Please see also 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines [PubMed Abstract]. Circulation. 2022 Jan 18;145(3):e4-e17.
In this post, I link to and excerpt from 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 [PubMed Abstract] [Full-Text HTML] [Full-Text PDF]. J Am Coll Cardiol. 2022 Jan 18;79(2):e21-e129.
The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use.
Structure
Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients’ interests.
Top 10 Take-Home Messages
1.
Treatment decisions regarding 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.
2.
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.
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 coronary artery disease and left main disease that is equally suitable for surgical or percutaneous revascularization.
4.
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.
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.
Radial artery access is recommended in patients undergoing percutaneous intervention who have acute coronary syndrome or stable ischemic heart disease, to reduce bleeding and vascular complications compared with a femoral approach. Patients with acute coronary syndrome 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 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.
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 percutaneous coronary intervention 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, percutaneous intervention of the non-culprit artery can be harmful in patients in cardiogenic shock.
9.
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.
10.
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.
1.4. Scope of the Guideline
The scope of the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization” is to provide an update to and to consolidate the 2011 coronary artery bypass graft (CABG) surgery (1) and the 2011 and 2015 percutaneous coronary intervention (PCI) guidelines (2,3), with the added consideration of using a patient-centric disease approach. The applicable sections on revascularization from the 2012 stable ischemic heart disease (SIHD) guideline (4), as well as the 2013 ST-segment–elevation myocardial infarction (STEMI) (5) and 2014 non–ST-segment–elevation myocardial infarction (NSTEMI) guidelines (6), will also be updated. This present guideline will affect the following documents:
Replace/retire the 2015 update in PCI in STEMI guideline (3).
4.
Replace/retire the 2013 STEMI guideline, Sections 4.1, 4.2, 4.3, 4.4, 5.3 (deals with transfer after lytic with intent to do PCI), 6.2, 6.4, 7.1, and 7.2 (5).
Replace/retire the 2012 SIHD guideline, Section 5 (4).
The intended primary target audience consists of cardiovascular clinicians who are involved in the care of patients for whom revascularization is considered or indicated. Coronary artery disease (CAD) is to be approached with the most current treatment options and treated as a “condition.” Recommendations are stated in reference to the patients and their condition. The focus is to provide the most up-to-date evidence to inform the clinician during shared decision-making with the patient. Although the document is not intended to be a procedural-based manual of recommendations that outlines the best practice for coronary revascularization, there are certain techniques that surgeons or interventional cardiologists might use that are associated with improved clinical outcomes.
In developing the 2021 coronary artery revascularization guideline, the writing committee reviewed previously published guidelines and related statements. Table 1 contains a list of these publications and statements deemed pertinent to this writing effort and is intended for use as a resource, thus obviating the need to repeat existing guideline recommendations.
Table 2. Applying ACC/AHA Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated May 2019)∗
1.6. Abbreviations
Abbreviation
Meaning/Phrase
ACS
acute coronary syndrome
AKI
acute kidney injury
AMI
acute myocardial infarction
AVR
aortic valve replacement
BIMA
bilateral internal mammary artery
BMS
bare-metal stent
CABG
coronary artery bypass graft
CAD
coronary artery disease
CKD
chronic kidney disease
COR
Class of Recommendation
CTO
chronic total occlusion
CVD
cardiovascular disease
DAPT
dual antiplatelet therapy
DES
drug-eluting stent
ECG
electrocardiogram
FFR
fractional flow reserve
GDMT
guideline-directed medical therapy
iFR
instantaneous wave-free ratio
IMA
internal mammary artery
ISR
in-stent restenosis
IVUS
intravascular ultrasound
LAD
left anterior descending
LIMA
left internal mammary artery
LOE
Level of Evidence
MACE
major adverse cardiovascular events
MI
myocardial infarction
NSTE-ACS
non–ST-segment–elevation acute coronary syndrome
NSTEMI
non–ST-segment–elevation myocardial infarction
OCT
optical coherence tomography
PCI
percutaneous coronary intervention
RCT
randomized controlled trial
SCAD
spontaneous coronary artery dissection
SIHD
stable ischemic heart disease
STEMI
ST-segment–elevation myocardial infarction
SVG
saphenous vein graft
SYNTAX
Synergy Between PCI With TAXUS and Cardiac Surgery
TAVR
transcatheter aortic valve replacement
UFH
unfractionated heparin
VT
ventricular tachycardia
2. Improving Equity of Care in Revascularization and Shared Decision-Making
