2021 ACC revascularization guidelines: Endorsing radial access, shorter DAPT feature among major recommendations.

The American College of Cardiology and American Heart Association (ACC/AHA) have issued new guidelines for the revascularization of coronary artery disease which have now been published in Circulation journal. Recommendations from the earlier percutaneous coronary intervention and coronary artery bypass graft surgery guidelines have been updated with new evidence to guide clinicians in caring for patients undergoing coronary revascularization.

The key takeaways from these guidelines are:

1. Clinical indications take precedence over demographic features: The latest guidelines recommend that treatment decisions regarding coronary revascularization should be based on clinical indications, regardless of sex, race, or ethnicity.

2. In patients being considered for coronary revascularization for whom the optimal treatment strategy is unclear, a multidisciplinary Heart Team approach is recommended.

3. The most practice changing recommendation: One big change is the emphasis on a radial-first approach, both in acute coronary syndrome (ACS) and stable ischemic heart disease (SIHD) patients undergoing percutaneous intervention (PCI).

Radial access is now a class 1A indication.

4. Shorter DAPT is finally "in": The new guidelines emphasize shorter-duration dual antiplatelet therapy (DAPT) following PCI. In most patients, DAPT for 1 to 3 months is considered a reasonable option (class 2a, level of evidence A) to reduce the risk of bleeding events.

5. Staged, complete revascularization after STEMI also gets a strong recommendation on the basis of the COMPLETE trial. PCI of non-infarct-related arteries shouldn't be performed in STEMI patients complicated by cardiogenic shock.

6. SIHD: Decisions to be made on "survival" or "symptom" basis:

With mortality as the focus, CABG is recommended to improve survival (class 1, level of evidence B) in stable patients with multivessel CAD and severe left ventricular systolic dysfunction (LVEF < 35%), largely on the basis of the STITCH trial. Surgery is also recommended (class 1, level of evidence B) to improve survival for SIHD patients with significant left main stenosis.

For stable multivessel disease without reduced EF or significant left main involvement, CABG surgery has been downgraded from a prior class 1 recommendation to a class 2b (level of evidence B) recommendation based largely on new evidence from the BARI-2D and ISCHEMIA trials.

7. In patients with multivessel disease considered complex or diffuse (SYNTAX score > 33), it is reasonable to choose CABG over PCI. Same is the case for patients with diabetes and multivessel CAD that includes the LAD artery.

8. In terms of reducing outcomes other than mortality in stable patients, the guidelines give CABG and PCI a class 2a indication (level of evidence B) to lower the risk of cardiovascular events, such as spontaneous MI, urgent unplanned revascularization, or cardiac death.

9. STEMI: PCI or surgery (if PCI is not feasible) is a class 1 indication in STEMI patients with cardiogenic shock or hemodynamic instability irrespective of symptom onset and rescue PCI is a class I indication after failed fibrinolytic therapy. PCI is not recommended for patients without ongoing symptoms or severe ischemia who present after more than 24 hours with a totally occluded infarct-related artery.

10. NSTEMI: In those with NSTE ACS, an invasive strategy with the intent of performing revascularization is recommended to reduce the risk of cardiovascular events (class 1, level of evidence A).

It is also recommended for NSTE ACS patients in cardiogenic shock, those with refractory angina, or hemodynamic or electrical instability. An early strategy (within 24 hours) is a reasonable approach (class 2a, level of evidence B) in stabilized NTSE-ACS patients at high risk for ischemic events.

11. Road to CTOs is still not clear: The guidelines throw some cold water on the treatment of chronic total occlusions (CTOs), stating that the benefit of PCI for the improvement of symptoms is uncertain (class 2b, level of evidence B).

Source: Circulation journal:

1. https://doi.org/10.1161/CIR.0000000000001039

2. https://doi.org/10.1161/CIR.0000000000001038