Coronary Artery Revascularization
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...
...quity of Care in Revascularization and Sha...
...ng Equity of Care in Revasculariza...
...ts who require coronary revascularizati...
...ure 1. Shared Decision-Making...
...ision-Making and Informed Consent...
...s undergoing revascularization, decisions...
...patients undergoing coronary angiography or reva...
...The numbering of the following table...
...1. Ideal Components of the Shared De...
Preprocedural Assessment and the Heart Team
...eprocedural Assessment and the Heart Team
...am In patients for whom the optimal treatment...
...Phases of Patient-Centric Care in...
...s for Consideration by the Heart TeamHavin...
Predicting Patient Risk of Death With CABG...
...le 3. Assessment of Risk Factors Not Quantified in...
Evaluation
...valuati...
...ng Lesion Severity...
...ry Artery Lesion Complexity: Calcu...
...giographic Features Contributing to Increasing...
...Coronary Physiology to Guide Revasc...
...atients with angina or an anginal equiv...
...able patients with angiographically in...
...ltrasound to Assess Lesion Severity...
Treatment
...atment...
...ascularization in STEMI...
...ation of the Infarct Artery in Patients...
...atients with STEMI and ischemic symptoms for...
...tients with STEMI and cardiogenic shock...
...In patients with STEMI who have mechanical c...
...patients with STEMI and evidence of failed rep...
...patients with STEMI who are treated with fibrinoly...
...In patients with STEMI who are stable an...
...In patients with STEMI in whom PCI is not fea...
...In patients with STEMI complicated b...
...tomatic stable patients with STEMI who h...
...ith STEMI, emergency CABG should NOT b...
...Indications for Revascularization i...
...ion of the Non-Infarct Artery in Patien...
...emodynamically stable patients with STEMI...
...patients with STEMI with complex multivessel...
...d hemodynamically stable patients with S...
...patients with STEMI complicated by ca...
...Clinical Status Definitions to Guide Rev...
...cularization of Non–Infarct-Related Cor...
...scularization in NSTE...
...Angiography and Revascularization i...
...n patients with NSTE-ACS who are at elevated ri...
...ents with NSTE-ACS and cardiogenic sh...
...ppropriate patients with NSTE-ACS who hav...
...tients with NSTE-ACS who are initially stabilized...
...nts with NSTE-ACS who are initially...
...nts with NSTE-ACS who have failed PCI...
...atients with NSTE-ACS who present in cardioge...
...of Invasive Strategy in Patients With NSTE-AC*...
Revascularization...
...vascularization to Improve Survival in...
...ular dysfunction and multivessel CAD...
...nts with SIHD and multivessel CAD ap...
...atients with SIHD and multivessel CAD...
Left main...
...nts with SIHD and significant left main...
...lected patients with SIHD and significant...
...tivessel CAD...
...ith SIHD, normal ejection fraction, significant s...
...ients with SIHD, normal ejection fraction...
...nosis in the proximal LA...
...ents with SIHD, normal left ventricular ejection f...
...ouble-vessel disease not involving the...
...patients with SIHD, normal left ventricular eject...
...with SIHD who have ≥1 coronary art...
...Revascularization in Patients With SI...
...larization to Reduce Cardiovascular Events...
...ssel CAD In patients with SIHD a...
...vascularization to Improv...
...In patients with refractory angina de...
...In patients with angina but no anatomic or p...
...ituations in Which PCI or CABG Would Be...
...nts With Complex Disease...
...atients who require revascularization fo...
...ients who require revascularization for multivess...
Patients With Di...
...ith diabetes and multivessel CAD with t...
...patients with diabetes who have multive...
In patients with diabetes who have left main s...
...With Previous CABG...
...ith previous CABG with a patent LIMA to the LAD...
...nts with previous CABG and refractory angina...
...ith previous CABG and complex CAD, it may be rea...
...rence In patients with multivessel CAD...
...opulations and Situations...
...ization in Pregnant Patients...
...In pregnant patients with STEMI not caused b...
...In pregnant patients with NSTE-AC...
...scularization in Older Patients...
In older adults, as in all patients...
...ization in Patients With CKD...
...tients with CKD undergoing contrast media...
...with STEMI and CKD, coronary angiography and re...
...gh-risk patients with NSTE-ACS and C...
...sk patients with NSTE-ACS and CKD, it...
In asymptomatic patients with stabl...
...able 6. Best Practices in the Catheterization L...
...tion in Patients Before Noncardiac Surgery In...
...scularization in Patients to Reduce Ventri...
...nts with ventricular fibrillation, polymor...
...atients with CAD and suspected sca...
...scularization in Patients With SCAD...
...with SCAD who have hemodynamic instability or ong...
...outine revascularization for SCAD shoul...
...on in Patients With Cardiac Allografts...
...patients with cardiac allograft vasculopathy and...
...ral Procedural Issues for PC...
...l and Femoral Approaches for PCI...
...patients with ACS undergoing PCI, a radial...
...with SIHD undergoing PCI, the radial approach is...
