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...
...Improving Equity o...
...Improving Equit...
In patients who require coronary rev...
...1. Shared Decision-Mak...
...Shared Decision-Making...
...nts undergoing revascularization, decision...
...undergoing coronary angiography or revasculariz...
...: The numbering of the following tables and figu...
...deal Components of the Shared Decis...
Preprocedural Assessment and the Heart Team
...Preprocedural...
...In patients for whom the optimal treatment...
...ases of Patient-Centric Care in the Treatment...
...rs for Consideration by the Heart Team...
...redicting Patient Risk of Death With CABG In p...
...essment of Risk Factors Not Quantif...
Evaluation
...Defining Lesio...
...ry Artery Lesion Complexity: Calcu...
...ographic Features Contributing to Increasing Compl...
...Use of Cor...
...ts with angina or an anginal equivalent, undoc...
...atients with angiographically intermediate stenose...
...Ultrasound to Assess Lesion Severity In p...
Treatment
...Revascularization in...
...Revascularization of the...
...ts with STEMI and ischemic symptoms for...
...ith STEMI and cardiogenic shock or hemody...
...ents with STEMI who have mechanical complications...
...s with STEMI and evidence of failed reperfu...
...In patients with STEMI who are treated with fibri...
...patients with STEMI who are stable and p...
...with STEMI in whom PCI is not feasible or s...
...with STEMI complicated by ongoing ischemi...
...atic stable patients with STEMI who have a totall...
...tients with STEMI, emergency CABG should NOT b...
...dications for Revascularization in...
...Revascula...
...ected hemodynamically stable patients with STEMI a...
...selected patients with STEMI with complex mul...
...n selected hemodynamically stable patients wit...
...s with STEMI complicated by cardiogenic shock, ro...
...nt Clinical Status Definitions to...
...Revascularization of Non–Infarct-Related Coro...
Re...
...Coronary Angiography...
...tients with NSTE-ACS who are at ele...
...ients with NSTE-ACS and cardiogenic shock wh...
...n appropriate patients with NSTE-ACS who have refr...
...n patients with NSTE-ACS who are initially s...
...n patients with NSTE-ACS who are ini...
...ents with NSTE-ACS who have failed PCI and have o...
...In patients with NSTE-ACS who pr...
...Timing of Invasive Strategy in Pat...
...Revasculariza...
...Revascularization to Impr...
...Left ventricular...
In patients with SIHD and multivessel C...
...patients with SIHD and multivessel CA...
...Left main CAD...
...In patients with SIHD and significant le...
...lected patients with SIHD and signific...
...Multivessel...
...ts with SIHD, normal ejection fraction, sign...
...tients with SIHD, normal ejection frac...
...Stenosis in the pr...
...ts with SIHD, normal left ventricula...
...Single- o...
In patients with SIHD, normal left ventric...
...ents with SIHD who have ≥1 coronary art...
...ularization in Patients With SIHD...
...Re...
...ltivessel CAD In patients with SIHD and m...
...Revasc...
...s with refractory angina despite medical th...
...nts with angina but no anatomic or phys...
...Situations in Which PCI...
...Patients With Complex Dis...
...patients who require revascularization for...
...atients who require revascularizati...
...Patients Wi...
In patients with diabetes and multivessel CAD...
...ents with diabetes who have multivess...
...atients with diabetes who have left...
Patien...
...patients with previous CABG with a patent LI...
...nts with previous CABG and refract...
...with previous CABG and complex CA...
...Adherence In patients with multivessel CA...
Speci...
...Revasc...
...egnant patients with STEMI not caus...
...ant patients with NSTE-ACS, an invasive stra...
...Revascularization in Ol...
In older adults, as in all patient...
...Revasculariza...
...atients with CKD undergoing contrast m...
...ith STEMI and CKD, coronary angiography an...
...In high-risk patients with NSTE-ACS and...
...In low-risk patients with NSTE-ACS a...
...omatic patients with stable CAD and CKD, rou...
...t Practices in the Catheterization Labo...
...evascularization in Patients Before Noncardia...
...Revascularization i...
...nts with ventricular fibrillation, polym...
In patients with CAD and suspected sca...
...Revascularization in Pat...
...ts with SCAD who have hemodynamic...
...ine revascularization for SCAD should NOT be p...
...ation in Patients With Cardiac Allografts In p...
...General Procedural...
