Coronary Artery Revascularization

Publication Date: December 8, 2021
Last Updated: September 2, 2022

Overview

Improving Equity of Care in Revascularization

  1. In patients who require coronary revascularization, treatment decisions should be based on clinical indication, regardless of sex, or race or ethnicity, and efforts to reduce disparities of care are warranted.
(I, B-NR)
573

Shared Decision-Making and Informed Consent

  1. In patients undergoing revascularization, decisions should be patient-centered — that is, considerate of the patient’s preferences and goals, cultural beliefs, health literacy, and social determinants of health — and made in collaboration with the patient’s support system.
(I, C-LD)
573
  1. In patients undergoing coronary angiography or revascularization, adequate information about benefits, risks, therapeutic consequences, and potential alternatives in the performance of percutaneous and surgical myocardial revascularization should be given, when feasible, with sufficient time for informed decision-making to improve clinical outcomes.
(I, C-LD)
573

Preprocedural Assessment and the Heart Team

The Heart Team

  1. 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.
(I, B-NR)
573

Predicting Patient Risk of Death With CABG

  1. In patients who are being considered for CABG, calculation of the STS risk score is recommended to help stratify patient risk.
(I, B-NR)
573

Evaluation

Defining Lesion Severity

Defining Coronary Artery Lesion Complexity: Calculation of the SYNTAX Score

  1. In patients with multivessel CAD, an assessment of CAD complexity, such as the SYNTAX score, may be useful to guide revascularization.
(IIb, B-NR)
573

Use of Coronary Physiology to Guide Revascularization With PCI

  1. In patients with angina or an anginal equivalent, undocumented ischemia, and angiographically intermediate stenoses, the use of FFR or iFR is recommended to guide the decision to proceed with PCI.
(I, A)
573
  1. In stable patients with angiographically intermediate stenoses and FFR >0.80 or iFR >0.89, PCI should NOT be performed.
(III - No Benefit, B-R)
573

Intravascular Ultrasound to Assess Lesion Severity

  1. In patients with intermediate stenosis of the left main artery, IVUS is reasonable to help define lesion severity.
(IIa, B-NR)
573

Treatment

Revascularization in STEMI

Revascularization of the Infarct Artery in Patients With STEMI

  1. In patients with STEMI and ischemic symptoms for <12 hours, PCI should be performed to improve survival.
(I, A)
573
  1. In patients with STEMI and cardiogenic shock or hemodynamic instability, PCI or CABG (when PCI is not feasible) is indicated to improve survival, irrespective of the time delay from MI onset.
(I, B-R)
573
  1. In patients with STEMI who have mechanical complications (e.g., ventricular septal rupture, mitral valve insufficiency because of papillary muscle infarction or rupture, or free wall rupture), CABG is recommended at the time of surgery, with the goal of improving survival.
(I, B-NR)
573
  1. In patients with STEMI and evidence of failed reperfusion after fibrinolytic therapy, rescue PCI of the infarct artery should be performed to improve clinical outcomes.
(I, C-LD)
573
  1. In patients with STEMI who are treated with fibrinolytic therapy, angiography within 3 to 24 hours with the intent to perform PCI is reasonable to improve clinical outcomes.
(IIa, B-R)
573
  1. In patients with STEMI who are stable and presenting 12 to 24 hours after symptom onset, PCI is reasonable to improve clinical outcomes.
(IIa, B-NR)
573
  1. In patients with STEMI in whom PCI is not feasible or successful, with a large area of myocardium at risk, emergency or urgent CABG can be effective as a reperfusion modality to improve clinical outcomes.
(IIa, B-NR)
573
  1. In patients with STEMI complicated by ongoing ischemia, acute severe heart failure, or life-threatening arrhythmia, PCI can be beneficial to improve clinical outcomes, irrespective of time delay from MI onset.
(IIa, C-EO)
573
  1. In asymptomatic stable patients with STEMI who have a totally occluded infarct artery >24 hours after symptom onset and are without evidence of severe ischemia, PCI should NOT be performed.
(III - No Benefit, B-R)
573
In patients with STEMI, emergency CABG should NOT be performed after failed primary PCI:
  • In the absence of ischemia or a large area of myocardium at risk, or
  • If surgical revascularization is not feasible because of a no-reflow state or poor distal targets.
(III - Harm, C-EO)
573

