Transatlantic Editorial: a comparison between European and North American guidelines on myocardial revascularization

The 2014 edition of the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society of Cardiology (ESC) joint Guidelines on Myocardial Revascularization (MR) marks the 50th anniversary of the first coronary artery bypass grafting (CABG) procedure [ 1 ]. The first percutaneous coronary intervention (PCI) procedure was performed 13 years later, in 1977. Since these early times, MR techniques have gained clinical importance worldwide and are now one of the most commonly performed interventions in modern medicine. On the other side of the Atlantic, the American societies have also published several guidelines on MR: in 2011, the ACCF/AHA Guidelines for CABG Surgery [ 2 ]; the 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischaemic heart disease [ 3 ]; the 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update [ 4 ] and in 2015, the Society of Thoracic Surgeons (STS) Clinical Practice Guidelines on Arterial Conduits [ 5 ]. In view of the rapidly evolving landscape of therapeutic options, this Transatlantic Editorial is intended to compare the European and American societies' guidelines on MR, covering important topics such as decision-making, patient information, timing of revascularization, risk scores, ischaemia testing, revascularization with CABG versus PCI, use of arterial conduits in CABG, on-pump versus off-pump surgery, revascularization in diabetic patients and implementation of guidelines. The American as well as European guidelines strongly advocate the implementation of ‘Heart Team’ decisions for complex and stable coronary artery disease (CAD) as a class of recommendation (COR) I, with level of evidence (LOE) C. Recommendations for Heart Team involvement in stable multivessel CAD are stronger in the European guidelines (‘required’) compared with the American guidelines (‘recommended’). Furthermore, the description of the Heart Team differs: according to the EACTS/ESC Guidelines, at least three specialists (clinical cardiologist, interventional cardiologist and surgeon) should meet on a regular basis and protocols be followed [ 1 ]. On the other side of the Atlantic, the American guidelines do not describe this multidisciplinary Heart Team in a conference style, but recommend that the interventional cardiologist and surgeon, together as a Heart Team, should discuss the treatment options [ 3 ]. For centres without infrastructure for on-site coronary surgery, the European guidelines recommend institutional protocols that need to be established with partner institutions providing surgery. The benefit of a Heart Team decision is convincingly presented throughout all available literature in line with the authors' attitudes. The superiority of a team decision-based treatment is derived from comparing randomized and registry cohorts with better results for the registry cohorts [ 6 , 7 ]. It has been shown that the initiation of the structured Heart Team approach could lead to beneficial clinical outcomes [ 8 ]. Other centres report that the decision and referral strategies did not change at all after initiation of the European guidelines, which is a clear example of how deep-set local habits and beliefs can be and how resistant some practitioners can be to change [ 9 ]. Interestingly, re-discussing the same patients after 1 year leads to different decisions in 24% of the cases. This fact underscores that, in some CAD patients, both treatment modalities might be appropriate [ 10 ]. Also, the importance of including other clinical specialists as part of the Heart Team is reflected by the fact that taking the severe cases into this conference might lead to a significant proportion of treatment recommendations other than MR (e.g. heart transplantation, ventricular assist device, valve surgery or medical therapy) [ 8 ]. Patient consent discussion is handled differently in the existing guidelines. While the EACTS/ESC Guidelines expand on that topic including specific recommendation categorization, informed consent is only mentioned as a prerequisite of ‘any invasive or non-invasive procedure’ in the American guidelines [ 3 ]. Conversely, the American guidelines are much more precise on the topic of Patient Education. The EACTS/ESC Guidelines put forward the importance of patient information and need for an extensive informed consent process. They conclude that enough time should be allowed for informed decision-making. Specifically, in a high proportion of patients with stable CAD, a gap between diagnostic angiography and revascularization should exist to allow sufficient time to receive information about all therapeutic alternatives. Written informed consent is specifically needed for all procedures done with the exception of patients in shock or with ST-segment elevation myocardial infarction (STEMI). The treatment of STEMI patients with primary emergency PCI is unquestionable. The EACTS and ESC representatives have included this patient cohort in the joint guidelines, whereas the major American societies have formulated separate