Chronic stable angina revascularization percutaneous coronary intervention indications: Difference between revisions

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__NOTOC__
{{Chronic stable angina}}
{{Chronic stable angina}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[Lakshmi Gopalakrishnan, M.B.B.S.]]
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[Lakshmi Gopalakrishnan, M.B.B.S.]]


==Indications==
==2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (Updating the 2004 Guideline and 2007 Focused Update) (DO NOT EDIT)<ref name="pmid19942100">{{cite journal |author=Kushner FG, Hand M, Smith SC, King SB, Anderson JL, Antman EM, Bailey SR, Bates ER, Blankenship JC, Casey DE, Green LA, Hochman JS, Jacobs AK, Krumholz HM, Morrison DA, Ornato JP, Pearle DL, Peterson ED, Sloan MA, Whitlow PL, Williams DO |title=2009 focused updates: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction (updating the 2004 guideline and 2007 focused update) and ACC/AHA/SCAI guidelines on percutaneous coronary intervention (updating the 2005 guideline and 2007 focused update) a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines |journal=[[Journal of the American College of Cardiology]] |volume=54 |issue=23|pages=2205–41|year=2009|month=December|pmid=19942100|doi=10.1016/j.jacc.2009.10.015|url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(09)03518-9|accessdate=2011-12-06}}</ref>==
*PCI has been shown to reduce the frequency of anginal symptoms and improve exercise tolerance in patients with [[CAD|single and double-vessel coronary artery disease]].<ref name="pmid1345754">Parisi AF, Folland ED, Hartigan P (1992) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=1345754 A comparison of angioplasty with medical therapy in the treatment of single-vessel coronary artery disease. Veterans Affairs ACME Investigators.] ''N Engl J Med'' 326 (1):10-6. [http://dx.doi.org/10.1056/NEJM199201023260102 DOI:10.1056/NEJM199201023260102] PMID: [http://pubmed.gov/1345754 1345754]</ref><ref name="pmid9874045">Hartigan PM, Giacomini JC, Folland ED, Parisi AF (1998) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9874045 Two- to three-year follow-up of patients with single-vessel coronary artery disease randomized to PTCA or medical therapy (results of a VA cooperative study). Veterans Affairs Cooperative Studies Program ACME Investigators. Angioplasty Compared to Medicine.] ''Am J Cardiol'' 82 (12):1445-50. PMID: [http://pubmed.gov/9874045 9874045]</ref><ref name="pmid9180111">Folland ED, Hartigan PM, Parisi AF (1997) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9180111 Percutaneous transluminal coronary angioplasty versus medical therapy for stable angina pectoris: outcomes for patients with double-vessel versus single-vessel coronary artery disease in a Veterans Affairs Cooperative randomized trial. Veterans Affairs ACME InvestigatorS.] ''J Am Coll Cardiol'' 29 (7):1505-11. PMID: [http://pubmed.gov/9180111 9180111]</ref> 
===Asymptomatic Ischemia or CCS Class I or II Angina (DO NOT EDIT)<ref name="pmid19942100">{{cite journal |author=Kushner FG, Hand M, Smith SC, King SB, Anderson JL, Antman EM, Bailey SR, Bates ER, Blankenship JC, Casey DE, Green LA, Hochman JS, Jacobs AK, Krumholz HM, Morrison DA, Ornato JP, Pearle DL, Peterson ED, Sloan MA, Whitlow PL, Williams DO|title=2009 focused updates: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction (updating the 2004 guideline and 2007 focused update) and ACC/AHA/SCAI guidelines on percutaneous coronary intervention (updating the 2005 guideline and 2007 focused update) a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines|journal=[[Journal of the American College of Cardiology]] |volume=54 |issue=23|pages=2205–41|year=2009 |month=December|pmid=19942100|doi=10.1016/j.jacc.2009.10.015|url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(09)03518-9|accessdate=2011-12-06}}</ref>===
{|class="wikitable"
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|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]
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|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' [[Chronic stable angina revascularization percutaneous coronary intervention|PCI]] is not recommended in patients with [[Chronic stable angina revascularization with PCI and CABG in asymptomatic patients|asymptomatic ischemia]] or [[Canadian cardiovascular society classification of angina pectoris|CCS class I or II angina]] who do not meet the criteria as listed under the class II recommendations or who have 1 or more of the following:


