September 26, 2014 — In response to new science showing that complete revascularization of all significantly blocked arteries leads to better outcomes in some heart attack patients, the American College of Cardiology (ACC) has withdrawn its Choosing Wisely recommendation that patients and caregivers examine whether this practice is truly necessary.
As part of its Choosing Wisely list of five things providers and patients should question that was released in April 2012, the ACC recommended questioning any intervention beyond unblocking just the “culprit” artery responsible for the heart attack in a hemodynamically stable patient. At the time the list was released, there were several non-randomized studies demonstrating harm to patients when treating all significantly blocked arteries. However, over the last two years, new science has emerged showing potential improvements for some patients in their overall outcomes as a result of complete revascularization.
“Science is not static but rather constantly evolving,” said ACC President Patrick T. O’Gara, M.D., FACC. “As such, one of the ACC’s primary roles is to stay abreast of this evolution and provide cardiovascular professionals and patients with the most up-to-date information on which to base decisions about the most appropriate and necessary treatment. The newest findings regarding coronary revascularization are great examples of science on the move, and we are responding accordingly.”
Results from the Complete Versus Lesion Only PRimary-PCI Trial (CvLPRIT) released earlier this month found that patients undergoing complete revascularization had better outcomes and experienced fewer major adverse cardiac events compared to those who had only their “culprit” artery revascularized. These results reinforce data from another trial, the Preventive Angioplasty in Myocardial Infarction (PRAMI) trial released in 2013, that show stenting all coronary arteries with major stenoses improves outcomes.
While some questions remain about the exact timing of the procedures; whether certain patients benefit versus others; whether fractional flow reserve (FFR) might guide decisions; and the role of patient complexity and hemodynamic stability, there is additional need for further data across larger populations. The COMPLETE trial, which is currently in the enrollment phase, will hopefully answer some of these questions over the next several years.
“Nearly 60 organizations have published lists of tests, treatments and procedures they say are overused in their specialty as part of the Choosing Wisely campaign. These lists are based on the latest science and evidence available at their time of publication,” said Daniel Wolfson, M.H.S.A., executive vice president and chief operating officer of the ABIM Foundation. “The ABIM Foundation recognizes that new research and medical guidelines are published on a regular basis and has developed a set of operating principles to ensure the accuracy of all Choosing Wisely lists is maintained. After the initial publication of a list, Choosing Wisely partners have committed to review it at least annually and also to make any needed updates based on new evidence or changes to clinical guidelines. Providing the most accurate, up-to-date information to physicians and patients is just good medicine. We appreciate ACC’s careful review and update of its Choosing Wisely list.”
O’Gara noted the ACC is working with its partners to address current clinical guideline and appropriate use criteria recommendations in light of the new research. The college will also be working with the ABIM Foundation to update its current list of recommendations, as well as develop an additional list, in the future. “The more access patients and providers have to accurate information about treatment options, the more we can ensure care that is truly necessary, free from harm and cost-effective,” O’Gara said.
For more information: www.cardiosource.org/acc
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