...Type In patients undergoing PCI, DES sho...
...Intravascular Imaging...
...ndergoing coronary stent implantation, IVUS c...
...tients undergoing coronary stent implantatio...
...atients with stent failure, IVUS or OCT is re...
...tomy In patients with STEMI, routine aspira...
...t of Calcified Lesions...
...with fibrotic or heavily calcified lesion...
...ith fibrotic or heavily calcified lesions, plaque...
...f Saphenous Vein Graft Disease (Pr...
...atients with previous CABG undergoing PCI of a...
...ts with previous CABG, if PCI of a dise...
...ents with a chronic occlusion of a SVG,...
...nt of CTO In patients with suitable anatomy wh...
...ent of Patients With Stent Restenosis...
...ents who develop clinical ISR for whom repeat...
...patients with symptomatic recurrent dif...
...In patients who develop recurrent ISR, bra...
...upport for Complex PCI In selected...
...armacotherapy in Patients Undergoing...
...in and Oral P2Y12 Inhibitors in Patients Undergo...
In patients undergoing PCI, a loadi...
...patients with ACS undergoing PCI, a load...
...patients with SIHD undergoing PCI, a loading dose...
...patients undergoing PCI within 24 hours a...
...patients with ACS undergoing PCI, it...
...In patients
...In patients undergoing PCI who have a history of...
...indications to ticagrelor: previous intracranial...
...ble 7. Oral and Parental Antiplatelet Age...
...2Y12 Inhibitors in Patients Undergoing P...
...ients undergoing PCI who are P2Y12 inh...
Intravenous Glycoprotein IIb/IIIa Inhibitors in...
...ients with ACS undergoing PCI with large thrombu...
...nts with SIHD undergoing PCI, the routine us...
...n, Low-Molecular-Weight Heparin, and Bivalir...
...tients undergoing PCI, administration of i...
...with heparin-induced thrombocytope...
...patients undergoing PCI, bivalirud...
...In patients treated with upstream subcutaneous...
...In patients on therapeutic subcutaneous e...
.... Anticoagulant Dosing During PCI*Havin...
...neral Procedural Issues for CAB...
...ioperative Considerations in Patients Unde...
...For patients undergoing CABG, establishment of...
...able 9. Perioperative Anesthetic and Monito...
...ass Conduits in Patients Undergoing C...
...undergoing isolated CABG, the use of...
...s undergoing CABG, an IMA, prefera...
...undergoing CABG, BIMA grafting by...
Table 10. Best Practices for the Use o...
...tients Undergoing Other Cardiac Surgery...
...ients undergoing valve surgery, aortic surge...
...undergoing valve surgery, aortic surg...
...e of Epiaortic Ultrasound in Patie...
...n patients undergoing CABG, the routine...
...monary Bypass in Patients Undergoin...
...with significant calcification of the aorta,...
...s with significant pulmonary disease, off-pu...
...acotherapy in Patients Undergo...
...Infusion and Other Measures to Reduce S...
In patients undergoing CABG, an intra...
...undergoing CABG, the use of continu...
...ts undergoing CABG, a comprehensive approach...
...tients undergoing CABG, the usefulness of co...
...Practices to Reduce Sternal Wound Infec...
...erapy in Patients Undergoing CABG...
...In patients undergoing CABG who are alre...
...n patients referred for urgent CABG,...
...s undergoing CABG, discontinuation of short-...
...s undergoing elective CABG who receive P2Y12 rec...
...ndergoing elective CABG who are not already taki...
...Blockers and Amiodarone in Patients Und...
...tients undergoing CABG, who do not have a c...
...ents undergoing CABG, preoperative amiodarone i...
...In patients undergoing CABG, who do no...
...In patients undergoing CABG, the role...
...acotherapy in Patients After Revascularization...
...Antiplatelet Therapy in Patients After PCI...
...atients undergoing PCI, shorter-duration DA...
...e of DAPT for Patients After PCI...
...et Therapy in Patients After CABG...
...In patients undergoing CABG, aspirin (...
...patients undergoing CABG, DAPT with aspirin an...
...in Patients After Revascularization...
...ients with SIHD and normal left ventricular functi...
...s for the Prevention of Atrial Fibr...
...after CABG, beta blockers are recommended and s...
...atelet Therapy in Patients With Atri...
...ents with atrial fibrillation who...
...n patients with atrial fibrillation who are...
...ng Psychosocial Factors and Lifestyle Changes Af...
...Rehabilitation and Educatio...
...In patients who have undergone revascul...
...ents who have undergone revascularization...
...n in Patients After Revascularization...
...atients who use tobacco and have under...
...ts who use tobacco and have undergone cor...
...logical Interventions in Patients...
...atients who have undergone coronary reva...
...n patients who have undergone coronar...
...tional and Psychosocial Risk Factors for ASC...
Revascularization Outcomes
...cularization Outcomes
...ment of Outcomes in Patients After Reva...
...h the goal of improving patient outco...
...al of improving patient outcomes, it is reasonab...
...olume cardiac surgery and PCI program...