ACC Withdraws Recommendation Against Complete Revascularization

September 22, 2014—The American College of Cardiology (ACC) announced that it has withdrawn its Choosing Wisely recommendation that patients and caregivers examine whether the practice of complete revascularization of all significantly blocked arteries is truly necessary. The ACC stated that it is responding to new science showing that complete revascularization of all significantly blocked arteries leads to better outcomes in some heart attack patients.

As part of the 2012 ABIM Foundation Choosing Wisely list of five things providers and patients should question, the ACC recommended questioning any intervention beyond unblocking just the “culprit” artery responsible for the heart attack in a hemodynamically stable patient. When that list was released, there were several nonrandomized studies demonstrating harm to patients when treating all significantly blocked arteries. However, over the last 2 years, new studies have emerged showing potential improvements for some patients in their overall outcomes as a result of complete revascularization.

As reported in Cardiac Interventions Today, results of the CvLPRIT (Complete Versus Lesion-Only Primary PCI Trial) were presented on September 1 at the European Society of Cardiology’s ESC Congress 2014 in Barcelona, Spain. The study found that in patients being treated for myocardial infarction, complete revascularization of all significantly blocked arteries leads to better outcomes compared to a strategy of unblocking just the “culprit” artery responsible for the myocardial infarction.

The ACC advised that these results reinforce data from the PRAMI (Preventive Angioplasty in Myocardial Infarction) trial that show stenting all coronary arteries with major stenoses improves outcomes. PRAMI was presented last year at the ESC Congress 2013 in Amsterdam, the Netherlands, and published in the New England Journal of Medicine (2013;369:1115–1123).

Although some questions remain about the exact timing of the procedures, whether certain patients benefit versus others, whether fractional flow reserve 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.

In the society’s press release, ACC President Patrick T. O’Gara, MD, commented, “Science is not static but rather constantly evolving. 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.”

Dr. O’Gara noted that the ACC is working with its partners to address current clinical guideline and appropriate use criteria recommendations in light of the new research. The ACC 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,” stated Dr. Gara.

Daniel Wolfson, executive vice president and chief operating officer of the ABIM Foundation, added, “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. 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.”

Information about the Choosing Wisely campaign, including the complete lists and additional details about the recommendations and evidence supporting them, is available online at www.choosingwisely.org. The ABIM Foundation is a not-for-profit foundation established by the American Board of Internal Medicine in 1999 to advance medical professionalism and physician leadership in quality assessment and improvement. More information is available online at www.abimfoundation.org.