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2021 ACC-AHA-SCAI Guideline of Coronary Artery Revascularization PowerPoint Presentation

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This medical is clinical update adapted from The 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization provides recommendations for the management of patients with stable ischemic heart disease (SIHD) and acute coronary syndromes (ACS).

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Slide 1-

Clinical Update ADAPTED FROM: 2021 ACC/AHA/SCAI Guideline of Coronary Artery Revascularization
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Table 1. Applying ACC/AHA Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated May 2019)* COR and LOE are determined independently (any COR may be paired with any LOE). A recommendation with LOE C does not imply that the recommendation is weak. Many important clinical questions addressed in guidelines do not lend themselves to clinical trials. Although RCTs are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective. *The outcome or result of the intervention should be specified (an improved clinical outcome or increased diagnostic accuracy or incremental prognostic information). †For comparative-effectiveness recommendation (COR 1 and 2a; LOE A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated. ‡The method of assessing quality is evolving, including the application of standardized, widely-used, and preferably validated evidence grading tools; and for systematic reviews, the incorporation of an Evidence Review Committee. COR indicates Class of Recommendation; EO, expert opinion; LD, limited data; LOE, Level of Evidence; NR, nonrandomized; R, randomized; and RCT, randomized controlled trial. 2
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Improving Equity of Care in Revascularization 3 Abbreviations: CVD indicates cardiovascular disease. Health disparities by sex and race are evident across the spectrum of CVD in the United States. Women and non-White patients are less likely to receive guideline-based therapies. Women and non-White patients derive comparable benefit from revascularization after controlling for other factors. 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 (Class 1).
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Shared Decision-Making and Informed Consent 4 Informed Consent Clinician provides the best available evidence for treatment options, including the risks & benefits of each option Patient-Centered Care Treatment & care options take into consideration individual values & preferences Shared Decision-Making A collaborative decision about treatment or care is documented and shared with relevant stakeholders
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Factors for Consideration by the Heart Team Coronary Anatomy Left main disease Multivessel disease High anatomic complexity (i.e., bifurcation disease, high SYNTAX score) Comorbidities Diabetes Systolic dysfunction Coagulopathy Valvular heart disease Frailty Malignancy ESRD COPD Immunosuppression Debilitating neurological disorders Liver disease/cirrhosis Prior CVA Calcified aorta Aortic aneurysm Procedural Factors Local and regional outcomes Access site for PCI Surgical risk PCI risk Patient Factors Unstable presentation or shock Patient preferences Inability or unwillingness to adhere to DAPT Religious beliefs Patient education, knowledge, and understanding Guiding Principle: Ideal situations for Heart Team consideration include patients with complex coronary disease, comorbid conditions that could impact the success of the revascularization strategy, and other clinical or social situations that may impact outcomes. Abbreviations: COPD indicates chronic obstructive pulmonary disease; CVA, cerebral vascular accident; DAPT, dual antiplatelet therapy; ESRD, end-stage renal disease; PCI, percutaneous coronary intervention; and SYNTAX, Synergy Between PCI With TAXUS and Cardiac Surgery. 5
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Assessing Risk for Patients Undergoing CABG Guiding Principle: In patients who are being considered for CABG, calculation of the STS risk score is recommended to help stratify patient risk. The MELD score, gait speed, and the MUST score may help in patients with cirrhosis, frailty, and malnutrition respectively. Abbreviations: CABG indicates coronary artery bypass grafting; MELD, Model for End-Stage Liver Disease; MUST, Malnutrition Universal Screening Tool; and STS, Society of Thoracic Surgeons. * See: https://www.sts.org/resources/risk-calculator In patients who are being considered for CABG, calculation of the Society of Thoracic Surgeons (STS) risk score is recommended to help stratify patient risk (Class 1).* Reoperation Prolonged Ventilation Renal Failure Death Permanent Stroke Deep Sternal Wound Infections Prolonged Length of Stay 6
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Defining Lesion Severity 7 Lesion Severity Coronary Physiology (Class 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. Coronary Physiology (Class 3: No Benefit) In stable patients with angiographically intermediate stenoses and FFR >0.80 or iFR >0.89, PCI should not be performed. IVUS (Class 2a) In patients with intermediate stenosis of the left main artery, intravascular ultrasound (IVUS) is reasonable to help define lesion severity. SYNTAX Score (Class 2b) In patients with multivessel CAD, an assessment of CAD complexity, such as the SYNTAX score, may be useful to guide revascularization. Coronary Angiography Significant stenosis is defined as >70% for non-LMT and >50% for LMT. Intermediate stenoses (40-69%) generally warrant additional investigation. No standard cutoffs for lesion length used to classify a severe stenosis. Abbreviations: CAD indicates coronary artery disease; FFR, fractional flow reserve; iFR, instantaneous wave-free ratio; IVUS, intravascular ultrasound; LMT, left main trunk; PCI, percutaneous coronary intervention; and SYNTAX, Synergy Between PCI With TAXUS and Cardiac Surgery.