guidelines for the management of STEMI [ 11 ]. For those patients with non-ST-segment elevation (NSTE)-acute coronary syndrome (ACS), the European guidelines recommend revascularization within 24 or 72 h, according to patient risk stratification. Primary criteria for urgency (invasive strategy within 24 h) are met with rising troponin levels, dynamic ST-segment or T-wave changes or a GRACE score of >140 [ 1 ]. In the American guidelines [ 2–4 ], the recommendation for these urgent patients is based on a more general rule, indicating that the acuity of presentation and extent of ischaemia dictate the timing of intervention. Interestingly, both guidelines see only the need for revascularization strengthened. However, the choice of revascularization method is mainly independent of the urgency and influenced by the same considerations for choosing PCI or CABG in the stable patient cohort. However, American guidelines state that PCI is reasonable in patients undergoing revascularization for NSTE-ACS. Both guidelines favour CABG over PCI for NSTE-ACS patients with diabetes mellitus with complex CAD. Comparisons between American and European Guidelines for patients with NSTE-ACS are outlined in Table 1 . ACCF/AHA and EACTS/ESC Guidelines on NSTEMI ACCF: American College of Cardi o logy Foundation; ACS: acute coronary syndrome; AHA: American Heart Association; CABG: coronary artery bypass grafting; CAD: coronary artery disease; DM: diabetes mellitus; EACTS: European Association for Cardio-Thoracic Surgery; ESC: European Society of Cardiology; LAD: left anterior descending; LM: left main; LOE: level of evidence; NSTEMI: non-ST-segment elevation myocardial infarction; PCI: percutaneous coronary intervention. ACCF/AHA and EACTS/ESC Guidelines on NSTEMI ACCF: American College of Cardi o logy Foundation; ACS: acute coronary syndrome; AHA: American Heart Association; CABG: coronary artery bypass grafting; CAD: coronary artery disease; DM: diabetes mellitus; EACTS: European Association for Cardio-Thoracic Surgery; ESC: European Society of Cardiology; LAD: left anterior descending; LM: left main; LOE: level of evidence; NSTEMI: non-ST-segment elevation myocardial infarction; PCI: percutaneous coronary intervention. For stable patients without severe symptoms, the EACTS/ESC Guidelines consider a maximum waiting time of 6 weeks to revascularization appropriate. Whenever symptoms are severe, anatomy high-risk or left ventricular function depressed, the European guidelines recommend revascularization within 2 weeks [ 1 ]. Interestingly, the American guidelines do not cover this problem. The waiting times in American centres appear to have been reduced and this topic might not be of the same significance as in previous years [ 14 ]. Also, differences in payer systems in Europe and America contribute to timing considerations. In addition, cultural and social expectations are likely to be different among patients and cardiologists across the Atlantic. Various risk scores validated for the short-term mortality after CABG are available (STS score, EuroSCORE and EuroSCORE II, ACEF), but these scores do not predict medium- or long-term outcome. The SYNTAX score was developed to summarize the complexity of coronary lesions [ 15 ]. It was found that medium- and long-term outcomes correlated with the SYNTAX score. Both guidelines see an important role of using risk scores—especially the SYNTAX score. The American guidelines provide a COR IIa (LOE B) for the use of STS and SYNTAX scores in patients with complex CAD and unprotected left main (LM) disease, whereas the EACTS/ESC Guidelines recommend the use of the SYNTAX score to assess medium- to long-term outcome before CABG or PCI (COR I, LOE B). The STS score (COR I, LOE B) or the EuroSCORE II (COR IIa, LOE B) should be used to assess short-term outcome after CABG. Also, some recommendations in the choice of treatment modality are based on the SYNTAX score in the guidelines (see specific paragraph). Of exist in all risk and the in the specific patient cohort should be into The risk scores should only be used as an whereas the Heart decision based on the clinical The EACTS/ESC Guidelines recommend diagnostic in stable CAD only in patients and based on the of significant In patients with of significant disease, using or is (COR I, LOE for all angiography should be (COR IIa, LOE In of coronary angiography is (COR I, LOE is not The American guidelines into the recommendation of diagnostic in which are presented in an [ 3 ]. together the COR from the recommend the use of in those patients with (COR I, LOE In patients with with or is (COR I, LOE B). In patients to or should be performed (COR I, LOE B). angiography should be (COR IIa, LOE in several with results or to class the results of the SYNTAX a clear benefit for several [ ], the European guidelines on the of the complexity of the coronary disease according to the SYNTAX score. these guidelines a clear COR (LOE or B) for surgery of coronary disease left anterior coronary artery disease and However, PCI is as an for patients with and disease with disease with a SYNTAX score and disease