Coronary Artery Revascularization
Key Points
Key Points
- Treatment decisions with regard to coronary revascularization in patients with coronary artery disease should be based on clinical indications, regardless of sex, race, or ethnicity, because there is no evidence that some patients benefit less than others, and efforts to reduce disparities of care are warranted.
- In patients being considered for coronary revascularization for whom the optimal treatment strategy is unclear, a multidisciplinary Heart Team approach is recommended. Treatment decisions should be patient-centered, incorporate patient preferences and goals, and include shared decision-making.
- For patients with significant left main disease, surgical revascularization is indicated to improve survival relative to that likely to be achieved with medical therapy. Percutaneous revascularization is a reasonable option to improve survival, compared with medical therapy, in selected patients with low to medium anatomic complexity of coronary artery disease and left main disease that is equally suitable for surgical or percutaneous revascularization.
- Updated evidence from contemporary trials supplement older evidence with regard to mortality benefit of revascularization in patients with stable ischemic heart disease, normal left ventricular ejection fraction, and triple-vessel coronary artery disease. Surgical revascularization may be reasonable to improve survival. A survival benefit with percutaneous revascularization is uncertain. Revascularization decisions are based on consideration of disease complexity, technical feasibility of treatment, and a Heart Team discussion.
- The use of a radial artery as a surgical revascularization conduit is preferred to the use of a saphenous vein conduit to bypass the second most important target vessel with significant stenosis after the left anterior descending coronary artery. Benefits include superior patency, reduced adverse cardiac events, and improved survival.
- Radial artery access is recommended in patients undergoing percutaneous intervention who have acute coronary syndromes or stable ischemic heart disease, to reduce bleeding and vascular complications compared with a femoral approach. Patients with acute coronary syndromes also benefit from a reduction in mortality rate with this approach.
- A short duration of dual antiplatelet therapy after percutaneous revascularization in patients with stable ischemic heart disease is reasonable to reduce the risk of bleeding events. After consideration of recurrent ischemia and bleeding risks, select patients may safely transition to P2Y12 inhibitor monotherapy and stop aspirin after 1 to 3 months of dual antiplatelet therapy.
- Staged percutaneous intervention (while in hospital or after discharge) of a significantly stenosed non-culprit artery in patients presenting with an ST-segment-elevation myocardial infarction is recommended in select patients to improve outcomes. Percutaneous intervention of the non-culprit artery at the time of primary percutaneous coronary intervention is less clear and may be considered in stable patients with uncomplicated revascularization of the culprit artery, low-complexity non-culprit artery disease, and normal renal function. In contrast, percutaneous intervention of the non-culprit artery can be harmful in patients in cardiogenic shock.
- Revascularization decisions in patients with diabetes and multivessel coronary artery disease are optimized by the use of a Heart Team approach. Patients with diabetes who have triple-vessel disease should undergo surgical revascularization; percutaneous coronary intervention may be considered if they are poor candidates for surgery.
- Treatment decisions for patients undergoing surgical revascularization of coronary artery disease should include the calculation of a patient’s surgical risk with the Society of Thoracic Surgeons score. The usefulness of the SYNTAX score calculation in treatment decisions is less clear because of the interobserver variability in its calculation and its absence of clinical variables.
Overview
...vervie...
...of Care in Revascularization and Sh...
...roving Equity of Care in Revascularizatio...
...patients who require coronary revas...
...Shared Decision-Making...
...hared Decision-Making and Informed Consent...
...In patients undergoing revascularization, dec...
...ients undergoing coronary angiography or r...
...The numbering of the following tables and...
...l Components of the Shared Decision-Makin...
Preprocedural Assessment and the Heart Team
...procedural Assessment and the Heart T...
...art Team In patients for whom the optimal treatm...
...s of Patient-Centric Care in the Treatment of Cor...
...rs for Consideration by the Heart TeamHav...
...icting Patient Risk of Death With CABG...
...Assessment of Risk Factors Not Quantifie...
Evaluation
Evaluatio...
...Lesion Severity...
...ining Coronary Artery Lesion Complexity: Cal...
...ngiographic Features Contributing...
...onary Physiology to Guide Revascularization With P...
...atients with angina or an anginal equiv...
...ble patients with angiographically intermedi...
...trasound to Assess Lesion Severity...
Treatment
Treatmen...
...larization in STEM...
...ization of the Infarct Artery in Patients W...
...ts with STEMI and ischemic symptoms for...
