The guidelines introduce substantial changes in the recommended method of revascularization in various situations. There is a strong emphasis on risk stratification using the SYNTAX score; in fact, the guidelines include a primer on how to calculate it.
Based largely on the results of the meta-analysis as well as 5-year follow-up in the SYNTAX trial (Lancet 2013;381:629-38), the guidelines now regard percutaneous coronary intervention as equivalent to coronary artery bypass graft surgery in several patient subsets where CABG was previously preferred. These include patients with left main or triple-vessel disease and a SYNTAX score below 22. In patients with one- or two-vessel disease and proximal left anterior descending coronary artery stenosis, both PCI and CABG get a Class I recommendation.
The new guidelines emphasize the value of intracoronary fractional flow reserve measurement to identify hemodynamically relevant lesions warranting revascularization in patients with stable coronary artery disease lacking noninvasive evidence of ischemia.
• Aortic diseases. Routine screening for abdominal aortic aneurysm via ultrasound is recommended in all men over age 65 and “may be considered” in women over 65 with a history of smoking, according to the new guidelines. That’s a much stronger proscreening stance than has been taken by the U.S. Preventive Services Task Force.
Former ESC guidelines were confined to aortic dissection and focused on the thoracic aorta. The new guidelines expand in scope to include intramural hematomas, thoracic and abdominal aneurysms, aortic valve lesions, and penetrating ulcers.
“We are not only dealing with the thoracic aorta, but are taking the holistic view of the aorta as one organ,” according to guidelines task force cochair Dr. Raimund Erbel, professor of medicine at the University of Essen (Germany).
“When an aortic aneurysm is identified at any location, assessment of the entire aorta and aortic valve is recommended at baseline and during follow-up,” he added.
All of the new guidelines can be downloaded in their entirely at the ESC website (escardio.org/guidelines).