also with a SYNTAX score. Conversely, PCI should not be used (COR in patients with disease and high SYNTAX score or with disease and or high SYNTAX score. The American guidelines, in appear more with the use of PCI in patients with disease or complexity is and more disease is They are not structured according to the SYNTAX score or other the complexity of the coronary a of clinical is into Comparisons between American and European guidelines for patients with stable CAD are in Table 2 . ACCF/AHA and EACTS/ESC Guidelines on Myocardial Revascularization IIa (LOE CABG reasonable over PCI with complex CAD are for CABG (LOE PCI of benefit IIa (LOE CABG reasonable over PCI with complex CAD are for CABG (LOE PCI of benefit ACCF: American College of Cardiology Foundation; ACS: acute coronary syndrome; AHA: American Heart Association; CABG: coronary artery bypass grafting; CAD: coronary artery disease; DM: diabetes mellitus; EACTS: European Association for Cardio-Thoracic Surgery; ESC: European Society of Cardiology; LAD: left anterior descending; left LM: left main; LOE: level of evidence; PCI: percutaneous coronary Society of Thoracic ACCF/AHA and EACTS/ESC Guidelines on Myocardial Revascularization IIa (LOE CABG reasonable over PCI with complex CAD are for CABG (LOE PCI of benefit IIa (LOE CABG reasonable over PCI with complex CAD are for CABG (LOE PCI of benefit ACCF: American College of Cardiology Foundation; ACS: acute coronary syndrome; AHA: American Heart Association; CABG: coronary artery bypass grafting; CAD: coronary artery disease; DM: diabetes mellitus; EACTS: European Association for Cardio-Thoracic Surgery; ESC: European Society of Cardiology; LAD: left anterior descending; left LM: left main; LOE: level of evidence; PCI: percutaneous coronary Society of Thoracic 1 and 2 in patients with stable CAD without or with coronary artery to the and to the need for discussion of patient with protocols from ESC Guidelines on the management of stable [ ]. coronary intervention or coronary artery bypass surgery in stable coronary artery disease without left main coronary artery CABG: coronary artery bypass grafting; LAD: left anterior descending; PCI: percutaneous coronary intervention. a and of in or CABG is the in most patients or discussion by the Heart to local and to CABG be allowed in these patients, discussion in a multidisciplinary team is not from Guidelines on Myocardial Revascularization from [ ] with of European Society of ]. coronary intervention or coronary artery bypass surgery in stable coronary artery disease with left main coronary artery CABG: coronary artery bypass grafting; PCI: coronary intervention. a and of in or in to local and decision be without multidisciplinary but with protocols from Guidelines on Myocardial Revascularization from [ ] with of European Society of ]. the basis for with arterial versus bypass the ACCF/AHA Guidelines are in a of been published the benefit of versus the to only from a in a recommendation that and use of a to the left or coronary artery is reasonable to the of and to (COR IIa, LOE B). the to this the least followed patient cohorts available in the literature at the time of guideline [ , ]. the of randomized have influenced the the and evidence artery The discussion of the risk of was not extensive literature on the and was on the that the for have on the risk of The European guidelines, on the other to a of that have in the years between the of these of guidelines [ , ], are much more of the use of The specifically the risk of well as other with the approach to and the risk of in and patients, with to the The in the conclude that grafting is 5 years and to However, in the guideline the for a more grafting should be in patients years of as a COR IIa, LOE is is that both of guidelines the recommendation as a COR IIa, LOE with It is of evidence in should be the that from the only on the topic be as with is likely to as as [ ]. This is based on the ACCF/AHA Guidelines for CABG Surgery [ 2 ], in with the 2014 Guidelines on MR [ 1 ]. a general the European guidelines are more than the American guidelines. The 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update [ 4 ] not guidelines with to artery The STS has published Clinical Practice Guidelines on Arterial Conduits that do the [ 5 ]. The recommendations of the STS Practice Guidelines grafting be outlined as The ACCF/AHA Guidelines a COR be based on LOE for the use of the for CABG. Specifically, the recommendation the importance of a severe using an which was as of or for a The is but that are to to a than a coronary It is well that arterial including the not only by but can also and [ ]. that the is more on the of the than the [ , ]. The ACCF/AHA Guidelines also a COR LOE the importance of not grafting the coronary artery with an arterial not specifically has a The 2014 Guidelines the of several important randomized and grafting [ ]. in these guidelines the and of the in to and left and that of but is likely than the left or [ 1 ]. Also, and are these guidelines more strongly recommend the (COR I, LOE B) than the American guidelines, but the American