proximal LAD CAD
No anatomic or physiologic criteria for
revascularization
COR
IIbUncertain
benefit
III: Harm
III: Harm
Clinical Scenario
Survivors of sudden cardiac death with presumed
ischemia-mediated VT
COR
I
Multivessel CAD Caveats
Reasonable to choose CABG over PCI for good CABG
candidates with complex 3-vessel CAD
Reasonable to choose CABG over PCI for
multivessel CAD in patients with DM
COR
IIa
IIa
PCI to Improve Symptoms
Clinical/Anatomic Setting
COR
≥1 significant stenoses amenable to revascularization
and unacceptable angina despite GDMT
≥1 significant stenoses and unacceptable angina in
whom GDMT cannot be implemented because of
medication contraindications, adverse effects, or
patient preferences
Previous CABG with ≥1 significant stenoses associated
with ischemia and unacceptable angina despite GDMT
No anatomic or physiologic criteria for
revascularization
I
IIa
IIa
III: Harm
Caveat
COR
CABG preferred over PCI for complex 3 VD and a good
candidate for CABG
IIa
Cumulative 3-Year Incidence of MACE in Patients
With 3-Vessel CAD in the SYNTAX trial
Results For Each SYNTAX Tercile
Hybrid Coronary Revascularization
Recommendation
Hybrid coronary revascularization in patients with
one or more of the following:
•limitations to traditional CABG, such as heavily
calcified proximal aorta or poor target vessels for
CABG (but amenable to PCI)
•lack of suitable graft conduits
•unfavorable LAD for PCI ( excessive vessel
tortuosity or CTO)
Hybrid coronary revascularization as an alternative
to multivessel PCI or CABG in an attempt to improve
the overall risk/benefit ratio of the procedures
COR
IIa
IIb
Clinical Factors That May Influence The
Choice of Revascularization
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•
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•
•
•
Diabetes mellitus
Chronic kidney disease
Completeness of revascularization
LV systolic dysfunction
Previous CABG
Ability to comply with and tolerate DAPT
2011 ACCF/AHA/SCAI
Guideline for Percutaneous
Coronary Intervention
PCI Revascularization
Recommendations
2011 ACCF/AHA/SCAI
Guideline for Percutaneous
Coronary Intervention
Pre-Procedural Considerations
Pre-Procedural Considerations
Recommendations
Contrast-Induced AKI
Assessment for risk of contrast-induced (CI) AKI
COR
I
Adequate preparatory hydration
I
Minimization of volume of contrast media in patients with CKD
I
Administration of N-acetyl-L-cysteine for the prevention of CI-AKI
Anaphylactoid Reactions
Appropriate prophylaxis prior to repeat contrast administration in
patients with prior evidence of an anaphylactoid reaction to contrast
media
Anaphylactoid prophylaxis for contrast reaction in patients with prior
history of allergic reactions to shellfish or seafood
Statins
Administration of high-dose statin prior to PCI to reduce the risk of
periprocedural MI
Bleeding Risk
Evaluation for risk of bleeding prior to PCI
CKD
Estimation of GFR and dosage adjustment of renally-cleared
medications
III: No
Benefit
I
III: No
Benefit
IIa
I
I
Contrast-Induced Acute Kidney Injury
(AKI) Risk Reduction
Recommendation
COR
Assessment for risk of contrast-induced AKI
I
Adequate preparatory hydration
I
Minimization of volume of contrast media in
patients with CKD
I
Administration of N-acetyl-L-cysteine for the
prevention of contrast-induced AKI
III: No
Benefit
2011 ACCF/AHA/SCAI
Guideline for Percutaneous
Coronary Intervention
Procedural Considerations
Vascular Access
Recommendation
Radial artery access to decrease access site
complications
COR
IIa
General Considerations in Deciding Between an Early Invasive
Strategy and an Initial Conservative Strategy in UA/NSTEMI
Early Invasive Strategy
Generally Preferred
Initial Conservative Strategy
Generally Preferred or Reasonable
 Recurrent angina or ischemia at rest or
with low level activities despite intensive
medical therapy
 Elevated cardiac biomarkers (TnT or TnI)
 New or presumably new ST-depression
 Signs or symptoms of heart failure
 Hemodynamic instability
 High risk score (e.g., GRACE, TIMI)
 Sustained ventricular tachycardia
 PCI within 6 mo
 Prior CABG
 Diabetes mellitus
 Mild to moderate renal dysfunction
 Reduced LV function (LVEF <40%)
 Low risk score (e.g., GRACE, TIMI)
 Absence of high-risk features
 High risk for catheterization-related
complications
 Patient not a revascularization candidate
(with either PCI or CABG)
 Patient prefers conservative therapy
Coronary Angiography in STEMI
Indications
COR
Immediate coronary angiography
Candidate for primary PCI
Severe heart failure or cardiogenic shock (if suitable
