It is an aggressive goal, said Sidney C. Smith, Jr, M.D., FAHA, FACC, who headed the guideline writing committee and is a professor of medicine and director of the Center for Cardiovascular Science and Medicine at the University of North Carolina at Chapel Hill. "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."
Percutaneous coronary intervention (PCI) encompasses a variety of procedures used to treat patients with diseased arteries of the heart -- for example, chest pain caused by a build-up of fats, cholesterol, and other substances from the blood (referred to as plaque) that can reduce blood flow to a near-trickle, or a heart attack caused by a large blood clot that completely blocks the artery.
Typically, PCI is performed by threading a slender balloon-tipped tube--a catheter--from an artery in the groin to a trouble-spot in an artery of the heart. The interventional cardiologist then inflates the balloon to open the coronary artery, often also inserting an expandable metal stent.
The PCI Guidelines were last revised in 2001. In four short years, there have been dramatic advances in PCI techniques, devices, and medications. Drug-eluting stents are among the most notable. These stents not only prop open the artery, they also slowly release medication that prevents the overgrowth of scar tissue that can renarrow the artery and block blood flow to the heart, a complication known as restenosis.
Drug-eluting stents were not even commercially available in 2001. Today, they are widely used and are the focus of intense research. "The use of drug-eluting stents is rapidly changing the treatment of coronary artery disease," said Ted Feldman, M.D., FSCAI, FACC, professor of medicine at Northwestern University Medical School in Chicago and director of the cardiac catheterization laboratory at Evanston Hospital, Evanston, IL. "These guidelines address the real-world issues that are important to the use of drug-eluting stents."
Additional highlights of the guidelines include:
- Updated recommendations on using anti-clotting medications, such as clopidogrel, low-molecular-weight heparin, and bivalirudin, before, during, and after PCI;
- A recommendation that new protective devices be used to trap bits of plaque and blood clots that can break loose during PCI of aging veins from the legs transplanted to the heart during coronary artery bypass surgery;
- A detailed analysis of the circumstances under which PCI is the best treatment for heart attack;
- A recommendation for early follow-up of patients who have PCI of the left main coronary artery, which supplies blood to a large portion of the heart; and
- Strategies for ensuring the best possible patient outcomes and for monitoring the quality of care.
Indeed, although guidelines are written as a reference for physicians to use in clinical decision-making, their use by hospitals, health insurers, and governmental regulators is becoming increasingly common. "These guidelines have applications--and implications--far beyond the practice of interventional cardiology," said William W. O'Neill, M.D., FACC, FSCAI, corporate chairman of cardiology for the William Beaumont Hospital System in Royal Oak, MI. "It's imperative that physicians and hospital administrators carefully review the guidelines, because they may be used to grade performance."
The American College of Cardiology, a 33,000-member nonprofit professional medical society and teaching institution, is dedicated to fostering optimal cardiovascular care and disease prevention through professional education, promotion of research, leadership in the development of standards and guidelines, and the formulation of health care policy.
About the American Heart Association:
Since 1924 the American Heart Association has helped protect people of all ages and ethnicities from the ravages of heart disease and stroke. These diseases, the nation's No. 1 and No. 3 killers, claim more than 930,000 American lives a year. The association invested more than $439 million in fiscal year 2003-04 for research, professional and public education, advocacy and community service programs so people across America can live stronger, longer lives.
Headquartered in Bethesda, MD, the Society for Cardiovascular Angiography and Interventions is a 3,400-member professional organization representing invasive and interventional cardiologists. SCAI's mission is to promote excellence in invasive and interventional cardiovascular medicine through physician education and representation, and advancement of quality standards to enhance patient care. SCAI was organized in 1976 under the guidance of Drs. F. Mason Sones and Melvin P. Judkins. The first SCAI Annual Scientific Sessions were held in Chicago in 1978.