guidelines, the importance of a of the coronary The guidelines do not the in the the describe that of the is strongly for lesions In the the conclude that the is a reasonable for a arterial is to of The STS Practice Guidelines [ 5 ] recommend a Heart Team approach for decisions revascularization, including the of (COR I, LOE The STS Practice Guidelines recommend a arterial a or an (COR IIa, LOE in appropriate that patient the and of different the should be to a coronary artery with a severe (COR IIa, LOE in addition, is and (COR IIa, LOE but is evidence to recommendation use of The American and European societies the importance of the of for based on by coronary than as by has importance in percutaneous revascularization, and both the American and European guidelines recommend this for PCI [ ]. is some evidence that coronary surgery is with [ , ]. or in with for grafting or coronary surgery in is at this In a the of arterial revascularization is mentioned in the ACCF/AHA Guidelines as a COR (LOE be reasonable in patients years of with or discussion or to specific of discussion of the topic is in the European guidelines, recommendations are one for patients with (COR I, LOE without based on and recommendations for and the other that should be in patients with reasonable (COR LOE B) based on a [ ]. in of only in this which the of [ , ]. the of the guideline the of on the clinical the use of arterial only a of such [ ]. Comparisons are with grafting and use of and as well as the of in versus and the use of which have been used for interventional the [ ]. The major is or not a strategy of benefit compared with or to have been but [ ]. more be needed to changes in the and societies have performed a focused update for the diagnosis and management of patients with stable ischaemic heart disease [ 4 ], this did not the of off-pump and on-pump CABG, and the and on these topics are based on the ACCF/AHA Guidelines for CABG Surgery [ 2 ] and the 2014 Guidelines on MR [ 1 ]. The ACCF/AHA Guidelines the use of bypass as well as the more specific of off-pump versus on-pump CABG. a of the basis for the and clinical as and and a focused of the available evidence comparing and off-pump the to guideline recommendations strategies for of most specifically as and of and use of all mentioned without It is this of evidence that has the European to the the of versus on-pump to CABG surgery, the was by the in the The of early [ , ] and the of the [ ] have left the with an of registry which was in the high-risk patient [ ]. The focused on the of of an versus off-pump approach in patients with evidence of disease, that this be more with an off-pump It that patients with be more with an on-pump In be patients for one approach or the other be consider approach to be reasonable for the of undergoing recommendation was The European on the other the benefit of more on and high-risk patients, to a in or outcomes or off-pump CABG was performed by [ , ]. Interestingly, based on some of the same available to the American [ , ], the more of the of off-pump surgery in high-risk patients, with to and that off-pump CABG be for of high-risk patients in off-pump centres as a COR IIa based on LOE American the European was more of and off-pump CABG on-pump techniques for patients with significant disease as a COR with LOE have that complexity of the and patient in that the short-term for off-pump need to be the long-term for the on-pump The reduced in a of [ ], with from a of and in over patients, which a among as to on-pump patients [ ]. Interestingly, evidence that the in be to a role for use of arterial conduits of the strategy by the time the guidelines are better evidence be available to in which patients are likely to benefit from which the American guidelines [ 2 ] the update [ 4 ] included recommendations invasive surgery. The 2014 European guidelines [ 1 ] did that invasive coronary artery bypass be for disease (COR IIa, LOE In the the that the and of are to that with or off-pump coronary surgery, these do in of of and a better of early surgery. The in the American guidelines the of a invasive of and and also as the most invasive [ ]. However, the American guidelines mainly on the of a other of a in of of of all coronary and the to provide revascularization with have to in bypass with an and of the coronary artery artery or as a revascularization the benefit of an for revascularization, and the reduced of PCI for in with the results of PCI, with revascularization is commonly to a invasive approach for left artery bypass a for bypass in with PCI is with the [ ], and likely to be by more than one of the invasive [ ]. the American guidelines do specific recommendations on The American guidelines recommend revascularization as COR IIa, LOE in multivessel disease patients revascularization or PCI is to be more or [ ], for patients to a and for PCI patients percutaneous revascularization of the is to be to local The American guidelines do a COR LOE as an to CABG or approach is intended to risk and the to PCI or CABG. a Heart Team such a decision the did not on the of this the European guidelines