Coronary Artery Revascularization Clinical Practice Guidelines (ACC/AHA/SCAI, 2022)

American College of Cardiology, American Heart Association, and Society for Cardiovascular Angiography and Interventions

These are some of the highlights of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

March 01, 2022

Guidelines on coronary artery revascularization were published in January 2022 by the American College of Cardiology (ACC), American Heart Association (AHA), and Society for Cardiovascular Angiography and Interventions (SCAI) in the Journal of the American College of Cardiology.[1,2]

Top 10 Take-Home Messages

Form coronary revascularization treatment decisions on the basis of clinical indications for individuals of all races, ethnicities, and genders who have coronary artery disease (CAD).

For individuals under consideration for coronary revascularization but whose optimal treatment strategy is unclear, the ACC/AHA/SCAI recommend a multidisciplinary heart team approach, as well as shared, patient-oriented decision making in treatment decisions.

Surgical revascularization is indicated for significant left main disease to improve survival relative to that likely to be achieved with medical therapy. Percutaneous revascularization is a reasonable option versus medical therapy for survival improvement in select patients with low to medium anatomic complexity of CAD and left main disease that is equally suitable for surgical or percutaneous revascularization.

Surgical revascularization may be reasonable to improve survival in those with stable ischemic heart disease (SIHD), normal left ventricular ejection fraction (LVEF), and triple-vessel CAD. It is uncertain whether there is a survival benefit with percutaneous revascularization. Base revascularization decisions on consideration of the disease complexity, the technical feasibility of treatment, and a heart team discussion.

A radial artery is preferred as a surgical revascularization conduit over that of a saphenous vein conduit to bypass the second most important target vessel with significant stenosis after the left anterior descending (LAD) coronary artery. Superior patency, reduced adverse cardiac events, and improved survival are among the benefits.

In patients undergoing percutaneous intervention (PCI) who have acute coronary syndrome (ACS) or SIHD, radial artery access is recommended over a femoral approach to reduce bleeding and vascular complications. This approach also confers a reduction in mortality in those with ACS.

In patients with SIHD, it is reasonable to administer a short course of dual antiplatelet therapy (DAPT) after percutaneous revascularization to lower the risk of bleeding events. After evaluation of the risks of recurrent ischemia and bleeding, select patients may safely transition to P2Y12 inhibitor monotherapy and stop aspirin after 1-3 months of DAPT.

To improve outcomes, the ACC/AHA/SCAI recommend staged PCI (in hospital or post discharge) of a significantly stenosed nonculprit artery in select patients who present with an ST-segment–elevation myocardial infarction (STEMI). Less clarity exists regarding PCI of the nonculprit artery at the time of primary PCI; it may be considered in stable patients with uncomplicated revascularization of the culprit artery, low-complexity nonculprit artery disease, and normal renal function. Note that patients in cardiogenic shock can be harmed by PCI of the nonculprit artery.

A heart team approach optimizes revascularization decisions in diabetic persons with multivessel CAD. Surgical revascularization is recommended for those with diabetes and triple-vessel disease; consider PCI if they are poor surgical candidates.

For patients undergoing surgical revascularization of CAD, treatment decisions should include use of the Society of Thoracic Surgeons (STS) score to calculate a patient’s surgical risk. Less clarity exists regarding the utility of the SYNTAX score calculation in treatment decisions (owing to interobserver variability in its calculation and its absence of clinical variables).

For more information, please go to Coronary Artery Bypass Grafting, Percutaneous Coronary Intervention (PCI), and Comparison of Coronary Artery Bypass Grafting (CABG) and Percutaneous Coronary Intervention (PCI), as well as Acute Coronary Syndrome, Cardiogenic Shock, and Myocardial Infarction.

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