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

2. PCI Revascularization Recommendations Pre-Procedural Considerations Procedural Considerations Post-Procedural Considerations

3. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention Revascularization Recommendations

4. 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

5. UPLM PCI to Improve Survival (ACS) COR IIa  For UA/NSTEMI if not a CABG candidate IIa  For STEMI when distal coronary flow is <TIMI grade 3 and PCI can be performed more rapidly and safely than CABG

6. Single and Multivessel CAD PCI To Improve Survival (SIHD) Anatomic ScenarioCOR 2-3 Vessel CAD or 1 VD With Proximal LAD CAD IIb  Uncertain benefit 1 VD Without Proximal LAD CADIII: Harm No anatomic or physiologic criteria for revascularization III: Harm Clinical ScenarioCOR Survivors of sudden cardiac death with presumed ischemia-mediated VT I Multivessel CAD CaveatsCOR Reasonable to choose CABG over PCI for good CABG candidates with complex 3-vessel CAD IIa Reasonable to choose CABG over PCI for multivessel CAD in patients with DM IIa

7. PCI to Improve Symptoms Clinical/Anatomic SettingCOR ≥1 significant stenoses amenable to revascularization and unacceptable angina despite GDMT I ≥1 significant stenoses and unacceptable angina in whom GDMT cannot be implemented because of medication contraindications, adverse effects, or patient preferences IIa Previous CABG with ≥1 significant stenoses associated with ischemia and unacceptable angina despite GDMT IIa No anatomic or physiologic criteria for revascularization III: Harm Caveat COR CABG preferred over PCI for complex 3 VD and a good candidate for CABG IIa

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

9. Hybrid Coronary Revascularization RecommendationCOR Hybrid coronary revascularization in patients with one or more of the following: limitations to traditional CABG, such as heavily calcified proximal aorta or poor target vessels for CABG (but amenable to PCI) lack of suitable graft conduits unfavorable LAD for PCI ( excessive vessel tortuosity or CTO) IIa Hybrid coronary revascularization as an alternative to multivessel PCI or CABG in an attempt to improve the overall risk/benefit ratio of the procedures IIb

10. 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

11. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention PCI Revascularization Recommendations

12. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention Pre-Procedural Considerations

13. Pre-Procedural Considerations RecommendationsCOR Contrast-Induced AKI Assessment for risk of contrast-induced (CI) AKII Adequate preparatory hydrationI Minimization of volume of contrast media in patients with CKDI Administration of N-acetyl-L-cysteine for the prevention of CI-AKIIII: No Benefit Anaphylactoid Reactions Appropriate prophylaxis prior to repeat contrast administration in patients with prior evidence of an anaphylactoid reaction to contrast media I Anaphylactoid prophylaxis for contrast reaction in patients with prior history of allergic reactions to shellfish or seafood III: No Benefit Statins Administration of high-dose statin prior to PCI to reduce the risk of periprocedural MI IIa Bleeding Risk Evaluation for risk of bleeding prior to PCII CKD Estimation of GFR and dosage adjustment of renally-cleared medications I

14. Contrast-Induced Acute Kidney Injury (AKI) Risk Reduction RecommendationCOR Assessment for risk of contrast-induced AKII Adequate preparatory hydrationI Minimization of volume of contrast media in patients with CKD I Administration of N-acetyl-L-cysteine for the prevention of contrast-induced AKI III: No Benefit

15. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention Procedural Considerations

16. Vascular Access RecommendationCOR Radial artery access to decrease access site complications IIa

17. General Considerations in Deciding Between an Early Invasive Strategy and an Initial Conservative Strategy in UA/NSTEMI Early Invasive Strategy Generally Preferred Initial Conservative Strategy Generally Preferred or Reasonable  Recurrent angina or ischemia at rest or with low level activities despite intensive medical therapy  Elevated cardiac biomarkers (TnT or TnI)  New or presumably new ST-depression  Signs or symptoms of heart failure  Hemodynamic instability  High risk score (e.g., GRACE, TIMI)  Sustained ventricular tachycardia  PCI within 6 mo  Prior CABG  Diabetes mellitus  Mild to moderate renal dysfunction  Reduced LV function (LVEF <40%)  Low risk score (e.g., GRACE, TIMI)  Absence of high-risk features  High risk for catheterization-related complications  Patient not a revascularization candidate (with either PCI or CABG)  Patient prefers conservative therapy