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Table 8. Patient Clinical Status Definitions to Guide Revascularization Elective Cardiac function has been stable in the days-weeks before intervention. The intervention could be deferred without increased risk of compromise to cardiac outcome. Urgent Intervention is required during the same hospitalization to minimize chance of further clinical deterioration. Examples include worsening sudden chest pain, heart failure, acute myocardial infarction, anatomy, intra-aortic balloon pump, unstable angina, with intravenous nitroglycerin, or rest angina. Emergency Patients requiring emergency intervention will have ongoing, refractory, unrelenting cardiac compromise, with or without hemodynamic instability, and not responsive to any form of therapy except cardiac intervention. There should be no delay in providing operative intervention. Emergency/salvage Patients requiring emergency/salvage intervention are those who require cardiopulmonary resuscitation in route to intervention, before induction of anesthesia or who require extracorporeal membrane oxygenation to maintain life. 8
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Revascularization of Infarct Artery in STEMI to Improve Survival/Clinical Outcomes Patient with STEMI PCI if… ischemic symptoms for <12 hr (1) failed reperfusion after fibrinolytic therapy, then rescue PCI (1) cardiogenic shock or hemodynamic instability (1) Fibrinolytics w/ angiography 3 to 24 hr with PCI intent (2a) stable &12 to 24 hr after symptom onset (2a) ongoing ischemia, acute severe HF, or life-threatening arrhythmia (2a) In asymptomatic stable STEMI w/ total occlusion >24 hr after symptom onset & no severe ischemia, PCI should not be performed. (3:No Benefit) CABG if… mechanical complications: ventricular septal rupture mitral valve insufficiency due to papillary muscle infarction or rupture free wall rupture) (1) cardiogenic shock or hemodynamic instability (1) If PCI is not feasible or successful, with a large area of myocardium at risk (2a) In STEMI, emergency CABG should NOT be performed after failed primary PCI: In absence of ischemia or large area of myocardium at risk, or If surgical revascularization is not feasible because of a no-reflow state or poor distal targets. (3:Harm) Abbreviations: CABG indicates coronary artery bypass grafting; HF, heart failure; hr, hour; MI, myocardial infarction; PCI, percutaneous coronary intervention; STEMI, ST-segment–elevation myocardial infarction; and w/, with. 9
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Revascularization of Non–Infarct-Related Coronary Artery Lesions in STEMI Patients without significant comorbidities with large non-infarct vessels 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. (Class 1) low-complexity multivessel disease, PCI of a non-infarct artery stenosis may be considered at time of primary PCI to reduce cardiac events. (Class 2b) In STEMI… in selected patients with complex multivessel non-infarct artery disease, after successful primary PCI, elective CABG is reasonable. (Class 2a) complicated by cardiogenic shock, routine PCI of a non-infarct artery at time of primary PCI should NOT be performed due to higher risk of death or renal failure. (Class 3:Harm) 10 Abbreviations: CABG indicates coronary artery bypass grafting; MI, myocardial infarction; PCI, percutaneous coronary intervention; and STEMI, ST-segment–elevation myocardial infarction.