...with STEMI and cardiogenic shock or hemodyna...
...patients with STEMI who have mechanical com...
...s with STEMI and evidence of failed...
...with STEMI who are treated with fibrinol...
...with STEMI who are stable and presen...
...In patients with STEMI in whom PCI is not feasi...
...tients with STEMI complicated by ongoin...
...asymptomatic stable patients with STEMI wh...
...ents with STEMI, emergency CABG should NOT be per...
...Indications for Revascularization in STEMI (...
...vascularization of the Non-Infarct Arte...
...lected hemodynamically stable patients with STEM...
...cted patients with STEMI with complex multiv...
...selected hemodynamically stable patients with STEM...
...In patients with STEMI complicated by cardiog...
...5. Patient Clinical Status Definitions to Gu...
...evascularization of Non–Infarct-Rela...
...rization in NSTE-ACS...
...ography and Revascularization in Patients With...
...ts with NSTE-ACS who are at elevated risk of recu...
...tients with NSTE-ACS and cardiogenic shock who ar...
...appropriate patients with NSTE-ACS who...
...n patients with NSTE-ACS who are initially stab...
...ts with NSTE-ACS who are initially stabilized...
...with NSTE-ACS who have failed PCI and have ongoin...
...patients with NSTE-ACS who present...
...of Invasive Strategy in Patients...
...arization in SIHD...
...ularization to Improve Survival in SIHD Compar...
...ular dysfunction and multivessel...
...with SIHD and multivessel CAD app...
...In selected patients with SIHD and mu...
...ft main CAD
...n patients with SIHD and significant left...
...d patients with SIHD and significant left...
...tivessel CA...
...In patients with SIHD, normal ejection fractio...
...s with SIHD, normal ejection fraction, sign...
...sis in the proximal LAD arte...
...patients with SIHD, normal left ventr...
...le-vessel disease not involving the proxi...
...s with SIHD, normal left ventricular ejectio...
In patients with SIHD who have ≥1 co...
...cularization in Patients With SIHD...
...ation to Reduce Cardiovascular Events i...
...ssel CAD In patients with SIHD and multives...
...ization to Improve Symptoms...
...atients with refractory angina despite medical th...
...patients with angina but no anatomic or phys...
...in Which PCI or CABG Would Be Preferred
...With Complex Disease...
...who require revascularization for significant...
...nts who require revascularization for...
...ts With Diabetes...
...patients with diabetes and multives...
...atients with diabetes who have multivessel CAD...
...s with diabetes who have left main stenosi...
...With Previous CABG...
...In patients with previous CABG with a patent LIMA...
...nts with previous CABG and refractor...
...nts with previous CABG and complex...
...ce In patients with multivessel CAD amenable t...
...ecial Populations and S...
...ularization in Pregnant Patients...
...gnant patients with STEMI not caused...
...nt patients with NSTE-ACS, an invasive...
...arization in Older Patient...
...ults, as in all patients, the treatment st...
...evascularization in Patients...
...In patients with CKD undergoing contrast...
...s with STEMI and CKD, coronary angiogr...
...k patients with NSTE-ACS and CKD, it is...
...k patients with NSTE-ACS and CKD, it is rea...
...ptomatic patients with stable CAD and CKD, rout...
...able 6. Best Practices in the Catheteri...
...vascularization in Patients Before Noncardiac S...
...ascularization in Patients to Reduce Ventricular...
...In patients with ventricular fibri...
...with CAD and suspected scar-mediated sustained...
...cularization in Patients W...
...ts with SCAD who have hemodynamic instability or...
...Routine revascularization for SCAD shoul...
...on in Patients With Cardiac Allografts...
...Procedural Issues for P...
...d Femoral Approaches for PCI...
...atients with ACS undergoing PCI, a...
...s with SIHD undergoing PCI, the radial appr...
...nt Type In patients undergoing PCI, DES...
...ntravascular Imagin...
...patients undergoing coronary stent im...
...patients undergoing coronary stent implanta...
...tients with stent failure, IVUS or OCT is r...
...omy In patients with STEMI, routine asp...
...t of Calcified Lesions...
In patients with fibrotic or heavily calcified...
...nts with fibrotic or heavily calcified les...
...of Saphenous Vein Graft Disease (Previous CABG...
...In select patients with previous CABG underg...
...with previous CABG, if PCI of a diseased n...
...In patients with a chronic occlusion o...
Treatment of CTO In patients with suita...