18. Coronary Angiography in STEMI IndicationsCOR Immediate coronary angiography Candidate for primary PCII Severe heart failure or cardiogenic shock (if suitable revascularization candidate) I Moderate to large area of myocardium at risk and evidence of failed fibrinolysis IIa Coronary angiography 3 to 24 hours after fibrinolysis Hemodynamically stable patients with evidence for successful fibrinolysis IIa Coronary angiography before hospital discharge Stable patientsIIb Coronary angiography at any time Patients in whom the risks of revascularization are likely to outweigh the benefits or the patient or designee does not want invasive care III: No Benefit

19. PCI in STEMI IndicationsCOR Primary PCI STEMI symptoms within 12 hI Severe heart failure or cardiogenic shockI Contraindications to fibrinolytic therapy with ischemic symptoms <12 h I Clinical and/or ECG evidence of ongoing ischemia between 12 and 24 h after symptom onset IIa Asymptomatic patient presenting between 12 and 24 h after symptom onset and higher risk IIb Noninfarct artery PCI at the time of primary PCI in patients without hemodynamic compromise III: Harm Delayed or Elective PCI in Patients with STEMI (i.e. Non-Primary PCI) Clinical evidence for fibrinolytic failure or infarct artery reocclusionIIa Patent infarct artery 3 to 24 h after fibrinolytic therapyIIa Ischemia on noninvasive testingIIa Hemodynamically significant stenosis in a patent infarct artery >24 hours after STEMI IIb Totally occluded infarct artery >24 h after STEMI in a hemodyamically stable asymptomatic patient without evidence of severe ischemia III: No Benefit

20. Cardiogenic Shock RecommendationCOR Immediate coronary angiography in patients with STEMI with severe heart failure or cardiogenic shock who are suitable candidates for revascularization I PCI for patients with acute MI who develop cardiogenic shock and are suitable candidates I Hemodynamic support device for patients with cardiogenic shock after STEMI who do not quickly stabilize with pharmacological therapy I

21. 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

22. Coronary Stents Risk of restenosis needs to be weighted against the likelihood of the patient to be able to tolerate and comply with (prolonged) DAPT RecommendationCOR DES as an alternative to BMS to reduce the risk of restenosis in cases in which the risk of restenosis is increased and the patient is likely to be able to tolerate and comply with prolonged DAPT I Before implantation of a DES, interventional cardiologist discussion with the patient regarding the need for and duration of DAPT and the ability of the patient to comply with and tolerate DAPT I Use of balloon angioplasty or BMS (instead of DES) in patients with high bleeding risk, inability to comply with 12 months of DAPT, or with anticipated invasive or surgical procedures within the next 12 months I PCI with coronary stenting in cases in which the patient is not likely to be able to tolerate and to comply with DAPT III - Harm DES implantation in cases in which the patient is not likely to be able to tolerate and comply with prolonged DAPT, or this cannot be determined prior to stent implantation III - Harm

23. Clinical Situations Associated With DES or BMS Selection Preference DES Generally Preferred Over BMS (efficacy considerations) BMS Preferred Over DES (safety considerations)  Left main disease  Small vessels  In-stent restenosis  Bifurcation lesions  Long lesions  Multiple lesions  Saphenous vein graft lesions  Diabetic patients  Patients unable to tolerate or comply with prolonged DAPT  Anticipated surgery requiring discontinuation of DAPT within 12 months  High risk of bleeding

24. Aspirin in PCI Time Relative to PCI RecommendationCOR Pre-PCIAspirin 81-325 mg before PCI if already on aspirin therapy I Nonenteric-coated aspirin 325 mg before PCI if not on aspirin therapy I PCI Aspirin administered at time of PCII Post-PCIAfter PCI, aspirin continued indefinitely.I After PCI, use of 81 mg/d of aspirin in preference to higher maintenance doses. IIa

