Title: ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention—Summary Article
Abstract: HomeCirculationVol. 113, No. 1ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention—Summary Article Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention—Summary ArticleA Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention) WRITING COMMITTEE MEMBERS Sidney C. SmithJr, MD, FACC, FAHA, Chair, Ted E. Feldman, MD, FACC, FSCAI, John W. HirshfeldJr, MD, FACC, FSCAI, Alice K. Jacobs, MD, FACC, FAHA, FSCAI, Morton J. Kern, MD, FACC, FAHA, FSCAI, Spencer B. KingIII, MD, MACC, FSCAI, Douglass A. Morrison, MD, PhD, FACC, FSCAI, William W. O'Neill, MD, FACC, FSCAI, Hartzell V. Schaff, MD, FACC, FAHA, Patrick L. Whitlow, MD, FACC, FAHA, David O. Williams, MD, FACC, FAHA, FSCAI, Elliott M. Antman, TASK FORCE MEMBERS:, MD, FACC, FAHA, Chair, Sidney C. SmithJr, MD, FACC, FAHA, Vice-Chair, Cynthia D. Adams, MSN, APRN-BC, FAHA, Jeffrey L. Anderson, MD, FACC, FAHA, David P. Faxon, MD, FACC, FAHA, Valentin Fuster, MD, PhD, FACC, FAHA, FESC, Jonathan L. Halperin, MD, FACC, FAHA, Loren F. Hiratzka, MD, FACC, FAHA, Sharon Ann Hunt, MD, FACC, FAHA, Alice K. Jacobs, MD, FACC, FAHA, Rick Nishimura, MD, FACC, FAHA, Joseph P. Ornato, MD, FACC, FAHA, Richard L. Page, MD, FACC, FAHA and Barbara Riegel, DNSc, RN, FAHA WRITING COMMITTEE MEMBERS , Sidney C. SmithJrSidney C. SmithJr , Ted E. FeldmanTed E. Feldman , John W. HirshfeldJrJohn W. HirshfeldJr , Alice K. JacobsAlice K. Jacobs , Morton J. KernMorton J. Kern , Spencer B. KingIIISpencer B. KingIII , Douglass A. MorrisonDouglass A. Morrison , William W. O'NeillWilliam W. O'Neill , Hartzell V. SchaffHartzell V. Schaff , Patrick L. WhitlowPatrick L. Whitlow , David O. WilliamsDavid O. Williams , Elliott M. AntmanElliott M. Antman , Sidney C. SmithJrSidney C. SmithJr , Cynthia D. AdamsCynthia D. Adams , Jeffrey L. AndersonJeffrey L. Anderson , David P. FaxonDavid P. Faxon , Valentin FusterValentin Fuster , Jonathan L. HalperinJonathan L. Halperin , Loren F. HiratzkaLoren F. Hiratzka , Sharon Ann HuntSharon Ann Hunt , Alice K. JacobsAlice K. Jacobs , Rick NishimuraRick Nishimura , Joseph P. OrnatoJoseph P. Ornato , Richard L. PageRichard L. Page and Barbara RiegelBarbara Riegel Originally published3 Jan 2006https://doi.org/10.1161/CIRCULATIONAHA.105.170815Circulation. 2006;113:156–175The American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions (ACC/AHA/SCAI) 2005 Guideline Update for Percutaneous Coronary Intervention (PCI) contains changes in the recommendations, along with supporting text. For the purpose of comparison, this summary contains a list of the updated recommendations (middle column) alongside a list of the 2001 recommendations (left column), with each set accompanied by a comment (right column) that provides the rationale for the changes, additions, or deletions (see Table 1). References that support either the 2001 recommendations that have changed or the new or revised recommendations are cited in parentheses at the end of each recommendation or comment. A list of abbreviations is included in the Appendix. The reader is referred to the full-text guideline posted on the World Wide Web sites of the ACC, the AHA, and the SCAI for a more detailed explanation of the changes discussed here. Please note that we have changed the table of contents headings in the 2001 ACC/AHA Guidelines for Percutaneous Coronary Intervention from roman numerals to unique identifying numbers. 2001 Recommendation2005 New or Revised RecommendationComments3. Outcomes3.2 Acute Outcome: Procedural ComplicationsClass IClass INoneAll patients who have signs or symptoms suggestive of MI during or after PCI and those with complicated procedures should have CK-MB and troponin I or T measured after the procedure. (Level of Evidence: B)This recommendation appeared in the text of the 2001 revision for CK-MB only. Troponin I or T measurement has been added, and it is now listed as a class I, level of evidence B recommendation (1–10).Class IIaClass IIaNoneRoutine measurement of cardiac biomarkers (CK-MB and/or troponin I or T) in all patients undergoing PCI is reasonable 8 to 12 hours after the procedure. (Level of Evidence: C)Routine measurement of CK-MB or troponin I or T is added as a new class IIa, level of evidence C recommendation. The committee did not think that evidence regarding the clinical utility of routine measurement of biomarkers in all patients was strong enough to warrant a class I recommendation.4. Institutional and Operator Competency4.1 Quality AssuranceClass IClass INone1. An institution that performs PCI should establish an ongoing mechanism for valid peer review of its quality and outcomes. Review should be conducted both at the level of the entire program and at the level of the individual practitioner. Quality-assessment reviews should take risk adjustment, statistical power, and