ESC/EACTS guidelines on myocardial revascularization post-SYNTAX

It is befitting that the new ESC/EACTS guidelines have been formulated on the occasion of the 50th anniversary following the performance of the first coronary artery bypass operation in 1964 [1]. Treatment strategies for patients with coronary artery disease (CAD) have undergone the most extensive scrutiny by way of randomized, controlled trials (RCTs), meta-an alyses and in-depth evaluation of large registries over the last five decades. Based on the evidence provided by these research tools, guidelines on myocardial revascularization for CAD have been formulated every 4– 5y ears by selected experts in the field, with the intent of not only assisting cardiologists, cardiac surgeons and physicians of selecting the optimum management strategy for each individual patient, but also of creating educational tools and implementation programmes for the next generation of physicians. More importantly, the guidelines are non-partisan and are exclusively supported by the best available clinical, ethical and technical evidence without economic or industry influence. The 2010 ESC/EACTS guidelines were unique in several aspects [2]. The writing committee, which included a proportionate number of cardiologists and cardiac surgeons for the first time, emphasized the importance of the Multidisciplinary/ Heart Team in decision-making in patients with complex stable CAD and communication of appropriate evidence-based information to patients requiring nonemergency interventions. The new 2014 ESC/EACTS guidelines have incorporated these unique and other recommendations with appropriate amendments based on new evidence available since the last edition. They involve a broad systematic overview on all facets of CAD and provide the best possible evidence-based recommendations for diagnostic strategies, risk stratification, treatment policies for simple and complicated CAD with and without associated diseases, complementary therapies like post-procedural medications and secondary prevention. Finally, for the first time, the assessment of the impact of procedural volumes on patient outcomes has led to the creation of recommendations for training, proficiency and operator/institutional competence in CABG and percutaneous coronary intervention (PCI) [3]. Invasive coronary angiography is the diagnostic tool of choice in symptomatic patients, in whom CAD is highly anticipated. In patients with an intermediate probability of disease, noninvasive or functional testing through stress echocardiography, nuclear imaging, stress magnetic resonance imaging or positron emission tomography is initially recommended, followed by invasive angiography if needed. Once the decision to perform revascularization has been made, risk stratification and the optimal timing and mode of revascularization have to be established, the latter being potentially the most debated topic due to rapid technological advancements in CABG and PCI. Optimal timing and mode of revascularization have always played an important role in achieving satisfactory outcomes in patients with acute coronary syndrome and cardiogenic shock. Primary PCI of the culprit vessel within 12 h from symptom onset with new-generation drug-eluting stents (DES) continues to remain the treatment of choice in patients with ST-elevation myocardial infarction (STEMI). In patients presenting later, primary PCI should be performed in case of ongoing ischaemia, life-threatening arrhythmias or chest pain. CABG is only reserved for candidates not amenable to PCI or at the time of repair of mechanical complications of STEMI. In patients with non-STEMI, an early invasive strategy is recommended for high-risk patients (rising cardiac enzymes, dynamic ST- or T-wave changes, poor left ventricular function etc.) with the choice of revascularization therapy according to a predefined Heart Team protocol based on clinical status, comorbidities and anatomical severity of CAD. Acute coronary syndrome complicated by cardiogenic shock due to left ventricular failure should be revascularized (preferably by PCI) emergently with periprocedural support of short-term mechanical circulatory assist devices in haemodynamically unstable patients. Routine use of intra-aortic balloon (IABP) support, which was a level I recommendation in these patients according to previous guidelines, has been disapproved in the current version [3], because of failure of the IABP-SHOCK II trial to prove its efficacy [4]. A new feature, in the current guidelines, is the recommendation of a time-line of 2 weeks for revascularization of highly symptomatic patients (Canadian Cardiovascular Society class 3) with stable, but anatomically high-risk multivessel CAD [MVCAD: left main (LMD) or equivalent, three-vessel (3VD) or proximal left anterior descending artery (LAD) disease] and 6 weeks for all other patients once the decision of revascularization has been made. This could potentially avoid the occurrence of untoward events in patients awaiting revascularization. However, this should not be used as a rationale for unrestricted performance of ad hoc PCI, the indications of which should be clearly outlined in institutional protocols formulated by the Heart Team in accordance with current guidelines. Several risk stratification models have been developed to evaluate

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