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A multidisciplinary heart team -- including an interventional cardiologist and a cardiac surgeon -- should work together to develop a care plan for each patient with coronary artery disease (CAD), according to updated guidelines from the American College of Cardiology Foundation and the American Heart Association.

The team would review the patient's medical condition and coronary anatomy. They would then determine whether percutaneous coronary intervention (PCI) and/or coronary artery bypass grafting (CABG) were feasible and reasonable. After discussing options with the patient, a treatment strategy would be selected, according to the guidelines, which are the result of a first-time collaboration between writing committees from both organizations.

"Support for this approach comes from reports that patients with complex coronary artery disease referred specifically for PCI or CABG in concurrent trial registries have lower mortality rates than those randomly assigned to PCI or CABG in controlled trials," the authors wrote in the Dec. 6 issue of the Journal of the American College of Cardiology.

The team concept was included as a class I recommendation for patients with unprotected left main or complex CAD.

Another new recommendation in the guideline is the use of the SYNTAX (Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery) score when making treatment decisions for patients with multivessel disease. This system uses angiography results to estimate the extent and complexity of arterial disease and gives a more objective way to guide decision making.

"Although some results from SYNTAX are best categorized as sub-group analyses and 'hypothesis generating,' SYNTAX nevertheless represents the latest and most comprehensive comparison of contemporary PCI and CABG," wrote the authors. "Therefore, the results of SYNTAX have been considered appropriately when formulating our revascularization recommendations."

Both groups also worked toward updating the sections on revascularization. The authors noted that PCI is being used to treat conditions that were unheard of when the last revision of the guidelines took place.

"The question of whom to revascularize and how to do it comes up frequently in a busy practitioner's office," said CABG committee chair L. David Hillis, MD, in an accompanying press release. "I think the physician will hone in on this section because it addresses an every day question and because the debate over PCI versus CABG has seen the most action since the 2004 guidelines."

The guidelines say that PCI is a reasonable alternative to CABG in stable patients with left main artery CAD, low risk of PCI complications, and a high risk for adverse surgical outcomes. They also confirm the superiority of CABG compared to both medical therapy and PCI in patients with three-vessel disease.

Specific to CABG, the experts also weighed in on the use of anti-platelet therapy both before and after the operation. The guidelines suggest aspirin should be given to CABG patients preoperatively. In those undergoing elective procedures, clopidogrel (Plavix) and ticagrelor (Brilinta) should be stopped five days before elective surgery. In emergent situations, they should be discontinued for at least 24 hours if possible.

After the operation, aspirin should be started within the first six hours if not already begun before the procedure. Clopidogrel was termed a "reasonable alternative" in patients allergic to aspirin.

The PCI group also addressed anti-platelet therapy. The committee simplified the regimen for aspirin use, suggesting using 81 mg daily following PCI instead of higher maintenance doses. They also provided a class I recommendation for dosing ticagrelor for at least 12 months following insertion of both drug-eluting and bare metal stents.

From the American Heart Association: