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
Overview
...oving Equity of Care in Revascularizat...
...proving Equity of Care in Revasc...
...atients who require coronary revasculari...
...Shared Decision-Making...
...ion-Making and Informed Consent...
...In patients undergoing revascula...
...undergoing coronary angiography or revascularizat...
...ering of the following tables and figures...
...le 1. Ideal Components of the Shar...
Preprocedural Assessment and the Heart Team
...reprocedural Assessment and t...
...In patients for whom the optimal tre...
...re 2. Phases of Patient-Centric Care in th...
Table 2. Factors for Consideration b...
...icting Patient Risk of Death With CABG In patien...
...sment of Risk Factors Not Quantified in the S...
Evaluation
Evaluat...
...Lesion Severity...
...ning Coronary Artery Lesion Complex...
...le 4. Angiographic Features Contributing to Increa...
...of Coronary Physiology to Guide Revascul...
...In patients with angina or an angina...
...able patients with angiographically intermediate...
...cular Ultrasound to Assess Lesion Severi...
Treatment
...reatment
...vascularization in STEMI...
...arization of the Infarct Artery in Patients With...
...n patients with STEMI and ischemic symptoms for...
...nts with STEMI and cardiogenic shock or hemodyna...
...tients with STEMI who have mechanical compli...
...In patients with STEMI and evidence of failed re...
...with STEMI who are treated with fibrinolytic the...
...ith STEMI who are stable and presenting...
...In patients with STEMI in whom PCI...
...s with STEMI complicated by ongoing...
In asymptomatic stable patients with ST...
In patients with STEMI, emergency C...
...ications for Revascularization in S...
...larization of the Non-Infarct Artery in Patie...
...lected hemodynamically stable patie...
...patients with STEMI with complex mult...
...In selected hemodynamically stable patients wit...
...ith STEMI complicated by cardiogenic shock, ro...
...ent Clinical Status Definitions to Guide Rev...
...4. Revascularization of Non–Infarct-Related Cor...
...ascularization in NSTE-...
...raphy and Revascularization in Patients...
...ts with NSTE-ACS who are at elevat...
...patients with NSTE-ACS and cardiogenic shock who...
...appropriate patients with NSTE-ACS wh...
...patients with NSTE-ACS who are initially...
In patients with NSTE-ACS who are initially st...
...ents with NSTE-ACS who have failed...
...In patients with NSTE-ACS who present in cardioge...
...iming of Invasive Strategy in Patients With NSTE-...
...larization in SIHD...
...on to Improve Survival in SIHD Compared With...
...ft ventricular dysfunction and multivess...
...ith SIHD and multivessel CAD appropriate f...
...lected patients with SIHD and multiv...
...eft main CAD...
...In patients with SIHD and significant left mai...
...selected patients with SIHD and signif...
...ivessel CAD...
...n patients with SIHD, normal ejection fract...
...nts with SIHD, normal ejection frac...
...s in the proximal LAD arter...
...ents with SIHD, normal left ventricul...
Single- or double-vessel disease n...
...ents with SIHD, normal left ventricular...
...In patients with SIHD who have ≥1 coronary art...
...Revascularization in Patients With SIHD...
...ion to Reduce Cardiovascular Events in SIH...
...el CAD In patients with SIHD and multivessel...
...arization to Improve Symptoms...
...atients with refractory angina despite medical the...
...patients with angina but no anatomic or...
...ich PCI or CABG Would Be Preferred...
...atients With Complex...
...ho require revascularization for significant lef...
...In patients who require revascularization for mu...
...nts With Diabet...
...ts with diabetes and multivessel CAD with the inv...
...atients with diabetes who have multivessel CAD...
...n patients with diabetes who have lef...
...ients With Previous CABG...
...atients with previous CABG with a patent LIMA to t...
...In patients with previous CABG and refractor...
...patients with previous CABG and complex CAD, i...
DAPT Adherence In patients with multivess...
...l Populations and Situatio...
...arization in Pregnant Patients...
...patients with STEMI not caused by...
...t patients with NSTE-ACS, an invasive strategy...
...evascularization in Older...
...lder adults, as in all patients, the treatment str...
Revascularization in Patie...
...In patients with CKD undergoing co...
...s with STEMI and CKD, coronary angiography a...
...sk patients with NSTE-ACS and CKD,...
...In low-risk patients with NSTE-ACS...
...symptomatic patients with stable CAD and CKD,...
...e 6. Best Practices in the Catheterization Labor...
...ularization in Patients Before Noncardiac Surg...
Revascularization in Patients to Reduce Ventricul...
...n patients with ventricular fibrillation,...
...with CAD and suspected scar-mediated sus...
...ascularization in Patients With SCAD...
...ith SCAD who have hemodynamic instability or ongoi...
...utine revascularization for SCAD should...
...rization in Patients With Cardiac Allo...
...ral Procedural Issues for PC...
...dial and Femoral Approaches for PC...
...In patients with ACS undergoing PCI,...
...with SIHD undergoing PCI, the radial app...
Choice of Stent Type In patients...
