ACC/AHA/SCAI updated guideline for coronary artery revascularization

Given below are the key points from the guideline:

1. Treatment decisions regarding coronary revascularization in patients with coronary artery disease (CAD) 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.
2. 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.
3. For patients with the 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 CAD and left main disease that is equally suitable for surgical or percutaneous revascularization.
4. Updated evidence from contemporary trials supplements older evidence with regard to the mortality benefit of revascularization in patients with stable ischemic heart disease, normal left ventricular ejection fraction, and triple-vessel CAD. 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, the technical feasibility of treatment, and a Heart Team discussion.
5. The use of a radial artery as a surgical revascularization conduit is preferred versus 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.
6. Radial artery access is recommended in patients undergoing percutaneous intervention who have acute coronary syndrome or stable ischemic heart disease, to reduce bleeding and vascular complications compared with a femoral approach. Patients with acute coronary syndrome also benefit from a reduction in mortality rate with this approach.
7. 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.
8. Staged percutaneous intervention (while in a hospital or after discharge) of a significantly stenosed nonculprit artery in patients presenting with an ST-segment–elevation myocardial infarction is recommended in select patients to improve outcomes. Percutaneous intervention of the nonculprit 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 nonculprit artery disease, and normal renal function. In contrast, the percutaneous intervention of the nonculprit artery can be harmful in patients in cardiogenic shock.
9. Revascularization decisions in patients with diabetes and multivessel CAD are optimized by the use of a Heart Team approach. Patients with diabetes who have the triple-vessel disease should undergo surgical revascularization; percutaneous coronary intervention may be considered if they are poor candidates for surgery.
10. Treatment decisions for patients undergoing surgical revascularization of CAD should include the calculation of a patient's surgical risk with the Society of Thoracic Surgeons score. The usefulness of the SYNTAX (Synergy Between PCI With TAXUS and Cardiac Surgery) score calculation in treatment decisions is less clear because of the interobserver variability in its calculation and its absence of clinical variables.