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

...verview

...proving Equity of Care in Revascularizati...

...ving Equity of Care in Revascul...

...n patients who require coronary revasculari...

...1. Shared Decision-Making...

...red Decision-Making and Informe...

In patients undergoing revascularizatio...

...ients undergoing coronary angiography or reva...

...ing of the following tables and figures...

...al Components of the Shared Decision-...


Preprocedural Assessment and the Heart Team

...eprocedural Assessment and the Heart T...

...m In patients for whom the optimal treatme...


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


...Factors for Consideration by the Hear...


...ing Patient Risk of Death With CABG In...


Table 3. Assessment of Risk Factors...


Evaluation

...aluation...

...g Lesion Severity...

Defining Coronary Artery Lesion Complexity: Calc...

...e 4. Angiographic Features Contrib...

...Physiology to Guide Revascularizat...

...ients with angina or an anginal equivalent, und...

...In stable patients with angiographically inte...

...ltrasound to Assess Lesion Severity I...


Treatment

...eatment...

Revascularization in...

...vascularization of the Infarct Artery...

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

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

...ts with STEMI who have mechanical co...

...ts with STEMI and evidence of failed reperfusion a...

In patients with STEMI who are treated...

...patients with STEMI who are stable a...

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

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

...symptomatic stable patients with STEMI who have a...

In patients with STEMI, emergency CABG s...

...ure 3. Indications for Revascularization in STEMI...

...vascularization of the Non-Infarct A...

...ed hemodynamically stable patients with STEM...

...ected patients with STEMI with complex...

...elected hemodynamically stable patients...

...ts with STEMI complicated by cardiogenic...

...Clinical Status Definitions to Gu...

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


...larization in NSTE-ACS...

...oronary Angiography and Revascularization i...

...patients with NSTE-ACS who are at elev...

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

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

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

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

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

...atients with NSTE-ACS who present in car...

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


...vascularization in SIHD...

...ation to Improve Survival in SIHD Compared With M...

...ntricular dysfunction and multivessel CAD...

...ients with SIHD and multivessel CAD appropr...

...elected patients with SIHD and multivess...

Left main...

...In patients with SIHD and signifi...

...n selected patients with SIHD and significan...

...ultivessel CAD...

...ith SIHD, normal ejection fraction, signifi...

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

...nosis in the proximal LAD artery...

...patients with SIHD, normal left ventri...

...r double-vessel disease not involving t...

...ts with SIHD, normal left ventricular...

...tients with SIHD who have ≥1 coronary arteri...

...ularization in Patients With SIHD...

...ation to Reduce Cardiovascular Events in SIHD...

...vessel CAD In patients with SIHD and multives...

...ization to Improve Symptoms...

...patients with refractory angina despite medical th...

...s with angina but no anatomic or physiological...


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

...With Complex Disease...

...tients who require revascularization...

...atients who require revascularizat...

Patients With D...

...tients with diabetes and multivessel CAD with...

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

...ents with diabetes who have left main...

...nts With Previous CABG...

...In patients with previous CABG with a...

...nts with previous CABG and refractory an...

...In patients with previous CABG and comple...

DAPT Adherence In patients with multivessel CAD...

...ecial Populations and Situatio...

...ation in Pregnant Patients...

In pregnant patients with STEMI not caused by S...

...atients with NSTE-ACS, an invasive strategy is...

...ization in Older Patients

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

...ularization in Patients With CKD...

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

...ith STEMI and CKD, coronary angiograp...

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

...atients with NSTE-ACS and CKD, it is reasonable to...

...tic patients with stable CAD and CKD...

Table 6. Best Practices in the Catheterization Lab...

...evascularization in Patients Before Noncard...

...zation in Patients to Reduce Ventricular...

In patients with ventricular fibrillati...

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

...ularization in Patients With SCAD...

...In patients with SCAD who have hemodynamic insta...

...e revascularization for SCAD should NOT...

...arization in Patients With Cardiac Allografts...


...eral Procedural Issues for PCI...

...nd Femoral Approaches for PCI...

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

...n patients with SIHD undergoing PCI, the radia...

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

...travascular Imaging...

...s undergoing coronary stent implantation,...

...In patients undergoing coronary stent...

...In patients with stent failure, IVUS or OC...