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Figure 5. Recommendations Timing of Invasive Strategy in NSTE-ACS NSTE-ACS Cardiogenic shock Refractory angina or hemodynamic instability At high risk (e.g., GRACE score* >140) for clinical events In initially stabilized patients who are at intermediate or low risk for clinical events Immediate invasive strategy (1) Early invasive strategy within 24 hours (2a) Invasive strategy with intent to perform revascularization before hospital discharge (2a) Guiding Principle: Revascularization in the context of NSTE-ACS should consider clinical stability, risk of recurrent event(s), coronary anatomy, and degree of myocardium at risk. *https://www.mdcalc.com/grace-acs-risk-mortality-calculator Abbreviations: GRACE indicates Global Registry of Acute Coronary Events; and NSTE-ACS, non–ST-segment–elevation acute coronary syndrome 11
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Figure 6. Revascularization in Patients With SIHD Abbreviations: CABG indicates coronary artery bypass grafting; CAD, coronary artery disease; EF, ejection fraction; GDMT, guideline-directed medical therapy; PCI, percutaneous coronary intervention; and SIHD, stable ischemic heart disease. SIHD Refractory angina on medical therapy? Revascularization (1) YES NO CABG (1) Left main disease? YES NO Significant left main stenosis & high anatomic complexity CAD? YES NO Suitable candidate for CABG? YES NO Heart Team Discussion (1) GMDT with or w/o PCI CABG (1) PCI (2a) Multivessel CAD with anatomy suitable for PCI or CABG? YES NO GMDT Ischemic cardiomyopathy EF< 50%? YES NO EF>50% and triple-vessel disease CABG (2b) PCI (2b) Suitable candidate for CABG? YES NO Heart Team Discussion (1) GMDT with or w/o PCI EF<35% EF 35% to 50% CABG (1) CABG (2a) Indications to improve symptoms Anatomic indications to improve survival 12
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Revascularization Based Approach to Improve Mortality Compared with Medical Therapy in SIHD Patient Subsets Deriving Class I Benefits of Revascularization Patient Subsets Deriving Class 2a or 2b Recommendations Abbreviations: CABG indicates coronary artery bypass grafting; EF, ejection fraction; LAD, left anterior descending artery; LVEF, left ventricle ejection fraction; PCI, percutaneous coronary intervention; and SIHD, stable ischemic heart disease. 13
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Revascularization Based Approach to Improve Mortality Compared with Medical Therapy in SIHD Patient Subsets Deriving Class 3 Recommendations Abbreviations: CABG indicates coronary artery bypass grafting; EF, ejection fraction; LAD, left anterior descending artery; LVEF, left ventricle ejection fraction; PCI, percutaneous coronary intervention; and SIHD, stable ischemic heart disease. 14
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Revascularization Approach to Reduce Cardiovascular Events in SIHD Compared with Medical Therapy Revascularization Approach to Improve Symptoms Abbreviations: CABG indicates coronary artery bypass grafting; EF, ejection fraction; LAD, left anterior descending artery; LVEF, left ventricle ejection fraction; PCI, percutaneous coronary intervention; and SIHD, stable ischemic heart disease. 15
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PCI vs CABG in Patients with COMPLEX DISEASE Patients with Complex Disease Guiding Principle: CABG improves survival compared with PCI in patients with left main and complex CAD. Abbreviations: CABG indicates coronary artery bypass grafting; CAD, coronary artery disease; PCI , percutaneous coronary intervention; and SYNTAX, synergy between percutaneous coronary intervention with Taxus and cardiac surgery. 16
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PCI vs CABG in Patients with COMPLEX DISEASE Patients With Diabetes Guiding Principle: CABG compared to PCI has a benefit in mortality and repeat revascularizations in diabetics. Abbreviations: CABG indicates coronary artery bypass grafting; CAD, coronary artery disease; LAD, left anterior descending artery; LIMA, left internal mammary artery; LM, left main artery; and MACO, major adverse cardiovascular outcomes. 17 Diabetes with multivessel CAD Appropriate candidate for CABG CABG with LIMA to LAD is recommended (Class 1)