Revascularization of the Non-Infarct Artery in Patients With STEMI

  1. In selected hemodynamically stable patients with STEMI and multivessel disease, after successful primary PCI, staged PCI of a significant non-infarct artery stenosis is recommended to reduce the risk of death or MI.
(I, A)
573
  1. In selected patients with STEMI with complex multivessel non-infarct artery disease, after successful primary PCI, elective CABG is reasonable to reduce the risk of cardiac events.
(IIa, C-EO)
573
  1. In selected hemodynamically stable patients with STEMI and low-complexity multivessel disease, PCI of a non-infarct artery stenosis may be considered at the time of primary PCI to reduce cardiac event rates.
(IIb, B-R)
573
  1. In patients with STEMI complicated by cardiogenic shock, routine PCI of a non-infarct artery at the time of primary PCI should NOT be performed because of the higher risk of death or renal failure.
(III - Harm, B-R)
573

Revascularization in NSTE-ACS

Coronary Angiography and Revascularization in Patients With NSTE-ACS

  1. In patients with NSTE-ACS who are at elevated risk of recurrent ischemic events and are appropriate candidates for revascularization, an invasive strategy with the intent to proceed with revascularization is indicated to reduce cardiovascular events.
(I, A)
573
  1. In patients with NSTE-ACS and cardiogenic shock who are appropriate candidates for revascularization, emergency revascularization is recommended to reduce risk of death.
(I, B-R)
573
  1. In appropriate patients with NSTE-ACS who have refractory angina or hemodynamic or electrical instability, an immediate invasive strategy with intent to perform revascularization is indicated to improve outcomes.
(I, C-LD)
573
  1. In patients with NSTE-ACS who are initially stabilized and are at high risk of clinical events, it is reasonable to choose an early invasive strategy (within 24 hours) over a delayed invasive strategy to improve outcomes.
(IIa, B-R)
573
  1. In patients with NSTE-ACS who are initially stabilized and are at intermediate or low risk of clinical events, an invasive strategy with intent to perform revascularization is reasonable before hospital discharge to improve outcomes.
(IIa, B-R)
573
  1. In patients with NSTE-ACS who have failed PCI and have ongoing ischemia, hemodynamic compromise, or threatened occlusion of an artery with substantial myocardium at risk, who are appropriate candidates for CABG, emergency CABG is reasonable.
(IIa, B-NR)
573
  1. In patients with NSTE-ACS who present in cardiogenic shock, routine multivessel PCI of non-culprit lesions in the same setting should NOT be performed.
(III - Harm, B-R)
573

Revascularization in SIHD

Revascularization to Improve Survival in SIHD Compared With Medical Therapy

Left ventricular dysfunction and multivessel CAD
  1. In patients with SIHD and multivessel CAD appropriate for CABG with severe left ventricular systolic dysfunction (left ventricular ejection fraction <35%), CABG is recommended to improve survival.
(I, B-R)
573
  1. In selected patients with SIHD and multivessel CAD appropriate for CABG and mild-to-moderate left ventricular systolic dysfunction (ejection fraction 35%–50%), CABG (to include a LIMA graft to the LAD) is reasonable to improve survival.
(IIa, B-NR)
573
Left main CAD
  1. In patients with SIHD and significant left main stenosis, CABG is recommended to improve survival.
(I, B-R)
573
  1. In selected patients with SIHD and significant left main stenosis for whom PCI can provide equivalent revascularization to that possible with CABG, PCI is reasonable to improve survival.
(IIa, B-NR)
573
Multivessel CAD
  1. In patients with SIHD, normal ejection fraction, significant stenosis in 3 major coronary arteries (with or without proximal LAD), and anatomy suitable for CABG, CABG may be reasonable to improve survival.
(IIb, B-R)
573
  1. In patients with SIHD, normal ejection fraction, significant stenosis in 3 major coronary arteries (with or without proximal LAD), and anatomy suitable for PCI, the usefulness of PCI to improve survival is uncertain.
(IIb, B-R)
573
Stenosis in the proximal LAD artery
  1. In patients with SIHD, normal left ventricular ejection fraction, and significant stenosis in the proximal LAD, the usefulness of coronary revascularization to improve survival is uncertain.
(IIb, B-R)
573
Single- or double-vessel disease not involving the proximal LAD
  1. In patients with SIHD, normal left ventricular ejection fraction, and 1- or 2-vessel CAD not involving the proximal LAD, coronary revascularization is NOT recommended to improve survival.
(III - No Benefit, B-R)
573
  1. In patients with SIHD who have ≥1 coronary arteries that are not anatomically or functionally significant (<70% diameter of non-left main coronary artery stenosis, FFR >0.80), coronary revascularization should NOT be performed with the primary or sole intent to improve survival.
(III - Harm, B-NR)
573

