New US guideline on coronary artery revascularization recommends a shorter 1- to 3-month duration of dual antiplatelet therapy after percutaneous coronary intervention in select patients
A new guideline on coronary artery revascularization has been published by the American Heart Association and American College of Cardiology in partnership with the Society for Cardiovascular Angiography.
The guideline provides recommendations on treatment strategies for patients undergoing percutaneous coronary intervention (PCI), including the following.
A shorter 1- to 3-month duration of dual antiplatelet therapy (DAPT) following PCI is recommended for selected patients, with subsequent transition to P2Y12 inhibitor monotherapy, to reduce the risk of bleeding events. Previously, DAPT was recommended for 6 to 12 months following PCI.
Anticoagulation therapy (subcutaneous low molecular weight heparin, intravenous unfractionated heparin, or the alternative agent bivalirudin) should be started on earliest recognition of non-ST-elevation myocardial infarction in patients undergoing PCI. Fondaparinux alone is no longer recommended due to a higher incidence of guiding-catheter thrombosis.
PCI using radial artery access is preferred for suitable patients over femoral artery access when a clinician experienced in radial access is available as it decreases procedural site complications.
Non-ST-elevation myocardial infarction (NSTEMI) is part of the acute coronary syndrome spectrum.
Symptoms are indistinguishable from those of unstable angina. Most patients present with chest pain. However, NSTEMI is differentiated from unstable angina by a rise in level of cardiac troponin.
ECG, biomarkers (high-sensitivity troponin), and echocardiogram are the first-line investigations in all patients. Other investigations (e.g., chest x-ray and computed tomography chest) are useful to exclude other conditions.
Early risk stratification and treatment with anti-ischemic (beta-blockers, nitrates), anticoagulant (heparin), and dual antiplatelet agents (aspirin plus a P2Y12 inhibitor) is needed. Higher-risk patients should be considered for an early invasive strategy (coronary angiography and revascularization in 12-24 hours).
Complications are progression or worsening of myocardial infarction, heart failure, cardiogenic shock, arrhythmias, and death.
Non-ST-elevation myocardial infarction (NSTEMI) is an acute ischemic event causing myocyte necrosis. The initial ECG may show ischemic changes such as ST depressions, T-wave inversions, or transient ST elevations; however, it may also be normal or show nonspecific changes. If persistent ST elevation, evidence of posterior myocardial infarction, or a new left bundle-branch block is present, then the patient should be evaluated as an ST-elevation myocardial infarction. NSTEMI, therefore, encompasses a broad spectrum of ischemic injury to the myocardium, which is detected by elevation of troponin. It can be distinguished from unstable angina pectoris, a condition in which troponin is not elevated.
History and exam
Key diagnostic factors
- chest pain
Other diagnostic factors
- shortness of breath
- nausea and vomiting
- abdominal pain
- early morning onset
- abnormal heart sounds
- atherosclerosis (history of angina, myocardial infarction, stroke, transient ischemic attack, peripheral vascular disease)
- family history of premature coronary artery disease (CAD)
- age >65 years
- obesity and metabolic syndrome phenotype
- physical inactivity
- cocaine use
- stent thrombosis or restenosis
- chronic kidney disease
- surgical procedures (including intraoperative and postoperative periods)
- sleep apnea
1st investigations to order
- cardiac biomarkers
- BUN and serum creatinine
- blood glucose
- chest x-ray
Investigations to consider
- brain natriuretic peptide (BNP) or N-terminal pro-BNP (NT-pro-BNP)
- angiography/cardiac catheterization
- stress testing
- coronary CT angiography (CCTA)
Cody S. Deen, MD
Assistant Professor of Medicine
Director of Cardiology
University of North Carolina
CSD was previously the Director of Cardiac Rehab for Chatham Hospital, which was financially set up as a consultancy relationship, until 2017. CSD has spoken (unpaid) at the Update in Cardiology and Update in Internal Medicine Conferences at UNC for the last 5 years. CSD has served as the PI for the Dal-GeneE (site now closed) and the ACCELERATE Trials at the University of North Carolina (trial now completed). Each trial required paid travel to an investigator meeting.
Dr Cody S. Deen would like to gratefully acknowledge Dr Sripal Bangalore, Dr Mina Owlia, Dr Thomas Vanhecke, and Dr Dena Krishnan, the previous contributors to this topic.
SB, MO, TV, and DK declare that they have no competing interests.
Syed Wamique Yusuf, MBBS, FRCPI
Professor of Medicine
Department of Cardiology
University of Texas
MD Anderson Cancer Center
SWY declares that he has no competing interests.
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