...of Intravascular Im...
...tients undergoing coronary stent implanta...
...In patients undergoing coronary ste...
...with stent failure, IVUS or OCT is reasonable...
...ombectomy In patients with STEMI, routine aspir...
...of Calcified Lesions...
...with fibrotic or heavily calcified lesions, plaqu...
...n patients with fibrotic or heavily calcified...
...of Saphenous Vein Graft Disease (...
...lect patients with previous CABG unde...
...ith previous CABG, if PCI of a diseased...
...s with a chronic occlusion of a SVG, per...
...atment of CTO In patients with suita...
...t of Patients With Stent Restenosi...
...who develop clinical ISR for whom repeat PCI is...
...tients with symptomatic recurrent diffuse...
...atients who develop recurrent ISR, brachyther...
...amic Support for Complex PCI In selected...
...herapy in Patients Undergoing PCI...
...and Oral P2Y12 Inhibitors in Patients Undergoing P...
...In patients undergoing PCI, a load...
...ts with ACS undergoing PCI, a load...
...ents with SIHD undergoing PCI, a loading do...
In patients undergoing PCI within 24...
...ents with ACS undergoing PCI, it is reasona...
...patients...
...atients undergoing PCI who have a history...
...aindications to ticagrelor: previous intracrani...
...in and Oral P2Y12 Inhibitors in Patien...
...Y12 Inhibitors in Patients Undergoi...
...ts undergoing PCI who are P2Y12 inhibitor naÃ...
...venous Glycoprotein IIb/IIIa Inhibitors in P...
...ith ACS undergoing PCI with large thr...
...In patients with SIHD undergoing PC...
...olecular-Weight Heparin, and Bivalirudin in P...
...In patients undergoing PCI, administrat...
...ts with heparin-induced thrombocytopenia undergoi...
...patients undergoing PCI, bivalirudin...
...n patients treated with upstream subcutaneous enox...
...on therapeutic subcutaneous enoxapa...
.... Anticoagulant Dosing During PCI*Having tro...
...eneral Procedural Issues...
...Considerations in Patients Undergoing CABG...
...nts undergoing CABG, establishment of...
...rioperative Anesthetic and Monitorin...
...duits in Patients Undergoing CABG...
...In patients undergoing isolated CABG, t...
...undergoing CABG, an IMA, preferably the...
In patients undergoing CABG, BIMA grafting by...
...Practices for the Use of Bypass Conduits in CA...
...s Undergoing Other Cardiac Surgery...
...nts undergoing valve surgery, aortic surgery,...
...nts undergoing valve surgery, aortic surgery,...
...Epiaortic Ultrasound in Patients Undergoing CAB...
...ents undergoing CABG, the routine use of epiaor...
...se of Cardiopulmonary Bypass in Patients U...
...nts with significant calcification of...
...ith significant pulmonary disease, o...
...macotherapy in Patients Undergoing CABG...
...sulin Infusion and Other Measures to Reduce Sterna...
...patients undergoing CABG, an intraoperativ...
...In patients undergoing CABG, the use of...
...patients undergoing CABG, a comprehens...
...nts undergoing CABG, the usefulness of continuo...
...able 11. Best Practices to Reduce Sternal Wou...
...rapy in Patients Undergoing CABG...
...patients undergoing CABG who are alread...
...atients referred for urgent CABG,...
...patients undergoing CABG, discontinuation of shor...
...ndergoing elective CABG who receive P2...
...ts undergoing elective CABG who are not...
...and Amiodarone in Patients Undergoing CABG...
...n patients undergoing CABG, who do not have a cont...
...nts undergoing CABG, preoperative a...
...undergoing CABG, who do not have a contraindicat...
...In patients undergoing CABG, the ro...
...macotherapy in Patients After Revascular...
...platelet Therapy in Patients After PCI...
...n selected patients undergoing PCI,...
...of DAPT for Patients After PCI
...let Therapy in Patients After CABG...
...In patients undergoing CABG, aspirin (100–325...
...cted patients undergoing CABG, DAPT...
...s in Patients After Revascularization...
In patients with SIHD and normal left ventr...
...a Blockers for the Prevention of Atrial Fibr...
...ents after CABG, beta blockers are recommende...
...atelet Therapy in Patients With Atrial Fibril...
...s with atrial fibrillation who are und...
...s with atrial fibrillation who are undergoing PCI,...
...Psychosocial Factors and Lifestyle Changes A...
...iac Rehabilitation and Education...
...tients who have undergone revascularization,...
...who have undergone revascularizat...
...n in Patients After Revascularization...
...patients who use tobacco and have under...
...nts who use tobacco and have undergone coro...
Psychological Interventions in Pat...
...s who have undergone coronary revascularizat...
...ts who have undergone coronary revascul...
...re 8. Traditional and Psychosocial Risk Fact...
Revascularization Outcomes
Revascularization Outcom...
...ssment of Outcomes in Patients After Revasculari...
...ith the goal of improving patient outcomes, it...
...ith the goal of improving patient o...
...Smaller volume cardiac surgery and PCI pro...