ACC-AHA 2021 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization
ACC/AHA｜循環器 / 冠動脈疾患｜97 ページ｜チャンク 1033｜推奨 14 件｜current
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| 頁 | クラス | レベル | 推奨文 | 表 |
|---|---|---|---|---|
| p.14 | 1 A | Downloaded from http://ahajournals.org by on October 7, 2026 1. In patients with multivessel CAD, an assessment of CAD complexity, such as the SYNTAX score, may be useful to guide revascularization.1-4 2b B-NR Synopsis The anatomic complexity of lesions, expected completeness of revascularization, predicted risk of death, and other adverse outcomes are important factors to consider for determining the type of revascularization for patients with CAD. Many factors contribute to the estimation of the complexity of CAD (Table 6). The SYNTAX score was prospectively derived from the SYNTAX trial to aid in this decision-making process by providing an objective measure to grade the anatomic complexity of Table 6. Angiographic Features Contributing to Increasing Complexity of CAD Multivessel disease Left main or proximal LAD artery lesion Chronic total occlusion Trifurcation lesion Complex bifurcation lesion Heavy calcification Severe tortuosity | ||
| p.16 | 1 A | Downloaded from http://ahajournals.org by on October 7, 2026 | ||
| p.18 | 1 A | 6. The benefit of PCI for asymptomatic patients presenting 12 to 24 hours after symptom onset is not well studied. The BRAVE-2 (Beyond 12 Hours Reperfusion Alternative Evaluation-2) trial examined the benefits of PCI in reducing infarct size in asymptomatic patients with STEMI and symptom onset >12 hours but <48 hours before presentation.21 In this small study, an invasive strategy of coronary stenting was associated with a reduction in left ventricular infarct size (primary endpoint) compared with a conservative strategy.21 Moreover, an invasive strategy was associated with a reduction in adjusted 4-year mortality rate compared with the conservative strategy.43 Observational data from the Prospective National Observational study also supported a lower adjusted 1-year mortality rate in patients with STEMI and symptom onset 12 to 24 hours before presentation.22 This information should be balanced by the potential for “harm” when PCI of a totally occluded artery is performed more than 24 hours after symptom onset. Therefore, delayed PCI of an infarct artery beyond 24 hours should be considered only in patients with a patent artery. 7. In patients with STEMI, there may be situations in which PCI is not possible for anatomic reasons or because of the presence of severe left main or multivessel CAD. Additionally, in unusual circumstances, PCI may not be successful. In such cases, CABG can be an effective primary reperfusion strategy, particularly if there is a large area of myocardium at risk.23,24 Downloaded from http://ahajournals.org by on October 7, 2026 8. There are no RCTs examining the benefit of PCI in patients with STEMI presenting >12 hours after symptom onset who have clinical evidence of ongoing ischemia, acute severe heart failure, or life-threatening arrhythmias. Intuitively, a strategy of delayed reperfusion in these unstable patient subsets would be expected to improve symptoms | ||
| p.21 | 1 A | CLINICAL STATEMENTS AND GUIDELINES | ||
| p.27 | 1 A | CLINICAL STATEMENTS AND GUIDELINES | ||
| p.28 | 1 A | Downloaded from http://ahajournals.org by on October 7, 2026 | ||
| p.35 | 1 A | CLINICAL STATEMENTS AND GUIDELINES | ||
| p.35 | 1 A | Downloaded from http://ahajournals.org by on October 7, 2026 | ||
| p.35 | 1 A | Over the past decade, the proportion of patients undergoing radial artery catheterization and PCI has increased exponentially.8 Patients prefer the transradial approach,9 and this approach offers the advantage of earlier time to ambulation, lower rate of vascular and bleeding complications, and improved cardiovascular outcomes in patients with ACS.4 An important caveat to radial access trials1,2,9 is that the treating physicians were required to have experience in radial artery access, and therefore, it is not surprising that femoral crossover rates were notably low among patients assigned to radial access.1-4 For this reason, it is encouraged that all operators gain experience in radial artery access so that they may ultimately acquire the skills needed to have expertise with this approach. The decision to use the transradial approach should be tempered with the possibility that the radial artery may be needed for bypass grafting in the future. In patients for whom there is a high likelihood of future CABG, the choice of vascular access may require discussion with the patient and the cardiac surgeon. In centers where expertise in the transradial approach is unavailable, or in those patients who are unable to get radial artery catheterization because of anatomic or clinical limitations, femoral artery access remains the default strategy. Recommendation-Specific Supportive Text 1. The MATRIX (Minimizing Adverse Haemorrhagic Events by TRansradial Access Site and Systemic Implementation of angioX Access) trial2 demonstrated a significantly lower rate of the coprimary endpoint of net adverse clinical events (30-day death, nonfatal infarction and stroke, | ||
