Coronary Artery Revascularization

Publication Date: December 9, 2021

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...

...Improving Equity...

...Improving Equit...

...patients who require coronary revascularizat...

...Shared Decision-Making...

...Shar...

...ndergoing revascularization, decisions...

...ts undergoing coronary angiography or r...

...e numbering of the following tables and fi...

...eal Components of the Shared Decision-Making...


Preprocedural Assessment and the Heart Team

...eam In patients for whom the optimal tre...


...es of Patient-Centric Care in the T...


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


...atient Risk of Death With CABG In p...


...sment of Risk Factors Not Quantifie...


Evaluation

...Evaluat...

...Defining Lesio...

...ing Coronary Artery Lesion Complexity: Calculat...

...able 4. Angiographic Features Contributing to I...

...with angina or an anginal equivalent, undocume...

...patients with angiographically intermedi...

...travascular Ultrasound to Assess Lesion Severity...


Treatment

...Treatmen...

...Revascularization in...

...Revascularization of t...

In patients with STEMI and ischemic symptoms f...

...ts with STEMI and cardiogenic shock or hemodynam...

...atients with STEMI who have mechanical complic...

...In patients with STEMI and evidence of failed rep...

...In patients with STEMI who are tre...

...In patients with STEMI who are stable and presen...

...atients with STEMI in whom PCI is not feasible or...

...In patients with STEMI complicated...

...tomatic stable patients with STEMI who have...

...patients with STEMI, emergency CABG s...

...dications for Revascularization in STEMI (Pa...

...Revascularizatio...

...ected hemodynamically stable patients with ST...

...atients with STEMI with complex multivess...

...In selected hemodynamically stable p...

In patients with STEMI complicated by...

Table 5. Patient Clinical Status Defin...

.... Revascularization of Non–Infarct-Related C...


...Revascul...

...Coronary Angiograph...

...s with NSTE-ACS who are at elevate...

...In patients with NSTE-ACS and cardiogenic...

...In appropriate patients with NSTE-ACS who...

...ith NSTE-ACS who are initially stabil...

...n patients with NSTE-ACS who are initially stabi...

...tients with NSTE-ACS who have failed...

...tients with NSTE-ACS who present in cardi...

...5. Timing of Invasive Strategy in Patients With N...


...Revascularizatio...

...Rev...

...Left ventric...

...In patients with SIHD and multivessel...

...selected patients with SIHD and multivessel...

...Left m...

In patients with SIHD and significant le...

...n selected patients with SIHD and signif...

...Multivessel CAD...

...ients with SIHD, normal ejection fraction, sign...

In patients with SIHD, normal ejection frac...

...Ste...

...ith SIHD, normal left ventricular ejecti...

...Single- or...

...ts with SIHD, normal left ventricu...

...ith SIHD who have ≥1 coronary arteries tha...

...6. Revascularization in Patients With SIH...

...Revascularizat...

Multivessel CAD In patients with SIH...

...Revascularization t...

...In patients with refractory angina despi...

...patients with angina but no anatom...


...Situations...

...Patients W...

...tients who require revascularization for signi...

...n patients who require revascularization for...

...Pat...

...ith diabetes and multivessel CAD with the...

...In patients with diabetes who have m...

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

...Patients With Previou...

...In patients with previous CABG wit...

...ents with previous CABG and refractory angina on G...

...s with previous CABG and complex CAD,...

...nce In patients with multivessel CAD amena...

...Special Populatio...

...Revascula...

...t patients with STEMI not caused by SCAD, it is re...

...nt patients with NSTE-ACS, an inva...

...Revasculariz...

...er adults, as in all patients, the treatment strat...

...ents with CKD undergoing contrast me...

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

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

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

...mptomatic patients with stable CAD and CKD, rout...

...Best Practices in the Catheterizatio...

Revascularization in Patients Before Nonc...

...Revascula...

...s with ventricular fibrillation, polymorphi...

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

...Reva...

...ents with SCAD who have hemodynamic instabil...

...cularization for SCAD should NOT be performe...

...on in Patients With Cardiac Allografts In pa...


...Gen...

...Radial a...

...n patients with ACS undergoing PCI, a r...