Figure 1. Shared Decision-Making Algorithm
Table 3. Ideal Components of the Shared Decision-Making and Informed Consent Process
Patient-Centered Care
Assess a patient’s ability to understand complex health information
Seek support of family/others
Elicit and respect cultural, racial, ethnic, or religious preferences and values
Evaluate social determinants of health (education, income, access to health care)
Improve telephone/telemedicine access
Discuss treatment alternatives and how each affects the patient’s quality of life
Shared Decision-Making
Encourage questions and explain the patient’s role in the decision-making partnership
Clearly and accurately communicate the potential risks and benefits of a particular procedure and alternative treatments
Ensure that patients have a key role in deciding what revascularization approach is appropriate
Spend sufficient time to engage in shared decision-making; allow for a second opinion
Work with a chaplain, social worker, or other team members to facilitate shared decision-making
Encourage patients to share their fears, stress, or other emotions, and address appropriately
Negotiate decision in partnership with the patient and family members
Respect patient’s autonomy to decline recommended treatment
Consent Procedures
Use plain language, avoiding jargon, and adopt the patient’s words; integrate pictures to teach
Document teach-back of patient’s knowledge and understanding
Conduct conversations with a trained interpreter, as needed
Provide patient-specific short- and long-term risks, benefits, and alternative treatments
Provide unbiased, evidence-based, reliable, accessible, and relevant information to patient
Discuss specific risks and benefits with regard to survival, relief of angina, quality of life, and potential additional intervention, as well as uncertainties associated with different treatment strategies
Provide patient time to reflect on the trade-offs imposed by the outcome estimates
Provide information on the level of operator expertise, volume of the facility, and local results in the performance of coronary revascularization options
Clearly inform of the need for continued medical therapy and lifestyle modifications
In patients for whom the optimal treatment strategy is unclear, a Heart Team approach that includes representatives from interventional cardiology, cardiac surgery, and clinical cardiology is recommended to improve patient outcomes (1, 2, 3, 4, 5, 6, 7).
Figure 2. Phases of Patient-Centric Care in the Treatment of Coronary Artery Disease
In patients who are being considered for CABG, calculation of the STS risk score is recommended to help stratify patient risk (1,2).
Recommendation-Specific Supporting Text
1.
The STS risk score has been validated in several studies and demonstrates excellent predictive value for estimating risk of adverse events (2, 3, 4). The STS risk score serves as a useful tool when a choice is being made among various treatment strategies because it allows the clinician, the patient, and the patient’s family to have a reasonable estimate of operative risk. The STS risk score performs better than the EuroSCORE II for the patient population with CABG, particularly at higher (>5%) predicted mortality rates (1,2). Commonly used cardiac surgery risk models, such as the STS and EuroSCORE II, are limited in assessing the influence of risk factors, including cirrhosis, frailty, and malnutrition, on outcome. Patients with liver cirrhosis, frailty, and malnutrition have increased risk of perioperative morbidity and mortality after cardiac surgery (6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17) and may be assessed by other tools (Table 5).
Table 5. Assessment of Risk Factors Not Quantified in the STS Score
Risk Factor
Assessment Tool
Cirrhosis
Model for End-Stage Liver Disease (MELD) score (1, 2, 3, 4, 5, 6)
4.1. Angiography to Define Anatomy and Assess Lesion Severity
Coronary angiography remains the default method to define coronary anatomy and characterize the severity of coronary arterial stenoses. A visually estimated diameter stenosis severity of ≥70% for non–left main disease and ≥50% for left main disease has been used to define significant stenosis and to guide revascularization strategy. Although the length of a lesion may contribute to physiological lesion severity (i.e., a longer moderate lesion may result in more ischemia than a focal severe lesion), there are no standard cutoffs for lesion length used to classify a severe stenosis. An angiographically intermediate coronary stenosis is defined as a diameter stenosis severity of 40% to 69%, and generally warrants additional investigation to assess physiological significance. There is controversy over whether visually estimated diameter stenosis or quantitative coronary angiography better predicts the functional significance of a coronary stenosis (1,2). The difference in mean diameter stenosis between quantitative coronary angiography and visual estimation varies from 10% to 20% and is dependent on stenosis severity (3, 4, 5). The use of optimal angiographic projections, multiple angiographic views, and adjunct imaging or physiology may aid in the assessment of coronary anatomy when coronary angiography is used.