revascularization candidate)
Moderate to large area of myocardium at risk and evidence
of failed fibrinolysis
I
I
IIa
Coronary angiography 3 to 24 hours after fibrinolysis
Hemodynamically stable patients with evidence for
successful fibrinolysis
IIa
Coronary angiography before hospital discharge
Stable patients
IIb
Coronary angiography at any time
Patients in whom the risks of revascularization are likely to
outweigh the benefits or the patient or designee does not
want invasive care
III: No
Benefit
PCI in STEMI
Indications
COR
STEMI symptoms within 12 h
Severe heart failure or cardiogenic shock
Contraindications to fibrinolytic therapy with ischemic symptoms
<12 h
Clinical and/or ECG evidence of ongoing ischemia between 12 and
24 h after symptom onset
Asymptomatic patient presenting between 12 and 24 h after
symptom onset and higher risk
Noninfarct artery PCI at the time of primary PCI in patients without
hemodynamic compromise
I
I
I
Primary PCI
IIa
IIb
III:
Harm
Delayed or Elective PCI in Patients with STEMI (i.e. Non-Primary PCI)
Clinical evidence for fibrinolytic failure or infarct artery reocclusion
Patent infarct artery 3 to 24 h after fibrinolytic therapy
Ischemia on noninvasive testing
Hemodynamically significant stenosis in a patent infarct artery >24
hours after STEMI
Totally occluded infarct artery >24 h after STEMI in a
hemodyamically stable asymptomatic patient without evidence of
severe ischemia
IIa
IIa
IIa
IIb
III: No
Benefit
Cardiogenic Shock
Recommendation
COR
Immediate coronary angiography in patients
with STEMI with severe heart failure or
cardiogenic shock who are suitable candidates
for revascularization
I
PCI for patients with acute MI who develop
cardiogenic shock and are suitable candidates
I
Hemodynamic support device for patients with
cardiogenic shock after STEMI who do not
quickly stabilize with pharmacological therapy
I
Recommendations for Initial Reperfusion Therapy
When Cardiogenic Shock Complicates STEMI
Cardiogenic
Shock
Delayed Onset Shock
Echocardiogram to rule out
mechanical defects
Early Shock, Diagnosed on
Hospital Presentation
Fibrinolytic therapy if all of the
following are present:
1. >90 minutes to PCI
2. <3 hours post MI onset?
3. No contraindications
Arrange rapid
transfer to invasive
capable center
Hemodynamic Support
Device
Arrange prompt transfer to
invasive capable center
Cardiac Catheterization and
Coronary Angiography
1-2 vessel CAD
Moderate 3-vessel CAD
PCI IRA
PCI IRA
Staged Multivessel PCI
Severe 3-vessel CAD
Left main CAD
Immediate CABG
Staged CABG
Cannot be performed
Dashed lines indicate that the procedure should be performed in
patients with specific indications only
Coronary Stents
Risk of restenosis needs to be weighted against the likelihood of the
patient to be able to tolerate and comply with (prolonged) DAPT
Recommendation
COR
DES as an alternative to BMS to reduce the risk of restenosis in
cases in which the risk of restenosis is increased and the patient is
likely to be able to tolerate and comply with prolonged DAPT
I
Before implantation of a DES, interventional cardiologist discussion
with the patient regarding the need for and duration of DAPT and the
ability of the patient to comply with and tolerate DAPT
Use of balloon angioplasty or BMS (instead of DES) in patients with
high bleeding risk, inability to comply with 12 months of DAPT, or with
anticipated invasive or surgical procedures within the next 12 months
I
PCI with coronary stenting in cases in which the patient is not likely to
be able to tolerate and to comply with DAPT
DES implantation in cases in which the patient is not likely to be able
to tolerate and comply with prolonged DAPT, or this cannot be
determined prior to stent implantation
III - Harm
I
III - Harm
Clinical Situations Associated With DES
or BMS Selection Preference
DES Generally Preferred Over BMS BMS Preferred Over DES
(efficacy considerations)
(safety considerations)
 Left main disease
 Patients unable to
 Small vessels
tolerate or comply with
 In-stent restenosis
prolonged DAPT
 Bifurcation lesions
 Anticipated surgery
 Long lesions
requiring discontinuation
 Multiple lesions
of DAPT within 12 months
 Saphenous vein graft lesions
 High risk of bleeding
 Diabetic patients
Aspirin in PCI
Time
Relative
to PCI
Recommendation
COR
Aspirin 81-325 mg before PCI if already on aspirin
therapy
I
Nonenteric-coated aspirin 325 mg before PCI if
not on aspirin therapy
I
PCI
Aspirin administered at time of PCI
I
Post-PCI
After PCI, aspirin continued indefinitely.