*In patients with [[Ischemia|objective large ischemia]] associated with severe angina, PCI has shown to significantly reduce mortality and provide greater symptomatic improvement. However, on the contrary, patients with mild symptoms do not benefit from PCI.<ref name="pmid9274581"> (1997) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9274581 Coronary angioplasty versus medical therapy for angina: the second Randomised Intervention Treatment of Angina (RITA-2) trial. RITA-2 trial participants.] ''Lancet'' 350 (9076):461-8. PMID: [http://pubmed.gov/9274581 9274581]</ref><ref name="pmid10395630">Pitt B, Waters D, Brown WV, van Boven AJ, Schwartz L, Title LM et al. (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10395630 Aggressive lipid-lowering therapy compared with angioplasty in stable coronary artery disease. Atorvastatin versus Revascularization Treatment Investigators.] ''N Engl J Med'' 341 (2):70-6. [http://dx.doi.org/10.1056/NEJM199907083410202 DOI:10.1056/NEJM199907083410202] PMID: [http://pubmed.gov/10395630 10395630]</ref><ref name="pmid10884254">Bucher HC, Hengstler P, Schindler C, Guyatt GH (2000) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10884254 Percutaneous transluminal coronary angioplasty versus medical treatment for non-acute coronary heart disease: meta-analysis of randomised controlled trials.] ''BMJ'' 321 (7253):73-7. PMID: [http://pubmed.gov/10884254 10884254]</ref>
:'''a.''' Only a small area of viable myocardium at risk. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''


*Despite the high rates of [[restenosis]] associated with PCI, it may be beneficial for [[Occlusive coronary artery thrombus|chronic total occlusions]] only in cases where the distal lumen could be accessed and favorable results could be obtained with [[Stent|stent implantation]].
:'''b.''' No objective evidence of [[ischemia]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''


*In patients with [[ischemia|refractory ischemia]] and [[PCI in the patient with severely depressed ventricular function|severe LV dysfunction]] with [[EF|ejection fraction less than 35%]] may benefit from PCI in comparison to [[Chronic stable angina revascularization coronary artery bypass grafting(CABG)|CABG]].
:'''c.''' Lesions that have a low likelihood of successful dilatation. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''


*In patients with [[PCI in the unprotected left main patient|unprotected left main]] [[CAD|disease]] associated with high peri-operative risk for [[Chronic stable angina revascularization coronary artery bypass grafting(CABG)|CABG]], PCI with stent implantation may be considered as an revascularization option.<ref name="pmid12927190">Kelley MP, Klugherz BD, Hashemi SM, Meneveau NF, Johnston JM, Matthai WH et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12927190 One-year clinical outcomes of protected and unprotected left main coronary artery stenting.] ''Eur Heart J'' 24 (17):1554-9. PMID: [http://pubmed.gov/12927190 12927190]</ref><ref name="pmid12888147">Arampatzis CA, Lemos PA, Tanabe K, Hoye A, Degertekin M, Saia F et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12888147 Effectiveness of sirolimus-eluting stent for treatment of left main coronary artery disease.] ''Am J Cardiol'' 92 (3):327-9. PMID: [http://pubmed.gov/12888147 12888147]</ref><ref name="pmid15389236">de Lezo JS, Medina A, Pan M, Delgado A, Segura J, Pavlovic D et al. (2004) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15389236 Rapamycin-eluting stents for the treatment of unprotected left main coronary disease.] ''Am Heart J'' 148 (3):481-5. [http://dx.doi.org/10.1016/j.ahj.2004.03.011 DOI:10.1016/j.ahj.2004.03.011] PMID: [http://pubmed.gov/15389236 15389236]</ref>
:'''d.''' Mild symptoms that are unlikely to be due to [[myocardial ischemia]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''