Revascularization to Reduce Cardiovascular Events in SIHD Compared With Medical Therapy

Multivessel CAD
  1. In patients with SIHD and multivessel CAD appropriate for either CABG or PCI, revascularization is reasonable to lower the risk of cardiovascular events such as spontaneous MI, unplanned urgent revascularizations, or cardiac death.
(IIa, B-R)
573

Revascularization to Improve Symptoms

  1. In patients with refractory angina despite medical therapy and with significant coronary artery stenoses amenable to revascularization, revascularization is recommended to improve symptoms.
(I, A)
573
  1. In patients with angina but no anatomic or physiological criteria for revascularization, neither CABG nor PCI should be performed.
(III - Harm, C-LD)
573

Situations in Which PCI or CABG Would Be Preferred

Patients With Complex Disease

  1. In patients who require revascularization for significant left main CAD with high-complexity CAD, it is recommended to choose CABG over PCI to improve survival.
(I, B-R)
573
  1. In patients who require revascularization for multivessel CAD with complex or diffuse CAD (e.g., SYNTAX score >33), it is reasonable to choose CABG over PCI to confer a survival advantage.
(IIa, B-R)
573

Patients With Diabetes

  1. In patients with diabetes and multivessel CAD with the involvement of the LAD, who are appropriate candidates for CABG, CABG (with a LIMA to the LAD) is recommended in preference to PCI to reduce mortality and repeat revascularizations.
(I, A)
573
  1. In patients with diabetes who have multivessel CAD amenable to PCI and an indication for revascularization and are poor candidates for surgery, PCI can be useful to reduce long-term ischemic outcomes.
(IIa, B-NR)
573
  1. In patients with diabetes who have left main stenosis and low-or intermediate-complexity CAD in the rest of the coronary anatomy, PCI may be considered an alternative to CABG to reduce major adverse cardiovascular outcomes.
(IIb, B-R)
573

Patients With Previous CABG

  1. In patients with previous CABG with a patent LIMA to the LAD who need repeat revascularization, if PCI is feasible, it is reasonable to choose PCI over CABG.
(IIa, B-NR)
573
  1. In patients with previous CABG and refractory angina on GDMT that is attributable to LAD disease, it is reasonable to choose CABG over PCI when an IMA can be used as a conduit to the LAD.
(IIa, C-LD)
573
  1. In patients with previous CABG and complex CAD, it may be reasonable to choose CABG over PCI when an IMA can be used as a conduit to the LAD.
(IIb, B-NR)
573

DAPT Adherence

  1. In patients with multivessel CAD amenable to treatment with either PCI or CABG who are unable to access, tolerate, or adhere to DAPT for the appropriate duration of treatment, CABG is reasonable in preference to PCI.
(IIa, B-NR)
573

