Abbreviations and acronyms

  • ACCF/AHA

    American College of Cardiology Foundation/American Heart Association

  • ACCOAST

    A Comparison of Prasugrel at the Time of Percutaneous Coronary Intervention (PCI) Or as Pre-treatment at the Time of Diagnosis in Patients With Non-ST-Elevation Myocardial Infarction (NSTEMI)

  • ACE

    angiotensin-converting enzyme

  • ACEF

    age, creatinine, ejection fraction

  • ACS

    acute coronary syndromes

  • ACUITY

    Acute Catheterization and Urgent Intervention Triage strategy

  • ADAPT-DES

    Assessment of Dual AntiPlatelet Therapy with Drug-Eluting Stents

  • AF

    atrial fibrillation

  • APPRAISE-2

    Apixaban for Prevention of Acute Ischemic and Safety Events

  • aPTT

    activated partial thromboplastin time

  • ARCTIC

    Assessment by a double Randomization of a Conventional antiplatelet strategy vs. a monitoring-guided strategy for drug-eluting stent implantation and, of Treatment Interruption vs. Continuation one year after stenting

  • ARMYDA

    Antiplatelet therapy for Reduction of MYocardial Damage during Angioplasty

  • ARTS

    Arterial Revascularization Therapies Study

  • ASA

    acetylsalicylic acid

  • ASCERT

    American College of Cardiology Foundation–Society of Thoracic Surgeons Database Collaboration

  • ATLAS ACS 2–TIMI 51

    Anti-Xa Therapy to Lower cardiovascular events in Addition to Standard therapy in subjects with Acute Coronary Syndrome–Thrombolysis In Myocardial Infarction 51

  • ATOLL

    Acute STEMI Treated with primary PCI and intravenous enoxaparin Or UFH to Lower ischaemic and bleeding events at short- and Long-term follow-up

  • AVR

    aortic valve replacement

  • AWESOME

    Angina With Extremely Serious Operative Mortality Evaluation

  • b.i.d.

    bis in diem (twice daily)

  • BARI-2D

    Bypass Angioplasty Revascularization Investigation 2 Diabetes

  • BASKET–PROVE

    BASKET–Prospective Validation Examination

  • BMS

    bare-metal stent

  • BRAVE

    Bavarian Reperfusion Alternatives Evaluation

  • BRIDGE

    Bridging Anticoagulation in Patients who Require Temporary Interruption of Warfarin Therapy for an Elective Invasive Procedure or Surgery

  • CABG

    coronary artery bypass grafting

  • CAD

    coronary artery disease

  • CARDIA

    Coronary Artery Revascularization in Diabetes

  • CAS

    carotid artery stenting

  • CASS

    Coronary Artery Surgery Study

  • CCS

    Canadian Cardiovascular Society

  • CE

    Conformité Européenne

  • CEA

    carotid endarterectomy

  • CHA2DS2-VASc

    Congestive heart failure or left ventricular dysfunction, Hypertension, Age ≥75 [Doubled], Diabetes, Stroke [Doubled]–Vascular disease, Age 65–74 and Sex category [Female]

  • CHAMPION

    Cangrelor vs. Standard Therapy to Achieve Optimal Management of Platelet Inhibition

  • CI

    confidence interval

  • CIN

    contrast-induced nephropathy

  • CKD

    chronic kidney disease

  • COMFORTABLE-AMI

    Comparison of Biolimus Eluted From an Erodible Stent Coating With Bare-Metal Stents in Acute ST-Elevation Myocardial Infarction

  • COURAGE

    Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation

  • COX

    cyclo-oxygenase

  • CREDO

    Clopidogrel for the Reduction of Events During Observation

  • CRT

    cardiac resynchronization therapy

  • CT

    computed tomography

  • CTO

    chronic total occlusion

  • CURE

    Clopidogrel in Unstable Angina to Prevent Recurrent Events

  • CURRENT-OASIS 7

    Clopidogrel and Aspirin Optimal Dose Usage to Reduce Recurrent Events−Seventh Organization to Assess Strategies in Ischemic Syndromes 7