national benchmark statistics into consideration. Quality-assessment reviews should include both tabulation of adverse event rates for comparison with benchmark values and case review of complicated procedures and some uncomplicated procedures. (Level of Evidence: C)Quality assurance is an important responsibility for all institutions in which PCI is performed. Institutions must monitor the PCI program with respect to process, appropriateness, and outcomes and correct any circumstances in which quality falls below accepted norms. The quality assessment should be conducted at the level of both the entire program and the individual practitioner.2. An institution that performs PCI should participate in a recognized PCI data registry for the purpose of benchmarking its outcomes against current national norms. (Level of Evidence: C)Participation in a recognized PCI registry for benchmarking outcomes against current national norms is an important part of the quality-improvement process. The ACC–National Cardiovascular Data Registry® or other databases may serve as a valuable resource in this regard.4.2 Operator and Institutional VolumeClass IClass IPCI done by operators with acceptable volume (greater than or equal to 75) at high-volume centers (greater than 400). (Level of Evidence: B)1. Elective PCI should be performed by operators with acceptable annual volume (at least 75 procedures) at high-volume centers (more than 400 procedures) with on-site cardiac surgery. (Level of Evidence: B)Wording has been added to clarify this statement and emphasize that it relates to elective PCI performed at centers with on-site cardiac surgery.2. Elective PCI should be performed by operators and institutions whose historical and current risk-adjusted outcomes statistics are comparable to those reported in contemporary national data registries. (Level of Evidence: C)This recommendation was added to emphasize that historical and current risk-adjusted outcomes for operators and institutions are an essential part of the quality-improvement process.3. Primary PCI for STEMI should be performed by experienced operators who perform more than 75 elective PCI procedures per year and, ideally, at least 11 PCI procedures for STEMI per year. Ideally, these procedures should be performed in institutions that perform more than 400 elective PCIs per year and more than 36 primary PCI procedures for STEMI per year. (Level of Evidence: B)This recommendation is expanded based on data from the New York State registry indicating that physicians performing more than 10 primary PCI procedures per year have lower mortality rates (11–13).Class IIaClass IIa1. PCI done by operators with acceptable volume (75 or more) at low-volume centers (200–400). (Level of Evidence: C)1. It is reasonable that operators with acceptable volume (at least 75 PCI procedures per year) perform PCI at low-volume centers (200 to 400 PCI procedures per year) with on-site cardiac surgery. (Level of Evidence: B)Wording has been changed to comply with current recommended phrasing for class IIa recommendation. The fact that this recommendation applies to centers with on-site cardiac surgery is emphasized. Level of evidence has been changed to B based on accumulated published evidence (14).2001 Recommendation2005 New or Revised RecommendationComments2. PCI done by low-volume operators (fewer than 75) at high-volume centers (more than 400). Note: Ideally operators with an annual procedure volume less than 75 should only work at institutions with an activity level of more than 600 procedures/year.* (Level of Evidence: C)2. It is reasonable that low-volume operators (fewer than 75 PCI procedures per year) perform PCI at high-volume centers (more than 400 PCI procedures per year) with on-site cardiac surgery. Ideally, operators with an annual procedure volume less than 75 should only work at institutions with an activity level of more than 600 procedures per year. Operators who perform fewer than 75 procedures per year should develop a defined mentoring relationship with a highly experienced operator who has an annual procedural volume of at least 150 procedures per year. (Level of Evidence: B)Wording has been changed to comply with current recommended phasing. Level of evidence has been changed to B based on accumulated published evidence (15).*Operators who perform fewer than 75 procedures per year should develop a defined mentoring relationship with a highly experienced operator who has an annual procedural volume of at least 150 procedures per year.Class IIbClass IIbNoneThe benefit of primary PCI for STEMI patients eligible for fibrinolysis when performed by an operator who performs fewer than 75 procedures per year (or fewer than 11 PCIs for STEMI per year) is not well established. (Level of Evidence: C)This recommendation has been added to address the issue of low-volume operators performing primary PCI. It reflects the relative lack of evidence supporting a benefit of primary PCI for low-volume operators.Class IIIClass IIIPCI done by low-volume operators (fewer than 75) at low-volume centers (200–400). Note: An institution with a volume of fewer than 200 procedures/year, unless in a region that is underserved because of geography, should carefully consider whether it should continue to offer service.