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PCI vs CABG in Patients with COMPLEX DISEASE Patients with previous CABG * When an IMA can be used as a conduit to the LAD. Guiding Principle: A Heart Team approach is important for those patients with a prior history of CABG requiring revascularization. Abbreviations: CABG indicates coronary artery bypass grafting; CAD, coronary artery disease; GDMT, guideline-directed medical therapy; IMA, internal mammary artery; LIMA, left internal mammary artery; and PCI, percutaneous coronary intervention. Previous CABG Patent LIMA to LAD who need repeat revascularization Refractory angina on GDMT attributable to LAD disease Complex CAD It is reasonable to choose PCI over CABG (Class 2a) Is PCI feasible? It is reasonable to choose CABG over PCI* (Class 2a) It may be reasonable to choose CABG over PCI* (Class 2a) 18
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Revascularization in Special Populations and Situations Pregnant Patients Older Patients Abbreviations: AKI indicates acute kidney injury; CAD, coronary artery disease; CKD, chronic kidney disease; NSTE-ACS, Non-ST segment elevation acute coronary syndrome; PCI, percutaneous coronary intervention; SCAD; spontaneous coronary artery dissection; and STEMI, ST segment elevation myocardial infarction 19
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Revascularization in Special Populations and Situations Chronic Kidney Disease 20 Abbreviations: AKI indicates acute kidney injury; CAD, coronary artery disease; CKD, chronic kidney disease; NSTE-ACS, Non-ST segment elevation acute coronary syndrome; PCI, percutaneous coronary intervention; SCAD; spontaneous coronary artery dissection; and STEMI, ST segment elevation myocardial infarction
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Best Practices in Cath Lab for Patients with CKD Undergoing Angiography RECOMMENDATIONS Assess the risk of contrast-induced AKI before the procedure. Administer adequate preprocedural hydration. Record the volume of contrast media administered, and minimize contrast use. Pretreat with high-intensity statins. Use radial artery if feasible. Delay CABG in stable patients after angiography beyond 24 hours when clinically feasible. Do not administer N-acetyl-L-cysteine to prevent contrast-induced AKI. Do not give prophylactic renal replacement therapy. Abbreviations: AKI indicates acute kidney injury; CABG, coronary artery bypass grafting; and CKD, chronic kidney disease. 21
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Revascularization in Special Populations and Situations Patients with SCAD Patients with Cardiac Allografts Reducing Ventricular Arrhythmias Before Noncardiac Surgery 22 Abbreviations: AKI indicates acute kidney injury; CAD, coronary artery disease; CKD, chronic kidney disease; NSTE-ACS, Non-ST segment elevation acute coronary syndrome; PCI, percutaneous coronary intervention; SCAD; spontaneous coronary artery dissection; and STEMI, ST segment elevation myocardial infarction
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General Procedural Issues for PCI: Procedure Considerations Vascular Access for PCI Stent Selection in PCI Intravascular Imaging in PCI , target vessel revascularization. Abbreviations: ACS indicates acute coronary syndrome; BMS, bare metal stent; CVA, cerebrovascular accident; DES, drug-eluting stent; IVUS, intravascular ultrasound; LM, left main coronary artery; MACE, major adverse coronary events; MI, myocardial infarction; OCT, optical coherence tomography; PCI, percutaneous coronary intervention; SIHD, stable ischemic heart disease; TLR, target lesion revascularization; and TVR, target vessel revascularization. PCI in ACS 30-day rates: Death Non-fatal MI and CVA Non-major bleeding Radial Approach (Class I) PCI in SIHD 30-day rates: Bleeding Vascular complications Significant reduction in: MI Restenosis Acute stent thrombosis DES should be used in preference to BMS (Class I) LM and complex coronary artery stenting Mechanism of stent failure Lesion preparation Stent sizing and expansion Evaluate complications IVUS and OCT can be useful for procedural guidance (2a) Compared with angiographic-guided PCI at 3 years, decreased MACE, TVR, TLR 23