==Supportive Trial Data==
:'''e.''' Factors associated with increased risk of morbidity or mortality. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
*The ''ACIP study''', a randomized study of 558 patients with increased cardiac events, compared the 12-week efficacy of three treatment strategies such as [[Chronic stable angina pharmacotherapy overview|medical therapy]], [[Chronic stable angina pharmacotherapy overview|medical therapy]] plus [[Chronic stable angina ambulatory ST segment monitoring|ambulatory ECG monitoring]] or [[Chronic stable angina revascularization|revascularization]] to suppress [[ischemia|cardiac ischemia]]. The goal of the study was to assess the feasibility of a [[Chronic stable angina prognosis|prognosis]] trial in patients with asymptomatic cardiac ischemia, demonstrated both stress-inducible ischemia and two or more ischemic episodes on holter monitoring.<ref name="pmid8006249">Pepine CJ, Geller NL, Knatterud GL, Bourassa MG, Chaitman BR, Davies RF et al. (1994) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=8006249 The Asymptomatic Cardiac Ischemia Pilot (ACIP) study: design of a randomized clinical trial, baseline data and implications for a long-term outcome trial.] ''J Am Coll Cardiol'' 24 (1):1-10. PMID: [http://pubmed.gov/8006249 8006249]</ref> '''Two years after randomization''' (1997), the total mortality was significantly reduced from 6.6% in the angina-guided strategy to 4.4% in the ischemia-guided strategy and 1.1% in the revascularization strategy ''(p=less than 0.02)''. The rate of composite primary end-points was also significantly reduced from 41.8% in the angina-guided strategy to 38.5% in the ischemia-guided strategy and 23.1% in the revascularization strategy ''(p=less than 0.001)''. Researchers concluded that a strategy of initial revascularization appeared to improve the prognosis but longer-term study was needed to further establish this relationship. <ref name="pmid9133513">Davies RF, Goldberg AD, Forman S, Pepine CJ, Knatterud GL, Geller N et al. (1997) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9133513 Asymptomatic Cardiac Ischemia Pilot (ACIP) study two-year follow-up: outcomes of patients randomized to initial strategies of medical therapy versus revascularization.] ''Circulation'' 95 (8):2037-43. PMID: [http://pubmed.gov/9133513 9133513]</ref><ref name="pmid9133513">Davies RF, Goldberg AD, Forman S, Pepine CJ, Knatterud GL, Geller N et al. (1997) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9133513 Asymptomatic Cardiac Ischemia Pilot (ACIP) study two-year follow-up: outcomes of patients randomized to initial strategies of medical therapy versus revascularization.] ''Circulation'' 95 (8):2037-43. PMID: [http://pubmed.gov/9133513 9133513]</ref>


*In the '''TIME study''' (2004), that assessed the long-term survival and quality of life in elderly patients with [[Canadian cardiovascular society classification of angina pectoris|CCS]] class II or greater angina receiving atleast two anti-anginal medication at baseline, demonstrated similar long-term survival benefits observed in both the groups; however, freedom from major cardiovascular events remained higher in invasive therapy group versus the medical therapy group ''(39% versus 20%, p=less than 0.0001)''. Irrespective of whether patients were catheterized initially or only after failure to respond to [[Chronic stable angina pharmacotherapy overview|medical therapy]], their survival rates were better if they were revascularized within the first year.<ref name="pmid15337691">Pfisterer M, Trial of Invasive versus Medical therapy in Elderly patients Investigators (2004) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15337691 Long-term outcome in elderly patients with chronic angina managed invasively versus by optimized medical therapy: four-year follow-up of the randomized Trial of Invasive versus Medical therapy in Elderly patients (TIME).] ''Circulation'' 110 (10):1213-8. [http://dx.doi.org/10.1161/01.CIR.0000140983.69571.BA DOI:10.1161/01.CIR.0000140983.69571.BA] PMID: [http://pubmed.gov/15337691 15337691]</ref> 
:'''f.''' [[Left main]] [[CAD|disease]] and eligibility for [[Chronic stable angina revascularization coronary artery bypass grafting|CABG]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''


*The '''GISSOC trial''' (2003), studied the benefit of stent implantation over balloon PTCA for the treatment of chronic total coronary occlusions. The study demonstrated a significant reduction in the major adverse cardiovascular events observed in the stent group during a 6-year follow-up ''(76.1% in the stent group versus 60.4% in the PTCA group; p=0.055)'' and attributed this reduction secondary to the target lesion revascularization free-survival rate ''(85.1% in the stent group versus 65.5% in the PTCA group; p=0.0165)''. However, in most cases, [[restenosis]] of the study occlusion was evident at nine-month angiography. Thus, the study concluded stent implantation was superior to balloon PTCA in chronic total occlusions that can be recanalized percutaneously and is a valuable long-term therapeutic option; however, at nine-month follow-up both the stent and PTCA results appear to remain stable.<ref name="pmid12742287">Rubartelli P, Verna E, Niccoli L, Giachero C, Zimarino M, Bernardi G et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12742287 Coronary stent implantation is superior to balloon angioplasty for chronic coronary occlusions: six-year clinical follow-up of the GISSOC trial.] ''J Am Coll Cardiol'' 41 (9):1488-92. PMID: [http://pubmed.gov/12742287 12742287]</ref>
:'''g.''' Insignificant disease (less than 50% coronary [[stenosis]]). ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}