  • CYP P450

    cytochrome P450

  • DANAMI

    DANish trial in Acute Myocardial Infarction

  • DAPT

    dual antiplatelet therapy

  • DEB-AMI

    Drug Eluting Balloon in Acute Myocardial Infarction

  • DELTA

    Drug Eluting stent for LefT main coronary Artery disease

  • DES

    drug-eluting stent

  • DI–DO

    door-in to door-out time

  • DIGAMI

    Diabetes, Insulin Glucose Infusion in Acute Myocardial Infarction

  • DPP-4

    dipeptidyl peptidase 4

  • DTB

    door-to-balloon time

  • EACTS

    European Association for Cardio-Thoracic Surgery

  • EAPCI

    European Association of Percutaneous Cardiovascular Interventions

  • EARLY-ACS

    Early glycoprotein IIb/IIIa inhibition in non-ST-segment elevation acute coronary syndrome

  • ECG

    electrocardiogram

  • EF

    ejection fraction

  • EMS

    emergency medical service

  • ESC

    European Society of Cardiology

  • EUROMAX

    European Ambulance Acute Coronary Syndrome Angiography

  • EXAMINATION

    Everolimus-eluting stent vs. BMS in ST-segment elevation myocardial infarction

  • EXCELLENT

    Efficacy of Xience/Promus vs. Cypher in reducing Late Loss After stenting

  • FAME

    Fractional Flow Reserve vs. Angiography for Multivessel Evaluation

  • FFR

    fractional flow reserve

  • FINESSE

    Facilitated Intervention with Enhanced Reperfusion Speed to Stop Events

  • FMCTB

    first-medical-contact-to-balloon

  • FRISC-2

    Fragmin during Instability in Coronary Artery Disease-2

  • FREEDOM

    Future Revascularization Evaluation in Patients with Diabetes Mellitus

  • GFR

    glomerular filtration rate

  • GP IIb/IIIa

    glycoprotein IIb/IIIa

  • GRACE

    Global Registry of Acute Coronary Events

  • GRAVITAS

    Gauging Responsiveness with A VerifyNow assay: Impact on Thrombosis And Safety

  • GUSTO

    Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries

  • HAS-BLED

    Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile INR, Elderly, Drugs/alcohol

  • HbA1c

    glycated haemoglobin A1c

  • HEAT-PCI

    How Effective are Antithrombotic Therapies in PPCI

  • HORIZONS-AMI

    Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction

  • HR

    hazard ratio

  • iFR

    instantaneous wave-free ratio

  • i.v.

    intravenous

  • IABP

    intra-aortic balloon pump

  • IABP-SHOCK

    Intra-aortic Balloon Pump in Cardiogenic Shock

  • ICD

    implantable cardioverter defibrillator

  • IMA

    internal mammary artery

  • INR

    international normalized ratio

  • ISAR-CABG

    Is Drug-Eluting-Stenting Associated with Improved Results in Coronary Artery Bypass Grafts

  • ISAR-REACT

    Intracoronary Stenting and Antithrombotic Regimen–Rapid Early Action for Coronary Treatment

  • ISAR-SAFE

    Intracoronary Stenting and Antithrombotic Regimen: Safety And eFficacy of a 6-month DAT after drug-Eluting stenting

  • IVUS

    intravascular ultrasound imaging

  • LAA

    left atrial appendage

  • LAD

    left anterior descending

  • LCx

    left circumflex

  • LDL-C

    low-density lipoprotein cholesterol

  • LM

    left main

  • LMWH

    low-molecular-weight heparin

  • LoE

    level of evidence

  • LV

    left ventricle/left ventricular

  • LVAD

    left ventricular assist device

  • LVEF

    left ventricular ejection fraction

  • LVESVI

    left ventricular end-systolic volume index

  • MACCE

    major adverse cardiac and cerebrovascular event

  • MACE

    major adverse cardiac event

  • MADIT II

    Multicentre Automatic Defibrillator Implantation Trial II

  • MADIT-CRT

    Multicenter Automatic Defibrillator Implantation Trial – Cardiac Resynchronization Therapy

