Coronary Artery Revascularization

Last updated May 9, 2022

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

Improving...

...Imp...

...ts who require coronary revasculari...

...ure 1. Shared Decision-Making...

...In patients undergoing revascularizati...

...undergoing coronary angiography or revas...

...The numbering of the following tables and...

...eal Components of the Shared Decision...


Preprocedural Assessment and the Heart Team

Preprocedur...

...he Heart Team In patients for whom the...


...igure 2. Phases of Patient-Centric Care in...


.... Factors for Consideration by the Heart...


...ent Risk of Death With CABG In patients who...


...e 3. Assessment of Risk Factors Not Qua...


Evaluation

...Evaluation...

...Defining Lesio...

...Coronary Artery Lesion Complexity: Calc...

...aphic Features Contributing to Increas...

...Use of...

...In patients with angina or an anginal eq...

...tients with angiographically intermediate sten...

Intravascular Ultrasound to Assess Lesion...


Treatment

...Tre...

...Revasc...

...Revasculari...

...n patients with STEMI and ischemic symptoms...

...nts with STEMI and cardiogenic shock...

...with STEMI who have mechanical complications (...

...nts with STEMI and evidence of fail...

In patients with STEMI who are treated...

...with STEMI who are stable and presenting 12 to 24...

...patients with STEMI in whom PCI is n...

...In patients with STEMI complicated by o...

...symptomatic stable patients with ST...

...patients with STEMI, emergency CABG should NOT b...

...gure 3. Indications for Revascularizat...

...Revascularization of the...

...In selected hemodynamically stabl...

...lected patients with STEMI with comple...

...lected hemodynamically stable patients w...

...In patients with STEMI complicated by...

...ient Clinical Status Definitions to Guide Revascu...

...4. Revascularization of Non–Infarct-Related Co...


...Revasculariz...

...Coronary Angiography and...

...In patients with NSTE-ACS who are a...

...n patients with NSTE-ACS and cardiogenic sh...

...ppropriate patients with NSTE-ACS who...

...atients with NSTE-ACS who are initi...

...tients with NSTE-ACS who are initially...

In patients with NSTE-ACS who have failed...

...In patients with NSTE-ACS who present i...

.... Timing of Invasive Strategy in Patien...


...Revascula...

...Revasculariz...

...Left ventricu...

...patients with SIHD and multivessel CA...

...ected patients with SIHD and multive...

...Left ma...

...patients with SIHD and significant left ma...

...In selected patients with SIHD and significant...

...ients with SIHD, normal ejection f...

...In patients with SIHD, normal ejection fraction,...

...Stenosis in the p...

...ents with SIHD, normal left ventricular ejectio...

...Single- or...

...with SIHD, normal left ventricular ejection...

...ith SIHD who have ≥1 coronary art...

Figure 6. Revascularization in Patients W...

...Revascularization t...

...essel CAD In patients with SIHD a...

...Revasc...

...with refractory angina despite medical th...

...patients with angina but no anatomi...


...Situat...

...Pati...

...In patients who require revascularization for s...

...s who require revascularization for multivessel...

...Patients With Diabete...

...with diabetes and multivessel CAD with the invol...

...ith diabetes who have multivessel CAD amenable to...

...tients with diabetes who have left main stenosis...

...Patients With...

...s with previous CABG with a patent LIMA to th...

...ients with previous CABG and refractor...

...In patients with previous CABG and...

...rence In patients with multivessel...

Special Po...

...Revascularizat...

In pregnant patients with STEMI...

In pregnant patients with NSTE-ACS, an...

Revascula...

...older adults, as in all patients, the treat...

...Revasculari...

...In patients with CKD undergoing contrast med...

...atients with STEMI and CKD, coronary an...

In high-risk patients with NSTE-ACS and CKD...

...-risk patients with NSTE-ACS and CKD, it is...

...atic patients with stable CAD and CK...

...6. Best Practices in the Catheterizatio...

...larization in Patients Before Noncardiac S...

...Revascularizatio...

...In patients with ventricular fibrillation,...

...ith CAD and suspected scar-mediated sustained...

...tients with SCAD who have hemodynamic instability...

...cularization for SCAD should NOT be performed...

...rization in Patients With Cardiac Allograft...


...General Pr...

...Radial...

...patients with ACS undergoing PCI, a rad...

...ients with SIHD undergoing PCI, the radial ap...

...nt Type In patients undergoing PC...

...Use of I...

...patients undergoing coronary stent implantation, I...

...ndergoing coronary stent implantatio...

...patients with stent failure, IVUS or OCT...

...rombectomy In patients with STEMI, routine...

...Treatment of Calcified Les...

...patients with fibrotic or heavily calcified lesi...

...tients with fibrotic or heavily calci...

...Treatment o...

...ct patients with previous CABG undergoing P...

...s with previous CABG, if PCI of a di...

...s with a chronic occlusion of a SVG, pe...

...ent of CTO In patients with suitable ana...

...Treatment of Patient...

...atients who develop clinical ISR for w...

...n patients with symptomatic recurrent...

...ients who develop recurrent ISR, brachyt...

...ic Support for Complex PCI In selected high-...

...Pharmacotherapy...

...Aspir...

...In patients undergoing PCI, a loading dose...

...atients with ACS undergoing PCI, a loading...

...In patients with SIHD undergoing P...

...atients undergoing PCI within 24 hours afte...

...atients with ACS undergoing PCI, it is reasonable...

In patie...

...In patients undergoing PCI who have a history o...

...ications to ticagrelor: previous i...

Table for Aspirin and Oral P2Y12...

...Intraveno...

...undergoing PCI who are P2Y12 inhibitor naïve...

...atients with ACS undergoing PCI with lar...

...with SIHD undergoing PCI, the routine use of...

Heparin,...

...patients undergoing PCI, administration of i...

...patients with heparin-induced thrombocytopenia...

...undergoing PCI, bivalirudin may b...

...n patients treated with upstream su...

...nts on therapeutic subcutaneous enoxapa...

...icoagulant Dosing During PCI* Drug...


...General Procedur...

...Perioperative Consid...

...For patients undergoing CABG, es...

...rioperative Anesthetic and Monitoring Consider...

...Bypass Co...

...undergoing isolated CABG, the use of a radi...

...ts undergoing CABG, an IMA, preferably the...

...undergoing CABG, BIMA grafting by experi...

...Best Practices for the Use of Bypass Co...

...CABG in Patients Undergoin...

...ents undergoing valve surgery, aortic sur...

...In patients undergoing valve surgery, a...

...Use...

...undergoing CABG, the routine use of epiaortic ult...

...Use of Cardiopul...

...nts with significant calcification of the aorta,...

...patients with significant pulmonary disease, off-p...

...Pharmacotherapy in Patie...

...Insulin Infusion a...

...ients undergoing CABG, an intraoperative contin...

...atients undergoing CABG, the use of continuous in...

...ndergoing CABG, a comprehensive approach to red...

...ndergoing CABG, the usefulness of...

.... Best Practices to Reduce Sternal Wound Infe...

...Antiplatele...

...ents undergoing CABG who are alread...

...patients referred for urgent CABG, clopido...

...tients undergoing CABG, discontinuation o...

...ndergoing elective CABG who receive P2Y12 re...

...ents undergoing elective CABG who are not alread...

...Beta Blocke...

...ts undergoing CABG, who do not have a...

...patients undergoing CABG, preoperative a...

...undergoing CABG, who do not have a contraindicat...

...ts undergoing CABG, the role of preoperati...


...Pharmacothe...

...Dual Antiplatelet...

...cted patients undergoing PCI, shor...

...se of DAPT for Patients After PCI...

...Antiplatelet The...

...ts undergoing CABG, aspirin (100–325 m...

...In selected patients undergoing CABG, D...

...Beta Blockers...

...n patients with SIHD and normal left ventr...

...Beta Blockers for t...

...ents after CABG, beta blockers are...

...Antiplatelet Thera...

...nts with atrial fibrillation who are undergoing PC...

...patients with atrial fibrillation who a...


...Addressing Psychos...

...Cardiac Reh...

In patients who have undergone revas...

...who have undergone revascularizatio...

...Smoking Cessation in Pat...

...who use tobacco and have undergone coronary r...

...who use tobacco and have undergone coron...

...ents who have undergone coronary revascularizati...

...patients who have undergone coronary revascul...

...aditional and Psychosocial Risk Factors for A...


Revascularization Outcomes

...Revasculari...

...Assessment of Ou...

...e goal of improving patient outcomes, it...

...of improving patient outcomes, it is reas...

...maller volume cardiac surgery and PCI pro...