*Similar benefits with stent implantation for chronic total occlusion were reported in few other studies such as:
{|class="wikitable"
:*The '''SICCO trial''' (1996), reported a significant reduction in the target lesion revascularization ''(22% in the stent group versus 42% in the PTCA group; p=0.025)'' and [[restenosis]] ''(32% patients with stent and 74% patients with PTCA only; p=0.025)'' noted in the stent implantation group.<ref name="pmid8917256">Sirnes PA, Golf S, Myreng Y, Mølstad P, Emanuelsson H, Albertsson P et al. (1996) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=8917256 Stenting in Chronic Coronary Occlusion (SICCO): a randomized, controlled trial of adding stent implantation after successful angioplasty.] ''J Am Coll Cardiol'' 28 (6):1444-51. PMID: [http://pubmed.gov/8917256 8917256]</ref>
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:*The '''TOSCA study''' (1999), demonstrated stent implantation significantly improved late patency and reduced the rates of [[restenosis]] ''(70% in the PTCA group versus 55% in the stent group; p=less than 0.01)'' and target-vessel revascularization ''(15.4% in the PTCA group versus 8.4% in the stent group; p=0.03)''. Hence, the study concluded stent implantation being superior to PTCA for non-acute coronary occlusions.<ref name="pmid10411846">Buller CE, Dzavik V, Carere RG, Mancini GB, Barbeau G, Lazzam C et al. (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10411846 Primary stenting versus balloon angioplasty in occluded coronary arteries: the Total Occlusion Study of Canada (TOSCA).] ''Circulation'' 100 (3):236-42. PMID: [http://pubmed.gov/10411846 10411846]</ref>
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
:*The '''SARECCO trial''' (1999), demonstrated a significant event free survival in the stent group observed during a 2-year follow-up ''(26% in the group that received angioplasty alone versus 52% in the stent group; p=less than 0.05)''.<ref name="pmid10468073">Sievert H, Rohde S, Utech A, Schulze R, Scherer D, Merle H et al. (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10468073 Stent or angioplasty after recanalization of chronic coronary occlusions? (The SARECCO Trial).] ''Am J Cardiol'' 84 (4):386-90. PMID: [http://pubmed.gov/10468073 10468073]</ref>
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:*The '''SPACTO trial''' (1999), demonstrated significant reduction in the rates of [[restenosis]] ''(29% in the stent group versus 72% in the PTCA group; p=less than 0.01)'' and [[reocclusion]] ''(3% in the stent group versus 24% in the PTCA group)'' observed in the stent group. At follow-up,there was also a significant reduction in cardiac events ''(p=less than 0.03)'' and marked improvement in the anginal class ''(p=less than 0.01)'' reported in the stent group.<ref name="pmid10483953">Höher M, Wöhrle J, Grebe OC, Kochs M, Osterhues HH, Hombach V et al. (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10483953 A randomized trial of elective stenting after balloon recanalization of chronic total occlusions.] ''J Am Coll Cardiol'' 34 (3):722-9. PMID: [http://pubmed.gov/10483953 10483953]</ref>
|bgcolor="LemonChiffon"|
:*The '''STOP study''' (2000), demonstrated significant reduction in the rate of [[restenosis]] ''(42.1% in the stent group versus 70.9% in the PTCA group; p=0.034)'' and [[reocclusion]] ''(7.9% in the stent group versus 16.1% in the PTCA group)'' observed with the stent implantation. However, stent group was associated with more a diffuse in-stent restenosis in comparison to a focal re-stenosis in the PTCA group that occurred at the point of total obstruction (within 5mm).<ref name="pmid11071802">Lotan C, Rozenman Y, Hendler A, Turgeman Y, Ayzenberg O, Beyar R et al. (2000) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11071802 Stents in total occlusion for restenosis prevention. The multicentre randomized STOP study. The Israeli Working Group for Interventional Cardiology.] ''Eur Heart J'' 21 (23):1960-6. [http://dx.doi.org/10.1053/euhj.2000.2295 DOI:10.1053/euhj.2000.2295] PMID: [http://pubmed.gov/11071802 11071802]</ref>
<nowiki>"</nowiki>'''1.''' [[Chronic stable angina revascularization percutaneous coronary intervention|PCI]] is reasonable in patients with [[Chronic stable angina revascularization with PCI and CABG in asymptomatic patients|asymptomatic ischemia]] or [[Canadian cardiovascular society classification of angina pectoris|CCS class I or II angina]] and with 1 or more significant lesions in 1 or 2 coronary arteries suitable for PCI with a high likelihood of success and a low risk of morbidity and mortality. The vessels to be dilated must subtend a moderate to large area of viable myocardium or be associated with a moderate to severe degree of ischemia on [[Chronic stable angina risk stratification in asymptomatic patients by noninvasive testing|noninvasive testing]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
:*The '''PRISON study''' (2004), that demonstrated a statistically significant reduction in the need for target lesion revascularization ''(29% in the PTCA group versus 13% in the stent group; p=less than 0.0001)'' and a non-significant rate of [[restenosis]] was observed ''(33% in the PTCA group versus 22% in the stent group; p=0.137)''.<ref name="pmid15131557">Rahel BM, Suttorp MJ, Laarman GJ, Kiemeneij F, Bal ET, Rensing BJ et al. (2004) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15131557 Primary stenting of occluded native coronary arteries: final results of the Primary Stenting of Occluded Native Coronary Arteries (PRISON) study.] ''Am Heart J'' 147 (5):e22. [http://dx.doi.org/10.1016/j.ahj.2003.11.023 DOI:10.1016/j.ahj.2003.11.023] PMID: [http://pubmed.gov/15131557 15131557]</ref>
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|bgcolor="LemonChiffon"|
<nowiki>"</nowiki>'''2.''' [[Chronic stable angina revascularization percutaneous coronary intervention|PCI]] is reasonable for patients with [[Chronic stable angina revascularization with PCI and CABG in asymptomatic patients|asymptomatic ischemia]] or [[Canadian cardiovascular society classification of angina pectoris|CCS class I or II angina]], and recurrent stenosis after PCI with a large area of viable myocardium or [[Chronic stable angina risk assessment in patients with an intermediate or high probability of coronary artery disease|high-risk criteria on noninvasive testing]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|
<nowiki>"</nowiki>'''3.''' Use of [[Chronic stable angina revascularization percutaneous coronary intervention|PCI]] is reasonable in patients with [[Chronic stable angina revascularization with PCI and CABG in asymptomatic patients|asymptomatic ischemia]] or [[Canadian cardiovascular society classification of angina pectoris|CCS class I or II angina]] with significant [[left main]] [[CAD]] (greater than 50% diameter[[stenosis]]) who are candidates for [[Chronic stable angina revascularization|revascularization]] but are not eligible for [[Chronic stable angina revascularization coronary artery bypass grafting|CABG]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}