...Radial and Femoral Ap...
...ients with ACS undergoing PCI, a radi...
...ts with SIHD undergoing PCI, the radial appr...
Choice of Stent Type In patients undergoing PCI,...
...Use of Intrava...
...s undergoing coronary stent implantation, IVUS c...
...undergoing coronary stent implantation, OCT...
...with stent failure, IVUS or OCT is rea...
...omy In patients with STEMI, routi...
...Treatment...
...s with fibrotic or heavily calcified lesions,...
...ients with fibrotic or heavily calcified...
...Treatment of Saph...
...lect patients with previous CABG un...
...ts with previous CABG, if PCI of a diseased n...
...s with a chronic occlusion of a SVG, percutaneo...
...f CTO In patients with suitable anatomy who have...
...Treatment...
...atients who develop clinical ISR for whom...
...In patients with symptomatic recurrent d...
...patients who develop recurrent ISR,...
...ic Support for Complex PCI In selected hig...
...Pharmacothera...
...Aspirin and Oral...
...patients undergoing PCI, a loading dose of as...
...with ACS undergoing PCI, a loading dose of P2Y12...
...ients with SIHD undergoing PCI, a loa...
...tients undergoing PCI within 24 hours...
...ents with ACS undergoing PCI, it is...
...In patients...
...n patients undergoing PCI who have a hi...
...traindications to ticagrelor: prev...
...ble for Aspirin and Oral P2Y12 Inhibitors...
...In patients undergoing PCI who are P2Y12 i...
...Intrav...
...patients with ACS undergoing PCI with larg...
...patients with SIHD undergoing PCI, th...
...H...
...nts undergoing PCI, administration of intravenous...
...with heparin-induced thrombocytopen...
In patients undergoing PCI, bivalirudin m...
...nts treated with upstream subcutaneous enox...
...nts on therapeutic subcutaneous enoxaparin, in who...
...gulant Dosing During PCI* Drug Pa...
...General Procedural Issue...
...Perioperat...
...or patients undergoing CABG, establishment of...
...able 9. Perioperative Anesthetic an...
...Bypass Conduits in Patient...
...patients undergoing isolated CABG, the use o...
...In patients undergoing CABG, an IMA, pre...
...undergoing CABG, BIMA grafting by experienced...
...st Practices for the Use of Bypass Conduits in C...
...CABG in Patient...
In patients undergoing valve surgery, aort...
...s undergoing valve surgery, aortic surgery...
...Use of...
...In patients undergoing CABG, the routine use of...
...Use of Ca...
...ts with significant calcification of...
...tients with significant pulmonary disease, off-pum...
...Pharmacot...
...Insulin Infusion and...
...In patients undergoing CABG, an intraopera...
...In patients undergoing CABG, the use of...
...In patients undergoing CABG, a comprehensive ap...
...undergoing CABG, the usefulness of...
...t Practices to Reduce Sternal Wound...
...Antiplatelet Therapy in P...
...In patients undergoing CABG who a...
...ents referred for urgent CABG, clopidogrel an...
...In patients undergoing CABG, discontinua...
...ients undergoing elective CABG who receive...
...In patients undergoing elective CABG wh...
...Beta Block...
...In patients undergoing CABG, who d...
...s undergoing CABG, preoperative amiodarone is rea...
...In patients undergoing CABG, who do...
...tients undergoing CABG, the role of preoperative...
...Pharmacotherapy i...
...Dual Antiplate...
...In selected patients undergoing PCI...
...e 7. Use of DAPT for Patients A...
...Antiplatelet...
...ents undergoing CABG, aspirin (100–325...
...ed patients undergoing CABG, DAPT with asp...
...Beta Blockers in...
...atients with SIHD and normal left ventri...
...patients after CABG, beta blockers are reco...
...Antiplat...
In patients with atrial fibrillation...
...with atrial fibrillation who are undergoing...
...Addre...
...Cardiac Reha...
...ho have undergone revascularizatio...
...nts who have undergone revascularization...
...Smoking Cess...
...tients who use tobacco and have undergone...
...n patients who use tobacco and have...
...Psychological I...
...In patients who have undergone coron...
...In patients who have undergone corona...
...itional and Psychosocial Risk Factors for ASCV...
Revascularization Outcomes
Asse...
...With the goal of improving patient outcomes...
With the goal of improving patient o...
...Smaller volume cardiac surgery and PCI program...