Recently, the 2007 SCAI/ACCF/AHA Expert Consensus Document on Percutaneous Coronary Intervention without On-Site Surgical Backup has been updated. The consensus document has found no indication of increased mortality or a greater need for emergency bypass surgery (CABG) for heart attack or elective PCI patients at centres without on-site cardiac surgery.

The 2012 clinical-practice guidelines for patients with stable CAD from the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons has been updated. The focused update discourages PCI prematurely after coronary angiography in patients with diabetes, and recommends CABG as the optimum treatment strategy in stable complex CAD patients with diabetes.

Determination of appropriate treatment strategy for coronary artery stenosis by means of coronary angiography is subjected to variation in subjective assessment. To combat this, various tools have been employed including stress testing and intracoronary imaging devicese.g. fractional flow reserve (FFR) and intravascular ultrasound (IVUS)into the cardiac catheter laboratory in recent years. American Heart Association guidelines now recommend that FFR should be used for assessing plaques of intermediate severity (50%-70%).¹ Previously, the randomized clinical trials of FFR in the Fractional Flow Reserve Versus Angiography in Multivessel Evaluation (FAME) and FAME 2 studies found the benefit of FFR in relation to PCI.^2,3 The FAME 2 trial was terminated early because of a significant reduction in the composite primary end point (of death, myocardial infarction, or urgent revascularization) in the FFR-guided PCI group. However, neither FAME nor FAME 2 found a mortality benefit for FFR-guided PCI. In a new observational study, the use of FFR or IVUS during PCI is not associated with improved long-term mortality rates when compared with standard angiography-guided PCI.⁴.

A guideline has been published by the American College of Cardiology Foundation (ACCF), American Heart Association (AHA), and Heart Rhythm Society (HRS) regarding ‘off-label’ use of implantable cardioverter-defibrillators (ICDs). Some patients who are not included or well represented in clinical trials and who, therefore, are not technically covered by formal practice guidelines may benefit from the devices:

Patients with Abnormal Troponin Unrelated to a Myocardial Infarction (MI)

Small troponin leaks sometimes occur in the context of demand ischemia (e.g., tachyarrhythmia, congestive heart failure, pulmonary embolism) or other conditions (renal failure, myocarditis) that are thought to be unrelated to MI. ICD implantation is only recommended in presence of standard primary- or secondary-prevention criteria.