Perspectives of ACC/AHA/SCAI myocardial revascularization 2022 guideline implementation in Kyrgyz Republic

Abstract

In the Kyrgyz Republic, 52% of all deaths are due to cardiovascular diseases, of which 2/3 is coronary artery disease (CAD) (1). The implementation of the ACC/AHA/SCAI Guideline for Coronary Artery Revascularization 2022 (2) is a necessary objective. This Guideline is the result of joint work of the American Heart Association, the American College of Cardiology and Society for Cardiovascular Angiography and Interventions (2). These recommendations are based on recent randomized clinical trials with a high-degree of evidence. However, their full implementation is hampered by local problems in equipment and skills. Unfortunately, the government does not provide the patients with consumables for coronary angiography, balloon angioplasty and stenting. Everything is purchased at their own expense. Therefore, primary percutaneous coronary interventions (PCI) is not performed in all the regions of the Kyrgyz Republic. The next reason for the difficulty in introducing primary PCI is the availability of a catheter laboratory in only three cities of the country. In four out of seven regions, there is no angiographic facility at all. In this regard, the main approach for the treatment of acute myocardial infarction with ST-segment elevation (STEMI) is thrombolytic therapy. In a small proportion of patients in cities where there is a catheter laboratory, a pharmaco-invasive reperfusion method is used. The situation is especially bad with the treatment of STEMI in the presence of pulmonary edema, cardiogenic shock. In this category of patients, PCI is challenging due to the lack of experience, absence of intra-aortic balloon pump and other means of mechanical circulatory support. Another problem is that in stable patients with acute myocardial infarction, if PCI is performed, then coronary artery bypass grafting is not performed in all cases with indication. After reviewing the clinical guidelines, we would like to note the recommendations that can be put into practice right now. The implementation of Heart Team approach Recommendations: In patients for whom the optimal treatment strategy is unclear, a Heart Team approach that includes representatives from interventional cardiology, cardiac surgery, and clinical cardiology is recommended to improve patient outcomes (I, B-NR). -The implementation of SYNTAX, STS scores Recommendations: In patients with multivessel CAD, an assessment of CAD complexity, such as the SYNTAX score, may be useful to guide revascularization (2b, BNR). -The implementation of physiological methods of assessing lesion significance fractional flow reserve (FFR) or instantaneous wave-free ratio (iFR). Recommendations: In patients with angina or an anginal equivalent, undocumented ischemia, and angiographically intermediate stenoses, the use of FFR or iFR is recommended to guide the decision to proceed with PCI (1, A). In stable patients with angiographically intermediate stenoses and FFR >0.80 or iFR >0.89, PCI should not be performed (3, B-R).