* (Level of Evidence: C)It is not recommended that elective PCI be performed by low-volume operators (fewer than 75 procedures per year) at low-volume centers (200 to 400) with or without on-site cardiac surgery. An institution with a volume of fewer than 200 procedures per year, unless in a region that is underserved because of geography, should carefully consider whether it should continue to offer this service. (Level of Evidence: B)Wording has been changed to reflect current preferred phrasing. Level of evidence changed to B on the basis of published data indicating poorer outcomes at low-volume centers (15).* Operators who perform fewer than 75 procedures per year should develop a defined mentoring relationship with a highly experienced operator who has an annual procedural volume of at least 150 procedures per year.4.3. Role of On-Site Cardiac Surgical Back-upClass IClass I1. Patients undergoing elective PCI in facilities with on-site cardiac surgery. (Level of Evidence: B)1. Elective PCI should be performed by operators with acceptable annual volume (at least 75 procedures per year) at high-volume centers (more than 400 procedures annually) that provide immediately available on-site emergency cardiac surgical services. (Level of Evidence: B)Phrasing has been changed to reflect current terminology and volume criteria; otherwise, no significant changes.2. Patients undergoing primary PCI in facilities with on-site cardiac surgery. (Level of Evidence: B)2. Primary PCI for patients with STEMI should be performed in facilities with on-site cardiac surgery. (Level of Evidence: B)Phrasing has been changed to reflect current terminology and to be consistent with the ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction.Class IIIClass IIIPatients undergoing elective PCI in facilities without on-site cardiac surgery. (Level of Evidence: C)Elective PCI should not be performed at institutions that do not provide on-site cardiac surgery. * (Level of Evidence: C)Phrasing has been changed to reflect current terminology. As with many dynamic areas in interventional cardiology, these recommendations may be subject to revision as clinical data and experience increase.*Several centers have reported satisfactory results based on careful case selection with well-defined arrangements for immediate transfer to a surgical program (18–28). A small, but real fraction of patients undergoing elective PCI will experience a life-threatening complication that could be managed with the immediate on-site availability of cardiac surgical support but cannot be managed effectively by urgent transfer. Wennberg et al. found higher mortality in the Medicare database for patients undergoing elective PCI in institutions without onsite cardiac surgery (29). These recommendations may be subject to revision as clinical data and experience increase.2001 Recommendation2005 New or Revised RecommendationCommentsSection 4.4 Primary PCI for STEMI Without On-Site Cardiac SurgeryClass IIbClass IIbPatients undergoing primary PCI in facilities without on-site cardiac surgery, but with a proven plan for rapid access (within 1 h) to a cardiac surgery operating room in a nearby facility with appropriate hemodynamic support capability for transfer. The procedure should be limited to patients with ST-segment elevation MI or new LBBB on ECG, and done in a timely fashion (balloon inflation within 90 plus or minus 30 min of admission) by persons skilled in the procedure (at least 75 PCIs/year) and only at facilities performing a minimum of 36 primary PCI procedures per year. (Level of Evidence: B)Primary PCI for patients with STEMI might be considered in hospitals without on-site cardiac surgery, provided that appropriate planning for program development has been accomplished, including appropriately experienced physician operators (more than 75 total PCIs and, ideally, at least 11 primary PCIs per year for STEMI), an experienced catheterization team on a 24 hours per day, 7 days per week call schedule, and a well-equipped catheterization laboratory with digital imaging equipment, a full array of interventional equipment, and intra-aortic balloon pump capability, and provided that there is a proven plan for rapid transport to a cardiac surgery operating room in a nearby hospital with appropriate hemodynamic support capability for transfer. The procedure should be limited to patients with STEMI or MI with new or presumably new LBBB on ECG and should