Special Populations and Situations

Revascularization in Pregnant Patients
  1. In pregnant patients with STEMI not caused by SCAD, it is reasonable to perform primary PCI as the preferred revascularization strategy.
(IIa, C-LD)
573
  1. In pregnant patients with NSTE-ACS, an invasive strategy is reasonable if medical therapy is ineffective for the management of life-threatening complications.
(IIa, C-LD)
573
Revascularization in Older Patients
  1. In older adults, as in all patients, the treatment strategy for CAD should be based on an individual patient’s preferences, cognitive function, and life expectancy.
(I, B-NR)
573
Revascularization in Patients With CKD
  1. In patients with CKD undergoing contrast media injection for coronary angiography, measures should be taken to minimize the risk of contrast-induced AKI.
(I, C-LD)
573
  1. In patients with STEMI and CKD, coronary angiography and revascularization are recommended, with adequate measures to reduce the risk of AKI.
(I, C-EO)
573
  1. In high-risk patients with NSTE-ACS and CKD, it is reasonable to perform coronary angiography and revascularization, with adequate measures to reduce the risk of AKI.
(IIa, B-NR)
573
  1. In low-risk patients with NSTE-ACS and CKD, it is reasonable to weigh the risk of coronary angiography and revascularization against the potential benefit.
(IIa, C-EO)
573
  1. In asymptomatic patients with stable CAD and CKD, routine angiography and revascularization are NOT recommended if there is no compelling indication.
(III - No Benefit, B-R)
573
Revascularization in Patients Before Noncardiac Surgery
  1. In patients with non-left main or noncomplex CAD who are undergoing noncardiac surgery, routine coronary revascularization is NOT recommended solely to reduce perioperative cardiovascular events.
(III - No Benefit, B-R)
573
Revascularization in Patients to Reduce Ventricular Arrhythmias
  1. In patients with ventricular fibrillation, polymorphic VT, or cardiac arrest, revascularization of significant CAD is recommended to improve survival.
(I, B-NR)
573
  1. In patients with CAD and suspected scar-mediated sustained monomorphic VT, revascularization is NOT recommended for the sole purpose of preventing recurrent VT.
(III - No Benefit, C-LD)
573
Revascularization in Patients With SCAD
  1. In patients with SCAD who have hemodynamic instability or ongoing ischemia despite conservative therapy, revascularization may be considered if feasible
(IIb, C-LD)
573
  1. Routine revascularization for SCAD should NOT be performed.
(III - Harm, C-LD)
573
  1. In patients with cardiac allograft vasculopathy and severe, proximal, discrete coronary lesions, revascularization with PCI is reasonable.
(IIa, C-LD)
573

General Procedural Issues for PCI

Radial and Femoral Approaches for PCI

  1. In patients with ACS undergoing PCI, a radial approach is indicated in preference to a femoral approach to reduce the risk of death, vascular complications, or bleeding
(I, A)
573
  1. In patients with SIHD undergoing PCI, the radial approach is recommended to reduce access site bleeding and vascular complications.
(I, A)
573

Choice of Stent Type

  1. In patients undergoing PCI, DES should be used in preference to BMS to prevent restenosis, MI, or acute stent thrombosis.
(I, A)
573

Use of Intravascular Imaging

  1. In patients undergoing coronary stent implantation, IVUS can be useful for procedural guidance, particularly in cases of left main or complex coronary artery stenting, to reduce ischemic events.
(IIa, B-R)
573
  1. In patients undergoing coronary stent implantation, OCT is a reasonable alternative to IVUS for procedural guidance, except in ostial left main disease.
(IIa, B-R)
573
  1. In patients with stent failure, IVUS or OCT is reasonable to determine the mechanism of stent failure.
(IIa, C-LD)
573

Thrombectomy

  1. In patients with STEMI, routine aspiration thrombectomy before primary PCI is NOT useful.
(III - No Benefit, A)
573

Treatment of Calcified Lesions

  1. In patients with fibrotic or heavily calcified lesions, plaque modification with rotational atherectomy can be useful to improve procedural success.
(IIa, B-R)
573
  1. In patients with fibrotic or heavily calcified lesions, plaque modification with orbital atherectomy, balloon atherotomy, laser angioplasty, or intracoronary lithotripsy may be considered to improve procedural success.
(IIb, B-NR)
573

Treatment of Saphenous Vein Graft Disease (Previous CABG)