  • MASS II

    Medical, Angioplasty or Surgery Study II

  • MDCT

    multi-detector computed tomography

  • MI

    myocardial infarction

  • MIDCAB

    minimally invasive direct coronary artery bypass

  • MPS

    myocardial perfusion stress

  • MRI

    magnetic resonance imaging

  • MT

    medical therapy

  • NCDR CathPCI

    National Cardiovascular Database Registry

  • NOAC

    non-vitamin K antagonist oral anticoagulant

  • NSAID

    non-steroidal anti-inflammatory drug

  • NSTE-ACS

    non-ST-segment elevation acute coronary syndrome

  • NSTEMI

    non-ST-segment elevation myocardial infarction

  • NYHA

    New York Heart Association

  • o.d.

    omni die (every day)

  • OASIS

    Optimal Antiplatelet Strategy for Interventions

  • OCT

    optical coherence tomography

  • On-TIME-2

    Continuing TIrofiban in Myocardial infarction Evaluation

  • OPTIMIZE

    Optimized Duration of Clopidogrel Therapy Following Treatment With the Zotarolimus-Eluting Stent in Real-World Clinical Practice

  • OR

    odds ratio

  • p.o.

    per os (by mouth)

  • PACCOCATH

    Paclitaxel-Coated Balloon Catheter

  • PAD

    peripheral artery disease

  • PARIS

    Patterns of Non-Adherence to Anti-Platelet Regimens In Stented Patients

  • PCAT

    Primary Coronary Angioplasty vs. Thrombolysis

  • PCI

    percutaneous coronary intervention

  • PEPCAD

    Paclitaxel-Eluting PTCA–Catheter In Coronary Disease

  • PES

    paclitaxel-eluting stent

  • PET

    positron emission tomography

  • PLATO

    Study of Platelet Inhibition and Patient Outcomes

  • PRAMI

    Preventive Angioplasty in Acute Myocardial Infarction

  • PRECOMBAT

    Premier of Randomized Comparison of Bypass Surgery vs. Angioplasty Using Sirolimus-Eluting Stent in Patients with Left Main Coronary Artery Disease

  • PROCAT

    Parisian Region Out of Hospital Cardiac Arrest

  • PRODIGY

    PROlonging Dual Antiplatelet Treatment In Patients With Coronary Artery Disease After Graded Stent-induced Intimal Hyperplasia studY

  • PROTECT AF

    Watchman Left Atrial Appendage System for Embolic Protection in Patients with Atrial Fibrillation

  • q.d.

    quaque die

  • RCT

    randomized clinical trial

  • REPLACE

    Randomized Evaluation in PCI Linking Angiomax to Reduced Clinical Events

  • RESET

    Real Safety and Efficacy of a 3-month Dual Antiplatelet Therapy Following Zotarolimus-eluting Stents Implantation

  • RIVAL

    RadIal Vs. femorAL access for coronary intervention

  • RR

    risk ratio

  • RRR

    relative risk reduction

  • s.c.

    subcutaneous

  • SAVOR-TIMI

    Saxagliptin and Cardiovascular Outcomes in Patients with Type 2 Diabetes Mellitus

  • SCAD

    stable coronary artery disease

  • SCAAR

    Swedish Coronary Angiography and Angioplasty Registry

  • SCD-HEFT

    Sudden Cardiac Death in Heart Failure Trial

  • SES

    sirolimus-eluting stent

  • SHOCK

    Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock

  • SOLVD

    Studies of Left Ventricular Dysfunction

  • SPECT

    single photon emission computed tomography

  • STE-ACS

    ST-segment elevation acute coronary syndrome

  • STEEPLE

    Safety and Efficacy of Intravenous Enoxaparin in Elective Percutaneous Coronary Intervention Randomized Evaluation

  • STEMI

    ST-segment elevation myocardial infarction

  • STICH

    Surgical Treatment for Ischemic Heart Failure

  • STREAM

    STrategic Reperfusion Early After Myocardial infarction

  • STS

    Society of Thoracic Surgeons

  • SVG

    saphenous vein graft

  • SVR

    surgical ventricular reconstruction

  • SYNTAX

    Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery.