Thrombectomy In patients with STEMI, routine a...

...reatment of Calcifie...

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

In patients with fibrotic or heavily calcified...

...Saphenous Vein Graft Disease (Previ...

...ients with previous CABG undergoing PCI of a S...

...atients with previous CABG, if PCI of...

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

...tment of CTO In patients with suitabl...

...Patients With Stent Restenosis...

...ts who develop clinical ISR for whom repeat PCI...

...n patients with symptomatic recurrent d...

...In patients who develop recurrent ISR, brachythera...

...amic Support for Complex PCI In selected high-ri...

...py in Patients Undergoing PCI...

...spirin and Oral P2Y12 Inhibitors in...

...ndergoing PCI, a loading dose of aspiri...

...s with ACS undergoing PCI, a loading dose of...

...with SIHD undergoing PCI, a loadin...

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

...ients with ACS undergoing PCI, it is reasonable...

...In patients...

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

...dications to ticagrelor: previous intracrani...

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

...P2Y12 Inhibitors in Patients Undergoing PCI...

...undergoing PCI who are P2Y12 inhibi...

...Glycoprotein IIb/IIIa Inhibitors in Patients...

...ients with ACS undergoing PCI with la...

...atients with SIHD undergoing PCI, the routine us...

...lecular-Weight Heparin, and Bivalir...

In patients undergoing PCI, admi...

...In patients with heparin-induced thr...

...patients undergoing PCI, bivalirudin may be a rea...

...ients treated with upstream subcutaneous eno...

...ts on therapeutic subcutaneous enoxapari...

...8. Anticoagulant Dosing During PCI*Having troub...


...l Procedural Issues for CABG...

...erative Considerations in Patients U...

...nts undergoing CABG, establishment of multi...

...erative Anesthetic and Monitoring Co...

...Conduits in Patients Undergoing...

...ients undergoing isolated CABG, the...

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

...undergoing CABG, BIMA grafting by experie...

...0. Best Practices for the Use of Bypass Con...

...in Patients Undergoing Other Cardiac Surgery...

...ts undergoing valve surgery, aortic s...

...ients undergoing valve surgery, aor...

...ic Ultrasound in Patients Undergoing CABG...

...atients undergoing CABG, the routine use of ep...

...f Cardiopulmonary Bypass in Patients Underg...

...atients with significant calcification...

...ents with significant pulmonary disease, off-...

...y in Patients Undergoing CABG...

Insulin Infusion and Other Measures to Reduce Ste...

...ndergoing CABG, an intraoperative continuous...

...tients undergoing CABG, the use of continuou...

...ents undergoing CABG, a comprehensive appr...

...ients undergoing CABG, the usefulness of con...

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

...telet Therapy in Patients Undergoing CABG...

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

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

In patients undergoing CABG, dis...

...In patients undergoing elective CABG...

...patients undergoing elective CABG who are...

...nd Amiodarone in Patients Undergoing CABG...

...s undergoing CABG, who do not have a contra...

...In patients undergoing CABG, preoperat...

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

...atients undergoing CABG, the role of p...


...acotherapy in Patients After Revasculariza...

...ual Antiplatelet Therapy in Patients...

...selected patients undergoing PCI, sho...

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

...t Therapy in Patients After CABG...

...nts undergoing CABG, aspirin (100–325 mg daily...

...n selected patients undergoing CABG,...

...rs in Patients After Revasculariza...

...ts with SIHD and normal left ventricular fun...

...ta Blockers for the Prevention of Atria...

In patients after CABG, beta blockers are...

...latelet Therapy in Patients With Atrial Fibri...

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

...with atrial fibrillation who are undergoing...


...g Psychosocial Factors and Lifestyle Chang...

...c Rehabilitation and Educatio...

...s who have undergone revascularization,...

Patients who have undergone revasculariza...

...ion in Patients After Revascularization...

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

...n patients who use tobacco and have un...

...nterventions in Patients After Revasculari...

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

...In patients who have undergone corona...

...8. Traditional and Psychosocial Risk Facto...


Revascularization Outcomes

...larization Outcomes...

...ment of Outcomes in Patients After Revascularizat...

...With the goal of improving patient outcomes,...

...goal of improving patient outcomes, it is reasona...

...volume cardiac surgery and PCI progr...