New evidence has led the American College of Cardiology (ACC) to withdraw one of its recommendations part of the ABIM Choosing Wisely Campaign. Previously, they had advocated against stenting non-culprit significant obstructive coronary artery lesions during primary PCI for myocardial infarction. If a patient was taken to angiography/PCI for treatment a STEMI or Non-STEMI, the culprit lesion (aka infarct related lesion) could be stenting as indicated, but it was recommended against stenting incidentally identified obstructive lesions. This was based on small observational and meta-analysis studies.
However the evidence has changed.
Two recent studies, PRAMI (Preventative Angioplasty in Acute Myocardial Infarction) and CVPRVIT, have found that revascularization of high-grade lesions during primary PCI led to a reduction in MACE (major adverse cardiac events) events over the next 12 months.
The Choosing Wisely Campaign, propagating a list of You-Shall-Not-Do recommendations is meant to generate a small consensus guidelines of ineffectual procedures and tests. Unfortunately, they required hard evidence for their recommendations and devalued the importance of clinical expertise so the initial contained some items that were contradictory to clinical experience and practice. I applaud the ACC’s rapid adaption in the face of evidence, but it is a sobering reminder that guidelines are just that, and are not always the definitive truth on a subject.
Charles, I am curious about the politics. They would withdraw from the entire campaign over a single issue. Was there much discussion between the two to resolve the issue in agreement prior to withdrawal?
It is my understanding that the ACC just withdraw that single recommendation, not from the entire campaign. Sorry for the confusion. The ABIM Choosing Wisely campaign has gathered lots of momentum and is influencing political and health care discussions. The ACC I am sure recognizes the value of this. What is interesting though is the change with evolution of the evidence.