  • TACTICS-TIMI 18

    Treat angina with Aggrastat and determine Cost of Therapy with an Invasive or Conservative Strategy–Thrombolysis in Myocardial Infarction

  • TARGET

    Do Tirofiban and Reo-Pro Give Similar Efficacy Outcome Trial

  • TASTE

    Thrombus Aspiration during PCI in Acute Myocardial Infarction

  • TAVI

    transcatheter aortic valve implantation

  • TIA

    transient ischaemic attack

  • TIMACS

    Timing of Intervention in Patients with Acute Coronary Syndromes

  • TIME

    Trial of Invasive Medical therapy in the Elderly

  • TIMI

    Thrombolysis in Myocardial Infarction

  • TRIGGER-PCI

    Testing Platelet Reactivity In Patients Undergoing Elective Stent Placement on Clopidogrel to Guide Alternative Therapy With Prasugrel

  • TRITON TIMI-38

    TRial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet InhibitioN with Prasugrel–Thrombolysis In Myocardial Infarction 38

  • TVR

    target vessel revascularization

  • UFH

    unfractionated heparin

  • VAD

    ventricular assist device

  • VF

    ventricular fibrillation

  • VKA

    vitamin K antagonist

  • VSD

    ventricular septal defect

  • VT

    ventricular tachycardia

  • WOEST

    What is the Optimal antiplatElet and anticoagulant therapy in patients with oral anticoagulation and coronary StenTing

  • ZEST-LATE/REAL-LATE

    Zotarolimus-Eluting Stent, Sirolimus-Eluting Stent, or PacliTaxel-Eluting Stent Implantation for Coronary Lesions - Late Coronary Arterial Thrombotic Events/REAL-world Patients Treated with Drug-Eluting Stent Implantation and Late Coronary Arterial Thrombotic Events

Preamble

Guidelines summarize and evaluate all available evidence, at the time of the writing process, on a particular issue with the aim of assisting health professionals in selecting the best management strategies for an individual patient with a given condition, taking into account the impact on outcome, as well as the risk–benefit ratio of particular diagnostic or therapeutic means. Guidelines and recommendations should help health professionals to make decisions in their daily practice; however, the final decisions concerning an individual patient must be made by the responsible health professional(s), in consultation with the patient and caregiver as appropriate.

A great number of guidelines have been issued in recent years by the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS), as well as by other societies and organisations. Because of their impact on clinical practice, quality criteria for the development of guidelines have been established in order to make all decisions transparent to the user. The recommendations for formulating and issuing ESC/EACTS Guidelines can be found on the ESC web site (http://www.escardio.org/guidelines-surveys/esc-guidelines/about/Pages/rules-writing.aspx). These ESC/EACTS guidelines represent the official position of these two societies on this given topic and are regularly updated.

Members of this Task Force were selected by the ESC and EACTS to represent professionals involved with the medical care of patients with this pathology. Selected experts in the field undertook a comprehensive review of the published evidence for management (including diagnosis, treatment, prevention and rehabilitation) of a given condition, according to the ESC Committee for Practice Guidelines (CPG) and EACTS Guidelines Committee policy. A critical evaluation of diagnostic and therapeutic procedures was performed, including assessment of the risk–benefit ratio. Estimates of expected health outcomes for larger populations were included, where data exist. The level of evidence and the strength of recommendation of particular management options were weighed and graded according to pre-defined scales, as outlined in Tables 1 and 2.

The experts of the writing and reviewing panels completed ‘declarations of interest’ forms which might be perceived as real or potential sources of conflicts of interest. These forms were compiled into one file and can be found on the ESC web site (http://www.escardio.org/guidelines). Any changes in declarations of interest that arise during the writing period must be notified to the ESC/EACTS and updated. The Task Force received its entire financial support from the ESC and EACTS, without any involvement from the healthcare industry.

The ESC CPG supervises and co-ordinates the preparation of new guidelines produced by Task Forces, expert groups or consensus panels. The Committee is also responsible for the endorsement process of these guidelines. The ESC and Joint Guidelines undergo extensive review by the CPG and partner Guidelines Committee and external experts. After appropriate revisions it is approved by all the experts involved in the Task Force. The finalized document is approved by the CPG/EACTS for simultaneous publication in the European Heart Journal and joint partner journal, in this instance the European Journal of Cardio-Thoracic Surgery. It was developed after careful consideration of the scientific and medical knowledge and the evidence available at the time of their dating.