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General Procedural Issues for PCI: Clinical Circumstances Thrombectomy No significant reduction in CV death, MI, cardiogenic shock, reinfarction, stent thrombosis or target lesion revascularization Increased risk of stroke Selective use in patients with high thrombus burden can be considered Calcified Lesions Abbreviations: CV indicates cardiovascular; MI, myocardial infarction; PCI, percutaneous coronary intervention; and STEMI, ST-elevation myocardial infarction. 24
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General Procedural Issues for PCI: Clinical Circumstances SVG Disease Increased periprocedural MI, no-reflow, stent thrombosis, TVR and death with SVG PCI Treatment of ISR Abbreviations: CABG indicates coronary artery bypass grafting; DAPT, dual antiplatelet therapy, DES, drug-eluting stent; ISR, in-stent restenosis; MI, myocardial infarction; PCI, percutaneous coronary intervention; SVG, saphenous vein graft; and TVR, target vessel revascularization. 25
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General Procedural Issues for PCI: Clinical Circumstances Hemodynamic Support RCT showed no benefit in the composite outcome of death, MI, CVA or repeat revascularization Significant reduction in major procedure complications, largely driven by improvement in hemodynamic support CTO Treatment 80% procedural success 1.3% 30-day mortality 4.8% perforation Euro CTO: significant reduction in angina frequency and improved QOL DECISION-CTO: no difference in symptoms or clinical outcomes Abbreviations: CTO indicates chronic total occlusion; CVA, stroke; IABP, intra-aortic balloon pump; MI, myocardial infarction; PCI, percutaneous coronary intervention; QOL, quality of life; and RCT, randomized controlled trial. 26
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Aspirin and Oral P2Y12 Inhibitors in Patients Undergoing PCI Abbreviations: ACS indicates acute coronary syndrome; PCI , percutaneous coronary intervention; SIHD, stable ischemic heart disease; ST, stent thrombosis; and TIA, transient ischemic attack. 27
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Aspirin and Oral P2Y12 Inhibitors in Patients Undergoing PCI Guiding Principle: The benefit of Gp IIb/IIIa inhibitors has decreased with shorter revascularization times and potent DAPT. Abbreviations: ACS indicates acute coronary syndrome; PCI , percutaneous coronary intervention; SIHD, stable ischemic heart disease; ST, stent thrombosis; and TIA, transient ischemic attack. 28
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Anticoagulation in Patients Undergoing PCI Guiding Principle: Antithrombotic therapy is a mainstay of treatment in patients undergoing PCI. Abbreviations: UFH indicates unfractionated heparin; NSTE-ACS, Non-ST elevation-acute coronary syndrome; and PCI, percutaneous coronary intervention. 29
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Figure 7: Use of DAPT for Patients After PCI Abbreviations: BMS indicates bare metal stent; DAPT, dual antiplatelet therapy; DES, drug eluting stent; PCI, percutaneous coronary intervention; and SIHD, stable ischemic heart disease. Patients Undergoing PCI SIHD ACS DES BMS 0 mo 1 mo 3 mo 6 mo 12 mo ≥1 mo aspirin plus clopidogrel (Class 1) ≥12 mo aspirin plus clopidogrel, or prasugrel, or ticagrelor (Class 1) Discontinue aspirin after 1-3 mo with continued P2Y12 monotherapy (Class 2a) Discontinue aspirin after 1-3 month with continued P2Y12 monotherapy (Class 2a) If high risk of bleeding or overt bleeding on DAPT, discontinuing P2Y12 after 3mo may be reasonable (Class 2b) If high risk of bleeding or overt bleeding on DAPT, discontinuing P2Y12 after 6mo may be reasonable (Class 2b) If no high risk of bleeding or significant overt bleeding on DAPT, >6 mo. DAPT may be reasonable (Class 2b) If no high risk of bleeding or significant overt bleeding on DAPT, >1 mo DAPT may be reasonable (Class 2b) If no high risk of bleeding or significant overt bleeding on DAPT, >1 y DAPT may be reasonable (Class 2b) ≥6 mo aspirin plus clopidogrel (Class 1) 30