...reatment of Patients With Stent Resten...
...atients who develop clinical ISR for...
...with symptomatic recurrent diffuse IS...
...nts who develop recurrent ISR, brachytherapy ma...
...upport for Complex PCI In selected high-risk p...
...rapy in Patients Undergoing...
...ral P2Y12 Inhibitors in Patients Undergoing PCI...
...ents undergoing PCI, a loading dose of aspirin, f...
...patients with ACS undergoing PCI, a loading do...
...with SIHD undergoing PCI, a loading...
...n patients undergoing PCI within 24 h...
...nts with ACS undergoing PCI, it is reaso...
...In patients...
...patients undergoing PCI who have a h...
...dications to ticagrelor: previous in...
...ble for Aspirin and Oral P2Y12 In...
...avenous P2Y12 Inhibitors in Patient...
...undergoing PCI who are P2Y12 inhibitor naïve, i...
...oprotein IIb/IIIa Inhibitors in Pat...
...In patients with ACS undergoing PC...
...with SIHD undergoing PCI, the routine...
...Molecular-Weight Heparin, and Bivalirudin in Pati...
...n patients undergoing PCI, administration of intra...
...ts with heparin-induced thrombocytopeni...
...In patients undergoing PCI, bivalirudin ma...
...ts treated with upstream subcutaneous enoxapar...
...s on therapeutic subcutaneous enoxapar...
...agulant Dosing During PCI*Having troub...
...eneral Procedural Issues for...
...perative Considerations in Patients...
...ents undergoing CABG, establishment of multidisci...
...9. Perioperative Anesthetic and Moni...
...ypass Conduits in Patients Undergoin...
...tients undergoing isolated CABG, the use of a r...
...In patients undergoing CABG, an IMA, pre...
...In patients undergoing CABG, BIMA graf...
...le 10. Best Practices for the Use of B...
...BG in Patients Undergoing Other C...
...atients undergoing valve surgery, aortic surgery,...
...n patients undergoing valve surgery, aortic sur...
...ic Ultrasound in Patients Undergoing CABG...
...In patients undergoing CABG, the routine use of...
...iopulmonary Bypass in Patients Undergoing...
...ents with significant calcification of the aorta...
...tients with significant pulmonary disease, off-...
...erapy in Patients Undergoing CABG...
...nfusion and Other Measures to Reduce Ste...
...ndergoing CABG, an intraoperative c...
...nts undergoing CABG, the use of conti...
...ients undergoing CABG, a comprehen...
...tients undergoing CABG, the usefulness of c...
...1. Best Practices to Reduce Sternal Wound In...
...ntiplatelet Therapy in Patients Undergoing CAB...
In patients undergoing CABG who are alread...
...s referred for urgent CABG, clopidogrel...
...ndergoing CABG, discontinuation of short-act...
...s undergoing elective CABG who recei...
...In patients undergoing elective CABG who are...
...kers and Amiodarone in Patients Undergo...
...In patients undergoing CABG, who do not have a...
...tients undergoing CABG, preoperativ...
...n patients undergoing CABG, who do not ha...
...In patients undergoing CABG, the role of pre...
...erapy in Patients After Revascular...
...ntiplatelet Therapy in Patients After PCI
...patients undergoing PCI, shorter-dur...
...gure 7. Use of DAPT for Patients Afte...
...latelet Therapy in Patients After CABG...
...ts undergoing CABG, aspirin (100–3...
...ted patients undergoing CABG, DAPT with a...
...in Patients After Revascularization...
...ts with SIHD and normal left ventricula...
...Blockers for the Prevention of Atrial Fibr...
...patients after CABG, beta blockers are reco...
...platelet Therapy in Patients With Atrial F...
...In patients with atrial fibrillation who are un...
...atients with atrial fibrillation who...
...Psychosocial Factors and Lifestyle Changes...
...ehabilitation and Education...
...who have undergone revascularization...
...have undergone revascularization...
...tion in Patients After Revascularizat...
...ients who use tobacco and have undergon...
...ents who use tobacco and have undergo...
...al Interventions in Patients After Revascularizat...
...s who have undergone coronary revasc...
...ents who have undergone coronary revasculariza...
...Traditional and Psychosocial Risk Factors for A...
Revascularization Outcomes
...scularization Outcomes...
...f Outcomes in Patients After Revascu...
...ith the goal of improving patient outcomes...
...al of improving patient outcomes,...
...volume cardiac surgery and PCI programs may c...