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
...verview...
...of Care in Revascularization and Shared Decision-...
...g Equity of Care in Revascularization...
...tients who require coronary revascularization, tr...
...re 1. Shared Decision-Makin...
...ision-Making and Informed Consent...
...ts undergoing revascularization, decisions s...
...In patients undergoing coronary angiography or r...
...bering of the following tables and figures differs...
...l Components of the Shared Decision-Making...
Preprocedural Assessment and the Heart Team
...cedural Assessment and the Heart Team...
...Heart Team In patients for whom the o...
...hases of Patient-Centric Care in the Treatment of...
Table 2. Factors for Consideration by the Hea...
...dicting Patient Risk of Death With CAB...
...sessment of Risk Factors Not Quantified in the STS...
Evaluation
...aluatio...
...efining Lesion Severity...
...nary Artery Lesion Complexity: Calculation...
...giographic Features Contributing to Increa...
...Physiology to Guide Revascularization With PCI...
...with angina or an anginal equivalent, undocume...
...atients with angiographically intermediate ste...
...ar Ultrasound to Assess Lesion Seve...
Treatment
...eatment...
...ularization in STEMI...
...on of the Infarct Artery in Patient...
...with STEMI and ischemic symptoms fo...
...patients with STEMI and cardiogenic shock o...
...ith STEMI who have mechanical complicatio...
...ents with STEMI and evidence of failed reperfu...
...ents with STEMI who are treated with fib...
...patients with STEMI who are stable and present...
...In patients with STEMI in whom PCI is...
...patients with STEMI complicated by ongoi...
...tic stable patients with STEMI who have a totally...
...ith STEMI, emergency CABG should NOT be perform...
...ure 3. Indications for Revasculariza...
...ion of the Non-Infarct Artery in Patients Wit...
...selected hemodynamically stable patients with S...
...In selected patients with STEMI with com...
...In selected hemodynamically stable pa...
...with STEMI complicated by cardiogenic sh...
...e 5. Patient Clinical Status Definitions...
...evascularization of Non–Infarct-Related Coronar...
...cularization in NSTE-ACS
...giography and Revascularization in P...
...In patients with NSTE-ACS who are at elevated...
...with NSTE-ACS and cardiogenic sho...
...te patients with NSTE-ACS who have refracto...
...n patients with NSTE-ACS who are initially s...
...with NSTE-ACS who are initially stabilized and are...
...ith NSTE-ACS who have failed PCI and have ongo...
...with NSTE-ACS who present in cardiogenic shoc...
...ure 5. Timing of Invasive Strategy i...
...cularization in SI...
...evascularization to Improve Survival in S...
...ular dysfunction and multivessel...
...s with SIHD and multivessel CAD ap...
...cted patients with SIHD and multivessel CAD approp...
...main CAD...
...ents with SIHD and significant left main...
...ected patients with SIHD and significant left...
Multivesse...
...ients with SIHD, normal ejection fraction, sig...
...In patients with SIHD, normal ejec...
...nosis in the proximal LAD ar...
...In patients with SIHD, normal left ven...
...uble-vessel disease not involving the prox...
...nts with SIHD, normal left ventricular ej...
...patients with SIHD who have ≥1 corona...
...ure 6. Revascularization in Patients...
...larization to Reduce Cardiovascular E...
...CAD In patients with SIHD and mul...
...ization to Improve Sympto...
...with refractory angina despite medical therapy an...
...with angina but no anatomic or phys...
...ons in Which PCI or CABG Would Be Preferre...
...With Complex Disease...
...patients who require revascularization for...
...who require revascularization for multi...
Patients With Diab...
...nts with diabetes and multivessel CA...
...In patients with diabetes who have...
...ients with diabetes who have left main stenosi...
...ents With Previous CA...
...ents with previous CABG with a patent LIMA to the...
...ients with previous CABG and refractory angina on...
...nts with previous CABG and complex CAD, it m...
...herence In patients with multivessel CAD...
...pecial Populations and Situ...
...zation in Pregnant Patients...
...In pregnant patients with STEMI not caused by...
...patients with NSTE-ACS, an invasive...
...zation in Older Patients...
...dults, as in all patients, the treatment strategy...
...vascularization in Patients Wi...
...patients with CKD undergoing contrast...
...ts with STEMI and CKD, coronary angi...
In high-risk patients with NSTE-ACS and CKD, i...
...n low-risk patients with NSTE-ACS and CKD,...
...In asymptomatic patients with stable...
...Best Practices in the Catheterizat...
...ularization in Patients Before Noncardiac Surgery...
...arization in Patients to Reduce Vent...
...ts with ventricular fibrillation, polymorphi...
...In patients with CAD and suspected scar-...
Revascularization in Patients Wi...
...ents with SCAD who have hemodynamic insta...
...Routine revascularization for SCAD shou...
...ation in Patients With Cardiac Allografts...
...patients with cardiac allograft vas...
...rocedural Issues for P...
...ial and Femoral Approaches for...
...In patients with ACS undergoing PCI,...
...with SIHD undergoing PCI, the radial appr...
