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

...erview...

...y of Care in Revascularization and Sha...

...ing Equity of Care in Revascularizatio...

...In patients who require coronary revasc...

...Shared Decision-Making...

...hared Decision-Making and Infor...

...ients undergoing revascularization, decisi...

...s undergoing coronary angiography...

...mbering of the following tables and figures diffe...

...1. Ideal Components of the Shared Decision...


Preprocedural Assessment and the Heart Team

...Assessment and the Heart Team...

...Team In patients for whom the optimal treatmen...


...2. Phases of Patient-Centric Care in the T...


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


...g Patient Risk of Death With CABG...


...ent of Risk Factors Not Quantified in the STS...


Evaluation

...luation...

...fining Lesion Seve...

...Coronary Artery Lesion Complexity: Calculatio...

...iographic Features Contributing to Incre...

...ary Physiology to Guide Revascular...

...patients with angina or an anginal equiva...

...ble patients with angiographically intermediate s...

...travascular Ultrasound to Assess Les...


Treatment

...atment

...scularization in STEMI...

...ization of the Infarct Artery in Patients With STE...

...s with STEMI and ischemic symptoms for...

...atients with STEMI and cardiogenic shock or...

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

...patients with STEMI and evidence of f...

...ients with STEMI who are treated with fibr...

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

...n patients with STEMI in whom PCI is not fea...

...with STEMI complicated by ongoing ischemi...

...In asymptomatic stable patients with STE...

...th STEMI, emergency CABG should NO...

...ure 3. Indications for Revascularization in S...

...ion of the Non-Infarct Artery in Pati...

...ted hemodynamically stable patients with...

...selected patients with STEMI with complex...

...d hemodynamically stable patients with STEMI and...

...with STEMI complicated by cardiogenic shock, ro...

...e 5. Patient Clinical Status Definitions...

...igure 4. Revascularization of Non–Infarc...


...cularization in NSTE...

Coronary Angiography and Revascularization...

...ts with NSTE-ACS who are at elevated r...

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

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

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

...patients with NSTE-ACS who are ini...

...ith NSTE-ACS who have failed PCI an...

...In patients with NSTE-ACS who present in c...

...ing of Invasive Strategy in Patient...


...arization in SIHD...

...arization to Improve Survival in SIHD Compa...

...cular dysfunction and multivessel CAD...

...nts with SIHD and multivessel CAD appropr...

...n selected patients with SIHD and mu...

...main CAD...

...ents with SIHD and significant left main s...

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

...ultivessel CA...

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

...atients with SIHD, normal ejection fraction, signi...

...s in the proximal LAD arter...

...ients with SIHD, normal left ventri...

...double-vessel disease not involving the proximal...

...n patients with SIHD, normal left ve...

...with SIHD who have ≥1 coronary ar...

...e 6. Revascularization in Patients With SIHD

...ascularization to Reduce Cardiovascula...

...ultivessel CAD In patients with SI...

...ascularization to Improve S...

...tients with refractory angina despite medi...

...In patients with angina but no anatomic or ph...


...uations in Which PCI or CABG Would Be...

Patients With Complex...

...ho require revascularization for significant...

...nts who require revascularization...

Patients With Diabe...

In patients with diabetes and multivess...

...patients with diabetes who have multivessel C...

...atients with diabetes who have left main st...

...With Previous CABG...

...tients with previous CABG with a patent LIMA...

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

...patients with previous CABG and compl...

...In patients with multivessel CAD amenable to trea...

...opulations and Situations...

...ularization in Pregnant Pati...

In pregnant patients with STEMI not...

...nt patients with NSTE-ACS, an invasive st...

...scularization in Older Pat...

...In older adults, as in all patients, the treatme...

...evascularization in Patients With CKD...

...ith CKD undergoing contrast media injection for...

...In patients with STEMI and CKD, coron...

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

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

...In asymptomatic patients with stab...

...est Practices in the Catheterization Laboratory f...

...ation in Patients Before Noncardiac Surge...

...ascularization in Patients to Reduce Ven...

...ith ventricular fibrillation, polymorph...

...In patients with CAD and suspected scar-m...

...larization in Patients With SCAD...

...atients with SCAD who have hemodynamic instabi...

...revascularization for SCAD should NOT...

...scularization in Patients With Cardiac Allog...


...Procedural Issues for PCI...

...Femoral Approaches for PC...

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

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

...Stent Type In patients undergoing PCI, DES sho...

...Intravascular Imaging...

...ndergoing coronary stent implantation,...