*In the '''PACTO study''' (2004), 48 consecutive patients received [[paclitaxel|paclitaxel-eluting stent]] implantation after successful recanalization of a chronic total occlusion, to assess the efficacy of drug-eluting stent in comparison to bare metal stent for the treatment of chronic total coronary occlusions. At 1-year follow-up, the incidence of major adverse cardiovascular events was significantly reduced in the [[paclitaxel]] group ''(12.5% in the Taxus group and 47.9% in the BMS group; p=less than 0.001)'' which was secondary to reduced need for repeat revascularization. The secondary end-points included the rate of [[restenosis]] ''(8.3% in the Taxus group and 51.1% in the BMS group; p=less than 0.001)'' and [[reocclusion]] ''(2.1% in the Taxus group and 23.4% in the BMS group; p=less than 0.005)'' which was also significantly reduced in the paclitaxel group. Thus, the study concluded, paclitaxel-eluting stent drastically reduced the incidence of major cardiovascular events and [[restenosis]], and almost eliminated [[reocclusion]] which is frequently observed with bare metal stents when used for chronic total occlusion.<ref name="pmid15607390">Werner GS, Krack A, Schwarz G, Prochnau D, Betge S, Figulla HR (2004) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15607390 Prevention of lesion recurrence in chronic total coronary occlusions by paclitaxel-eluting stents.] ''J Am Coll Cardiol'' 44 (12):2301-6. [http://dx.doi.org/10.1016/j.jacc.2004.09.040 DOI:10.1016/j.jacc.2004.09.040] PMID: [http://pubmed.gov/15607390 15607390]</ref>
{|class="wikitable"
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| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|bgcolor="LemonChiffon"|
<nowiki>"</nowiki>'''1.''' The effectiveness of [[Chronic stable angina revascularization percutaneous coronary intervention|PCI]] for patients with [[Chronic stable angina revascularization with PCI and CABG in asymptomatic patients|asymptomatic ischemia]] or [[Canadian cardiovascular society classification of angina pectoris|CCS class I or II angina]] who have 2- or 3-vessel disease with significant[[LAD|proximal LAD]] [[CAD]] who are otherwise eligible for [[Chronic stable angina revascularization coronary artery bypass grafting|CABG]]with 1 arterial conduit and who have treated [[diabetes]] or [[left ventricular dysfunction|abnormal LV function]] is not well established. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
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|bgcolor="LemonChiffon"|
<nowiki>"</nowiki>'''2.''' [[Chronic stable angina revascularization percutaneous coronary intervention|PCI]] might be considered for patients with [[Chronic stable angina revascularization with PCI and CABG in asymptomatic patients|asymptomatic ischemia]] or [[Canadian cardiovascular society classification of angina pectoris|CCS class I or II angina]] with non-proximal [[LAD]] [[CAD]] that subtends a moderate area of viable myocardium and demonstrates [[ischemia]] on
[[Chronic stable angina risk stratification in asymptomatic patients by noninvasive testing|noninvasive testing]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}


