ACC/AHA/SCAI Coronary Revascularization Guideline: Key Perspectives

Lawton JS, Tamis-Holland JE, Bangalore S, et al.
2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021;Dec 9:[Epub ahead of print].

The following are key perspectives from the 2021 American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions (ACC/AHA/SCAI) Guideline for Coronary Artery Revascularization:

  1. Overall, treatment decisions regarding coronary revascularization in patients with coronary artery disease (CAD) 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.
  2. A multidisciplinary Heart Team approach is recommended in patients being considered for coronary revascularization for whom the optimal treatment strategy is unclear. Treatment decisions should be patient centered, incorporate patient preferences and goals, and include shared decision making.
  3. 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 CAD and left main disease that is equally suitable for surgical or percutaneous revascularization.
  4. Evidence from contemporary trials supplements older evidence with regard to mortality benefit of revascularization in patients with stable ischemic heart disease, normal left ventricular ejection fraction, and triple-vessel CAD. Surgical revascularization may be reasonable to improve survival in these patients as a survival benefit with percutaneous revascularization is uncertain. Revascularization decisions should be based on consideration of disease complexity, technical feasibility of treatment, and a multidisciplinary Heart Team discussion.
  5. The use of a radial artery as a surgical revascularization conduit is preferred versus 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.
  6. In patients undergoing percutaneous coronary intervention (PCI) who have acute coronary syndromes or stable ischemic heart disease, radial artery access is recommended ito 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.
  7. A short duration of dual antiplatelet therapy after percutaneous revascularization in patients with stable ischemic heart disease (SIHD) 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 1-3 months of dual antiplatelet therapy.
  8. Staged percutaneous intervention (while in hospital or after discharge) of a significantly stenosed nonculprit artery in patients presenting with an ST-segment elevation myocardial infarction is recommended in select patients to improve outcomes. Percutaneous intervention of the nonculprit artery at the time of primary PCI is less clear and may be considered in stable patients with uncomplicated revascularization of the culprit artery, low-complexity nonculprit artery disease, and normal renal function. In contrast, PCI of the nonculprit artery can be harmful in patients in cardiogenic shock.
  9. Revascularization decisions in patients with diabetes and multivessel CAD are optimized by the use of a Heart Team approach. Patients with diabetes who have triple-vessel disease should undergo surgical revascularization; PCI may be considered only if they are poor candidates for surgery.
  10. The calculation of a patient’s surgical risk with the Society of Thoracic Surgeons score is indicated for making treatment decisions for patients undergoing surgical revascularization of CAD. The usefulness of the SYNTAX (Synergy Between PCI With TAXUS and Cardiac Surgery) score calculation in treatment decisions is less clear because of the interobserver variability in its calculation and its absence of clinical variables.

Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Cardiac Surgery, Cardiovascular Care Team, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Stable Ischemic Heart Disease, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Anticoagulation Management and ACS, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and SIHD, Interventions and ACS, Interventions and Coronary Artery Disease, Interventions and Imaging, Interventions and Vascular Medicine, Angiography, Nuclear Imaging, Chronic Angina

Keywords: Acute Coronary Syndrome, Angina, Stable, Angina, Unstable, Anticoagulants, Atherosclerosis, Cardiac Rehabilitation, Cardiac Surgical Procedures, Cardiomyopathies, Coronary Angiography, Coronary Artery Bypass, Coronary Artery Disease, Decision Making, Diabetes Mellitus, Health Equity, Hemodynamics, Myocardial Ischemia, Myocardial Revascularization, Outcome Assessment, Health Care, Patient Care Team, Percutaneous Coronary Intervention, Platelet Aggregation Inhibitors, Primary Prevention, Quality of Health Care, Risk Assessment, Secondary Prevention, ST Elevation Myocardial Infarction

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