2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention

Abstract

HomeCirculationVol. 124, No. 232011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessResearch ArticlePDF/EPUB2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary InterventionA Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions Writing Committee Members Glenn N. Levine, MD, FACC, FAHA, Eric R. Bates, MD, FACC, FAHA, James C. Blankenship, MD, FACC, FSCAI, Steven R. Bailey, MD, FACC, FSCAI, John A. Bittl, MD, FACC, Bojan Cercek, MD, FACC, FAHA, Charles E. Chambers, MD, FACC, FSCAI, Stephen G. Ellis, MD, FACC, Robert A. Guyton, MD, FACC, Steven M. Hollenberg, MD, FACC, Umesh N. Khot, MD, FACC, Richard A. Lange, MD, FACC, FAHA, Laura Mauri, MD, MSC, FACC, FSCAI, Roxana Mehran, MD, FACC, FAHA, FSCAI, Issam D. Moussa, MD, FACC, FAHA, FSCAI, Debabrata Mukherjee, MD, FACC, FSCAI, Brahmajee K. Nallamothu, MD, FACC and Henry H. Ting, MD, FACC, FAHA Writing Committee Members Appendix 1 Search for more papers by this author , Glenn N. LevineGlenn N. Levine Search for more papers by this author , Eric R. BatesEric R. Bates Appendix 1 Search for more papers by this author , James C. BlankenshipJames C. Blankenship Appendix 1 Search for more papers by this author , Steven R. BaileySteven R. Bailey Appendix 1 Search for more papers by this author , John A. BittlJohn A. Bittl Search for more papers by this author , Bojan CercekBojan Cercek Search for more papers by this author , Charles E. ChambersCharles E. Chambers Search for more papers by this author , Stephen G. EllisStephen G. Ellis Appendix 1 Search for more papers by this author , Robert A. GuytonRobert A. Guyton Appendix 1 Search for more papers by this author , Steven M. HollenbergSteven M. Hollenberg Appendix 1 Search for more papers by this author , Umesh N. KhotUmesh N. Khot Appendix 1 Search for more papers by this author , Richard A. LangeRichard A. Lange Search for more papers by this author , Laura MauriLaura Mauri Appendix 1 Search for more papers by this author , Roxana MehranRoxana Mehran Appendix 1 Search for more papers by this author , Issam D. MoussaIssam D. Moussa Search for more papers by this author , Debabrata MukherjeeDebabrata Mukherjee Search for more papers by this author , Brahmajee K. NallamothuBrahmajee K. Nallamothu Search for more papers by this author and Henry H. TingHenry H. Ting Search for more papers by this author Originally published7 Nov 2011https://doi.org/10.1161/CIR.0b013e31823ba622Circulation. 2011;124:e574–e651is corrected byCorrectionOther version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2011: Previous Version 1 Table of ContentsPreamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e576Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e5781.1. Methodology and Evidence Review . . . . . . .e5781.2. Organization of the Writing Committee . . . .e5791.3. Document Review and Approval. . . . . . . . . .e5791.4. PCI Guidelines: History and Evolution . . . .e579CAD Revascularization. . . . . . . . . . . . . . . . . . . . . .e5802.1. Heart Team Approach to Revascularization Decisions: Recommendations . . . . . . . . . . . .e5802.2. Revascularization to Improve Survival: Recommendations . . . . . . . . . . . . . . . . . . . .e5822.3. Revascularization to Improve Symptoms:Recommendations . . . . . . . . . . . . . . . . . . . .e5832.4. CABG Versus Contemporaneous Medical Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . .e5832.5. PCI Versus Medical Therapy . . . . . . . . . . . .e5842.6. CABG Versus PCI . . . . . . . . . . . . . . . . . . . .e5842.6.1. CABG Versus Balloon Angioplasty or BMS . . . . . . . . . . . . . . . . . . . . . . .e5842.6.2. CABG Versus DES . . . . . . . . . . . . . .e5852.7. Left Main CAD . . . . . . . . . . . . . . . . . . . . . .e5852.7.1. CABG or PCI Versus Medical Therapy for Left Main CAD. . . . . . . . . . . . . . .e5852.7.2. Studies Comparing PCI Versus CABG for Left Main CAD. . . . . . . . . . . . . . .e5862.7.3. Revascularization Considerations for Left Main CAD . . . . . . . . . . . . . . . . .e5862.8. Proximal LAD Artery Disease . . . . . . . . . . .e5872.9. Clinical Factors That May Influence the Choice of Revascularization . . . . . . . . . . . . . . . . . . .e5872.9.1. Diabetes Mellitus . . . . . . . . . . . . . . . .e5872.9.2. Chronic Kidney Disease . . . . . . . . . .e5872.9.3. Completeness of Revascularization . .e5872.9.4. LV Systolic Dysfunction. . . . . . . . . . .e5882.9.5. Previous CABG . . . . . . . . . . . . . . . . .e5882.9.6. Unstable Angina/NonST-Elevation Myocardial Infarction . . . . . . . . . . . . .e5882.9.7. DAPT Compliance and Stent Thrombosis: Recommendation . . . . . .e5882.10. TMR as an Adjunct to CABG. . . . . . . . . . . .e5882.11. Hybrid Coronary Revascularization: Recommendations . . . . . . . . . . . . . . . . . . . .e589PCI Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . .e5893.1. Definitions of PCI Success . . . . . . . . . . . . . .e5893.1.1. Angiographic Success. . . . . . . . . . . . .e5893.1.2. Procedural Success . . . . . . . . . . . . . . .e5893.1.3. Clinical Success . . . . . . . . . . . . . . . . .e5893.2. Predictors of Clinical Outcome After PCI . .e5903.3. PCI Complications . . . . . . . . . . . . . . . . . . . .e590Preprocedural Considerations . . . . . . . . . . . . . . . .e5914.1. Cardiac Catheterization Laboratory Requirements. . . . . . . . . . . . . . . . . . . . . . . . .e5914.1.1. Equipment . . . . . . . . . . . . . . . . . . . . . .e5914.1.2. Staffing . . . . . . . . . . . . . . . . . . . . . . . .e5914.1.3. ‘Time-Out’ Procedures . . . . . . . . . . . .e5924.2. Ethical Aspects . . . . . . . . . . . . . . . . . . . . . . . .e5924.2.1. Informed Consent . . . . . . . . . . . . . . . .e5924.2.2. Potential Conflicts of Interest . . . . . . .e5924.3. Radiation Safety: Recommendation . . . . . . . .e5924.4. Contrast-Induced AKI: Recommendations . . .e5934.5. Anaphylactoid Reactions: Recommendations . . . . . . . . . . . . . . . . . . . . .e5944.6. Statin Treatment: Recommendation . . . . . . . .e5944.7. Bleeding Risk: Recommendation . . . . . . . . . .e5944.8. PCI in Hospitals Without On-Site Surgical Backup: Recommendations . . . . . . . . . . . . . .e594Procedural Considerations . . . . . . . . . . . . . . . . . . .e5955.1. Vascular Access: Recommendation . . . . . . . .e5955.2. PCI in Specific Clinical Situations . . . . . . . . .e5965.2.1. UA/NSTEMI: Recommendations . . . . .e5965.2.2. ST-Elevation Myocardial Infarction . . .e5975.2.2.1. Coronary Angiography Strategies in STEMI: Recommendations . . . . . . . . .e5975.2.2.2. Primary PCI of the Infarct Artery: Recommendations . . .e5985.2.2.3. Delayed or Elective PCI inPatients With STEMI: Recommendations . . . . . . . . .e5995.2.3. Cardiogenic Shock: Recommendations . . . . . . . . . . . . . . . .e6005.2.3.1. Procedural Considerations for Cardiogenic Shock . . . . . . . . .e6005.2.4. Revascularization Before Noncardiac Surgery: Recommendations . . . . . . . . .e6005.3. Coronary Stents: Recommendations . . . . . . . .e6015.4. Adjunctive Diagnostic Devices . . . . . . . . . . .e6025.4.1. FFR: Recommendation . . . . . . . . . . . . .e6025.4.2. IVUS: Recommendations . . . . . . . . . . .e6025.4.3. Optical Coherence Tomography . . . . . .e6035.5. Adjunctive Therapeutic Devices . . . . . . . . . . .e6035.5.1. Coronary Atherectomy: Recommendations . . . . . . . . . . . . . . . .e6035.5.2. Thrombectomy: Recommendation. . . . .e6035.5.3. Laser Angioplasty: Recommendations . . . . . . . . . . . . . . . .e6035.5.4. Cutting Balloon Angioplasty: Recommendations . . . . . . . . . . . . . . . .e6035.5.5. Embolic Protection Devices:Recommendation . . . . . . . . . . . . . . . . .e6045.6. Percutaneous Hemodynamic Support Devices:Recommendation. . . . . . . . . . . . . . . . . . . . . . .e6045.7. Interventional Pharmacotherapy . . . . . . . . . . .e6045.7.1. Procedural Sedation . . . . . . . . . . . . . . .e6045.7.2. Oral Antiplatelet Therapy:Recommendations . . . . . . . . . . . . . . . .e6055.7.3. IV Antiplatelet Therapy:Recommendations . . . . . . . . . . . . . . .e6065.7.4. Anticoagulant Therapy . . . . . . . . . . .e6075.7.4.1. Use of Parenteral Anticoagulants During PCI:Recommendation . . . . . . . . .e6075.7.4.2. UFH: Recommendation . . . .e6075.7.4.3. Enoxaparin:Recommendations . . . . . . . .e6085.7.4.4. Bivalirudin and Argatroban:Recommendations . . . . . . . .e6085.7.4.5. Fondaparinux:Recommendation . . . . . . . . .e6095.7.5. No-Reflow Pharmacological Therapies:Recommendation . . . . . . . . . . . . . . . .e6105.8. PCI in Specific Anatomic Situations . . . . . .e6105.8.1. CTOs: Recommendation . . . . . . . . . .e6105.8.2. SVGs: Recommendations . . . . . . . . .e6105.8.3. Bifurcation Lesions:Recommendations . . . . . . . . . . . . . . .e6115.8.4. Aorto-Ostial Stenoses:Recommendations . . . . . . . . . . . . . . .e6115.8.5. Calcified Lesions:Recommendation . . . . . . . . . . . . . . . .e6115.9. PCI in Specific Patient Populations . . . . . . .e6125.9.1. Elderly . . . . . . . . . . . . . . . . . . . . . . . .e6125.9.2. Diabetes . . . . . . . . . . . . . . . . . . . . . . .e6125.9.3. Women . . . . . . . . . . . . . . . . . . . . . . .e6125.9.4. CKD: Recommendation . . . . . . . . . . .e6125.9.5. Cardiac Allografts . . . . . . . . . . . . . . .e6125.10. Periprocedural MI Assessment:Recommendations . . . . . . . . . . . . . . . . . . . .e6135.11. Vascular Closure Devices:Recommendations . . . . . . . . . . . . . . . . . . . .e613Postprocedural Considerations . . . . . . . . . . . . . . . .e6136.1. Postprocedural Antiplatelet Therapy:Recommendations . . . . . . . . . . . . . . . . . . . .e6136.1.1. PPIs and Antiplatelet Therapy:Recommendations . . . . . . . . . . . . . . .e6156.1.2. Clopidogrel Genetic Testing:Recommendations . . . . . . . . . . . . . . .e6156.1.3. Platelet Function Testing:Recommendations . . . . . . . . . . . . . . .e6166.2. Stent Thrombosis . . . . . . . . . . . . . . . . . . . . .e6166.3. Restenosis: Recommendations . . . . . . . . . . .e6166.3.1. Background and Incidence . . . . . . . . .e6166.3.2. Restenosis After BalloonAngioplasty . . . . . . . . . . . . . . . . . . . .e6176.3.3. Restenosis After BMS . . . . . . . . . . . .e6176.3.4. Restenosis After DES . . . . . . . . . . . .e6176.4. Clinical Follow-Up . . . . . . . . . . . . . . . . . . . .e6176.4.1. Exercise Testing:Recommendations . . . . . . . . . . . . . . .e6176.4.2. Activity and Return to Work . . . . . . .e6186.4.3. Cardiac Rehabilitation:Recommendation . . . . . . . . . . . . . . . . .e6186.5. Secondary Prevention . . . . . . . . . . . . . . . . . . .e618Quality and Performance Considerations . . . . . . . .e6187.1. Quality and Performance:Recommendations . . . . . . . . . . . . . . . . . . . . .e6187.2. Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e6197.3. Certification and Maintenance of Certification:Recommendation . . . . . . . . . . . . . . . . . . . . . .e6197.4. Operator and Institutional Competency and Volume: Recommendations . . . . . . . . . . . . . .e6197.5. Participation in ACC NCDR or National Quality Database . . . . . . . . . . . . . . . . . . . . . .e620Future Challenges . . . . . . . . . . . . . . . . . . . . . . . . .e620References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e620Appendix 1. Author Relationships With Industry andOther Entities (Relevant) . . . . . . . . . . . . .e643Appendix 2. Reviewer Relationships With Industry and Other Entities (Relevant) . . . . . . . . .e645Appendix 3. Abbreviation List . . . . . . . . . . . . . . . . . .e648Appendix 4. Additional Tables/Figures . . . . . . . . . . . .e649Jacobs Alice K., MD, FACC, FAHAPreambleThe medical profession should play a central role in evaluating the evidence related to drugs, devices, and procedures for the detection, management, and prevention of disease. When properly applied, expert analysis of available data on the benefits and risks of these therapies and procedures can improve the quality of care, optimize patient outcomes, and favorably affect costs by focusing resources on the most effective strategies. An organized and directed approach to a thorough review of evidence has resulted in the production of clinical practice guidelines that assist physicians in selecting the best management strategy for an individual patient. Moreover, clinical practice guidelines can provide a foundation for other applications, such as performance measures, appropriate use criteria, and both quality improvement and clinical decision support tools.The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have jointly produced guidelines in the area of cardiovascular disease since 1980. The ACCF/AHA Task Force on Practice Guidelines (Task Force), charged with developing, updating, and revising practice guidelines for cardiovascular diseases and procedures, directs and oversees this effort. Writing committees are charged with regularly reviewing and evaluating all available evidence to develop balanced, patient-centric recommendations for clinical practice.Experts in the subject under consideration are selected by the ACCF and AHA to examine subject-specific data and write guidelines in partnership with representatives from other medical organizations and specialty groups. Writing committees are asked to perform a formal literature review; weigh the strength of evidence for or against particular tests, treatments, or procedures; and include estimates of expected outcomes where such data exist. Patient-specific modifiers, comorbidities, and issues of patient preference that may influence the choice of tests or therapies are considered. When available, information from studies on cost is considered, but data on efficacy and outcomes constitute the primary basis for the recommendations contained herein.In analyzing the data and developing recommendations and supporting text, the writing committee uses evidence-based methodologies developed by the Task Force.1 The Class of Recommendation (COR) is an estimate of the size of the treatment effect considering risks versus benefits in addition to evidence and/or agreement that a given treatment or procedure is or is not useful/effective or in some situations may cause harm. The Level of Evidence (LOE) is an estimate of the certainty or precision of the treatment effect. The writing committee reviews and ranks evidence supporting each recommendation with the weight of evidence