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

Improving Equity of Care in Revascularization...

...g Equity of Care in Revascularizatio...

...atients who require coronary revascularization, tr...

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

Shared Decision-Making and Info...

...patients undergoing revascularizatio...

...In patients undergoing coronary ang...

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

...e 1. Ideal Components of the Shared...


Preprocedural Assessment and the Heart Team

...edural Assessment and the Heart Tea...

...m In patients for whom the optim...


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


...for Consideration by the Heart TeamHaving t...


...atient Risk of Death With CABG I...


Table 3. Assessment of Risk Factors Not Qu...


Evaluation

...luation...

...ng Lesion Severit...

...efining Coronary Artery Lesion Complexity:...

...aphic Features Contributing to Increasing...

...y Physiology to Guide Revascularizatio...

...ents with angina or an anginal equivalen...

...stable patients with angiographical...

...r Ultrasound to Assess Lesion Severity...


Treatment

...reatment...

...evascularization in STE...

...cularization of the Infarct Artery in Patients W...

...In patients with STEMI and ischemic...

...tients with STEMI and cardiogenic shock or hem...

...patients with STEMI who have mechanical...

...patients with STEMI and evidence of failed repe...

...with STEMI who are treated with fibri...

...ients with STEMI who are stable and presenting...

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

In patients with STEMI complicated by ongoing...

...omatic stable patients with STEMI wh...

...STEMI, emergency CABG should NOT be performed aft...

...gure 3. Indications for Revascularization in STEM...

...scularization of the Non-Infarct Artery i...

...lected hemodynamically stable patients wi...

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

...In selected hemodynamically stable pati...

...nts with STEMI complicated by cardiogenic sho...

...ient Clinical Status Definitions to Guide Rev...

...re 4. Revascularization of Non–Inf...


...rization in NSTE-ACS

...Angiography and Revascularization in Patien...

...n patients with NSTE-ACS who are at elevated risk...

In patients with NSTE-ACS and cardiogen...

...te patients with NSTE-ACS who have refrac...

...with NSTE-ACS who are initially stabilized and are...

...tients with NSTE-ACS who are initially s...

...In patients with NSTE-ACS who have f...

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

...ure 5. Timing of Invasive Strategy in...


Revascularization in SIHD

...tion to Improve Survival in SIHD Co...

...tricular dysfunction and multivessel CAD...

...patients with SIHD and multivessel CAD approp...

...elected patients with SIHD and multivessel CAD ap...

Left main C...

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

...n selected patients with SIHD and signifi...

...ivessel CAD...

...patients with SIHD, normal ejection...

...n patients with SIHD, normal ejection...

...nosis in the proximal LAD arte...

...with SIHD, normal left ventricular ej...

...gle- or double-vessel disease not involv...

...s with SIHD, normal left ventricular ejecti...

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

...ascularization in Patients With SIHD...

...arization to Reduce Cardiovascular Events in SIHD...

...CAD In patients with SIHD and multivessel CAD ap...

...scularization to Improve Symptom...

...nts with refractory angina despite medi...

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


...ituations in Which PCI or CABG Would Be Preferr...

...atients With Complex...

...ho require revascularization for significan...

...s who require revascularization for...

...nts With Diabetes...

...with diabetes and multivessel CAD...

...In patients with diabetes who have multi...

...ents with diabetes who have left m...

...ts With Previous CABG...

...atients with previous CABG with a pate...

...In patients with previous CABG and refra...

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

DAPT Adherence In patients with multivessel C...

...ulations and Situations...

...ularization in Pregnant Patients...

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

...egnant patients with NSTE-ACS, an inv...

...rization in Older Patients...

...lts, as in all patients, the treatment st...

...scularization in Patients With...

...n patients with CKD undergoing contrast media...

...ts with STEMI and CKD, coronary an...

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

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

...tic patients with stable CAD and CKD, routine angi...

...Best Practices in the Catheterization Laboratory...

...ation in Patients Before Noncardiac Surg...

...ation in Patients to Reduce Ventricular Arr...

...patients with ventricular fibrilla...

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

Revascularization in Patients...

...tients with SCAD who have hemodynamic...

...cularization for SCAD should NOT be pe...

...on in Patients With Cardiac Allografts In pati...


...ral Procedural Issues...

...and Femoral Approaches for...

...with ACS undergoing PCI, a radial appro...

...tients with SIHD undergoing PCI, the radial appro...

...of Stent Type In patients undergoing P...

...ntravascular Imaging...

