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GNL 2011

2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention (and Coronary Revascularization). GNL 2011. GNL 2011. Slide Set Organization. COR and LOE General Revascularization (CABG or PCI) Recommendations PCI Revascularization Recommendations Pre-Procedural Considerations

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GNL 2011

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  1. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention (and Coronary Revascularization) GNL 2011

  2. GNL 2011

  3. Slide Set Organization COR and LOE General Revascularization (CABG or PCI) Recommendations PCI Revascularization Recommendations Pre-Procedural Considerations Procedural Considerations Post-Procedural Considerations Quality and Performance Considerations GNL 2011

  4. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary InterventionClass of Recommendation (COR) and Level of Evidence (LOE) GNL 2011

  5. GNL 2011

  6. Class of Recommendation (COR) GNL 2011

  7. Comparative Effectiveness Class of Recommendation (COR) GNL 2011

  8. Level of Evidence (LOE) GNL 2011

  9. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary InterventionRevascularization Recommendations GNL 2011

  10. Heart Team Approach to UPLM or Complex CAD GNL 2011

  11. UPLM Revascularization to Improve Survival GNL 2011

  12. UPLM Revascularization to Improve Survival GNL 2011

  13. Single and Multivessel (Stable) CAD Revascularization to Improve Survival (slide 1 of 2) *Reasonable to choose CABG over PCI for good CABG candidates with complex 3-vessel disease(e.g., SYNTAX score >22) (Class IIa; LOE:B) #Reasonable to choose CABG over PCI for MVD in patients with DM (Class IIa; LOE:B) GNL 2011

  14. Single and Multivessel (Stable) CADRevascularization to Improve Survival (slide 2 of 2) GNL 2011

  15. Comparative Effectiveness Recommendations for Revascularization to Improve Survival GNL 2011

  16. Cumulative 3-Year Incidence of MACE in Patients With 3-Vessel CAD in the SYNTAX trial Results For Each SYNTAX Tercile GNL 2011

  17. One-Year Mortality Rates in Randomized Trials of Patients With Diabetes and Multivessel CAD, Comparing PCI With CABG GNL 2011

  18. Revascularization to Improve Symptoms GNL 2011

  19. Hybrid Coronary Revascularization GNL 2011

  20. TMR GNL 2011

  21. Clinical Factors That May Influence The Choice of Revascularization Diabetes mellitus Chronic kidney disease Completeness of revascularization LV systolic dysfunction Previous CABG Ability to comply with and tolerate DAPT GNL 2011

  22. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary InterventionPCI Revascularization Recommendations GNL 2011

  23. UPLM PCI to Improve Survival in SIHD Recommendations • 3 complementary recommendations based on the risk of PCI complication, likelihood of long-term durability, and surgical risk • Includes a new PCI class IIa recommendation • SYNERGY score and STS score can be used to help guide UPLM revascularization decisions GNL 2011

  24. UPLM PCI to Improve Survival (SIHD) Low Hi Hi Hi Low Low GNL 2011

  25. UPLM PCI to Improve Survival (ACS) GNL 2011

  26. Single and Multivessel CAD PCI To Improve Survival(SIHD) GNL 2011

  27. PCI to Improve Symptoms GNL 2011

  28. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary InterventionPre-Procedural Considerations GNL 2011

  29. Pre-Procedural Considerations GNL 2011

  30. Contrast-Induced Acute Kidney Injury (AKI) Risk Reduction GNL 2011

  31. Ethical Considerations Place the patient’s best interest first and foremost when making clinical decisions (beneficence). Ensure that patients actively participate in decisions affecting their care (autonomy). Consider how decisions regarding one patient may also affect other patients and providers (justice). Plan and perform procedures and provide care with the intention of improving the patient’s quality of life and/or decreasing the risk of mortality, independent of reimbursement considerations and without inappropriate bias or influence from industry, administrators, referring physicians or other sources. Before performing procedures, obtain informed consent after giving an explanation regarding details of the procedure, risks and benefits of both the procedure and alternatives to the procedure. Plan and perform procedures according to standards of care and recommended guidelines, and deviate from them when appropriate or necessary to the care of individual patients. Seek advice, assistance or consultation from colleagues when such consultation would benefit the patient. GNL 2011

  32. Radiation Safety *e.g., total air kerma at the international reference point (Ka,r), air kerma air product (PKA), fluoroscopy time, number of cine images GNL 2011

  33. Cath Lab Standards For Radiation Safety Specific procedures and policies are in place to minimize patient (and operator) risk A radiation safety officer coordinates all radiation safety issues and works conjointly with the medical or health physicist Patient radiation exposure is reduced to as low as reasonably achievable Patients at increased risk for high procedural radiation exposure are identified Informed consent includes radiation safety information, particularly in the high-risk patient GNL 2011

  34. Strategies to Reduce Radiation Exposure to Patient and Operator GNL 2011

  35. PCI in Hospitals Without On-Site Surgical Backup GNL 2011

  36. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary InterventionProcedural Considerations GNL 2011

  37. Vascular Access GNL 2011

  38. UA/NSTEMI: Choice of Strategy* *UA/NSTEMI GL with additional and more comprehensive recommendations **Early invasive strategy = diagnostic angiography with intent to perform revascularization ***Recs from the 2011 UA/NSTEMI focused update (not in PCI GL) GNL 2011

  39. General Considerations in Deciding Between an Early Invasive Strategy and an Initial Conservative Strategy in UA/NSTEMI GNL 2011

  40. Coronary Angiography in STEMI GNL 2011

  41. PCI in STEMI* *Systems goal of performing primary PCI within 90 minutes of first medical contact when the patient presents to a hospital with PCI capability (Class I, LOE: B), and within 120 minutes when the patient presents to a hospital without PCI capability (Class I, LOE: B). GNL 2011

  42. Cardiogenic Shock GNL 2011

  43. Recommendations for Initial Reperfusion Therapy When Cardiogenic Shock Complicates STEMI Dashed lines indicate that the procedure should be performed in patients with specific indications only GNL 2011

  44. Revascularization Before Noncardiac Surgery GNL 2011

  45. Coronary StentsRisk of restenosis needs to be weighted against the likelihood of the patient to be able to tolerate and comply with (prolonged) DAPT GNL 2011

  46. Clinical Situations Associated With DES or BMS Selection Preference GNL 2011

  47. Adjunctive Diagnostic Devices GNL 2011

  48. Adjunctive Therapeutic Devices GNL 2011

  49. Aspirin in PCI GNL 2011

  50. P2Y12 Inhibitors* and DAPT *P2Y12 Inhibitors = clopidogrel, prasugrel, or ticagrelor **Clopidogrel loading dose of 600 mg recommended GNL 2011

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