be performed in a timely fashion (goal of balloon inflation within 90 minutes of presentation) by persons skilled in the procedure (at least 75 PCIs per year) and at hospitals that perform a minimum of 36 primary PCI procedures per year. (Level of Evidence: B)Phrasing has been changed to reflect current terminology. Recommendations have been added that 1) physicians perform at least 11 primary PCIs per year for STEMI, 2) a 24 hours per day, 7 days per week call schedule be maintained, and 3) the catheterization laboratory be well equipped with digital imaging equipment, a full array of interventional equipment, and intra-aortic balloon pump capability. The intent is to ensure optimal experience availability and capability to perform primary PCI in patients with STEMI (16,17).Class IIIClass IIIPatients undergoing primary PCI in facilities without on-site cardiac surgery and without a proven plan for rapid access (within 1 h) to a cardiac surgery operating room in a nearby facility with appropriate hemodynamic support capability for transfer or when performed by lower-skilled operators (fewer than 75 PCIs per year) in a facility performing fewer than 36 primary PCI procedures per year. (Level of Evidence: C)Primary PCI should not be performed in hospitals without on-site cardiac surgery and without a proven plan for rapid transport to a cardiac surgery operating room in a nearby hospital or without appropriate hemodynamic support capability for transfer. (Level of Evidence: C)Phrasing has been changed to reflect current terminology and to place emphasis on need for inter-institutional planning and support.4.5 Elective PCI Without On-Site SurgeryClass IIIClass IIIPatients undergoing elective PCI in facilities without on-site cardiac surgery. (Level of Evidence: C)Elective PCI should not be performed at institutions that do not provide on-site cardiac surgery. (Level of Evidence: C) *Several centers have reported satisfactory results based on careful case selection with well-defined arrangements for immediate transfer to a surgical program (18–28). A small, but real fraction of patients undergoing elective PCI will experience a life-threatening complication that could be managed with the immediate on-site availability of cardiac surgical support but cannot be managed effectively by urgent transfer. Wennberg et al. found higher mortality in the Medicare database for patients undergoing elective PCI in institutions without onsite cardiac surgery (29). These recommendations may be subject to revision as clinical data and experience increase.Repeated from previous section for consistency. Phrasing has been changed to reflect current terminology.5.1. Patients With Asymptomatic Ischemia or Canadian Cardiovascular Society (CCS) Class I or II AnginaClass IClass IIaPatients who do not have treated diabetes with asymptomatic ischemia or mild angina with 1 or more significant lesions in 1 or 2 coronary arteries suitable for PCI with a high likelihood of success and a low risk of morbidity and mortality. The vessels to be dilated must subtend a large area of viable myocardium. (Level of Evidence: B)1. PCI is reasonable in patients with asymptomatic ischemia or CCS class I or II angina and with 1 or more significant lesions in 1 or 2 coronary arteries suitable for PCI with a high likelihood of success and a low risk of morbidity and mortality. The vessels to be dilated must subtend a moderate to large area of viable myocardium or be associated with a moderate to severe degree of ischemia on noninvasive testing. (Level of Evidence: B)Phrasing has been changed to reflect current terminology. This recommendation and all of those that follow in Section 5 have been reworded to be consistent with the CCS classification system of angina. This recommendation has been changed to class IIa to reflect the published data and Writing Committee consensus that not all patients in this clinical category must have PCI performed (30,31).Class IIa1. The same clinical and anatomic requirements for Class I, except the myocardial area at risk is of moderate size or the patient has treated diabetes. (Level of Evidence: B)This recommendation has been merged with other class IIa recommendations of this section, and the phrasing has been changed to reflect current terminology.2001 Recommendation2005 New or Revised RecommendationComments2. PCI is reasonable for patients with asymptomatic ischemia or CCS class I or II angina, and recurrent stenosis after PCI with a large area of viable myocardium or high-risk criteria on noninvasive testing. (Level of Evidence: C)This is a new recommendation dealing with the management of recurrent stenosis after PCI among patients with asymptomatic ischemia or class I or II angina.3. Use of PCI is reasonable in patients with asymptomatic ischemia or CCS class I or II angina with significant left main CAD (greater than 