  1. In select patients with previous CABG undergoing PCI of a SVG, the use of an embolic protection device, when technically feasible, is reasonable to decrease the risk of distal embolization.
(IIa, B-R)
573
  1. In patients with previous CABG, if PCI of a diseased native coronary artery is feasible, then it is reasonable to choose PCI of the native coronary artery over PCI of the severely diseased SVG.
(IIa, B-NR)
573
  1. In patients with a chronic occlusion of a SVG, percutaneous revascularization of the SVG should NOT be performed.
(III - No Benefit, C-LD)
573

Treatment of CTO

  1. In patients with suitable anatomy who have refractory angina on medical therapy, after treatment of non-CTO lesions, the benefit of PCI of a CTO to improve symptoms is uncertain.
(IIb, B-R)
573

Treatment of Patients With Stent Restenosis

  1. In patients who develop clinical ISR for whom repeat PCI is planned, a DES should be used to improve outcomes if anatomic factors are appropriate and the patient is able to comply with DAPT.
(I, A)
573
  1. In patients with symptomatic recurrent diffuse ISR with an indication for revascularization, CABG can be useful over repeat PCI to reduce recurrent events.
(IIa, C-EO)
573
  1. In patients who develop recurrent ISR, brachytherapy may be considered to improve symptoms.
(IIb, B-NR)
573
Hemodynamic Support for Complex PCI
  1. In selected high-risk patients, elective insertion of an appropriate hemodynamic support device as an adjunct to PCI may be reasonable to prevent hemodynamic compromise during PCI.
(IIb, B-R)
573

Pharmacotherapy in Patients Undergoing PCI

Aspirin and Oral P2Y12 Inhibitors in Patients Undergoing PCI
  1. In patients undergoing PCI, a loading dose of aspirin, followed by daily dosing, is recommended to reduce ischemic events.*
(I, B-R)
573
  1. In patients with ACS undergoing PCI, a loading dose of P2Y12 inhibitor, followed by daily dosing, is recommended to reduce ischemic events.
(I, B-R)
573
  1. In patients with SIHD undergoing PCI, a loading dose of clopidogrel, followed by daily dosing, is recommended to reduce ischemic events.
(I, C-LD)
573
  1. In patients undergoing PCI within 24 hours after fibrinolytic therapy, a loading dose of 300 mg of clopidogrel, followed by daily dosing, is recommended to reduce ischemic events.
(I, C-LD)
573
  1. In patients with ACS undergoing PCI, it is reasonable to use ticagrelor or prasugrel† in preference to clopidogrel to reduce ischemic events, including stent thrombosis.
(IIa, B-R)
573
  1. In patients <75 years of age undergoing PCI within 24 hours after fibrinolytic therapy, ticagrelor may be a reasonable alternative to clopidogrel to reduce ischemic events.
(IIb, B-R)
573
  1. In patients undergoing PCI who have a history of stroke or transient ischemic attack, prasugrel† should NOT be administered.
(III - Harm, B-R)
573
* Contraindications to ticagrelor: previous intracranial hemorrhage or ongoing bleeding.† Contraindications to prasugrel: previous intracranial hemorrhage, previous ischemic stroke or transient ischemic attack, or ongoing bleeding. Prasugrel should be used with caution at a lower dose in patients ≥75 years of age or with a body weight <60 kg.
Intravenous P2Y12 Inhibitors in Patients Undergoing PCI
  1. In patients undergoing PCI who are P2Y12 inhibitor naïve, intravenous cangrelor may be reasonable to reduce periprocedural ischemic events.
(IIb, B-R)
573
Intravenous Glycoprotein IIb/IIIa Inhibitors in Patients Undergoing PCI
  1. In patients with ACS undergoing PCI with large thrombus burden, no-reflow, or slow flow, intravenous glycoprotein IIb/IIIa inhibitor agents are reasonable to improve procedural success.
(IIa, C-LD)
573
  1. In patients with SIHD undergoing PCI, the routine use of an intravenous glycoprotein IIb/IIIa inhibitor agent is NOT recommended.
(III - No Benefit, B-R)
573
Heparin, Low-Molecular-Weight Heparin, and Bivalirudin in Patients Undergoing PCI
  1. In patients undergoing PCI, administration of intravenous UFH is useful to reduce ischemic events.
(I, C-EO)
573
  1. In patients with heparin-induced thrombocytopenia undergoing PCI, bivalirudin or argatroban should be used to replace UFH to avoid thrombotic complications.
(I, C-LD)
573
  1. In patients undergoing PCI, bivalirudin may be a reasonable alternative to UFH to reduce bleeding.
(IIb, A)
573
  1. In patients treated with upstream subcutaneous enoxaparin for unstable angina or NSTE-ACS, the use of intravenous enoxaparin may be considered at the time of PCI to reduce ischemic events.
(IIb, B-R)
573
  1. In patients on therapeutic subcutaneous enoxaparin, in whom the last dose was administered within 12 hours of PCI, UFH should NOT be used for PCI and may increase bleeding.
(III - Harm, B-R)
573

