The “Ten Commandments” of Myocardial Revascularization According to Europe

The new European guidelines on myocardial revascularization were developed by a joint effort of the European Society of Cardiology (ESC) and the European Association of Cardiovascular Surgery (EACTS). These guidelines are intended to support clinical practice with pragmatic recommendations based on currently available evidence and on personal experience, whenever evidence is missing.

Both coronary angioplasty and myocardial revascularization surgery are highly efficient in alleviating symptoms produced by myocardial ischemia, and both can improve prognosis.

The remaining gap between them could be summed up as angioplasty being associated with faster recovery and lower risk of early events (including stroke), and surgery being associated with improved survival and reduced risk of infarction and long-term revascularization.

Read also: Anticoagulation Plays a Controversial Role in TAVR.

The difference in recurrent ischemic events, favoring surgery, mainly depends on anatomical complexity and the presence of diabetes.

These guidelines were intended as a means to provide reasonable advice on revascularization to our patients.

1. Objective evidence of myocardial ischemia, whether it be non-invasive stress imaging or functional invasive assessment of lesions, is necessary to indicate revascularization, either by angioplasty or surgery.
2. With large amounts of inducible ischemia or relevant ventricular dysfunction, revascularization through angioplasty or surgery must be indicated to improve long-term survival.
3. Revascularization is also indicated for relief of symptoms of myocardial ischemia beyond optimized medical therapy.
4. The prognostic and symptomatic benefit of myocardial revascularization critically depends on the completeness of revascularization. The ability to achieve complete revascularization is key when choosing the most appropriate treatment modality.
5. Apart from individual surgical risk and technical feasibility, diabetes and anatomical complexity are predictors of better long-term survival with myocardial revascularization surgery.
6. The SYNTAX score is the recommended tool to assess anatomical complexity.
7. Complex cases must be discussed by the whole Heart Team so as to individualize treatment taking into account patient preferences and provide the best possible advice on his/her long- and short-term prognosis.
8. Radial access is preferred for any angioplasty, irrespective of clinical presentation, unless there are overriding procedural considerations.
9. Drug-eluting stents are recommended for all angioplasties, irrespective of clinical presentation, lesion type, anticipated duration of dual antiplatelet therapy, or need for concomitant anticoagulant therapy.
10. Myocardial revascularization surgery should use the highest possible number of arterial grafts, using the radial artery for critical lesions and the bilateral internal thoracic artery for patients who do not have an increased risk for sternal wound infection.

Original title: ‘Ten Commandments’ for the 2018 ESC/EACTS Guidelines on Myocardial Revascularization.

Reference: Neumann FJ et al. Eur Heart J. 2019 Jan 7;40(2):79-80.

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