50% diameter stenosis) who are candidates for revascularization but are not eligible for CABG. (Level of Evidence: B)This recommendation for PCI among patients who are eligible for CABG who have significant left main disease has been added to reflect the favorable results noted by several trials with PCI (32–35).Class IIbPatients with asymptomatic ischemia or mild angina with greater than or equal to 3 coronary arteries suitable for PCI with a high likelihood of success and a low risk of morbidity and mortality. The vessels to be dilated must subtend at least a moderate area of viable myocardium. In the physician's judgment, there should be evidence of myocardial ischemia by ECG exercise testing, stress nuclear imaging, stress echocardiography or ambulatory ECG monitoring or intracoronary physiologic measurements. (Level of Evidence: B)This recommendation has been eliminated and replaced by the following 2 recommendations. For each, the phrasing has been constructed to reflect current terminology.Class IIb1. The effectiveness of PCI for patients with asymptomatic ischemia or CCS class I or II angina who have 2- or 3-vessel disease with significant proximal LAD CAD who are otherwise eligible for CABG with 1 arterial conduit and who have treated diabetes or abnormal LV function is not well established. (Level of Evidence: B)Phrasing has been changed to reflect current terminology. Among patients who are eligible, CABG with 1 arterial conduit is generally preferred for treatment of multivessel disease with significant proximal LAD obstruction in patients with treated diabetes and/or abnormal LV function (36).2. PCI might be considered for patients with asymptomatic ischemia or CCS class I or II angina with nonproximal LAD CAD that subtends a moderate area of viable myocardium and demonstrates ischemia on noninvasive testing. (Level of Evidence: C)Phrasing has been changed to reflect current terminology. PCI might be considered in this clinical setting.Class IIIClass IIIPatients with asymptomatic ischemia or mild angina who do not meet the criteria as listed under Class I or Class II and who have:PCI is not recommended in patients with asymptomatic ischemia or CCS class I or II angina who do not meet the criteria as listed under the class II recommendations or who have 1 or more of the following:Phrasing has been changed to reflect current terminology. Recommendation has been reworded to be consistent with CCS classification system for angina. Level of evidence has been added for each subgroup. a. Only a small area of viable myocardium at risk a. Only a small area of viable myocardium at risk (Level of Evidence: C) b. No objective evidence of ischemia b. No objective evidence of ischemia (Level of Evidence: C) c. Lesions that have a low likelihood of successful dilatation c. Lesions that have a low likelihood of successful dilatation (Level of Evidence: C) d. Mild symptoms that are unlikely to be due to myocardial ischemia d. Mild symptoms that are unlikely to be due to myocardial ischemia (Level of Evidence: C) e. Factors associated with increased risk of morbidity or mortality e. Factors associated with increased risk of morbidity or mortality (Level of Evidence: C) f. Left main disease f. Left main disease and eligibility for CABG (Level of Evidence: C) g. Insignificant disease less than 50% (Level of Evidence: C) g. Insignificant disease (less than 50% coronary stenosis) (Level of Evidence: C)5.2 Patients With CCS Class III AnginaClass IClass IIaPatients with 1 or more significant lesions in 1 or more coronary arteries suitable for PCI with a high likelihood of success and low risk of morbidity or mortality. The vessel(s) to be dilated must subtend a moderate or large area of viable myocardium and have high risk. (Level of Evidence: B)1. It is reasonable that PCI be performed in patients with CCS class III angina and single-vessel or multivessel CAD who are undergoing medical therapy and who have 1 or more significant lesions in 1 or more coronary arteries suitable for PCI with a high likelihood of success and low risk of morbidity or mortality. (Level of Evidence: B)Phrasing has been changed to reflect current terminology. Recommendation has been reworded to be consistent with CCS classification system for angina. The recommendation class has been changed to IIa to reflect published data and Writing Committee consensus. Criteria regarding viable and high-risk myocardium have been deleted from this recommendation (30, 31).2001 Recommendation2005 New or Revised RecommendationCommentsClass IIaPatients with focal saphenous vein graft lesions or multiple stenoses who are poor candidates for reoperative surgery. (Level of Evidence: C)2. It is reasonable that PCI be performed in patients with CCS class III angina with single-vessel or multivessel CAD who are undergoing medical therapy with focal saphenous vein graft lesions