ranked as LOE A, B, or C according to specific definitions that are included in Table 1. Studies are identified as observational, retrospective, prospective, or randomized where appropriate. For certain conditions for which inadequate data are available, recommendations are based on expert consensus and clinical experience and are ranked as LOE C. When recommendations at LOE C are supported by historical clinical data, appropriate references (including clinical reviews) are cited if available. For issues for which sparse data are available, a survey of current practice among the clinicians on the writing committee is the basis for LOE C recommendations and no references are cited. The schema for COR and LOE is summarized in Table 1, which also provides suggested phrases for writing recommendations within each COR. A new addition to this methodology is separation of the Class III recommendations to delineate if the recommendation is determined to be of “no benefit” or is associated with “harm” to the patient. In addition, in view of the increasing number of comparative effectiveness studies, comparator verbs and suggested phrases for writing recommendations for the comparative effectiveness of one treatment or strategy versus another have been added for COR I and IIa, LOE A or B only.Table 1. Applying Classification of Recommendations and Level of EvidenceTable 1. Applying Classification of Recommendations and Level of EvidenceA recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Although randomized trials are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.*Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as sex, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use.†For comparative effectiveness recommendations (Class I and IIa; Level of Evidence A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated.In view of the advances in medical therapy across the spectrum of cardiovascular diseases, the Task Force has designated the term guideline-directed medical therapy (GDMT) to represent optimal medical therapy as defined by ACCF/AHA guideline recommended therapies (primarily Class I). This new term, GDMT, will be used herein and throughout all future guidelines.Because the ACCF/AHA practice guidelines address patient populations (and healthcare providers) residing in North America, drugs that are not currently available in North America are discussed in the text without a specific COR. For studies performed in large numbers of subjects outside North America, each writing committee reviews the potential influence of different practice patterns and patient populations on the treatment effect and relevance to the ACCF/AHA target population to determine whether the findings should inform a specific recommendation.The ACCF/AHA practice guidelines are intended to assist healthcare providers in clinical decision making by describing a range of generally acceptable approaches to the diagnosis, management, and prevention of specific diseases or conditions. The guidelines attempt to define practices that meet the needs of most patients in most circumstances. The ultimate judgment regarding care of a particular patient must be made by the healthcare provider and patient in light of all the circumstances presented by that patient. As a result, situations may arise for which deviations from these guidelines may be appropriate. Clinical decision making should involve consideration of the quality and availability of expertise in the area where care is provided. When these guidelines are used as the basis for regulatory or payer decisions, the goal should be improvement in quality of care. The Task Force recognizes that situations arise in which additional data are needed to inform patient care more effectively; these areas will be identified within each respective guideline when appropriate.Prescribed courses of treatment in accordance with these recommendations are effective only if followed. Because lack of patient understanding and adherence may adversely affect outcomes, physicians and other healthcare providers should make every effort to engage the patient's active participation in prescribed medical regimens and lifestyles. In addition, patients should be informed of the risks, benefits, and alternatives to a particular treatment and be involved in shared decision making whenever feasible, particularly for COR IIa and IIb, where the benefit-to-risk ratio may be lower.The Task Force makes every effort to avoid actual, potential, or perceived conflicts of interest that may arise as a result of industry relationships or personal interests among the members of the writing committee. All writing committee members and peer reviewers of the guideline are asked to disclose all such current relationships, as well as those existing 12 