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ACC/AHA/SCAI updated guideline for coronary artery revascularization
USA: A recent study reported in the journal Circulation provides clinical guidance by the American College of Cardiology (ACC)/American Heart Association (AHA)/Society for Cardiovascular Angiography and Interventions (SCAI) on coronary artery revascularization. The guidance was also co-published in the Journal of the American College of Cardiology (JACC).
The recommendations, replace the 2011 coronary artery bypass graft surgery guideline and the 2011 and 2015 percutaneous coronary intervention guidelines. The guidance offers a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization, as well as the supporting documentation to encourage their use.
For developing the guideline, Jennifer S. Lawton and the team performed a comprehensive literature search from May 2019 to September 2019 from online databases. Additional relevant studies, published through May 2021, were also considered.
Given below are the key points from the guideline:
- 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.
- 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 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.
- 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.
- 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.
- 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.
- 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 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.
- 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.
- 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.
Full guideline was reviewed by 2 official reviewers each nominated by the ACC and AHA; 1 reviewer each from the ACC, AHA, Society of Thoracic Surgeons, American Association for Thoracic Surgery, and the Society for Cardiovascular Angiography and Interventions; and 31 individual content reviewers.
Reference:
2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines, was published in the journal Circulation.
MSc. Biotechnology
Medha Baranwal joined Medical Dialogues as an Editor in 2018 for Speciality Medical Dialogues. She covers several medical specialties including Cardiac Sciences, Dentistry, Diabetes and Endo, Diagnostics, ENT, Gastroenterology, Neurosciences, and Radiology. She has completed her Bachelors in Biomedical Sciences from DU and then pursued Masters in Biotechnology from Amity University. She has a working experience of 5 years in the field of medical research writing, scientific writing, content writing, and content management. She can be contacted at editorial@medicaldialogues.in. Contact no. 011-43720751
Dr Kamal Kant Kohli-MBBS, DTCD- a chest specialist with more than 30 years of practice and a flair for writing clinical articles, Dr Kamal Kant Kohli joined Medical Dialogues as a Chief Editor of Medical News. Besides writing articles, as an editor, he proofreads and verifies all the medical content published on Medical Dialogues including those coming from journals, studies,medical conferences,guidelines etc. Email: drkohli@medicaldialogues.in. Contact no. 011-43720751