...patients with SIHD undergoing PCI, the radi...

...Type In patients undergoing PCI, DES should be...

...Use of Intravascular Ima...

...undergoing coronary stent implantation, IVUS can...

...atients undergoing coronary stent implanta...

...In patients with stent failure, IVU...

...tomy In patients with STEMI, routine as...

...Treatment...

...In patients with fibrotic or heavily cal...

...In patients with fibrotic or heavily calcifie...

...Treatment of Saphenous...

...lect patients with previous CABG undergoi...

...nts with previous CABG, if PCI of a...

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

...f CTO In patients with suitable anatom...

...Treatment of P...

...n patients who develop clinical ISR for whom repe...

...In patients with symptomatic recurrent diffuse...

...who develop recurrent ISR, brachytherapy may...

...upport for Complex PCI In selected hi...

...Pharmacotherapy in...

...Aspirin a...

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

...ts with ACS undergoing PCI, a loading dose o...

...with SIHD undergoing PCI, a loading dose...

...patients undergoing PCI within 24 hours...

...In patients with ACS undergoing PCI, it is rea...

...In patients...

...s undergoing PCI who have a history of str...

...aindications to ticagrelor: previous intrac...

...Aspirin and Oral P2Y12 Inhibitors in Patient...

...Int...

...n patients undergoing PCI who are P...

...Intra...

...with ACS undergoing PCI with large th...

...ents with SIHD undergoing PCI, the routine u...

...Heparin, Low-Mo...

...ients undergoing PCI, administration of intraven...

...ents with heparin-induced thrombocytopenia underg...

...In patients undergoing PCI, bivalir...

...In patients treated with upstream subcut...

...patients on therapeutic subcutaneous e...

...agulant Dosing During PCI* D...


...General Proc...

...Perioperative Con...

...atients undergoing CABG, establishment of mu...

...able 9. Perioperative Anesthetic and Mon...

...Bypass Conduits...

...In patients undergoing isolated CABG, the use o...

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

...patients undergoing CABG, BIMA grafting by exper...

...e 10. Best Practices for the Use of B...

...CABG in Pat...

...ndergoing valve surgery, aortic sur...

...tients undergoing valve surgery, aortic surger...

...Use of Epiaorti...

...ts undergoing CABG, the routine use o...

...Use of...

...ts with significant calcification of th...

In patients with significant pulm...

...Pharmac...

...Insulin...

...patients undergoing CABG, an intra...

...In patients undergoing CABG, the use...

...atients undergoing CABG, a comprehensive approa...

...n patients undergoing CABG, the usefulness of c...

...ble 11. Best Practices to Reduce Sternal Wound...

...Antiplatel...

...atients undergoing CABG who are already taking...

...In patients referred for urgent CABG, clopidogrel...

...ents undergoing CABG, discontinuation of shor...

...ients undergoing elective CABG who re...

...nts undergoing elective CABG who are not already...

...Be...

...n patients undergoing CABG, who do not have a...

...nts undergoing CABG, preoperative a...

...tients undergoing CABG, who do not hav...

...tients undergoing CABG, the role of preop...


...Pharmacothe...

...Dual Antiplatelet...

...ted patients undergoing PCI, shorter-dur...

...gure 7. Use of DAPT for Patients After P...

...Antiplatelet...

...ts undergoing CABG, aspirin (100–32...

...In selected patients undergoing CAB...

...Beta B...

...ients with SIHD and normal left ve...

...Bet...

...n patients after CABG, beta blockers are recomm...

...Antiplatelet Th...

...tients with atrial fibrillation who are...

...n patients with atrial fibrillation who are un...


...Addressing Psy...

...ents who have undergone revascularization, a comp...

...ho have undergone revascularization...

...Smoking...

...patients who use tobacco and have undergon...

...tients who use tobacco and have undergon...

...P...

...patients who have undergone coronary revascu...

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

...ure 8. Traditional and Psychosocial Risk Factors...


Revascularization Outcomes

...Revascularizati...

...Assessment of Outcome...

...With the goal of improving patient outc...

...h the goal of improving patient outcomes, it...

...e cardiac surgery and PCI programs ma...