months previously. In December 2009, the ACCF and AHA implemented a new policy for relationships with industry and other entities (RWI) that requires the writing committee chair plus a minimum of 50% of the writing committee to have no relevant RWI (Appendix 1 for the ACCF/AHA definition of relevance). These statements are reviewed by the Task Force and all members during each conference call and/or meeting of the writing committee and are updated as changes occur. All guideline recommendations require a confidential vote by the writing committee and must be approved by a consensus of the voting members. Members are not permitted to write, and must recuse themselves from voting on, any recommendation or section to which their RWI apply. Members who recused themselves from voting are indicated in the list of writing committee members, and section recusals are noted in Appendix 1. Authors' and peer reviewers' RWI pertinent to this guideline are disclosed in Appendixes 1 and 2, respectively. Additionally, to ensure complete transparency, writing committee members' comprehensive disclosure information—including RWI not pertinent to this document—is available as an online supplement. Comprehensive disclosure information for the Task Force is also available online at www.cardiosource.org/ACC/About-ACC/Leadership/Guidelines-and-Documents-Task-Forces.aspx. The work of the writing committee was supported exclusively by the ACCF, AHA, and the Society for Cardiovascular Angiography and Interventions (SCAI) without commercial support. Writing committee members volunteered their time for this activity.In an effort to maintain relevance at the point of care for practicing physicians, the Task Force continues to oversee an ongoing process improvement initiative. As a result, in response to pilot projects, several changes to these guidelines will be apparent, including limited narrative text, a focus on summary and evidence tables (with references linked to abstracts in PubMed) and more liberal use of summary recommendation tables (with references that support LOE) to serve as a quick reference.In April 2011, the Institute of Medicine released 2 reports: Finding What Works in Health Care: Standards for Systematic Reviews and Clinical Practice Guidelines We Can Trust.2,3 It is noteworthy that the ACCF/AHA guidelines were cited as being compliant with many of the standards that were proposed. A thorough review of these reports and of our current methodology is under way, with further enhancements anticipated.The recommendations in this guideline are considered current until they are superseded by a focused update or the full-text guideline is revised. Guidelines are official policy of both the ACCF and AHA.1. Introduction1.1. Methodology and Evidence ReviewThe recommendations listed in this document are, whenever possible, evidence based. An extensive evidence review was conducted through November 2010, as well as selected other references through August 2011. Searches were limited to studies, reviews, and other evidence conducted in human subjects and that were published in English. Key search words included but were not limited to the following: ad hoc angioplasty, angioplasty, balloon angioplasty, clinical trial, coronary stenting, delayed angioplasty, meta-analysis, percutaneous transluminal coronary angioplasty, randomized controlled trial (RCT), percutaneous coronary intervention (PCI) and angina, angina reduction, antiplatelet therapy, bare-metal stents (BMS), cardiac rehabilitation, chronic stable angina, complication, coronary bifurcation lesion, coronary calcified lesion, coronary chronic total occlusion (CTO), coronary ostial lesions, coronary stent (BMS and drug-eluting stents [DES]; and BMS versus DES), diabetes, distal embolization, distal protection, elderly, ethics, late stent thrombosis, medical therapy, microembolization, mortality, multiple lesions, multi-vessel, myocardial infarction (MI), non–ST-elevation myocardial infarction (NSTEMI), no-reflow, optical coherence tomography, proton pump inhibitor (PPI), return to work, same-day angioplasty and/or stenting, slow flow, stable ischemic heart disease (SIHD), staged angioplasty, STEMI, survival, and unstable angina (UA). Additional searches cross-referenced these topics with the following subtopics: anticoagulant therapy, contrast nephropathy, PCI-related vascular complications, unprotected left main PCI, multivessel coronary artery disease (CAD), adjunctive percutaneous interventional devices, percutaneous hemodynamic support devices, and secondary prevention. Additionally, the committee reviewed documents related to the subject matter previously published by the ACCF and AHA. References selected and published in this document are representative and not all-inclusive.To provide