25. P2Y 12 Inhibitors and DAPT RecommendationCOR Administration of a loading dose of a P2Y 12 receptor to patients undergoing PCI with stenting I Patients counseling on the need for and risks of DAPT before placement of intracoronary stents, especially a DES I P2Y 12 inhibitor therapy for at least 12 months in patients receiving a stent (BMS or DES) during PCI for ACS I Clopidogrel for at least 12 months in patients treated with a DES for a non–ACS indication, if patients are not at high risk of bleeding I Clopidogrel for a minimum of 1 month and ideally up to 12 months in patients receiving a BMS for a non-ACS indication (unless the patient is at increased risk of bleeding then it should be given for a minimum of 2 weeks) I Earlier discontinuation (e.g <12 months) of P2Y 12 inhibitor therapy after stent implantation if the risk of morbidity from bleeding outweighs the anticipated benefit afforded by a recommended duration of P2Y 12 inhibitor therapy IIa Continuation of DAPT beyond 12 months in patients undergoing DES implantation IIb Prasugrel administration in patients with a prior history of stroke or transient ischemic attack III – Harm

26. Antiplatelet And Antithrombin Rx at the Time of PCI RecommendationCOR Oral Antiplatelet Rx AspirinI P2Y 12 Inhibitor (clopidogrel, prasugrel or ticagrelor) in patients treated with stent implantation I GP IIb/IIIa Inhibitor Rx No clopidogrel pre-treatmentSTEMI:IIa UA/NSTEMII SIHDIIa With clopidogrel pre treatment STEMIIIa UA/NSTEMIIIa SIHDIIb Antithrombin Rx UFHI BivalirudinI EnoxaparinIIb Anti-Xa Inhibitors FondaparinuxIII - Harm

27. GP IIb/IIIa Inhibitor Therapy Clopidogrel Pre-Treatment ? Clinical SettingCOR No STEMIIIa UA/NSTEMII SIHDIIa Yes STEMIIIa UA/NSTEMIIIa SIHDIIb Additional RecommendationsCOR Administration of intracoronary (versus IV) abciximab administration in patients undergoing primary PCI with abciximab IIb Routine precatheterization laboratory (e.g ambulance or emergency room) administration of GP IIb/IIIa inhibitors as part of a upstream strategy for patients with STEMI undergoing PCI III – No Benefit

28. Dosing of Parental Anticoagulants During PCI DrugPatient has received prior anticoagulant therapyPatient has not received prior anticoagulant therapy UFHIV GPI planned: additional UFH as needed (e.g., 2000 to 5000 U) to achieve an ACT of 200 to 250 s IV GPI planned: 50 to 70 U/kg bolus to achieve an ACT of 200 to 250 s No IV GPI planned: additional UFH as needed (e.g., 2000 to 5000 U) to achieve an ACT of 250 to 300 for HemoTec, 300 to 350 s for Hemochron No IV GPI planned: 70 to 100 U/kg bolus to achieve target ACT of 250 to 300 s for HemoTec, 300 to 350 s for Hemochron EnoxaparinFor prior treatment with enoxaparin, if the last subcutaneous dose was administered 8 to 12 h earlier, or if only 1 SC dose has been administered, an IV dose of 0.3 mg/kg of enoxaparin should be given; 0.5-0.75 mg/kg IV bolus If the last subcutaneous dose was administered within the prior 8 h, no additional enoxaparin should be given BivalirudinFor patients who have received UFH, wait 30 min, then give 0.75 mg/kg IV bolus, then 1.75 mg/kg per hour IV infusion 0.75 mg/kg bolus, 1.75 mg/kg per h IV infusion FondaparinuxFor prior treatment with fondaparinux, administer additional IV treatment with an anticoagulant possessing anti-IIa activity, taking into account whether GPI receptor antagonists have been administered. N/A Argatroban200 µg/kg IV bolus then 15 µg/kg per min IV infusion (32)350 µg/kg bolus then 15 µg/kg per min IV infusion

29. Heparin-Induced Thrombocytopenia (HIT) RecommendationCOR Bivalirudin or argatroban use during PCI for patients with HIT I

