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Lawton et al 2021 ACC/AHA/SCAI Coronary Revascularization Guideline January 18, 2022 Circulation. 2022;145:e18–e114. DOI: 10.1161/CIR.0000000000001038 e32 CLINICAL STATEMENTS AND GUIDELINES been studied in randomized trials with clinical endpoints of death, myocardial infarction (MI), or repeat revascularization.1-5 There are other resting indices that have been compared with iFR or FFR in observational studies.9,10 These resting indices have varying degrees of accuracy relative to FFR and iFR but have not been studied in randomized trials with clinical endpoints. The FAME 2 (Fractional Flow-Reserve-Guided PCI versus Medical Therapy in Stable Coronary Disease) trial2 tested a strategy of PCI for all lesions with abnormal FFR compared with optimal medical therapy alone. Recruitment into the trial was stopped early because of a significant benefit of PCI over medical therapy in patients with an abnormal FFR with respect to death, MI, or urgent revascularization, with the benefit derived largely from a reduction in ischemia-driven revascularization. The role of FFR in guiding surgical revascularization is uncertain. Multiple small observational studies, as well as RCTs and meta-analyses of these trials, suggest that fewer distal anastomoses are performed, and off-pump CABG is more often chosen in patients undergoing CABG with FFR-guided revascularization than in those undergoing CABG with angiogram-guided revascularization.11-14 However, in these studies, no differences were found in clinical outcomes in patients undergoing CABG with FFR guidance compared with patients undergoing CABG with angiogram guidance.11-14 Additionally, not all studies included an angiogram-guided comparison group. Large, randomized trials that are appropriately powered are warranted to guide the use of FFR in patients undergoing surgical revascularization. Recommendation-Specific Supportive Text 1. In the FAME trial, PCI for a stenosis ≥50% with an abnormal FFR reduced the risk of the composite endpoint at 1 year as compared with PCI guided by angiography only,1 a benefit that was maintained at 2 years9 but not at 5 years. The DEFINE-FLAIR (Functional Lesion Assessment of Intermediate Stenosis to Guide Revascularisation and the Instantaneous Wave-free Ratio versus Fractional Flow Reserve in Patients with Stable Angina Pectoris or Acute Coronary Syndrome)4 and the iFR-SWEDEHEART (Instantaneous Wave-free Ratio versus Fractional Flow Reserve in Patients with Stable Angina Pectoris or Acute Coronary Syndrome) trials6 compared outcomes with the use of iFR- or FFR-guided PCI. In these trials, iFRguided PCI was found to be noninferior to FFRguided PCI. As compared with FFR, the use of iFR was associated with lower rates of procedurerelated chest pain and shorter procedural time. In randomized trials, the rates of short- and long-term MACE were lower among patients who had PCI guided by physiology with either FFR or iFR.4,6 2. Deferral of PCI when the FFR is >0.80 or the iFR is >0.89 is associated with low rates of long-term MACE.8-10 The DEFER (Deferral of Percutaneous Intervention) trial demonstrated similar rates of MACE in follow-up when PCI for angiographic intermediate lesions and FFR >0.75 was deferred, rather than performed, at 2 and 5 years of followup.8 Additionally, there were lower rates of MI in the deferred group at long-term follow-up.7 In patients enrolled in the FAME trial who had an FFR >0.80, 2-year rates of MI and revascularization were low, at 0.2% and 3.2%, respectively.9 Finally, in the DEFINE-FLAIR and the iFR-SWEDEHEART trials, rates of MACE in patients who had PCI deferred on the basis of an FFR >0.80 or an iFR >0.89 were 4.05% and 4.12%, respectively,10 with unplanned revascularization being the most frequent cause of MACE. The cutoffs of FFR and iFR provided were those used in the clinical trials. On occasion, borderline values may warrant further ischemia testing or additional investigations. 4.4 Intravascular Ultrasound to Assess Lesion Severity Recommendation for Intravascular Ultrasound to Assess Lesion Severity Referenced studies that support the recommendation are summarized in Online Data Supplement 6. COR LOE Recommendation 2a B-NR 1. In patients with intermediate stenosis of the left main artery, intravascular ultrasound (IVUS) is reasonable to help define lesion severity.1-5 Synopsis IVUS can offer important anatomic information beyond what is seen on coronary angiography. IVUS is particularly useful in lesions involving the left main artery where there may be limitations in coronary angiography due to overlapping vessels or foreshortening. IVUS offers significantly greater spatial resolution than angiography alone (IVUS axial resolution is 100 to 150 μm, and coronary angiography axial resolution is 300 μm). Detailed cross-sectional images provide accurate evaluation of lesion characteristics, including lumen dimensions, lesion length, plaque morphology and location, thrombus, dissection, and stent apposition and expansion. Additionally, minimal lumen area on IVUS has been shown to correlate with physiological indices.6 Recommendation-Specific Supportive Text 1. In the case of indeterminate left main disease, studies have shown that IVUS evaluation with deferral of intervention for a minimum lumen area of ≥6 to 7.5 mm2 is safe,1,2 although a smaller cutoff (4.5–4.8 mm2) may be more appropriate in patients of Asian descent.3 Moderate correlations Downloaded from http://ahajournals.org by on October 7, 2026