...Type In patients undergoing PCI, DE...
...ntravascular Imagin...
...undergoing coronary stent implantatio...
...patients undergoing coronary stent impl...
...patients with stent failure, IVUS o...
...In patients with STEMI, routine aspirati...
...tment of Calcified Lesions...
...In patients with fibrotic or heavily calc...
...with fibrotic or heavily calcified lesio...
...Saphenous Vein Graft Disease (Previ...
...patients with previous CABG undergoing PCI of...
...n patients with previous CABG, if PCI of a di...
In patients with a chronic occlusion of a...
...reatment of CTO In patients with suitable an...
...ment of Patients With Stent Restenosis...
...ts who develop clinical ISR for whom re...
...nts with symptomatic recurrent diffuse ISR with an...
In patients who develop recurrent ISR, brachyth...
...pport for Complex PCI In selected high-risk...
...therapy in Patients Undergoing PC...
...Oral P2Y12 Inhibitors in Patients Undergo...
...ts undergoing PCI, a loading dose of aspirin,...
In patients with ACS undergoing PCI, a l...
...In patients with SIHD undergoing PCI, a...
...patients undergoing PCI within 24 hours...
...ients with ACS undergoing PCI, it is rea...
In patien...
...atients undergoing PCI who have a histor...
...cations to ticagrelor: previous intracranial hemo...
...7. Oral and Parental Antiplatelet Agents for Pat...
...avenous P2Y12 Inhibitors in Patients Un...
...ents undergoing PCI who are P2Y12 inhibi...
...enous Glycoprotein IIb/IIIa Inhibitors in Patie...
...ents with ACS undergoing PCI with large thrombu...
...tients with SIHD undergoing PCI, the routine use...
...Molecular-Weight Heparin, and Bivali...
In patients undergoing PCI, admi...
...s with heparin-induced thrombocytopen...
...n patients undergoing PCI, bivalirudin may...
...ts treated with upstream subcutaneo...
...patients on therapeutic subcutaneous eno...
...agulant Dosing During PCI*Having trouble...
...eral Procedural Issues for...
...tive Considerations in Patients Unde...
For patients undergoing CABG, establis...
...9. Perioperative Anesthetic and Mon...
...uits in Patients Undergoing CABG...
...In patients undergoing isolated CABG, the use...
...In patients undergoing CABG, an IMA, prefera...
In patients undergoing CABG, BIMA graf...
...ractices for the Use of Bypass Con...
...ABG in Patients Undergoing Other Cardiac Sur...
...ents undergoing valve surgery, aortic...
...tients undergoing valve surgery, a...
...aortic Ultrasound in Patients Undergoing CABG...
...patients undergoing CABG, the routine use of epiao...
...se of Cardiopulmonary Bypass in Pati...
...ith significant calcification of the aorta...
...s with significant pulmonary disease, off-...
...erapy in Patients Undergoing CABG...
...lin Infusion and Other Measures to Reduce Sternal...
...tients undergoing CABG, an intraoperati...
...In patients undergoing CABG, the use of...
...In patients undergoing CABG, a compre...
...ents undergoing CABG, the usefulness of continuo...
...1. Best Practices to Reduce Sternal...
...tiplatelet Therapy in Patients Undergoi...
...ndergoing CABG who are already taking...
...s referred for urgent CABG, clopid...
...s undergoing CABG, discontinuation of short...
...atients undergoing elective CABG who...
...ients undergoing elective CABG who...
...ta Blockers and Amiodarone in Patients Undergoin...
...undergoing CABG, who do not have a con...
...tients undergoing CABG, preoperative amiodarone i...
...atients undergoing CABG, who do not have a contr...
...n patients undergoing CABG, the role of pr...
...py in Patients After Revascularization...
...elet Therapy in Patients After PCI...
...lected patients undergoing PCI, shorte...
Figure 7. Use of DAPT for Patient...
...platelet Therapy in Patients After CABG...
...undergoing CABG, aspirin (100–325 mg daily) sho...
...patients undergoing CABG, DAPT with aspiri...
...kers in Patients After Revascularization
...patients with SIHD and normal left vent...
...Blockers for the Prevention of Atr...
...In patients after CABG, beta blockers ar...
...Therapy in Patients With Atrial Fib...
...patients with atrial fibrillation who are...
...ith atrial fibrillation who are undergoing PC...
...sychosocial Factors and Lifestyle Changes After...
...rdiac Rehabilitation and Edu...
...who have undergone revascularization,...
...atients who have undergone revascularizatio...
...ion in Patients After Revascularization...
...patients who use tobacco and have...
...who use tobacco and have undergone...
...ological Interventions in Patients Af...
...tients who have undergone coronary revascula...
...ts who have undergone coronary revascularizati...
...ure 8. Traditional and Psychosocial Ri...
Revascularization Outcomes
Revascularization Outcom...
...f Outcomes in Patients After Revasculariz...
...the goal of improving patient outcomes...
...With the goal of improving patient outcomes, it is...
...er volume cardiac surgery and PCI pr...