General Procedural Issues for CABG

Perioperative Considerations in Patients Undergoing CABG

  1. For patients undergoing CABG, establishment of multidisciplinary, evidence-based perioperative management programs is recommended to optimize analgesia, minimize opioid exposure, prevent complications and to reduce time to extubation, length of stay, and healthcare costs.
(I, B-NR)
573

Bypass Conduits in Patients Undergoing CABG

  1. In patients undergoing isolated CABG, the use of a radial artery is recommended in preference to a saphenous vein conduit to graft the second most important, significantly stenosed, non-LAD vessel to improve long-term cardiac outcomes.
(I, B-R)
573
  1. In patients undergoing CABG, an IMA, preferably the left, should be used to bypass the LAD when bypass of the LAD is indicated to improve survival and reduce recurrent ischemic events
(I, B-NR)
573
  1. In patients undergoing CABG, BIMA grafting by experienced operators can be beneficial in appropriate patients to improve long-term cardiac outcomes.
(IIa, B-NR)
573

CABG in Patients Undergoing Other Cardiac Surgery

  1. In patients undergoing valve surgery, aortic surgery, or other cardiac operations who have significant CAD, CABG is recommended with a goal of reducing ischemic events.
(I, C-LD)
573
  1. In patients undergoing valve surgery, aortic surgery, or other cardiac operations who have intermediate CAD, CABG may be reasonable with a goal of reducing ischemic events.
(IIb, C-LD)
573

Use of Epiaortic Ultrasound in Patients Undergoing CABG

  1. In patients undergoing CABG, the routine use of epiaortic ultrasound scanning can be useful to evaluate the presence, location, and severity of plaque in the ascending aorta to reduce the incidence of atheroembolic complications.
(IIa, B-NR)
573

Use of Cardiopulmonary Bypass in Patients Undergoing CABG

  1. In patients with significant calcification of the aorta, the use of techniques to avoid aortic manipulation (off-pump techniques or beating heart) is reasonable to decrease the incidence of perioperative stroke when performed by experienced surgeons.
(IIa, B-R)
573
  1. In patients with significant pulmonary disease, off-pump surgery may be reasonable to reduce perioperative risk when performed by experienced surgeons.
(IIb, B-R)
573

