Coronary Artery Revascularization

Last updated May 24, 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

...Overview...

...Improving Equity...

...Improving Equity of...

...tients who require coronary revascularization,...

...Shared Decision-Making...

...Shared Decision-...

...In patients undergoing revascularization, de...

...n patients undergoing coronary angiography...

...ering of the following tables and figures di...

...able 1. Ideal Components of the Shared Decisio...


Preprocedural Assessment and the Heart Team

...Pre...

...e Heart Team In patients for whom the o...


.... Phases of Patient-Centric Care in t...


Table 2. Factors for Consideration by the H...


...edicting Patient Risk of Death With CABG...


...able 3. Assessment of Risk Factors...


Evaluation

...Evaluation...

...Defining Lesion Severity...

Defining Coronary Artery Lesion Complexity: Ca...

...ble 4. Angiographic Features Contributing to I...

...Use of Co...

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

...n stable patients with angiographically interme...

...ular Ultrasound to Assess Lesion Severi...


Treatment

...Revascularization in STEMI...

...Revascularizat...

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

...In patients with STEMI and cardiogenic shock or h...

...nts with STEMI who have mechanical comp...

...with STEMI and evidence of failed reperfus...

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

...ents with STEMI who are stable and prese...

...nts with STEMI in whom PCI is not feasible...

...with STEMI complicated by ongoing ischemia, ac...

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

...ents with STEMI, emergency CABG should NOT...

...3. Indications for Revascularization in STEMI (Pat...

...Revas...

In selected hemodynamically stable patients...

...d patients with STEMI with complex multivessel non...

...In selected hemodynamically stable pa...

...atients with STEMI complicated by cardiogenic shoc...

Table 5. Patient Clinical Status Definitions to G...

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


...Revascu...

...Coronar...

...ith NSTE-ACS who are at elevated risk of...

...tients with NSTE-ACS and cardiogenic shock...

...ropriate patients with NSTE-ACS who have refractor...

...ts with NSTE-ACS who are initially stabiliz...

...atients with NSTE-ACS who are initially stabilize...

...with NSTE-ACS who have failed PCI and have o...

...n patients with NSTE-ACS who present in cardiogen...

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


...Revascula...

...Revascularization...

...Left ventricular dys...

...In patients with SIHD and multivesse...

...d patients with SIHD and multivess...

...Left main CAD...

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

...patients with SIHD and significant left main sten...

...Multivessel C...

...with SIHD, normal ejection fraction, signific...

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

...Stenosis in th...

...In patients with SIHD, normal left ventricular...

...Single- or doubl...

...atients with SIHD, normal left ventric...

...tients with SIHD who have ≥1 coro...

...cularization in Patients With SIHD

...Revascularization...

...ltivessel CAD In patients with SIHD and mul...

...Revascularization to I...

...ith refractory angina despite medical the...

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


Situat...

...Patie...

...who require revascularization for sig...

...who require revascularization for multivessel CAD...

...Pati...

...ents with diabetes and multivessel CAD with th...

...In patients with diabetes who have multiv...

...ents with diabetes who have left mai...

...Patients...

...s with previous CABG with a patent LIMA to the LA...

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

...patients with previous CABG and c...

...erence In patients with multivessel CAD amenab...

...Special Popul...

...Revascularization in Pre...

...nant patients with STEMI not caused by...

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

R...

...ults, as in all patients, the treatment s...

...Revascularization i...

...s with CKD undergoing contrast media...

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

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

...k patients with NSTE-ACS and CKD, it is reasonabl...

...In asymptomatic patients with stable CAD and C...

...actices in the Catheterization Labo...

...n in Patients Before Noncardiac Surgery In pat...

...Revascularization in...

...with ventricular fibrillation, polymorphic...

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

...Revasculariza...

...n patients with SCAD who have hemodynamic i...

...ine revascularization for SCAD should NO...

...ion in Patients With Cardiac Allogr...