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Antiplatelet Therapy in Patients with Atrial Fibrillation on Anticoagulation After PCI Abbreviations: DAPT indicates dual antiplatelet therapy; and PCI, percutaneous coronary intervention. 31 Patients with atrial fibrillation who are undergoing PCI and are taking oral anticoagulant therapy Reduce the risk of bleeding Recommend discontinuing aspirin after 1-4 weeks while maintaining P2Y12 inhibitors in addition to a non–vitamin K oral anticoagulant or warfarin (Class 1) When treated with DAPT or a P2Y12 inhibitor monotherapy, it is reasonable to choose a non–vitamin K oral anticoagulant over warfarin (Class 2a)
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Antiplatelet Therapy in Patients After CABG Abbreviations: CABG indicates coronary artery bypass grafting; and DAPT, dual antiplatelet therapy. Patients undergoing CABG Initiate aspirin (100-325 mg daily) within 6 hours postoperatively and continue indefinitely (Class 1) Reduce saphenous vein graft occlusion and adverse cardiovascular events Initiate DAPT with aspirin and ticagrelor or clopidogrel for 1 year (Class 2b) Improve vein graft patency compared with aspirin alone Selected patients undergoing CABG (e.g. off-pump, high SYNTAX score) 32
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Beta Blockers in Patients After Revascularization Abbreviations: CABG indicates coronary artery bypass grafting; LV, left ventricle; and SIHD, stable ischemic heart disease. The routine use of chronic oral beta blockers is not beneficial to reduce cardiovascular events (Class 3: No Benefit) Beta blockers are recommended and should be started as soon as possible (Class 1) Reduce the incidence or clinical sequelae of postoperative atrial fibrillation Patients after undergoing CABG Patients with SIHD and normal LV function who receive complete revascularization 33
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Focus on Perioperative Considerations in Patients Undergoing CABG and Outcomes 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. (Class 1) Abbreviations: CABG indicates coronary artery bypass grafting; CNS, central nervous system; CV, cardiovascular disease; LOS, length of stay; SIHD, stable ischemic heart disease; STEMI, ST segment elevation myocardial infarction; and TEE, transesophageal echo. 34
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Bypass Conduits in Patients Undergoing CABG Radial artery Recommended in preference to a saphenous vein conduit to graft the second most important, significantly stenosed, non–LAD vessel (Class 1) Source: This Photo by Unknown Author is licensed under CC BY-SA IMA (prefer left) To LAD (Class 1) Source: This Photo by Unknown Author is licensed under CC BY-SA BIMA Improves long-term outcomes when procedure is done by experienced operators (Class 2a) Source: https://vpjournal.net/article/view/3141 Click here for more best practices Abbreviations: BIMA indicates bilateral internal mammary artery; IMA, internal mammary artery; LAD, left anterior descending; and SVG, saphenous vein graft.. 35
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Patients Undergoing Other Cardiac Surgery and Operative Approach Source: This Photo by Unknown Author is licensed under CC BY-NC Source: This Photo by Unknown Author is licensed under CC BY-NC 36 Concomitant CABG (Class 1) Decrease stroke risk Off-pump or beating heart approach may be reasonable (Class 2a) Significant Aortic Calcification OR Significant Pulmonary disease Valve, aortic, OR other cardiac surgery Significant CAD Abbreviations: CABG indicates coronary artery bypass grafting; and CAD, coronary artery disease.
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Use of Epiaortic Ultrasound in Patients Undergoing CABG 37 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 (Class 2a) Abbreviations: TEE indicates transesophageal echo; and US, ultrasound. Superior to digital palpation or TEE “Gold standard” for detection of presence, location, and severity
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Decrease Post-operative Deep Sternal Wound Infections 38 Intraop + Postop Target Serum Glucose Level: <180mg/dL (Class 1) Administer IV insulin continuous infusion AVOID hypoglycemia Click here for more best practices Abbreviations: IV indicates intravenous; and SWI, sternal wound infections.
