The new European Society of Cardiology guidelines on myocardial revascularisation: An appraisal
Thoraxcentre, Room Bd-420, Dr Molewaterplein 40, 3015 RD Rotterdam, The Netherlands.Heart (British Cardiac Society) (Impact Factor: 5.6). 01/2012; 98(1):11-4. DOI: 10.1136/heartjnl-2011-300803
The latest European Society of Cardiology (ESC) guidelines on myocardial revascularisation are reviewed. The nearly 300 recommendations make it difficult to apply them in their totality. The authors would propose 20-30 recommendations per guideline based on sound clinical evidence. Also, the scope of the current guidelines is very wide as it includes topics already incorporated in other guidelines, such as strategies for pre-intervention diagnosis and imaging as well as on secondary prevention. Some recommendations in the new guidelines are sensible and will not be disputed. In particular, the encouragement of a balanced multidisciplinary decision process (the 'heart team') is welcome. Although coronary revascularisation in unstable high risk patients is well accepted, this is less the case for the low risk patient with chest pain. This issue is controversial and a balanced discussion of the pros and cons of percutaneous coronary intervention is missing. Despite convincing evidence indicating lack of benefit of percutaneous coronary intervention for chronic total occlusion, this procedure is not discouraged. Lastly, most committee members were interventional cardiologists or cardiac surgeons. Guideline committees should be representative of the whole group of professionals as the interpretation of the evidence by specialists may be biased. There may be a role for procedure oriented guidelines but, in that case, the items at issue should remain confined to matters directly related to technical aspects of the procedure.
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ABSTRACT: Conventional therapeutic options to treat chronic angina pectoris are pharmacological interventions, coronary bypass surgery (CABG) and percutaneous coronary intervention (PCI). In animal models, it was shown that gene delivery strategies harbour an exciting potential to support and maybe even replace conventional anti-angina treatments, but the translation of the basic science to clinical practise appears problematic. Gene therapy targeting key elements of neointima formation (e.g. cell cycle regulators, metalloproteinases, inflammation and oxidative stress) reduce vein graft and stent failure in experimental models. Additionally, systemic gene delivery of genes targeting NO production, oxidative stress, inflammation and foam cell formation has been shown to prevent atherosclerosis in different animal models. During CABG the vein graft can be transfected ex vivo and during PCI, a stent carrying transfection vectors can be deployed. Both strategies result in the induction of local transgene expression at the site of interest. This limits unwarranted transgene expression and the toxicity seen with systemic gene delivery. However, with the development of new transfection vectors, able to induce local transgene expression without detrimental side effects, systemic anti-inflammatory and anti-oxidative, gene delivery could be a powerful tool in secondary prevention.
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ABSTRACT: The publication of new clinical practice guidelines always results in controversy. Guidelines are consensus documents and often their conclusions do not satisfy all the professionals involved in treating a particular disease. Current European guidelines on myocardial revascularization attempt to reconcile the available evidence on revascularization techniques with recent developments in different types of intervention. The principle contribution of the new guidelines is an acknowledgement that the outcomes obtained with a specific revascularization technique largely depend on the individual and center carrying out the procedure. In many situations, there is a range of therapeutic options, all of which are viable, and the patient's opinion should be taken into account once sufficient information has been provided. The guidelines recommend that a Heart Team, or cardiac team, be formed at each center to ensure adoption of the therapeutic approaches best suited to the local context and agreement on ways of dealing with situations on which currently available evidence is unclear. The temptation to improvise should be avoided, especially in clinically stable patients. This article presents a detailed review of the guidelines’ principal recommendations for clinical and anatomic scenarios encountered in everyday clinical practice. Another of the guidelines’ contributions, which has been questioned, concerns recommendations on drug treatment for patients undergoing revascularization, particularly via percutaneous intervention. It may be that these recommendations lie beyond the scope of the current guidelines. However, their inclusion is justified by the emergence of new findings on optimal antithrombotic treatment strategies for use with coronary interventions. Some of the more questionable recommendations have been corrected and clarified in subsequent guidelines developed separately for specific individual clinical contexts.
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