...Gen...

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

...patients with SIHD undergoing PCI,...

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

...Use of Intravascul...

...In patients undergoing coronary stent implantation...

...In patients undergoing coronary stent...

...ith stent failure, IVUS or OCT is...

...omy In patients with STEMI, routine aspir...

...Treatment o...

In patients with fibrotic or heavi...

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

...Treatment of...

...elect patients with previous CABG undergoi...

...ith previous CABG, if PCI of a diseased...

...n patients with a chronic occlusion...

Treatment of CTO In patients with suitable a...

...Treatment of Pat...

...atients who develop clinical ISR for whom repe...

...patients with symptomatic recurrent diffuse ISR...

...ho develop recurrent ISR, brachytherap...

...dynamic Support for Complex PCI In selected high...

...Pharmacotherapy in Pat...

...Aspirin and Oral P2Y12...

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

...tients with ACS undergoing PCI, a loading d...

...n patients with SIHD undergoing PCI, a l...

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

...with ACS undergoing PCI, it is reasonable to use...

...n patients

...ients undergoing PCI who have a history of...

...ntraindications to ticagrelor: previous intracran...

...le for Aspirin and Oral P2Y12 Inh...

...Intravenous P2Y12 In...

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

...Intravenous Glycoprote...

...nts with ACS undergoing PCI with large thromb...

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

...Heparin, Low-Molecular-...

...In patients undergoing PCI, administration o...

...In patients with heparin-induced thrombocytope...

...In patients undergoing PCI, bivalirudin may be a r...

...reated with upstream subcutaneous enoxaparin for u...

...on therapeutic subcutaneous enoxaparin, in wh...

...ticoagulant Dosing During PCI* Dru...


...Gen...

...Perioperativ...

...patients undergoing CABG, establishment o...

...operative Anesthetic and Monitorin...

...Bypass Conduits in...

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

...ndergoing CABG, an IMA, preferably the lef...

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

...Practices for the Use of Bypass Conduits in CABG...

...CABG in Patients Under...

...ndergoing valve surgery, aortic surgery, or other...

...undergoing valve surgery, aortic surge...

...Use of Epiaortic Ult...

...patients undergoing CABG, the routine...

...Use of Cardio...

In patients with significant calcification...

...ients with significant pulmonary disease,...

...Pharm...

...Insulin Infusion and Other...

...In patients undergoing CABG, an intrao...

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

...nts undergoing CABG, a comprehensive approach to...

...ndergoing CABG, the usefulness of continuous intr...

...est Practices to Reduce Sternal Wound Infection i...

...Anti...

In patients undergoing CABG who a...

...ients referred for urgent CABG, cl...

...ndergoing CABG, discontinuation of short-act...

...n patients undergoing elective CABG who receiv...

In patients undergoing elective CABG w...

Beta B...

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

...In patients undergoing CABG, preoperative ami...

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

...n patients undergoing CABG, the ro...


...Pharmacotherapy...

...Dual Antiplate...

...In selected patients undergoing PCI, shorter-...

...Use of DAPT for Patients After PCI...

...tients undergoing CABG, aspirin (100–325...

...patients undergoing CABG, DAPT wit...

...Beta Blo...

...In patients with SIHD and normal left...

...Beta Blockers for...

...s after CABG, beta blockers are recommend...

...ients with atrial fibrillation who are u...

...In patients with atrial fibrillation who ar...


...Addressing Psychosoci...

...Cardiac...

...patients who have undergone revascular...

...atients who have undergone revascularizati...

...Smoking Cessa...

...ts who use tobacco and have undergone co...

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

...Psychological...

In patients who have undergone coron...

...In patients who have undergone coronary...

...tional and Psychosocial Risk Factors for AS...


Revascularization Outcomes

...Revascularization Outco...

...Assessmen...

...h the goal of improving patient outco...

With the goal of improving patient outcomes...

Smaller volume cardiac surgery a...