| p.39 | 1 A | 3. In patients with chronic occlusion of an SVG, PCI of the SVG has been associated with low success rates and excessive risk of needing repeat intervention.7,8 However, experienced operators have used occluded SVGs as conduits for retrograde recanalization of CTOs in native coronary arteries.13 10.7 Treatment of CTO Recommendation for Treatment of CTO Referenced studies that support the recommendation are summarized in Online Data Supplement 29. Downloaded from http://ahajournals.org by on October 7, 2026 COR LOE Recommendation 1. In patients with suitable anatomy who have refractory angina on medical therapy, after treatment of non-CTO lesions, the benefit of PCI of a CTO to improve symptoms is uncertain.1-4 2b B-R Synopsis A CTO is found in approximately one-quarter of patients undergoing coronary angiography.5,6 Considerable progress in the technical aspects of interventional revascularization has yielded success rates in excess of 80% in the hands of skilled operators.7 However, the 30-day mortality rate after CTO PCI is 1.3%, and perforations occur in 4.8% of cases.8 Enthusiasm for treating these lesions was fueled by retrospective data suggesting improved clinical outcomes for those patients who underwent successful recanalization compared with those who had failed.9 However, RCTs have not demonstrated improved function4,10 and have been equivocal with regard to symptoms.1,2 For this reason, shared decision-making should inform the treatment of patients with refractory angina despite GDMT with remaining CTO coronary lesion, with careful discussions of the limitations of treating these lesions, as well as the potential benefits. | ||
| p.53 | 1 A | 14.2 Dual Antiplatelet Therapy in Patients After PCI Downloaded from http://ahajournals.org by on October 7, 2026 Recommendation for Dual Antiplatelet Therapy in Patients After PCI Referenced studies that support the recommendation are summarized in Online Data Supplement 44. COR LOE Recommendation 1. In selected patients undergoing PCI, shorterduration DAPT (1–3 months) is reasonable, with subsequent transition to P2Y12 inhibitor monotherapy to reduce the risk of bleeding events.1-4 2a A Synopsis After PCI, the use of DAPT prevents stent thrombosis and reduces ischemic events at the cost of increased bleeding.5 Pooled data have demonstrated less bleeding with shorter-term DAPT (3–6 months) and fewer ischemic events (including stent thrombosis) with longerterm DAPT (>12 months)5 (Figure 7). The 2016 guideline focused update on duration of DAPT6 highlights the importance of balancing ischemic and bleeding risk when DAPT is considered and provides recommendations for short and prolonged DAPT followed by aspirin monotherapy after revascularization. Since the release of those guidelines, more recent trials have been published.1-4,7 For this reason, additional recommendations for DAPT are provided. These recommendations should act as a supplement to the prior guideline focused update. Given the multiplicity of possible antiplatelet regimens available for use after revascularization, clinicians should weigh the risks of bleeding and recurrent ischemia when determining the choice of DAPT. | ||
| p.56 | 1 A | Recommendation-Specific Supporting Text 1. Two recent trials—the AUGUSTUS (Safety and Efficacy of Apixaban Versus Vitamin K Antagonist and Aspirin Versus Aspirin Placebo in Patients With Atrial Fibrillation and ACS and/or PCI) trial1 and the ENTRUST-AF-PCI (Edoxaban–Based Versus Vitamin K Antagonist–Based Antithrombotic Regimen After Successful Coronary Stenting in Patients With Atrial Fibrillation) trial4—examined regimens of apixaban and edoxaban and supported earlier findings,6,7 reporting lower bleeding | ||
| p.57 | 1 A | Recommendation-Specific Supportive Text | ||
| p.57 | 1 A | Downloaded from http://ahajournals.org by on October 7, 2026 1. The safety and effectiveness of the traditional, medically supervised center-based cardiac rehabilitation model are well established. Observational studies and RCTs have demonstrated that center-based cardiac rehabilitation is effective in reducing hospital readmissions, secondary events, and deaths in patients with CVD.1,2,4,11 Guidelines and standards of care have been well defined for center-based cardiac rehabilitation, including core components,10 core competencies,12 clinical practice guidelines,13 performance measures,12 and certification (program and individual).9 Home-based cardiac rehabilitation can help improve delivery of cardiac rehabilitation to eligible patients by overcoming common barriers that impede a patient’s participation in center-based cardiac rehabilitation, including transportation challenges, competing time demands, and lack of a center-based cardiac rehabilitation program near the patient’s home.14 Core components of home-based cardiac rehabilitation are similar to those for centerbased cardiac rehabilitation.14 Cochrane reviews concluded that home- and center-based cardiac rehabilitation have similar effects on quality of life and costs among patients with recent MI or coronary revascularization.15-17 |