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Perioperative Pharmacotherapy 39 Pre-op Anti-platelet Anti-Arrhythmics* Preop * In patients with no contraindications to usage BB and Amiodarone can reduce the incidence of post-op afib (Class 2a) BB may reduce mortality or postop complications (Class 2b) Abbreviations: AFIB indicates atrial fibrillation; ASA, aspirin; BB, beta blockers; D, days; and HRS, hours.
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Psychosocial Factors and Lifestyle Changes after Revascularization 40 Cardiac Rehabilitation and Education Smoking Cessation Psychological Interventions Abbreviations: CV indicates cardiovascular; CVD, cardiovascular disease; and QOL, quality of life.
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Traditional and Non-Traditional Risk Factors for CVD 41 After revascularization, patients should be educated about CVD risk factors and their modification to reduce CV events (Class 1). Behavioral interventions and pharmacotherapy (NRT, varenicline, bupropion) (Class 1) Cognitive behavioral therapy, psychological counseling, and/or pharmacological treatment (Class 1) 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease AHA’s Life’s Simple 7 program Abbreviations: ASCVD indicates atherosclerotic cardiovascular disease; CV, cardiovascular; CVD, cardiovascular disease; and NRT, nicotine replacement therapy.
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Revascularization Outcomes Revascularization centers should participate in clinical data registries to review and improve patient outcomes. 42 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-adjust outcomes as a quality assessment and improvement strategy (Class 1). With the goal of improving patient outcomes, is reasonable for cardiac surgery and PCI programs to have a QI program that routinely: reviews institutional quality programs and outcomes, reviews individual operator outcomes, provides peer review of difficult or complicated cases, performs random case reviews. (Class 2a) In asymptomatic stable STEMI w/ total occlusion >24 hr after symptom onset & no severe ischemia, PCI should not be performed. (3:No Benefit) Abbreviations: QI indicates quality improvement; and PCI, percutaneous coronary intervention.
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Unanswered Questions and Future DirectionsSpecial Clinical Situations: Left Ventricular Dysfunction Data from randomized control trials support surgical revascularization in the setting of left ventricular dysfunction to improve survival. Although commonly used to guide revascularization decisions, the role of myocardial viability imaging (for example, with PET or MRI) in guiding clinical practice is unclear. Further research is needed into whether PCI can improve survival in patients with systolic heart failure. Abbreviations: MRI indicates magnetic resonance imaging; PET, positron emission tomography; and PCI percutaneous coronary intervention. 43  ? ?
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Special Clinical Situations: Nonatherosclerotic Lesions 44 Spontaneous coronary artery dissection Expert consensus recommends conservative care for most patients. Research is needed to understand optimal management in patients with ongoing symptoms, hemodynamic instability, or severely compromised flow to a large myocardial territory. Coronary artery aneurysms Coronary artery aneurysms can be asymptomatic or lead to ischemia, thrombosis, fistula formation, or rupture. The ideal timing and mode of intervention is unknown. Myocardial bridging In cases of severe ischemia and significant myocardial bridging, surgical approaches are available, but the long-term risks and benefits are uncertain. Source: https://resident360.nejm.org/clinical-pearls/spontaneous-coronary-artery-dissection
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Unanswered Questions and Future Directions Special Clinical Situations: Considerations in Bypass Grafting 45 Heart Team discussions are appropriate for management of acute graft failure, obstructive graft disease, and PCI of native arteries via bypass grafts. There are no data to determine the optimal antithrombotic regimen of patients after ACS who undergo CABG and also have an indication for systemic anticoagulation. The roles of hybrid surgical/ percutaneous revascularization in multivessel disease and the use of non-sternotomy surgical approaches remain unknown. Abbreviations: ACS indicates acute coronary syndrome, CABG, coronary artery bypass grafting, and PCI percutaneous coronary intervention.  ? ?
