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
Overvi...
...quity of Care in Revascularization and Shared Deci...
...ing Equity of Care in Revascula...
...s who require coronary revascularization, treatmen...
...Shared Decision-Making
...ecision-Making and Informed Consent...
...In patients undergoing revascularization,...
...n patients undergoing coronary angiography o...
...mbering of the following tables and figure...
...Ideal Components of the Shared Decisio...
Preprocedural Assessment and the Heart Team
...cedural Assessment and the He...
...Heart Team In patients for whom the optima...
.... Phases of Patient-Centric Care in th...
...able 2. Factors for Consideration by the Heart...
...g Patient Risk of Death With CABG In patient...
...ssment of Risk Factors Not Quantified in the S...
Evaluation
...luation...
...g Lesion Severity...
...oronary Artery Lesion Complexity: Cal...
...aphic Features Contributing to Inc...
...of Coronary Physiology to Guide Reva...
...atients with angina or an anginal equivalent,...
...ble patients with angiographically interme...
...trasound to Assess Lesion Severity In...
Treatment
...eatment
...scularization in STEMI...
...ion of the Infarct Artery in Patien...
...n patients with STEMI and ischemic symp...
...In patients with STEMI and cardiogenic sh...
...In patients with STEMI who have mechanical compli...
...ts with STEMI and evidence of fail...
...ith STEMI who are treated with fibrinolytic t...
...ents with STEMI who are stable and presentin...
...s with STEMI in whom PCI is not fe...
...tients with STEMI complicated by ongoing ischemia...
In asymptomatic stable patients with STEMI wh...
...ts with STEMI, emergency CABG should NOT be perf...
...ications for Revascularization in STEMI (...
...evascularization of the Non-Infarct Artery...
...ed hemodynamically stable patients with STEMI...
In selected patients with STEMI with complex m...
...lected hemodynamically stable patien...
In patients with STEMI complicated by ca...
...able 5. Patient Clinical Status Definit...
...Revascularization of Non–Infarct-Related C...
...arization in NSTE-ACS...
...ry Angiography and Revascularization in...
...with NSTE-ACS who are at elevated...
...ts with NSTE-ACS and cardiogenic shock...
...opriate patients with NSTE-ACS who have...
In patients with NSTE-ACS who are initially sta...
...In patients with NSTE-ACS who are initi...
...s with NSTE-ACS who have failed PCI a...
...patients with NSTE-ACS who present i...
...ure 5. Timing of Invasive Strategy i...
...ascularization in SIHD...
...evascularization to Improve Surviv...
...ventricular dysfunction and multivessel CAD...
...In patients with SIHD and multivessel CAD appr...
...patients with SIHD and multivessel CAD approp...
...main CAD...
...patients with SIHD and significant left ma...
...atients with SIHD and significant...
...ltivessel CA...
...n patients with SIHD, normal eject...
...ients with SIHD, normal ejection fractio...
...in the proximal LAD artery...
...In patients with SIHD, normal left ven...
...ingle- or double-vessel disease not involving the...
...patients with SIHD, normal left ventricular ej...
...atients with SIHD who have ≥1 cor...
...scularization in Patients With SIHD...
...evascularization to Reduce Cardiov...
...ltivessel CAD In patients with S...
...cularization to Improve Symptoms...
...ents with refractory angina despite medi...
...ith angina but no anatomic or physiolo...
...Which PCI or CABG Would Be Preferred...
...atients With Complex D...
...who require revascularization for si...
...who require revascularization for multives...
...ts With Diabetes...
...ents with diabetes and multivessel CAD...
...with diabetes who have multivesse...
...ents with diabetes who have left ma...
...ents With Previous CAB...
...patients with previous CABG with a patent...
...ith previous CABG and refractory angina...
...ients with previous CABG and complex CAD,...
...In patients with multivessel CAD amenable to...
...opulations and Situation...
...cularization in Pregnant Patients
...t patients with STEMI not caused by SCAD, it is re...
In pregnant patients with NSTE-ACS, an inva...
...scularization in Older Patients...
...ults, as in all patients, the treatment str...
...ularization in Patients With C...
...In patients with CKD undergoing...
...ith STEMI and CKD, coronary angiograp...
...sk patients with NSTE-ACS and CKD, it is reaso...
...isk patients with NSTE-ACS and CKD...
...ymptomatic patients with stable CAD and...
Table 6. Best Practices in the Catheterization...
...scularization in Patients Before Noncardiac Sur...
...ation in Patients to Reduce Ventric...
...In patients with ventricular fibrillation, pol...
...s with CAD and suspected scar-mediated sustai...
...rization in Patients With SCAD
...ents with SCAD who have hemodynamic inst...
...ascularization for SCAD should NOT...
...ularization in Patients With Cardiac Allograf...
...Procedural Issues for PCI
...Femoral Approaches for PC...
...nts with ACS undergoing PCI, a radial a...
...atients with SIHD undergoing PCI, the radial...
...t Type In patients undergoing PCI, DES should...
