Track 3: Interventional Cardiology

Interventional cardiology guidelines are evidence-based recommendations designed to assist healthcare providers in the diagnosis, treatment, and management of cardiovascular diseases through catheter-based interventions. These guidelines are developed by professional organizations like the American College of Cardiology (ACC), American Heart Association (AHA), and European Society of Cardiology (ESC), based on clinical trials, expert consensus, and best practices.

Below is an overview of some of the key aspects of interventional cardiology guidelines:   1. General Principles

·         Patient Selection:

• Interventions should only be performed in patients where the potential benefits outweigh the risks.
• Shared decision-making should be emphasized, involving patients in treatment choices.

·         Multidisciplinary Team (Heart Team):

• Complex cases (e.g., valve replacement, revascularization) should involve a collaborative team of cardiologists, interventionalists, cardiac surgeons, and other specialists.

·         Evidence-Based Approach:

• Use therapies and procedures supported by strong clinical evidence (graded recommendations: Class I, IIa, IIb, III).

2. Guidelines for Coronary Artery Disease (CAD)

Percutaneous Coronary Intervention (PCI)

·         Indications for PCI:

• Stable Angina: Reserved for patients with significant symptoms despite optimal medical therapy or for high-risk coronary anatomy.
• Acute Coronary Syndromes:
• Primary PCI is the preferred treatment for ST-Elevation Myocardial Infarction (STEMI) if performed within 120 minutes of first medical contact.
• In Non-ST-Elevation Acute Coronary Syndromes (NSTEMI), PCI is indicated for high-risk patients.

·         Pre-Procedural Requirements:

• Dual antiplatelet therapy (DAPT) initiation (e.g., aspirin + clopidogrel/ticagrelor).
• Use of fractional flow reserve (FFR) or intravascular imaging (e.g., IVUS, OCT) for borderline lesions.

·         Post-Procedural Care:

• Continuation of DAPT (typically for 6–12 months, depending on stent type and patient risk).
• Lifestyle modification and risk factor management (e.g., lipid-lowering therapy, hypertension control).

3. Guidelines for Structural Heart Interventions

Aortic Valve Disease

• Transcatheter Aortic Valve Replacement (TAVR):
• Indicated for patients with severe symptomatic aortic stenosis who are at intermediate-to-high surgical risk.
• Shared decision-making is crucial for choosing between TAVR and surgical aortic valve replacement (SAVR).

Mitral Valve Disease

• Transcatheter Mitral Valve Repair (e.g., MitraClip):
• Indicated in symptomatic patients with severe primary mitral regurgitation who are at prohibitive surgical risk.

Congenital Heart Defects

• Closure of atrial septal defects (ASD) or patent foramen ovale (PFO) is indicated for:
• Prevention of paradoxical embolism (e.g., cryptogenic stroke).
• Symptomatic patients with significant left-to-right shunting.

4. Guidelines for Peripheral Artery Disease (PAD)

·         Peripheral Angioplasty and Stenting:

• Indicated for symptomatic PAD, especially in cases of claudication or critical limb ischemia.
• Pre-procedural imaging (e.g., duplex ultrasound, CTA, MRA) is recommended to assess lesion characteristics.

·         Carotid Artery Stenting:

• Recommended for patients at high risk for carotid endarterectomy (CEA) and with symptomatic carotid artery stenosis ≥50%.

5. Guidelines for Antithrombotic Therapy

·         Dual Antiplatelet Therapy (DAPT):

• Standard for patients undergoing PCI with stent implantation.
• Duration:
• Bare-metal stents (BMS): Minimum 1 month.
• Drug-eluting stents (DES): Minimum 6–12 months.
• High bleeding risk: Consider shorter DAPT duration (1–3 months).

·         Anticoagulation:

• In patients with atrial fibrillation undergoing PCI, combination therapy with anticoagulants and antiplatelets may be needed.

6. Guidelines for Imaging-Guided Interventions

·         Use intravascular imaging (e.g., IVUS or OCT) in:

• Assessing stent placement and optimization.
• Complex lesions (e.g., left main disease, bifurcation lesions).

·         Fractional Flow Reserve (FFR):

• Recommended for evaluating the functional significance of intermediate coronary lesions.

7. Guidelines for Device-Specific Interventions

·         Pacemakers and ICDs:

• Indications for implantation include life-threatening arrhythmias, bradycardia, or risk of sudden cardiac death (e.g., after myocardial infarction or in heart failure).

·         Left Atrial Appendage Occlusion:

• Recommended for stroke prevention in atrial fibrillation patients contraindicated for long-term anticoagulation.

8. Guidelines for Heart Failure and Circulatory Support

·         Mechanical Circulatory Support Devices:

• Intra-aortic balloon pump (IABP) or Impella is recommended for patients in cardiogenic shock.

·         Ventricular Assist Devices (VADs):

• Indicated for advanced heart failure as a bridge to transplantation or destination therapy.

9. Procedural Safety and Training

• Interventional procedures should be performed in accredited centers with expertise and adequate resources.
• Operators must meet competency requirements and undergo periodic training to stay updated with advancements.

10. Innovations and Emerging Guidelines

• Bioresorbable Scaffolds:
• Use is still being evaluated and is recommended only in select cases.
• Robotic PCI:
• Gaining traction as an option for enhanced precision but not widely adopted yet.

Adapting Guidelines to Practice

These guidelines are not rigid protocols but frameworks to guide decision-making. Treatment plans should be individualized based on patient needs, risks, and preferences.