*The '''AWESOME trial and registry''' (2004), demonstrated the benefit of PCI over CABG in patients with refractory ischemia and who are at increased risk of adverse events, which may also be applicable to patients with [[left ventricular dysfunction]].<ref name="pmid10588300">Morrison DA, Sethi G, Sacks J, Grover F, Sedlis S, Esposito R et al. (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10588300 A multicenter, randomized trial of percutaneous coronary intervention versus bypass surgery in high-risk unstable angina patients. The AWESOME (Veterans Affairs Cooperative Study #385, angina with extremely serious operative mortality evaluation) investigators from the Cooperative Studies Program of the Department of Veterans Affairs.] ''Control Clin Trials'' 20 (6):601-19. PMID: [http://pubmed.gov/10588300 10588300]</ref><ref name="pmid15219521">Sedlis SP, Ramanathan KB, Morrison DA, Sethi G, Sacks J, Henderson W et al. (2004) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15219521 Outcome of percutaneous coronary intervention versus coronary bypass grafting for patients with low left ventricular ejection fractions, unstable angina pectoris, and risk factors for adverse outcomes with bypass (the AWESOME Randomized Trial and Registry).] ''Am J Cardiol'' 94 (1):118-20. [http://dx.doi.org/10.1016/j.amjcard.2004.03.041 DOI:10.1016/j.amjcard.2004.03.041] PMID: [http://pubmed.gov/15219521 15219521]</ref>
===CCS Class III Angina (DO NOT EDIT)<ref name="pmid19942100">{{cite journal |author=Kushner FG, Hand M, Smith SC, King SB, Anderson JL, Antman EM, Bailey SR, Bates ER, Blankenship JC, Casey DE, Green LA, Hochman JS, Jacobs AK, Krumholz HM, Morrison DA, Ornato JP, Pearle DL, Peterson ED, Sloan MA, Whitlow PL, Williams DO |title=2009 focused updates: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction (updating the 2004 guideline and 2007 focused update) and ACC/AHA/SCAI guidelines on percutaneous coronary intervention (updating the 2005 guideline and 2007 focused update) a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines |journal=[[Journal of the American College of Cardiology]]|volume=54 |issue=23|pages=2205–41 |year=2009 |month=December |pmid=19942100|doi=10.1016/j.jacc.2009.10.015|url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(09)03518-9|accessdate=2011-12-06}}</ref>===


*In a '''sub-study''' (2002) of patients with prior [[Chronic stable angina revascularization coronary artery bypass grafting(CABG)|CABG]], the three-year survival rate between CABG and PCI groups did not differ significantly: 73% in the CABG group and 76% in the PCI group ''(p=NS)''. However, the '''patient choice registry''', reported that the patients with prior-CABG preferred PCI over repeat CABG.<ref name="pmid12475454">Morrison DA, Sethi G, Sacks J, Henderson WG, Grover F, Sedlis S et al. (2002) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12475454 Percutaneous coronary intervention versus repeat bypass surgery for patients with medically refractory myocardial ischemia: AWESOME randomized trial and registry experience with post-CABG patients.] ''J Am Coll Cardiol'' 40 (11):1951-4. PMID: [http://pubmed.gov/12475454 12475454]</ref>
{|class="wikitable"
|-
|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]
|-
|bgcolor="LightCoral"|
<nowiki>"</nowiki>'''1.''' [[Chronic stable angina revascularization percutaneous coronary intervention|PCI]] is not recommended for patients with [[Canadian cardiovascular society classification of angina pectoris|CCS class III angina]] with single-vessel or multivessel [[CAD]], no evidence of myocardial injury or [[ischemia]] on objective testing, and no trial of [[Chronic stable angina pharmacotherapy overview|medical therapy]], or who have 1 of the following:
 