clinicians with a comprehensive set of data, whenever deemed appropriate or when published, the absolute risk difference and number needed to treat or harm will be provided in the guideline, along with confidence intervals (CIs) and data related to the relative treatment effects such as odds ratio (OR), relative risk, hazard ratio (HR), or incidence rate ratio. The focus of this guideline is the safe, appropriate, and efficacious performance of PCI. The risks of PCI must be balanced against the likelihood of improved survival, symptoms, or functional status. This is especially important in patients with SIHD.1.2. Organization of the Writing CommitteeThe committee was composed of physicians with expertise in interventional cardiology, general cardiology, critical care cardiology, cardiothoracic surgery, clinical trials, and health services research. The committee included representatives from the ACCF, AHA, and SCAI.1.3. Document Review and ApprovalThis document was reviewed by 2 official reviewers nominated by the ACCF, AHA, and SCAI, as well as 21 individual content reviewers (including members of the ACCF Interventional Scientific Council and ACCF Surgeons' Scientific Council). All information on reviewers' RWI was distributed to the writing committee and is published in this document (Appendix 2). This document was approved for publication by the governing bodies of the ACCF, AHA, and SCAI.1.4. PCI Guidelines: History and EvolutionIn 1982, a 2-page manuscript titled “Guidelines for the Performance of Percutaneous Transluminal Coronary Angioplasty” was published in Circulation.4 The document, which addressed the specific expertise and experience physicians should have to perform balloon angioplasty, as well as laboratory requirements and the need for surgical support, was written by an ad hoc group whose members included Andreas Grüntzig. In 1980, the ACC and the AHA established the Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures, which was charged with the development of guidelines related to the role of new therapeutic approaches and of specific noninvasive and invasive procedures in the diagnosis and management of cardiovascular disease. The first ACC/AHA Task Force report on guidelines for coronary balloon angioplasty was published in 1988.5 The 18-page document discussed and made recommendations about lesion classification and success rates, indications for and contraindications to balloon angioplasty, institutional review of angioplasty procedures, ad hoc angioplasty after angiography, and on-site surgical backup. Further iterations of the guidelines were published in 1993,6 2001,7 and 2005.8 In 2007 and 2009, focused updates to the guideline were published to expeditiously address new study results and recent changes in the field of interventional cardiology.9,10 The 2009 focused update is notable in that there was direct collaboration between the writing committees for the STEMI guidelines and the PCI guidelines, resulting in a single publication of focused updates on STEMI and PCI.10The evolution of the PCI guideline reflects the growth of knowledge in the field and parallels the many advances and innovations in the field of interventional cardiology, including primary PCI, BMS and DES, intravascular ultrasound (IVUS) and physiologic assessments of stenosis, and newer antiplatelet and anticoagulant therapies. The 2011 iteration of the guideline continues this process, addressing ethical aspects of PCI, vascular access considerations, CAD revascularization including hybrid revascularization, revascularization before noncardiac surgery, optical coherence tomography, advanced hemodynamic support devices, no-reflow therapies, and vascular closure devices. Most of this document is organized according to “patient flow,” consisting of preprocedural considerations, procedural considerations, and postprocedural considerations. In a major undertaking, the STEMI, PCI, and coronary artery bypass graft (CABG) surgery guidelines were written concurrently, with additional collaboration with the SIHD guideline writing committee, allowing greater collaboration between the different writing committees on topics such as PCI in STEMI and revascularization strategies in patients with CAD (including unprotected left main PCI, multivessel disease revascularization, and hybrid procedures).In accordance with direction from the Task Force and feedback from readers, in this iteration of the guideline, the text has been shortened, with an emphasis on summary statements rather than detailed discussion of numerous individual trials. Online supplemental evidence and summary tables have been created to document the studies and data considered for new or changed guideline recommendations.2. CAD RevascularizationRecommendations and text in this secti