30. No Reflow Pharmacological Therapy RecommendationCOR Administration of an intracoronary vasodilator (adenosine, calcium channel blocker, or nitroprusside) to treat PCI- related no-reflow that occurs during primary or elective PCI IIa

31. SVG PCI RecommendationCOR Embolic protection device use when technically feasible I GP IIb/IIIa inhibitorsIII - No Benefit PCI for chronic SVG occlusionsIII - Harm

32. PCI in Specific Anatomic Situations RecommendationCOR SVGEmbolic protection device use in SVG PCI when technically feasibleI GP IIb/IIIa inhibitors in SVG PCIIII – No Benefit PCI for chronic SVG occlusionsIII: Harm CTOPCI of a CTO in patients with appropriate clinical indications and suitable anatomy (when performed by operators with appropriate expertise) IIa Bifurcation Lesions Provisional side branch stenting as the initial approach in patients with bifurcation lesions when the side branch is not large and has only mild or moderate focal disease at the ostium I Elective double stenting in patients with complex bifurcation morphology involving a large side branch where the risk of side branch occlusion is high and the likelihood of successful side branch re-access is low IIa Aorto-Ostial Stenoses IVUS for the assessment of angiographically indeterminant left main CADIIa DES use when PCI is indicated in patients with an aorto-ostial stenosisIIa Calcified Lesions Rotational atherectomy for fibrotic or heavily calcified lesions that might not be crossed by a balloon catheter or adequately dilated before stent implantation IIa

33. Periprocedural MI Assessment RecommendationCOR Measurement of cardiac biomarkers in patients with signs or symptoms suggestive of MI during or after PCI, or in asymptomatic patients with significant persistent angiographic complications I Routine measurement of cardiac biomarkers in all patients after PCI IIb

34. Vascular Closure Devices (VCD) RecommendationCOR Femoral angiogram pre-VCD to ensure anatomic suitability for deployment I VCD for the purposes of achieving faster hemostasis and earlier ambulation (compared with the use of manual compression) IIa Routine use of VCD for the purpose of decreasing vascular complications, including bleeding III – No Benefit

35. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention Post-Procedural Considerations

36. P2Y 12 Inhibitor Rx Post-Stent RecommendationCOR Post-Stent Implantation (BMS or DES) for ACS, P2Y 12 inhibitor Rx at least 12 months I Post-DES for non–ACS, clopidogrel for at least 12 mo if patients are not at high risk of bleeding. I Post-BMS for non-ACS, clopidogrel for a minimum of 1 mo and ideally up to 12 mo I Counseling patients on the importance of compliance with DAPT and to not discontinue Rx before discussion with the relevant cardiologist I Earlier discontinuation (e.g <12 mo) of P2Y 12 inhibitor if the risk of morbidity from bleeding outweighs the anticipated benefit afforded by a recommended duration of P2Y 12 inhibitor therapy after stent implantation IIa Continuation of P2Y 12 Rx beyond 12 mo in patients undergoing DES placement. IIb (P2Y 12 Inhibitor = clopidogrel, prasugrel or ticagrelor)

37. PPI Therapy and DAPT Recommendations based on risk of GI bleeding RecommendationCOR PPI use for patients with history of prior GI bleeding who require DAPT I PPI use for patients with increased risk of GI bleeding (advanced age, concomitant use of warfarin, steroids, NSAIDs, H pylori infection) who require DAPT. IIa Routine use of a PPI for patients at low risk of GI bleeding, who have much less potential to benefit from prophylactic therapy III: No Benefit

38. Restenosis RecommendationCOR Treatment of clinical restenosis after balloon angioplasty with BMS or DES if anatomic factors are appropriate and if the patient is able to comply with and tolerate DAPT I Treatment of clinical restenosis after BMS with DES if anatomic factors are appropriate and the patient is able to comply with and tolerate DAPT I IVUS to determine the mechanism of stent restenosisIIa Treatment of clinical restenosis after DES with repeat PCI with balloon angioplasty, BMS, or DES with the same drug or an alternative antiproliferative drug if anatomic factors are appropriate and patient is able to comply with and tolerate DAPT IIb