:'''a.''' Only a small area of myocardium at risk. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
 
:'''b.''' All lesions or the culprit lesion to be dilated with morphology that conveys a low likelihood of success. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
 
:'''c.''' A high risk of procedure-related morbidity or mortality. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
 
:'''d.''' Insignificant disease (less than 50% coronary stenosis). ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
 
:'''e.''' Significant [[left main]] [[CAD]] and candidacy for [[Chronic stable angina revascularization coronary artery bypass grafting|CABG]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|bgcolor="LemonChiffon"|
<nowiki>"</nowiki>'''1.''' It is reasonable that [[Chronic stable angina revascularization percutaneous coronary intervention|PCI]] be performed in patients with [[Canadian cardiovascular society classification of angina pectoris|CCS class III angina]] and single-vessel or multi-vessel [[CAD]] who are undergoing [[Chronic stable angina pharmacotherapy overview|medical therapy]] and who have 1 or more significant lesions in 1 or more coronary arteries suitable for [[Chronic stable angina revascularization percutaneous coronary intervention|PCI]] with a high likelihood of success and low risk of morbidity or mortality. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|
<nowiki>"</nowiki>'''2.''' It is reasonable that [[Chronic stable angina revascularization percutaneous coronary intervention|PCI]] be performed in patients with [[Canadian cardiovascular society classification of angina pectoris|CCS class III angina]] with single-vessel or multi-vessel [[CAD]] who are undergoing medical therapy with focal saphenous vein graft lesions or multiple stenoses who are poor candidates for reoperative surgery. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|
<nowiki>"</nowiki>'''3.''' Use of [[Chronic stable angina revascularization percutaneous coronary intervention|PCI]] is reasonable in patients with [[Canadian cardiovascular society classification of angina pectoris|CCS class III angina]] with significant [[left main]] [[CAD]](greater than 50% diameter stenosis) who are candidates for [[Chronic stable angina revascularization|revascularization]] but are not eligible for [[Chronic stable angina revascularization coronary artery bypass grafting|CABG]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|bgcolor="LemonChiffon"|
<nowiki>"</nowiki>'''1.''' [[Chronic stable angina revascularization percutaneous coronary intervention|PCI]] may be considered in patients with [[Canadian cardiovascular society classification of angina pectoris|CCS class III angina]] with single-vessel or multivessel [[CAD]] who are undergoing [[Chronic stable angina pharmacotherapy overview|medical therapy]] and who have 1 or more lesions to be dilated with a reduced likelihood of success. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|
<nowiki>"</nowiki>'''2.''' [[Chronic stable angina revascularization percutaneous coronary intervention|PCI]] may be considered in patients with [[Canadian cardiovascular society classification of angina pectoris|CCS class III angina]] and no evidence of [[ischemia]] on noninvasive testing or who are undergoing [[Chronic stable angina pharmacotherapy overview|medical therapy]] and have 2- or 3-vessel [[CAD]] with significant [[LAD|proximal LAD]] [[CAD]] and treated [[diabetes]] or [[left ventricular dysfunction|abnormal LV function]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
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Latest revision as of 19:31, 5 February 2013

Chronic stable angina Microchapters

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Risk calculators and risk factors for Chronic stable angina revascularization percutaneous coronary intervention indications

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S.

2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (Updating the 2004 Guideline and 2007 Focused Update) (DO NOT EDIT)[1]

Asymptomatic Ischemia or CCS Class I or II Angina (DO NOT EDIT)[1]

Class III
"1. PCI is not recommended in patients with asymptomatic ischemia or CCS class I or II angina who do not meet the criteria as listed under the class II recommendations or who have 1 or more of the following:
a. Only a small area of viable myocardium at risk. (Level of Evidence: C)
b. No objective evidence of ischemia. (Level of Evidence: C)
c. Lesions that have a low likelihood of successful dilatation. (Level of Evidence: C)
d. Mild symptoms that are unlikely to be due to myocardial ischemia. (Level of Evidence: C)
e. Factors associated with increased risk of morbidity or mortality. (Level of Evidence: C)
f. Left main disease and eligibility for CABG. (Level of Evidence: C)
g. Insignificant disease (less than 50% coronary stenosis). (Level of Evidence: C)"
Class IIa