Pharmacotherapy in Patients Undergoing CABG

Insulin Infusion and Other Measures to Reduce Sternal Wound Infection in Patients Undergoing CABG
  1. In patients undergoing CABG, an intraoperative continuous insulin infusion should be initiated to maintain serum glucose level <180 mg/dL to reduce sternal wound infection.
(I, B-R)
573
  1. In patients undergoing CABG, the use of continuous intravenous insulin to achieve and maintain an early postoperative blood glucose concentration of <180 mg/dL while avoiding hypoglycemia is indicated to reduce the incidence of adverse events, including deep sternal wound infection.
(I, B-R)
573
  1. In patients undergoing CABG, a comprehensive approach to reduce sternal wound infection is recommended.
(I, B-NR)
573
  1. In patients undergoing CABG, the usefulness of continuous intravenous insulin designed to achieve a target intraoperative blood glucose concentration <140 mg/dL is uncertain.
(IIb, B-R)
573
Antiplatelet Therapy in Patients Undergoing CABG
  1. In patients undergoing CABG who are already taking daily aspirin preoperatively, it is recommended that they continue taking aspirin until the time of surgery to reduce ischemic events.
(I, B-R)
573
  1. In patients referred for urgent CABG, clopidogrel and ticagrelor should be discontinued for at least 24 hours before surgery to reduce major bleeding complications.
(I, B-NR)
573
  1. In patients undergoing CABG, discontinuation of short-acting glycoprotein IIb/IIIa inhibitors (eptifibatide and tirofiban) for 4 hours and abciximab for 12 hours before surgery is recommended to reduce the risk of bleeding and transfusion.
(I, B-NR)
573
  1. In patients undergoing elective CABG who receive P2Y12 receptor inhibitors before surgery, it is reasonable to discontinue clopidogrel for 5 days, ticagrelor for 3 days, and prasugrel for 7 days before CABG to reduce risk of major bleeding and blood product transfusion.
(IIa, B-NR)
573
  1. In patients undergoing elective CABG who are not already taking aspirin, the initiation of aspirin (100–300 mg daily) in the immediate preoperative period (<24 hours before surgery) is NOT recommended.
(III - No Benefit, B-R)
573
Beta Blockers and Amiodarone in Patients Undergoing CABG
  1. In patients undergoing CABG, who do not have a contraindication to beta blockers, the administration of beta blockers before surgery can be beneficial to reduce the incidence of postoperative atrial fibrillation.
(IIa, B-R)
573
  1. In patients undergoing CABG, preoperative amiodarone is reasonable to reduce the incidence of postoperative atrial fibrillation.
(IIa, B-R)
573
  1. In patients undergoing CABG, who do not have a contraindication to beta blockers, preoperative use of beta blockers may be effective in reducing in-hospital and 30-day mortality rates.
(IIb, B-NR)
573
  1. In patients undergoing CABG, the role of preoperative beta blockers for the prevention of acute postoperative myocardial ischemia, stroke, AKI, or ventricular arrhythmia is uncertain.
(IIb, B-NR)
573

Pharmacotherapy in Patients After Revascularization

Dual Antiplatelet Therapy in Patients After PCI

  1. In selected patients undergoing PCI, shorter-duration DAPT (1–3 months) is reasonable, with subsequent transition to P2Y12 inhibitor monotherapy to reduce the risk of bleeding events.
(IIa, A)
573
Antiplatelet Therapy in Patients After CABG
  1. In patients undergoing CABG, aspirin (100–325 mg daily) should be initiated within 6 hours postoperatively and then continued indefinitely to reduce the occurrence of SVG closure and adverse cardiovascular events.
(I, A)
573
  1. In selected patients undergoing CABG, DAPT with aspirin and ticagrelor or clopidogrel for 1 year may be reasonable to improve vein graft patency compared with aspirin alone.
(IIb, B-R)
573

Beta Blockers in Patients After Revascularization

  1. In patients with SIHD and normal left ventricular function, the routine use of chronic oral beta blockers is NOT beneficial to reduce cardiovascular events after complete revascularization
(III - No Benefit, C-LD)
573

Beta Blockers for the Prevention of Atrial Fibrillation After CABG

  1. In patients after CABG, beta blockers are recommended and should be started as soon as possible to reduce the incidence or clinical sequelae of postoperative atrial fibrillation.
(I, B-R)
573

Antiplatelet Therapy in Patients With Atrial Fibrillation on Anticoagulation After PCI

  1. In patients with atrial fibrillation who are undergoing PCI and are taking oral anticoagulant therapy, it is recommended to discontinue aspirin treatment after 1 to 4 weeks while maintaining P2Y12 inhibitors in addition to a non-vitamin K oral anticoagulant (rivaroxaban, dabigatran, apixaban, or edoxaban) or warfarin to reduce the risk of bleeding.
(I, B-R)
573
  1. In patients with atrial fibrillation who are undergoing PCI, are taking oral anticoagulant therapy, and are treated with DAPT or a P2Y12 inhibitor monotherapy, it is reasonable to choose a non-vitamin K oral anticoagulant over warfarin to reduce the risk of bleeding.
(IIa, B-R)
573