The task of developing ESC/EACTS Guidelines covers not only the integration of the most recent research, but also the creation of educational tools and implementation programmes for the recommendations. To implement the guidelines, condensed pocket versions, summary slides, booklets with essential messages, summary cards for non-specialists, electronic versions for digital applications (smart phones etc.) are produced. These versions are abridged and thus, if needed, one should always refer to the full-text version, which is freely available on the ESC and EACTS web sites. The national societies of the ESC and of the EACTS are encouraged to endorse, translate and implement the ESC Guidelines. Implementation programmes are needed because it has been shown that the outcome of disease may be favourably influenced by the thorough application of clinical recommendations.

Surveys and registries are needed to verify that real-life daily practice is in keeping with what is recommended in the guidelines, thus completing the loop between clinical research, writing of guidelines, disseminating them and implementing them into clinical practice.

Health professionals are encouraged to take the ESC/EACTS Guidelines fully into account when exercising their clinical judgment, as well as in the determination and the implementation of preventive, diagnostic or therapeutic medical strategies; however, the ESC/EACTS Guidelines do not, in any way whatsoever, override the individual responsibility of health professionals to make appropriate and accurate decisions in consideration of the condition of each patient’s health and in consultation with that patient and, where appropriate and/or necessary, the patient’s caregiver. It is also the health professional’s responsibility to verify the rules and regulations applicable to drugs and devices at the time of prescription.

Table 1

Classes of recommendations

graphic 
graphic 
Table 2

Levels of evidence

graphic 
graphic 

Introduction

Fifty years of myocardial revascularization

In 2014, coronary artery bypass grafting (CABG) celebrates the 50th anniversary of the first procedures performed in 1964.1 Thirteen years later, the first percutaneous coronary intervention (PCI) was performed.2 Since then both revascularization techniques have undergone continued advances, in particular the systematic use of arterial conduits in the case of CABG, and the advent of stents. In the meantime, PCI has become one of the most frequently performed therapeutic interventions in medicine,3 and progress has resulted in a steady decline of periprocedural adverse events, resulting in excellent outcomes with both revascularization techniques. Notwithstanding, the differences between the two revascularization strategies should be recognized. In CABG, bypass grafts are placed to the mid-coronary vessel beyond the culprit lesion(s), providing extra sources of bloodflow to the myocardium and offering protection against the consequences of further proximal obstructive disease. In contrast, coronary stents aim at restoring normal bloodflow of the native coronary vasculature by local treatment of obstructive lesions without offering protection against new disease proximal to the stent.

Myocardial revascularization has been subject to more randomized clinical trials (RCTs) than almost any other intervention (Figure 1). In order to inform the current Guidelines, this Task Force performed a systematic review of all RCTs performed since 1980, comparing head-to-head the different revascularization strategies—including CABG, balloon angioplasty, and PCI with bare-metal stents (BMS) or with various US Food and Drug Administration-approved drug-eluting stents (DES)—against medical treatment as well as different revascularization strategies, and retrieved 100 RCTs involving 93 553 patients with 262 090 patient-years of follow-up.4

Figure 1

Randomized trials in myocardial revascularization therapy over the past five decades.

Figure 1

Randomized trials in myocardial revascularization therapy over the past five decades.

Formulation of the best possible revascularization approach, also taking into consideration the social and cultural context, will often require interaction between cardiologists and cardiac surgeons, referring physicians, or other specialists as appropriate. Patients need help with taking informed decisions about their treatment and the most valuable advice will probably be provided to them by the ‘Heart Team’.5 Recognizing the importance of the interaction between cardiologists and cardiac surgeons, the leadership of both the ESC and the EACTS has given this Joint Task Force, along with their respective Guideline Committees, and the reviewers of this document the mission to draft balanced, patient-centred, evidence-driven practice guidelines on myocardial revascularization. The respective Chairpersons of these two associations and CPG Chairperson were also given the task to adapt to the declaration of interest policy and to ensure that their Task Force members followed it throughout the development proc