or multiple stenoses who are poor candidates for reoperative surgery. (Level of Evidence: C)Phrasing has been changed to reflect current terminology.3. Use of PCI is reasonable in patients with CCS class III angina with significant left main CAD (greater than 50% diameter stenosis) who are candidates for revascularization but are not eligible for CABG. (Level of Evidence: B)This recommendation for PCI among patients with significant left main disease who are not eligible for CABG has been added to reflect the favorable results noted by several trials with PCI (32–35).Class IIbClass IIbPatient has 1 or more lesions to be dilated with reduced likelihood of success or the vessel(s) subtend a less than moderate area of viable myocardium. Patients with 2- or 3-vessel disease, with significant proximal LAD CAD and treated diabetes or abnormal LV function. (Level of Evidence: B)1. PCI may be considered in patients with CCS class III angina with single-vessel or multivessel CAD who are undergoing medical therapy and who have 1 or more lesions to be dilated with a reduced likelihood of success. (Level of Evidence: B)Phrasing has been changed to reflect current terminology. The 2001 recommendation has been split into 2 separate recommendations.2. PCI may be considered in patients with CCS class III angina and no evidence of ischemia on noninvasive testing or who are undergoing medical therapy and have 2- or 3-vessel CAD with significant proximal LAD CAD and treated diabetes or abnormal LV function. (Level of Evidence: B)Phrasing has been changed to reflect current terminology. The use of noninvasive testing to evaluate for evidence of ischemia has been added.Class IIIClass IIIPatient has no evidence of myocardial injury or ischemia on objective testing and has not had a trial of medical therapy, or hasPCI is not recommended for patients with CCS class III angina with single-vessel or multivessel CAD, no evidence of myocardial injury or ischemia on objective testing, and no trial of medical therapy, or who have 1 of the following:Phrasing has been changed to reflect current terminology. Class III recommendations #2 and #3 from the 2001 guidelines have been merged into this recommendation. a. Only a small area of myocardium at risk a. Only a small area of myocardium at risk (Level of Evidence: C) b. All lesions or the culprit lesion to be dilated with morphology with a low likelihood of success b. All lesions or the culprit lesion to be dilated with morphology that conveys a low likelihood of success (Level of Evidence: C) c. A high risk of procedure-related morbidity or mortality. (Level of Evidence: C) c. A high risk of procedure-related morbidity or mortality (Level of Evidence: C) d. Insignificant disease (less than 50% coronary stenosis) (Level of Evidence: C) e. Significant left main CAD and candidacy for CABG (Level of Evidence: C)2. Patients with insignificant coronary stenosis (e.g., less than 50% diameter). (Level of Evidence: C)See above.3. Patients with significant left main CAD who are candidates for CABG. (Level of Evidence: B)See above.5.3 Unstable Angina/Non–ST-Elevation Myocardial Infarction (UA/NSTEMI)(Note: Some of these recommendations have been repeated from above because the sections for the 2005 guideline were revised slightly.)Class IAn early invasive PCI strategy is indicated for patients with UA/NSTEMI who have no serious comorbidity and who have coronary lesions amenable to PCI. Patients must have any of the following high-risk features:Added to maintain consistency with the ACC/AHA 2002 Guideline Update for the Management of Patients With Unstable Angina and Non–ST-Segment Myocardial Infarction (37). a. Recurrent ischemia despite intensive anti-ischemic therapy (Level of Evidence: A) b. Elevated troponin level (Level of Evidence: A) c. New ST-segment depression (Level of Evidence: A) d. CHF symptoms or new or worsening MR (Level of Evidence: A) e. Depressed LV systolic function (Level of Evidence: A) f. Hemodynamic instability (Level of Evidence: A) g. Sustained ventricular tachycardia (Level of Evidence: A) h. PCI within 6 months (Level of Evidence: A) i. Prior CABG (Level of Evidence: A)2001 Recommendation2005 New or Revised RecommendationCommentsClass IIaClass IIa1. Patients with focal saphenous vein graft lesions or multiple stenoses who are poor candidates for reoperative surgery. (Level of Evidence: C)1. It is reasonable that PCI be performed in patients with UA/NSTEMI and single-vessel or multivessel CAD who are undergoing medical therapy with focal saphenous vein graft lesions or multiple stenoses who are poor candidates for reoperative surgery. (Level of Evidence: C)Phrasing has been changed to reflect current terminology.2. In the absence of high-risk features associated with UA/NSTEMI, it is reasonable to perform PCI in patients with amenable lesions and no contraindication for PCI wit