I
Pre-PCI
After PCI, use of 81 mg/d of aspirin in preference
to higher maintenance doses.
IIa
P2Y12 Inhibitors and DAPT
Recommendation
COR
Administration of a loading dose of a P2Y12 receptor to patients undergoing PCI
with stenting
Patients counseling on the need for and risks of DAPT before placement of
intracoronary stents, especially a DES
P2Y12 inhibitor therapy for at least 12 months in patients receiving a stent (BMS
or DES) during PCI for ACS
Clopidogrel for at least 12 months in patients treated with a DES for a non–ACS
indication, if patients are not at high risk of bleeding
Clopidogrel for a minimum of 1 month and ideally up to 12 months in patients
receiving a BMS for a non-ACS indication (unless the patient is at increased risk
of bleeding then it should be given for a minimum of 2 weeks)
Earlier discontinuation (e.g <12 months) of P2Y12 inhibitor therapy after stent
implantation if the risk of morbidity from bleeding outweighs the anticipated
benefit afforded by a recommended duration of P2Y12 inhibitor therapy
I
Continuation of DAPT beyond 12 months in patients undergoing DES
implantation
Prasugrel administration in patients with a prior history of stroke or transient
ischemic attack
I
I
I
I
IIa
IIb
III –
Harm
Antiplatelet And Antithrombin Rx at the Time of PCI
Recommendation
Oral Antiplatelet Rx
Aspirin
P2Y12 Inhibitor (clopidogrel, prasugrel or
ticagrelor) in patients treated with stent
implantation
GP IIb/IIIa Inhibitor Rx
No clopidogrel pre-treatment
STEMI:
UA/NSTEMI
SIHD
With clopidogrel pre
STEMI
treatment
UA/NSTEMI
SIHD
Antithrombin Rx
UFH
Bivalirudin
Enoxaparin
Anti-Xa Inhibitors
Fondaparinux
COR
I
I
IIa
I
IIa
IIa
IIa
IIb
I
I
IIb
III - Harm
GP IIb/IIIa Inhibitor Therapy
Clopidogrel
Pre-Treatment ?
No
Yes
Clinical Setting
COR
STEMI
UA/NSTEMI
SIHD
STEMI
UA/NSTEMI
SIHD
IIa
I
IIa
IIa
IIa
IIb
Additional Recommendations
COR
Administration of intracoronary (versus IV)
abciximab administration in patients undergoing
primary PCI with abciximab
Routine precatheterization laboratory (e.g
ambulance or emergency room) administration of
GP IIb/IIIa inhibitors as part of a upstream strategy
for patients with STEMI undergoing PCI
IIb
III – No
Benefit
Dosing of Parental Anticoagulants During PCI
Drug
UFH
Patient has received prior anticoagulant therapy
Patient has not received prior
anticoagulant therapy
IV GPI planned: additional UFH as needed (e.g., 2000 to
5000 U) to achieve an ACT of 200 to 250 s
IV GPI planned: 50 to 70 U/kg bolus to
achieve an ACT of 200 to 250 s
No IV GPI planned: additional UFH as needed (e.g., 2000 to
5000 U) to achieve an ACT of 250 to 300 for HemoTec, 300
to 350 s for Hemochron
No IV GPI planned: 70 to 100 U/kg
bolus to achieve target ACT of 250 to
300 s for HemoTec, 300 to 350 s for
Hemochron
0.5-0.75 mg/kg IV bolus
Enoxaparin
For prior treatment with enoxaparin , if the last
subcutaneous dose was administered 8 to 12 h earlier, or if
only 1 SC dose has been administered, an IV dose of 0.3
mg/kg of enoxaparin should be given;
If the last subcutaneous dose was administered within the
prior 8 h, no additional enoxaparin should be given
Bivalirudin
For patients who have received UFH, wait 30 min, then give
0.75 mg/kg IV bolus, then 1.75 mg/kg per hour IV infusion
For prior treatment with fondaparinux, administer
additional IV treatment with an anticoagulant possessing
anti-IIa activity, taking into account whether GPI receptor
antagonists have been administered.