...s undergoing coronary stent implantation, OCT is...

...atients with stent failure, IVUS or OCT is...

...my In patients with STEMI, routine aspiration th...

Treatment of Calcified Lesio...

...ts with fibrotic or heavily calcified...

...s with fibrotic or heavily calcified lesions, pla...

...phenous Vein Graft Disease (Previous CABG...

...patients with previous CABG undergoing...

...tients with previous CABG, if PCI of a diseased...

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

...TO In patients with suitable anatomy...

...of Patients With Stent Restenosis...

...ho develop clinical ISR for whom repeat PCI is p...

...atients with symptomatic recurrent diffuse ISR...

...tients who develop recurrent ISR,...

...Support for Complex PCI In selected...

...rmacotherapy in Patients Undergoing P...

...rin and Oral P2Y12 Inhibitors in Patients Und...

...undergoing PCI, a loading dose of aspirin, fol...

...In patients with ACS undergoing PC...

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

...ts undergoing PCI within 24 hours after fibrinolyt...

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

...In patients...

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

...indications to ticagrelor: previous intra...

...ble for Aspirin and Oral P2Y12 In...

...enous P2Y12 Inhibitors in Patients Under...

...undergoing PCI who are P2Y12 inhi...

...coprotein IIb/IIIa Inhibitors in Patients Under...

...ients with ACS undergoing PCI with large...

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

...w-Molecular-Weight Heparin, and Biv...

...patients undergoing PCI, administrat...

...nts with heparin-induced thrombocytopenia...

...In patients undergoing PCI, bivalirudin...

...patients treated with upstream subcutaneous en...

...n patients on therapeutic subcutaneous enoxapa...

...oagulant Dosing During PCI*Having trouble view...


...Procedural Issues for CABG...

...erative Considerations in Patients Undergoing CA...

...tients undergoing CABG, establishment of mu...

...9. Perioperative Anesthetic and Monitoring Co...

...Conduits in Patients Undergoing CABG...

...nts undergoing isolated CABG, the use of...

...In patients undergoing CABG, an IMA, preferably...

...ients undergoing CABG, BIMA grafting by exp...

...ractices for the Use of Bypass Conduits in CAB...

...Patients Undergoing Other Cardiac Sur...

In patients undergoing valve surgery, aortic su...

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

...piaortic Ultrasound in Patients Underg...

...undergoing CABG, the routine use of epiao...

Use of Cardiopulmonary Bypass in P...

...ents with significant calcificatio...

...ts with significant pulmonary disease, off-pump...

...erapy in Patients Undergoing CABG...

...on and Other Measures to Reduce Sternal Wound In...

...undergoing CABG, an intraoperative continuous i...

...patients undergoing CABG, the use of co...

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

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

...Best Practices to Reduce Sternal Wound I...

...platelet Therapy in Patients Undergoing CABG...

...undergoing CABG who are already taking dai...

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

...patients undergoing CABG, discontinuation of sho...

...patients undergoing elective CABG who receive...

In patients undergoing elective CABG who a...

...d Amiodarone in Patients Undergoing CABG...

...ndergoing CABG, who do not have a contraindicatio...

In patients undergoing CABG, preope...

...tients undergoing CABG, who do not have a contrai...

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


...otherapy in Patients After Revascularizati...

...telet Therapy in Patients After...

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

...Use of DAPT for Patients After PC...

...iplatelet Therapy in Patients After C...

...In patients undergoing CABG, aspirin (100–32...

...cted patients undergoing CABG, DAPT with...

...Blockers in Patients After Revasculariz...

...ith SIHD and normal left ventricular func...

...for the Prevention of Atrial Fibrillation...

...after CABG, beta blockers are recommended and sh...

...telet Therapy in Patients With Atrial Fibril...

...nts with atrial fibrillation who a...

...ents with atrial fibrillation who are...


...Psychosocial Factors and Lifestyle Changes A...

...c Rehabilitation and Edu...

...ho have undergone revascularizatio...

...have undergone revascularization should...

...ng Cessation in Patients After Revas...

...patients who use tobacco and have under...

...ents who use tobacco and have undergone coro...

...Interventions in Patients After R...

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

...who have undergone coronary revasc...

...ional and Psychosocial Risk Factors for ASCV...


Revascularization Outcomes

...arization Outcomes...

...sment of Outcomes in Patients After Revascula...

...ith the goal of improving patient outcomes, i...

...ith the goal of improving patient...

...me cardiac surgery and PCI programs ma...