...patients undergoing coronary stent impl...

...In patients undergoing coronary stent implanta...

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

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

...tment of Calcified Lesion...

...In patients with fibrotic or heavily calcifi...

...nts with fibrotic or heavily calcified le...

...aphenous Vein Graft Disease (Previous CABG)...

...In select patients with previous CA...

In patients with previous CABG, if PCI of a...

...n patients with a chronic occlusion of a S...

...nt of CTO In patients with suitable ana...

...reatment of Patients With Stent Rest...

...In patients who develop clinical ISR for who...

...patients with symptomatic recurrent diffu...

...atients who develop recurrent ISR, br...

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

...herapy in Patients Undergoing PCI

...and Oral P2Y12 Inhibitors in Patients Unde...

...nts undergoing PCI, a loading dose...

...with ACS undergoing PCI, a loading dose of P2Y...

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

...In patients undergoing PCI within 24 hours after...

...In patients with ACS undergoing PCI, i...

...n patients

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

...ations to ticagrelor: previous intr...

...in and Oral P2Y12 Inhibitors in Pati...

...ntravenous P2Y12 Inhibitors in Patients Undergoing...

...atients undergoing PCI who are P2Y1...

...avenous Glycoprotein IIb/IIIa Inhibitors in Patie...

...ents with ACS undergoing PCI with larg...

In patients with SIHD undergoing PC...

...arin, Low-Molecular-Weight Heparin, and Bivali...

...ndergoing PCI, administration of intravenous UFH i...

...ents with heparin-induced thrombocytopenia...

...patients undergoing PCI, bivalirudi...

...ents treated with upstream subcutaneous enoxapa...

...patients on therapeutic subcutaneous enoxapa...

...8. Anticoagulant Dosing During PCI*Ha...


...cedural Issues for CABG...

...rioperative Considerations in Patients...

...atients undergoing CABG, establishment of mu...

...erioperative Anesthetic and Monitoring...

...ypass Conduits in Patients Under...

...n patients undergoing isolated CABG,...

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

...In patients undergoing CABG, BIMA graf...

...Best Practices for the Use of Bypass Conduits in C...

...ABG in Patients Undergoing Other Car...

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

...undergoing valve surgery, aortic surgery, or...

...c Ultrasound in Patients Undergoing CABG...

...In patients undergoing CABG, the routine use of...

...of Cardiopulmonary Bypass in Patients...

...n patients with significant calcification o...

In patients with significant pulmonary d...

...armacotherapy in Patients Under...

...n and Other Measures to Reduce Sternal...

...ients undergoing CABG, an intraoperative conti...

...ts undergoing CABG, the use of continuous...

...In patients undergoing CABG, a comprehensive appro...

...ts undergoing CABG, the usefulness o...

...able 11. Best Practices to Reduce Ste...

...iplatelet Therapy in Patients Undergo...

...In patients undergoing CABG who are already t...

...s referred for urgent CABG, clopidogr...

...patients undergoing CABG, discontinuation of short...

...undergoing elective CABG who receive P2Y...

...n patients undergoing elective CABG who are not al...

...eta Blockers and Amiodarone in Patient...

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

...ients undergoing CABG, preoperativ...

In patients undergoing CABG, who do...

...ents undergoing CABG, the role of preoperative b...


...acotherapy in Patients After Revascularization...

...Antiplatelet Therapy in Patients...

...lected patients undergoing PCI, shorter-duration...

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

...let Therapy in Patients After CAB...

...s undergoing CABG, aspirin (100–3...

...In selected patients undergoing CABG...

...ckers in Patients After Revascularization...

...ients with SIHD and normal left ventricular f...

...ockers for the Prevention of Atrial Fibrillat...

...In patients after CABG, beta blockers are recomm...

...erapy in Patients With Atrial Fibrillat...

...s with atrial fibrillation who are un...

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


...ychosocial Factors and Lifestyle Changes...

...abilitation and Education...

...who have undergone revascularization, a com...

...atients who have undergone revascul...

...Cessation in Patients After Revascularizat...

...tients who use tobacco and have und...

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

...ical Interventions in Patients After Re...

...patients who have undergone coronary revascul...

...n patients who have undergone coronary revascul...

...Traditional and Psychosocial Risk Factors...


Revascularization Outcomes

Revascularization Outcomes

...nt of Outcomes in Patients After Revascular...

...With the goal of improving patient o...

...th the goal of improving patient ou...

...Smaller volume cardiac surgery and PC...