0.75 mg/kg bolus, 1.75 mg/kg per h IV
infusion
N/A
200 µg/kg IV bolus then 15 µg/kg per min IV infusion (32)
350 µg/kg bolus then 15 µg/kg per
min IV infusion
Fondaparinux
Argatroban
Heparin-Induced Thrombocytopenia
(HIT)
Recommendation
COR
Bivalirudin or argatroban use during PCI for
patients with HIT
I
No Reflow Pharmacological Therapy
Recommendation
Administration of an intracoronary
vasodilator (adenosine, calcium channel
blocker, or nitroprusside) to treat PCIrelated no-reflow that occurs during
primary or elective PCI
COR
IIa
SVG PCI
Recommendation
Embolic protection device use when
technically feasible
GP IIb/IIIa inhibitors
PCI for chronic SVG occlusions
COR
I
III - No
Benefit
III - Harm
PCI in Specific Anatomic Situations
Recommendation
SVG
CTO
Bifurcation
Lesions
Aorto-Ostial
Stenoses
Calcified
Lesions
Embolic protection device use in SVG PCI when technically feasible
GP IIb/IIIa inhibitors in SVG PCI
PCI for chronic SVG occlusions
PCI of a CTO in patients with appropriate clinical indications and suitable
anatomy (when performed by operators with appropriate expertise)
COR
I
III – No
Benefit
III: Harm
IIa
Provisional side branch stenting as the initial approach in patients with
bifurcation lesions when the side branch is not large and has only mild or
moderate focal disease at the ostium
I
Elective double stenting in patients with complex bifurcation
morphology involving a large side branch where the risk of side branch
occlusion is high and the likelihood of successful side branch re-access is
low
IIa
IVUS for the assessment of angiographically indeterminant left main CAD
IIa
DES use when PCI is indicated in patients with an aorto-ostial stenosis
IIa
Rotational atherectomy for fibrotic or heavily calcified lesions that might
not be crossed by a balloon catheter or adequately dilated before stent
implantation
IIa
Periprocedural MI Assessment
Recommendation
COR
Measurement of cardiac biomarkers in
patients with signs or symptoms suggestive
of MI during or after PCI, or in
asymptomatic patients with significant
persistent angiographic complications
I
Routine measurement of cardiac
biomarkers in all patients after PCI
IIb
Vascular Closure Devices (VCD)
Recommendation
Femoral angiogram pre-VCD to ensure
anatomic suitability for deployment
VCD for the purposes of achieving faster
hemostasis and earlier ambulation
(compared with the use of manual
compression)
Routine use of VCD for the purpose of
decreasing vascular complications, including
bleeding
COR
I
IIa
III – No
Benefit
2011 ACCF/AHA/SCAI
Guideline for Percutaneous
Coronary Intervention
Post-Procedural Considerations
P2Y12 Inhibitor Rx Post-Stent
(P2Y12 Inhibitor = clopidogrel, prasugrel or ticagrelor)
Recommendation
COR
Post-Stent Implantation (BMS or DES) for ACS,
P2Y12 inhibitor Rx at least 12 months
Post-DES for non–ACS, clopidogrel for at least 12 mo if
patients are not at high risk of bleeding.
Post-BMS for non-ACS, clopidogrel for a minimum of 1 mo
and ideally up to 12 mo
Counseling patients on the importance of compliance with
DAPT and to not discontinue Rx before discussion with the
relevant cardiologist
Earlier discontinuation (e.g <12 mo) of P2Y12 inhibitor if the
risk of morbidity from bleeding outweighs the anticipated
benefit afforded by a recommended duration of P2Y12
inhibitor therapy after stent implantation
Continuation of P2Y12 Rx beyond 12 mo in patients
undergoing DES placement.
I
I
I
I
IIa
IIb
PPI Therapy and DAPT
Recommendations based on risk of GI bleeding
Recommendation
COR
PPI use for patients with history of prior GI bleeding
who require DAPT
I
PPI use for patients with increased risk of GI
bleeding (advanced age, concomitant use of
warfarin, steroids, NSAIDs, H pylori infection) who
require DAPT.
IIa
Routine use of a PPI for patients at low risk of GI
bleeding, who have much less potential to benefit
from prophylactic therapy
III: No
Benefit
Restenosis
Recommendation
COR
Treatment of clinical restenosis after balloon angioplasty
with BMS or DES if anatomic factors are appropriate and
if the patient is able to comply with and tolerate DAPT
Treatment of clinical restenosis after BMS with DES if
anatomic factors are appropriate and the patient is able
to comply with and tolerate DAPT
IVUS to determine the mechanism of stent restenosis
I
Treatment of clinical restenosis after DES with repeat PCI
with balloon angioplasty, BMS, or DES with the same
drug or an alternative antiproliferative drug if anatomic
factors are appropriate and patient is able to comply
with and tolerate DAPT
I
IIa
IIb