"1. PCI is reasonable in patients with asymptomatic ischemia or CCS class I or II angina and with 1 or more significant lesions in 1 or 2 coronary arteries suitable for PCI with a high likelihood of success and a low risk of morbidity and mortality. The vessels to be dilated must subtend a moderate to large area of viable myocardium or be associated with a moderate to severe degree of ischemia on noninvasive testing. (Level of Evidence: B)"

"2. PCI is reasonable for patients with asymptomatic ischemia or CCS class I or II angina, and recurrent stenosis after PCI with a large area of viable myocardium or high-risk criteria on noninvasive testing. (Level of Evidence: C)"

"3. Use of PCI is reasonable in patients with asymptomatic ischemia or CCS class I or II angina with significant left main CAD (greater than 50% diameterstenosis) who are candidates for revascularization but are not eligible for CABG. (Level of Evidence: B)"

Class IIb

"1. The effectiveness of PCI for patients with asymptomatic ischemia or CCS class I or II angina who have 2- or 3-vessel disease with significantproximal LAD CAD who are otherwise eligible for CABGwith 1 arterial conduit and who have treated diabetes or abnormal LV function is not well established. (Level of Evidence: B)"

"2. PCI might be considered for patients with asymptomatic ischemia or CCS class I or II angina with non-proximal LAD CAD that subtends a moderate area of viable myocardium and demonstrates ischemia on noninvasive testing. (Level of Evidence: C)"

CCS Class III Angina (DO NOT EDIT)[1]

Class III

"1. PCI is not recommended for patients with CCS class III angina with single-vessel or multivessel CAD, no evidence of myocardial injury or ischemia on objective testing, and no trial of medical therapy, or who have 1 of the following:

a. Only a small area of myocardium at risk. (Level of Evidence: C)
b. All lesions or the culprit lesion to be dilated with morphology that conveys a low likelihood of success. (Level of Evidence: C)
c. A high risk of procedure-related morbidity or mortality. (Level of Evidence: C)
d. Insignificant disease (less than 50% coronary stenosis). (Level of Evidence: C)
e. Significant left main CAD and candidacy for CABG. (Level of Evidence: C)"
Class IIa

"1. It is reasonable that PCI be performed in patients with CCS class III angina and single-vessel or multi-vessel CAD who are undergoing medical therapy and who have 1 or more significant lesions in 1 or more coronary arteries suitable for PCI with a high likelihood of success and low risk of morbidity or mortality. (Level of Evidence: B)"

"2. It is reasonable that PCI be performed in patients with CCS class III angina with single-vessel or multi-vessel CAD who are undergoing medical therapy with focal saphenous vein graft lesions or multiple stenoses who are poor candidates for reoperative surgery. (Level of Evidence: C)"

"3. Use of PCI is reasonable in patients with CCS class III angina with significant left main CAD(greater than 50% diameter stenosis) who are candidates for revascularization but are not eligible for CABG. (Level of Evidence: B)"

Class IIb

"1. PCI may be considered in patients with CCS class III angina with single-vessel or multivessel CAD who are undergoing medical therapy and who have 1 or more lesions to be dilated with a reduced likelihood of success. (Level of Evidence: B)"

"2. PCI may be considered in patients with CCS class III angina and no evidence of ischemia on noninvasive testing or who are undergoing medical therapy and have 2- or 3-vessel CAD with significant proximal LAD CAD and treated diabetes or abnormal LV function. (Level of Evidence: B)"

References

  1. ↑ 1.0 1.1 1.2 Kushner FG, Hand M, Smith SC, King SB, Anderson JL, Antman EM, Bailey SR, Bates ER, Blankenship JC, Casey DE, Green LA, Hochman JS, Jacobs AK, Krumholz HM, Morrison DA, Ornato JP, Pearle DL, Peterson ED, Sloan MA, Whitlow PL, Williams DO (2009). "2009 focused updates: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction (updating the 2004 guideline and 2007 focused update) and ACC/AHA/SCAI guidelines on percutaneous coronary intervention (updating the 2005 guideline and 2007 focused update) a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Journal of the American College of Cardiology. 54 (23): 2205–41. doi:10.1016/j.jacc.2009.10.015. PMID 19942100. Retrieved 2011-12-06. Unknown parameter |month= ignored (help)

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