...se of Intravascular Ima...
...In patients undergoing coronary stent implantati...
...patients undergoing coronary stent implantation...
...with stent failure, IVUS or OCT is reas...
...In patients with STEMI, routine aspiration thr...
...atment of Calcified Lesions...
...tients with fibrotic or heavily ca...
...patients with fibrotic or heavily c...
...eatment of Saphenous Vein Graft Disease (P...
...atients with previous CABG undergoing PCI of...
...In patients with previous CABG, if PCI of a...
...In patients with a chronic occlusion o...
...ment of CTO In patients with suitable anatomy...
...atment of Patients With Stent Restenosis...
...patients who develop clinical ISR for whom...
...with symptomatic recurrent diffuse ISR wit...
...ho develop recurrent ISR, brachyther...
...ort for Complex PCI In selected high-risk patie...
...rapy in Patients Undergoing PCI...
...ral P2Y12 Inhibitors in Patients Undergo...
...ients undergoing PCI, a loading dose of...
...ents with ACS undergoing PCI, a loading dose of...
...patients with SIHD undergoing PCI,...
...ts undergoing PCI within 24 hours afte...
...In patients with ACS undergoing PCI, it is re...
...patients...
...patients undergoing PCI who have a histor...
...ontraindications to ticagrelor: previous i...
...spirin and Oral P2Y12 Inhibitors in Patients Und...
...venous P2Y12 Inhibitors in Patients U...
...ents undergoing PCI who are P2Y12 inhib...
...ous Glycoprotein IIb/IIIa Inhibitors in Patients...
...tients with ACS undergoing PCI with large...
...ith SIHD undergoing PCI, the routine use of an i...
...parin, Low-Molecular-Weight Heparin, and Biv...
In patients undergoing PCI, administra...
In patients with heparin-induced...
...patients undergoing PCI, bivalirudin may be a r...
...In patients treated with upstream subcutan...
...In patients on therapeutic subcutaneous enox...
...le 8. Anticoagulant Dosing During PCI*Having...
...neral Procedural Issues for CABG...
...perative Considerations in Patients Undergoing C...
...For patients undergoing CABG, establishment of m...
...e 9. Perioperative Anesthetic and Monitoring Con...
...Conduits in Patients Undergoing CABG...
...ients undergoing isolated CABG, th...
...patients undergoing CABG, an IMA, preferably th...
...n patients undergoing CABG, BIMA grafting b...
...able 10. Best Practices for the Use of Bypass C...
...Undergoing Other Cardiac Surgery...
...patients undergoing valve surgery, aortic su...
...atients undergoing valve surgery, a...
...tic Ultrasound in Patients Undergoing CABG...
...atients undergoing CABG, the routine use of epi...
...iopulmonary Bypass in Patients Undergoing CABG...
...tients with significant calcification of the aort...
...ts with significant pulmonary disease, o...
Pharmacotherapy in Patients Unde...
...ion and Other Measures to Reduce St...
...ts undergoing CABG, an intraoperative...
...atients undergoing CABG, the use of continuo...
In patients undergoing CABG, a compr...
...undergoing CABG, the usefulness of continu...
...Best Practices to Reduce Sternal Wo...
...herapy in Patients Undergoing CABG...
...patients undergoing CABG who are already t...
...ents referred for urgent CABG, clopid...
...n patients undergoing CABG, disconti...
...undergoing elective CABG who receive P2Y12...
...nts undergoing elective CABG who are not al...
...kers and Amiodarone in Patients Undergoing C...
...undergoing CABG, who do not have a contraindic...
...ndergoing CABG, preoperative amiodarone i...
...ts undergoing CABG, who do not have a contrain...
...tients undergoing CABG, the role of p...
...cotherapy in Patients After Revascularization...
...latelet Therapy in Patients After PCI...
...In selected patients undergoing PCI, sho...
...7. Use of DAPT for Patients After...
Antiplatelet Therapy in Patien...
...patients undergoing CABG, aspirin (100–325 mg d...
...In selected patients undergoing...
...kers in Patients After Revasculariza...
...ith SIHD and normal left ventricular function,...
...rs for the Prevention of Atrial Fibril...
...after CABG, beta blockers are recom...
...elet Therapy in Patients With Atrial Fibri...
...ith atrial fibrillation who are un...
...patients with atrial fibrillation who are und...
...Psychosocial Factors and Lifestyle Cha...
...Rehabilitation and Education...
...In patients who have undergone revascularizat...
...nts who have undergone revascularization...
...oking Cessation in Patients After Revascularizat...
...atients who use tobacco and have undergone...
...ents who use tobacco and have undergone...
...al Interventions in Patients After Revasculariz...
...tients who have undergone coronary revas...
...ients who have undergone coronary revasculari...
...igure 8. Traditional and Psychosoc...
Revascularization Outcomes
Revascularization Outcomes
...t of Outcomes in Patients After Re...
...With the goal of improving patient outcomes...
...ith the goal of improving patient ou...
...Smaller volume cardiac surgery and PCI pr...