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Unanswered Questions and Future Directions Special Clinical Situations: Completeness of Revascularization 46 Observational data have shown worse outcomes in patients with multivessel disease if severe stenoses in major epicardial arteries are not revascularized during the index procedure. However, patients in these studies who underwent incomplete revascularization had more significant comorbidities, and the motivations behind an individual operator's procedural decisions are complex. It is reasonable to assume that improving perfusion to as large a myocardial territory as possible is likely beneficial, but evidence from RCTs is lacking. RCTs are needed compare the outcomes of complete versus incomplete revascularization in stable ischemic heart disease. Abbreviations: RCT indicates randomized controlled trial.  ? ? 
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Special Clinical Situations: Elective Revascularization prior to other Procedures 47 Further research is needed to determine whether routine revascularization prior to TAVR improves clinical outcomes. It is common for a patient to be referred for revascularization in preparation for solid organ transplantation. Patients awaiting solid organ transplant are complex, and it remains unclear whether revascularization prior to organ transplantation positively impacts survival. Abbreviations: CAD indicates coronary artery disease; PCI, percutaneous coronary intervention; and TAVI, transcatheter aortic valve implantation. ? ? 
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Acknowledgments Many thanks to our Guideline Ambassadors who were guided by Dr. Elliott Antman in developing this translational learning product in support of the ACC/AHA/SCAI Guideline for Coronary Artery Revascularization Karen Deffenbacher, MD Amit Goyal, MD Madonna Lee, MD Madeline Mahowald, MD Manolo Rubio Garcia, MD Hanjay Wang, MD 48 The American Heart Association requests this electronic slide deck be cited as follows: Deffenbacher, K., Goyal, A., Lee, M., Mahowald, M., Garcia, M., Wang, H., Bezanson, J. L., & Antman, E. M. (2021). Clinical Update; Adapted from: ACC/AHA/SCAI Guideline for Coronary Artery Revascularization [PowerPoint slides]. Retrieved from https://professional.heart.org/en/science-news
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Appendix
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Table 13. Best Practices for the Use of Bypass Conduits in CABG Objectively assess palmar arch completeness and ulnar compensation before harvesting the radial artery. Use the arm with the best ulnar compensation for radial artery harvesting. Use radial artery grafts to target vessels with subocclusive stenoses. Avoid the use of the radial artery after transradial catheterization. Avoid the use of the radial artery in patients with chronic kidney disease and a high likelihood of rapid progression to hemodialysis. Use oral calcium channel blockers for the first postoperative year after radial artery grafting. Avoid bilateral percutaneous or surgical radial artery procedures in patients with coronary artery disease to preserve the artery for future use. Harvest the internal mammary artery using the skeletonization technique to reduce the risk of sternal wound complications. Use an endoscopic saphenous vein harvest technique in patients at risk of wound complications. Use a no-touch saphenous vein harvest technique in patients at low risk of wound complications. Use the skeletonized right gastroepiploic artery to graft right coronary artery target vessels with subocclusive stenosis if the operator is experienced with the use of the artery. 50  Return to previous slide Abbreviations: CABG indicates coronary artery bypass grafting.
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Table 14. Best Practices to Reduce Sternal Wound Infection in Patients Undergoing CABG Perform nasal swab testing for Staphylococcus aureus (8). Apply mupirocin 2% ointment to known nasal carriers of S aureus (8). Apply preoperative intranasal mupirocin 2% ointment to those patients whose nasal culture or PCR result is unknown (8). Redose prophylactic antimicrobials for long procedures (>2 half-lives of the antibiotic) or in cases of excessive blood loss during CABG (10, 11, 27). Measure perioperative HbA1c (31). Treat all distant extrathoracic infections before nonemergency surgical coronary revascularization (19). Advise smoking cessation before elective CABG surgery (7). Apply topical antibiotics (vancomycin) to the cut edges of the sternum on opening and before closing in cardiac surgical procedures involving a median sternotomy (4, 32). Use skeletonized harvest of IMA in BIMA grafting (16). Do not continue prophylactic antibiotics beyond 48 hours (9, 11) 51  Return to previous slide Abbreviations: CABG indicates coronary artery bypass grafting.