are more about of revascularization, only that be in specific patient cohorts and in institutions (COR LOE In the that the have a of revascularization by including not only patients with coronary surgery and PCI, but also PCI and other The European did a recommendation to in patients with a COR I, LOE The or the and revascularization are more than for other of coronary bypass surgery [ ]. The importance of diabetes mellitus in the of revascularization strategy was in the 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update [ 4 ] and the 2014 Guidelines on MR [ 1 ] 2 While both of guidelines consider CABG to be a COR in the European provide a COR IIa for PCI in with SYNTAX the recommendation for use of the to the American guidelines do not into the of how diabetes might grafting The European the of grafting on the diabetic patient and that grafting should be (COR IIa, LOE B). both of guidelines the for risk of with in diabetic patients, was not the of the STS Clinical Practice Guidelines on Arterial Conduits for CABG [ 5 ] that specific strategies for this risk the use of a approach is as a COR IIa, LOE diabetes is an established risk for the risk of is with or without was with an risk of at 1 year and years in the [ , ]; the use of an compared with grafting was with reduced in the diabetic cohort. In the use of an as a arterial to be in of [ , ]. Surgeons in have about an of PCI over CABG with of PCI use and of CABG for stable ischaemic heart In this the report of the for and more specific information on the use of revascularization techniques in the different European the and some other of coronary revascularization procedures is with an PCI proportion of performed in [ ]. is a in these with the revascularization of about procedures in by the of PCI in a PCI proportion of at the published [ , ] an in the of PCI and CABG. For in an of and in a of 9 In the for coronary revascularization published in [ ]. The of PCI have in the to the of the [ , is to a in the of PCI for stable or ischaemic heart disease, the for acute have Furthermore, the proportion of PCI procedures to be has as well [ ]. The differences in the worldwide use of PCI and CABG be by different with in and to treatment options in the or be by and extent and which revascularization procedures are performed to the European and American CAD guidelines be on the basis of most the treatment of disease as well as between stable CAD and acute are not in to the guidelines medical systems are established in the of the mentioned The use of a Heart Team in the guidelines from both of the should the the of PCI versus CABG. However, the extent to which a Heart Team involvement or institutional protocols are as in the guidelines, guideline implementation and is of major importance in the to more specific in and allow for the and more to structured in and of treatment on guideline should be put this could convincingly a between the ACCF/AHA Guidelines for CABG including over the and the 2014 Guidelines on Whenever the same patient cohorts the American and European guidelines major recommendation in at least 6 11 major recommendations are in the same only in which the guidelines different which most to the time gap in between the of the of guidelines. for of between and the recommendations for revascularization of disease and disease in stable coronary heart disease, a high level of between both guidelines was the timing of guidelines in the by 3 the Guidelines in more and as the results of the SYNTAX and more on for multivessel revascularization and specific recommendations including the complexity of the coronary is general in bypass surgery as an or procedure compared with PCI, a significant is The and of both guidelines is by a worldwide the specific and medical the and with independent guidelines these However, has also that is a significant in and proportion of the techniques by of PCI have been by non-invasive cardiologists and general on the one or by in the of patient on the reasonable and as by medical guidelines with of in the is to and of and and systems in to the major criteria used for according to the treatment For the of institutional protocols or Heart Team decisions is strongly on the and of between the interventional and cardiologists and the in institutions with or a role of the or of state be to guideline implementation in the of medicine. The of guidelines is to a to this and European societies strongly recommend a Heart Team approach (COR in the of different medical such as the of PCI to coronary bypass is to patient differences but differences in or change in the of of PCI for stable ischaemic heart disease in the followed the of the that can change with appropriate systems with appropriate at the or or with should that is is a in the that revascularization is not Heart can patient using the treatment as outlined in the revascularization as clinical a more of the of the For to the other this to need to of the fact that is the patient from is not the that cardiologists and are on the same Heart of that is in part by the in

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