Addressing Psychosocial Factors and Lifestyle Changes After Revascularization

Cardiac Rehabilitation and Education

  1. In patients who have undergone revascularization, a comprehensive cardiac rehabilitation program (home based or center based) should be prescribed either before hospital discharge or during the first outpatient visit to reduce deaths and hospital readmissions and improve quality of life.
(I, A)
573
  1. Patients who have undergone revascularization should be educated about CVD risk factors and their modification to reduce cardiovascular events.
(I, C-LD)
573

Smoking Cessation in Patients After Revascularization

  1. In patients who use tobacco and have undergone coronary revascularization, a combination of behavioral interventions + pharmacotherapy is recommended to maximize cessation and reduce adverse cardiac events.
(I, A)
573
  1. In patients who use tobacco and have undergone coronary revascularization, smoking cessation interventions are recommended during hospitalization and should include supportive follow-up for at least 1 month after discharge to facilitate tobacco cessation and reduce morbidity and mortality.
(I, A)
573

Psychological Interventions in Patients After Revascularization

  1. In patients who have undergone coronary revascularization who have symptoms of depression, anxiety, or stress, treatment with cognitive behavioral therapy, psychological counseling, and/or pharmacological interventions is beneficial to improve quality of life and cardiac outcomes.
(I, B-R)
573
  1. In patients who have undergone coronary revascularization, it may be reasonable to screen for depression and refer or treat when it is indicated to improve quality of life and recovery.
(IIb, C-LD)
573

Revascularization Outcomes

Assessment of Outcomes in Patients After Revascularization

  1. With the goal of improving patient outcomes, it is recommended that cardiac surgery and PCI programs participate in state, regional, or national clinical data registries and receive periodic reports of their risk-adjusted outcomes as a quality assessment and improvement strategy.
(I, B-NR)
573
  1. With the goal of improving patient outcomes, it is reasonable for cardiac surgery and PCI programs to have a quality improvement program that routinely 1) reviews institutional quality programs and outcomes, 2) reviews individual operator outcomes, 3) provides peer review of difficult or complicated cases, and 4) performs random case reviews.
(IIa, C-LD)
573
  1. Smaller volume cardiac surgery and PCI programs may consider affiliating with a high volume center to improve patient care.
(IIb, C-EO)
573

Recommendation Grading

Overview

Title

Coronary Artery Revascularization

Authoring Organizations

American College of Cardiology

American Heart Association

Society for Cardiovascular Angiography and Interventions

Publication Month/Year

December 8, 2021

Last Updated Month/Year

October 2, 2024

Document Type

Guideline

Country of Publication

US

Document Objectives

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.

Target Patient Population

Patients with coronary artery disease or patients who are considering coronary revascularization

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Ambulatory, Emergency care, Outpatient, Operating and recovery room

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Diagnosis, Assessment and screening, Treatment, Management

Diseases/Conditions (MeSH)

D062645 - Percutaneous Coronary Intervention, D001026 - Coronary Artery Bypass, D009204 - Myocardial Revascularization

Keywords

revascularization, percutaneous coronary intervention (PCI), ST-elevation myocardial infarction (STEMI), coronary artery bypass grafting (CABG), PCI, STEMI, cabg, Coronary Artery Revascularization, NSTE-ACS, acute coronary syndromes

Source Citation

Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM, Don CW, Fremes SE, Gaudino MF, Goldberger ZD, Grant MC, Jaswal JB, Kurlansky PA, Mehran R, Metkus TS Jr, Nnacheta LC, Rao SV, Sellke FW, Sharma G, Yong CM, Zwischenberger BA. 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. Circulation. 2021 Dec 9:CIR0000000000001039. doi: 10.1161/CIR.0000000000001039. Epub ahead of print. PMID: 34882436.

Methodology

Number of Source Documents
1175
Literature Search Start Date
April 30, 2019
Literature Search End Date
August 31, 2019